A while ago I wrote a blog post entitled "After 60, nothing is free." Your kids don't have to come see you any more, and your body will become unfriendly unless you take care of it. After 70, the stakes go up a notch. In the absence of a disease process, you have to do what athletes do and warm up every day, exercise enough to stay strong, and be proactive in maintaining equilibrium and proprioception (the sense of yourself in space). The greatest enemies are chronic pain from arthritis (or something else), loss of balance, and muscle weakness. A sports doctor I visited for a shoulder problem said, "The question is not 'Do I have arthritis," because everybody has arthritis. The question is 'Does your arthritis hurt?'" Getting circulation into the affected parts of your body, and strengthening and relaxing the supporting muscles can greatly reduce arthritis pain. Tai chi, dancing, and standing yoga balances can help maintain equilibrium, and prolonged activity, like a long walk, strengthens stamina. Exercise: I play tennis when I am at Sea Ranch with its plentiful tennis courts and constant good weather, but am not always at Sea Ranch. I sprained my ankle and couldn't walk, tore a rotator cuff muscle in my shoulder and couldn't swim, and have needed to recuperate after an operation and didn't exercise for four months. So many people call it quits when a daunting obstacle appears, saying old age has got them now. Don't buy into that. Purchase of a fitness gauge such as Withings watch or a Fitbit provides discipline: I set 8,000 steps a day as my goal and can no longer fool myself that I am "walking a lot" when I am not because the truth lies right there on my wrist. (My Withings watch does not record any activity when I am stationery, such as doing yoga, tai chi, or even aerobics which don't require much movement other than, say, side to side steps). Articles recommend 10,000 steps a day, but that takes well over an hour and puts demands on your body that your body may not be ready for. Whatever can be accomplished every day (more or less) is what is right for you. Establish one or two areas of expertise: It you are like me, pumping away in a gym on an exercise bike or a stepmaster is boring as hell. I can't keep it up. If you take yoga classes, or follow the subscription service yogaglo.com online, you will find yourself constantly improving, which keeps it interesting. Being in live classes is even better because you develop a camaraderie with fellow practitioners, and you have a teacher with whom you can discuss problems. You can become an accomplished yogi at any level. Pay attention to what any decent instructor will tell you -- practice within your own limits, keeping your judgments on the low side until you know what your body can do. Tai chi is a set of flow, graceful movements done standing up. It is what people do in Chinese parks. If you have seen videos you will know that even very old people can do it. An everyday practice will warm up the body and provide balance exercise without making unduly harsh demands on the body. It can be taken to a very challenging level, but you can do all that is necessary without pushing yourself that far. If my neck, shoulder, hip, or back hurt me there's nothing better to relax the muscles and promote good alignment than a Feldenkrais class. Live classes and practitioners can be found through a Google search, and there are also online resources. I have purchased a dozen mp3s, focusing on different activities or parts of the body through feldenkraisresources.com, clicking on the "shop online" link at the bottom of the page. I'm impressed how much doing the Feldenkrais classes is helping my tennis game. Feldenkrais aims to retrain the body, replacing bad patterns with good until they become second nature. I have learned that movement is spread throughout the body. I am not hitting the tennis ball with my arm (which could injure my shoulder), but with my legs, shoulders, head, and torso as well. Take the time to find recreational resources accessible to you. The local YMCA may have volleyball nights, or other activities which will be fun and challenging. Badminton is one of my favorites, though it is out of vogue these days and I haven't found a place where I can play it. Nature walks or a hiking club might be offered near you. In Hoboken, there are kayaking and canoeing activities, and rowing and sailing clubs too. Adding a social dimension to whatever activity you choose will make it easier to sustain. Find help: When my neck goes nuts, I have a great chiropractor. Leaving a neck out of whack will only make things worse. I have a great physical therapist for when something gets injured (I haven't been for years, but I know he's there). My alternative doctor has an alternative assessment of good health. It is worthwhile investigating some of the alternative practitioners near you, especially if regular allopathic medicine has not been able to help you. I follow the instructions of both kinds of doctor, and they do not conflict, though I must admit that more and more of my day is spent following instructions than before. That is inevitable if I want to stay well and fit. Walt Clyde Frasier, the famed basketball player, said that when he was playing ball he was constantly getting injured, until he started doing yoga. After that he was never injured again. Refining the practice of yoga, tai chi, the Alexander Technique, or any other discipline that keeps you well aligned, well balanced and well oxygenated can be the difference between being 75 and looking 75, and the difference between being 75 and feeling 75. After 70, it's no longer a choice.Warm up every day by stretching, bearing weight, and breathing deeply, following whatever method appeals to you. We'll all become feeble and weak at some point, but you have a say in when that happens, and how comfortably you pass your days before that point.
On Friday, April 3rd, I had surgery to correct a prolapse of the bladder and rectum, a hysterectomy, and various other repairs in the area. In Part One of this blog post, I related the lamentable experience in Mt. Sinai Hospital right after the surgery. This is part two -- a snapshot of the aftercare and recovery, and some advice and suggestions for others undergoing similar surgery. Saturday was as bedeviled as the day of the surgery, beginning with an aide who gave me a toothbrush loaded with toothpaste, and then a washcloth loaded with soap, without any means of rinsing afterwards. I couldn’t stand, so leaned on the sink with one hand and cupped water to my mouth and face with the other. The aide watched me, apparently confused. Morphine had finally tamed the intractable pain and I had a calm night. I was expected to go home on Saturday, so all IVs, including hydration and morphine, were dismantled. The nurse explained that we had to be sure we had a regimen of oral medications that would work back home, since you can't take morphine with you. The oral meds did not work, and a miscommunication between the covering doctor and my nurse resulted in another contentious delay in getting me reasonably comfortable. It wasn’t until the late afternoon, when Dr. K (the surgeon) granted me an extra day in the hospital and thus another night with morphine, that the pain was controlled again. The main project for the day was to see if I could void the bladder. Dr. K had said 85% of women can, so I wasn’t too worried. I was in robust good health, had been doing yoga every morning for many years, and would fit nicely within the eighty-five percent. For this test the bladder is filled through the Foley catheter with 500 millileters of sterile solution. Then the patient sits for 15 minutes over a plastic “hat” (in the shape of an inverted hat) which is placed under the toilet seat so as to measure how much is voided. With a full bladder pressing on the sutured surgical area, the process was painful. The nurse did not come back after 15 minutes and I was getting dizzy from the pain, so I waited a little longer and then pulled the emergency cord next to the toilet. I thought this would be considered urgent – I might have fallen, hemorrhaged, or passed out -- but it was another ten minutes before she arrived. When I complained about the slow response she snapped, “I was with another patient.” I had thought the cord alerted a central area where more than one person would be available for emergencies. I couldn’t void a drop, and asked first the covering doctor, then the surgeon, why. The first said, “You have a lazy bladder,” and the second, “You have to relax. Female urination can’t happen when you’re tight.” This failure was apparently my fault. After she walked me back to my bed, the nurse inserted a new Foley catheter – twice. The first was defective, the second was too small in diameter. (This was, after all, the Orthopedic ward not the Gynecology ward.) The covering doctor inserted a third catheter. With the pain under control and a catheter in place, I slept and healed, and by the time the morphine was removed the next morning, my pain was only a 6 or so, rising only when I moved. Sunday began with a visit from the covering doctor. I wasn’t happy about going home with a catheter attached to my thigh, so asked if we could try the void test again. She looked annoyed. “Oh no!! You only get one chance in the hospital. If you can’t do it then, you have to wait for your next doctor’s visit.” The surgeon countermanded the covering doctor and I was given the test again, and failed. I wondered what percentage of patients failed the void test twice. I was worried that something had gone wrong, but Dr. K reassured me, “You can never tell. Some women are stitched up and down and pee like a racehorse the next day, and some don’t. Don’t worry about it.” By the time I left the hospital late Sunday afternoon I had eaten a couple of spoonfuls of mashed potatoes, a tablespoon of potato soup, and a few bites of toast since the Thursday night before the surgery. I couldn’t reach the water on the bedside table and when someone passed me the cup I had to drink sideways, spilling water on the sheet and floor. I was unable to reach the food trays because I could not sit up. The constant hassles and persistent pain, the worry about the stress being put on my husband, and the concern that something had gone wrong in the surgery diverted my attention from a subject I have studied for 40 years – nutrition. This fasting and dehydration weakened me and affected the serious struggles I would have with constipation after I got home. I arrived in our 18th floor Hoboken apartment late Sunday afternoon with mixed feelings. I was no longer at the mercy of overstressed, disorganized, sometimes nasty, and often incompetent hospital staff…on the other hand, I was on my own. Thank goodness I had a loving and patient husband to take care of me. Dr. K, had office hours on Wednesday, three days after I went home. On the first Wednesday, I again failed the void test. On the second Wednesday, I partially voided, so Dr. K suggested disconnecting the catheter. He gave my husband a few minutes of training so he could insert a manual catheter and drain the bladder manually if I couldn't void. (I wonder how many husbands would undertake to do this.) Back home, I could not void, and we could not thread the manual catheter, so we rushed to the emergency room at Palisades Hospital, where they installed a Foley catheter. They were efficient, pleasant, and timely enough. Two Fridays after the first surgery, we trekked back to Mt. Sinai for a second surgery. This time, things went smoothly, and I was home that night with no complaints. My failure to void had not been the result of a “lazy bladder” or my inability to relax – there was a large blood clot restricting urine flow, and the sling holding my bladder in place needed to be loosened. Once these obstructions were removed, I passed the void test, and the healing phase began. ---------------------- The pelvis is a 24/7 factory which cannot be stilled. In yoga, it is the First Chakra, the grounding chakra which connects us to the basic facts of life – sex and reproduction, elimination of wastes, and turning and walking. In such an active environment, stitches and incisions are constantly disturbed, causing pain until the healing is well advanced. Of course, it depends on the kind of surgery -- the anterior wall of the vagina has little sensation, but posterior recovery is slower and more painful. The healing process can take weeks or months, and happens in stages. As I write this, I am five weeks into recovery and still find it difficult to sit or walk for long and the pelvic functions don’t yet work comfortably, but in a week or two I’m expecting to be back to my normal schedule and habits. Friends have told me that they still felt small tweaks of pain or discomfort six months later, but these did not impede their activities. I’ve gathered some information and advice that I wish I had known before I had this operation. My own anxiety and pain would have been reduced, and it would also have been easier on my husband, who has been patient, innovative, and as helpful a caretaker as I could have hoped for. PATIENT CHECKLIST: A few days before your operation, your brain begins to prepare for the upcoming trauma. The intake nurse told me that people become forgetful and unreliable. That was true for me. (I even forgot my health care proxy! I had trouble tying the knot of the hospital gown.). It is best to gather your things ahead of time. Some of the items you should remember are:
- An index card listing your medications and dosages, existing conditions and previous operations, allergies, and other pertinent information. Though you fill out similar forms several times before entering the hospital, they’ll keep asking you the same questions again and again.
- Your Health Proxy form.
- Your cell phone AND the charging cord. Be sure your doctor’s direct phone is installed in your Contacts list and that all other relevant phone numbers are at hand.
- Copies of your pre-op tests and the permission letter from your primary care physician. (They can get lost – the hospital did not have my EKG and had to take another one.)
- Discuss the pain management protocols before you become helpless. If I understand Mt. Sinai’s written report correctly, they started me on Percocet; when that didn’t work, they doubled the Percocet. When that didn’t lower the pain level, they tried an anti-cramping medicine; after that, there were no further instructions. Waiting for the doctor to get out of the Operating Room and approve morphine took over an hour, and it took still another hour for the pharmacy to fulfill the order. Given the sophisticated pain management methods in place today, there is no excuse for leaving a patient in level 10 pain for 3-4 hours, but once you are at the mercy of the system, there is nothing you can do about it. Clarify the post-op pain regimen BEFOREHAND.
- Check your upcoming schedule. Recovery times vary, and if you can, you should not plan any professional appearances or other demanding activities for six weeks. If you recover more quickly, you can reinvigorate your schedule; that is preferable to canceling scheduled meetings or appearances, as I had to do.
- Scout out a wheelchair, or rent one. The hospital delivers you to your car in a wheelchair, but you will have to get from the car into your house or apartment, and for the next couple of weeks you might need it to go to doctors’ appointments, or, in my case, the Emergency Room. (We were fortunate. There was an abandoned wheelchair in the storage room of our apartment building.)
- Have some supplies ready for when you get home. These might include sanitary pads (bleeding lasts about two weeks), a bolster for the bed (you can’t raise and lower your bed at home), analgesic wipes (Tucks, Preparation H female wipes), enema supplies and/or laxatives (you won’t know beforehand which will work best), a water bottle that a supine patient can easily drink out of, and stock of soups or light foods. Have recommended pain relievers (in my case, Motrin) on hand.
- Consult your resources outside the allopathic medical community, as they may help you recover more quickly. Dr. K was readily available by phone, but his answer to all problems was yet another medicine. A holistic doctor, nutritionist, acupuncturist, homeopathic doctor, or naturopath may have suggestions and treatments that don’t have side effects, as medicines do, or the risk of unfavorable interactions, increased constipation, or allergies. Acupuncture, homeopathic formulations, and laser treatments speeded my healing.
- Dr. K repeatedly advised frequent soaks in a mineral bath. He said Epsom salts (magnesium sulfate), but my holistic doctor recommended magnesium chloride (I order it online), which was more effective for me. Dr. K said to take three baths a day in the beginning. I still take one such bath a day. It helps calm inflammation, swelling, and pain, and relaxes the whole body.
From my point of view as a patient, the systemic failures during my recent surgery were widespread and serious. Some lapses were funny, in a Keystone Cops kind of way, most were not. When I shared the muddles and anxiety these lapses caused, I was surprised at the reactions: “All hospitals are the same. It’s just going to get worse.” “There’s nothing you can do about it, so stop complaining.” “You’re going to be okay and that’s the important thing. All the rest is behind you.” I do not share these attitudes. As a patient, a citizen, a former professor, and a writer, I am drawn to telling the story about my recent operation and hospital stay during which my care was often inexcusably lacking in focus and effectiveness. -------------- On April 3rd, I became one of the 200,000 American women per year who have surgery for pelvic organ prolapse. The urogynecological surgeon, Dr. K., diagnosed Grade III uterine prolapse, cystocele, and rectocele; Grade III vaginal vault prolapse; and gaping vaginal introitus. After the diagnosis, a friend who had had similar surgery loaned me books which gave me hope that I might avoid surgery. I did the exercises and followed the suggestions in the books but the symptoms failed to improve. I dithered about seeing Dr. K. again, but my primary care physician, Dr. D., tipped the scales when he said, “Do it now before you become too old for surgery.” I’m 73. I told Dr. K. that I was ready to follow his recommendations: transvaginal hysterectomy, enterocele repair, suburethral sling urethropexy procedure, anterior and posterior colporrhaphy perineoplasty, and a sacrospinous vaginal vault suspension procedure. After reading this, my husband remarked, “easier done than said.” This was my first major surgery and I was daunted by the long list of procedures, but Dr. K and Dr. D. both said I’d probably be home the next day, and after a couple of recovery weeks I might still be sore, but could go about my daily life. Though skeptical of my doctors' sunny predictions , I was ready to proceed. Another concern was that I would be cut off from Dr. B., the holistic doctor who has been my most effective health care provider over the past 25 years. Both Dr. D. and Dr. K. are open to what are often disdainfully referred to as “alternative treatments,” but hospitals do not integrate this kind of care. Pre-op instructions were simple: See primary care physician within 14 days of surgery, and have a chest x-ray, blood work, and an EKG. Check with your GP about your regular medications. Do not eat or drink after midnight the night prior to surgery. If you develop a cold, rash, etc. tell the surgeon. Take off all jewelry and body piercing items. The intake at Mt. Sinai hospital was crisp and efficient. I was checked in and given a wrist band with a round identity chip on it. I later found out that it would enable the staff to scan my wristband to make sure they were working with the right person. My husband was given a transponder. They would beep him at pertinent points, and let him know when the surgery was over. So far I was impressed by their clever use of technology. I was then sent to a registration cubicle where I signed forms and an intake clerk typed my information into a computer. I felt at ease; Mt. Sinai had gone digital and my information would be instantly available to everyone from then on. My belongings were sealed in plastic bags with a scanning code so they couldn’t get lost. I got my hospital garb, and then I was escorted to the surgical waiting area. During my two hours there, an assisting Fellow, a nurse, and the anesthesiologist gathered the same information that the intake clerk had collected. I asked the Fellow why and he said, “I know. It’s crazy. They want us to take down the same information by hand.” My brain was frowning. The doctor came to the waiting area to be sure I understood what he would do. Since they were going to put a sling on my bladder and make other repairs, they would check the next day to see whether I could void the bladder. If I could, great; otherwise I’d have to go home with a Foley catheter He assured me that 85% of women could void their bladders, so not to worry. I was as ready as I would ever be. I was bundled onto a rolling stretcher and went barreling down the hall. The orderly clicked on the Operating Room Door button, and it swung open automatically as he shouted, “Patient Incoming! Patient incoming!” Everyone looked at me; Dr. K., the Fellow, the nurse, another doctor, the anesthesiologist, and a couple of other people arranging stuff. I’m claustrophobic, and when the anesthesiologist put a mask over my face I started to panic, but repeated “OOOOOOOOOOOOOHM” to myself. They put pressure sleeves on my legs and an IV needle in my arm. Dr. K. put his hand firmly on my thigh, almost as if he were resting on a table, and I calmed down. He was there, watching. I woke up in the Recovery Room. A male nurse was chirping “Good morning, time to wake up! Everything went well! You can wake up now!” He busied himself taking vitals, and rearranging things. “We’ve got to get you ready to go home! As soon as you fully wake up, you can go home!” “What? I’m not going home today.” “Oh yes you are! Everything went great and you can go home!” “That’s not what my doctor said. You’d better ask him about that.” I was alarmed at the prospect of going home right away, but couldn’t stay awake. Luckily, my husband was there and repeatedly insisted that the nurse check with the doctor, who confirmed that I was to stay overnight. When I next woke up, I was in a bed in the Orthopedic Ward rather than the Gynecology Ward where I belonged. When my husband asked why, he was told that the same recovery room nurse who had been ready to send me home had also given my place in the Gynecology Ward to someone else. I was in a lot of pain. The nurse gave me Percocet. No change. She gave me a second Percocet. No change. Dr. K visited and asked me about my pain level on a scale of 1 to 10. “Twelve” I said. He prescribed an anti-cramping medicine and left for his next surgery, but the pain did not subside. I was chilled and shaking, my teeth chattering. I told the nurse the pain was a combination of the worst menstrual cramps and a baby stuck in the birth canal. A nurse’s aide came to take my blood pressure, and when she saw 194 over 135 (I could see it, too), she cried out “Oh mercy! I’ve got to tell the doctor,” and steamed out of the room. My husband began asking about a morphine drip. Both Dr. D and Dr. K had said that morphine would be provided as needed, but no one was available to approve it. Dr. K and his assistants were in the OR and the Resident was nowhere to be found. My husband watched me suffer needlessly while the nurses and staff went about their business for the next hour seemingly unconcerned. Eventually, a nurse was dispatched to the operating room to get Dr. K’s permission for a morphine drip. Twenty-five minutes later she returned and said that Dr. K had approved it, and that the morphine had been ordered from the pharmacy. My husband sat down next to my bed as we waited for the morphine. Half an hour later the nurse passed through on her way to the other patient in the room and my husband called out “How long will it be? Is there no sense of urgency about this?”? “Sir, the pharmacy is backed up and you’ll just have to wait.” “Can’t someone go down and get the medication?” “It’s not magic sir,” she snapped, then turned on her heel and left. From start to finish, it took over three hours to tame my pain. Having read about the advances in pain management these days, including clinics devoted to nothing else, I wonder why there is not a post-operative pain management team at Mt. Sinai. This would efficiently deal with post-operative suffering, and free up medical and nursing staff to deal with things they are authorized and trained to do. I also wonder why the digital records resident in the intake clerk’s computer could not be distributed to other parties participating in my case. At the very least, the record of allergies, medications, past surgeries, and so on could have been printed out and pinned to my hospital gown, saving at least half an hour of further interviewing. (That suggestion made Dr. K. laugh.) The snafus in my care affected my recovery. My blood pressure spiked, my nervous system was in chaos, and I lost my confidence in one of the most famous hospitals in the world. I felt helpless in a system which had already tried to send me home too early, put me in the Orthopedic Ward, and failed to control post-operative pain. What else would go wrong? My husband and I had to make decisions we were unprepared to make, and had to watch keenly for other errors which might be invisible to us. I told my husband, “There’s no reason for you to sit there and watch me sleep.” He needed dinner, some fresh air, and a good night’s sleep. He had suffered too. Thus ended day one.
At my 91-year-old aunt’s table in the assisted living facility sit four women. Sometimes I join them for lunch. Old age has turned all four women into quiet companions, but my aunt looks forward to their company. When my aunt and I eat at a separate table, she keeps looking over to see how her companions are doing. Genevieve is a mild woman who raised her three children in a home less than five minutes away from where she sits now. She is interested in me and my book. Irene is a former international lawyer who prefers to be called “Doctor.” In the last few years she has suffered two broken legs, two bouts of pneumonia, and the loss of her son, but she has an old-school stoicism and suffers her pain with grace. The last, besides my aunt, is Georgie. She is 102 years old, which means she was born before the First World War, in 1912. When epidemics rage, Georgie is untouched. Sometimes she sits alone at the table while her three table mates fight off the latest bug to rage through the facility. Every day she plays backgammon with laughter but no trace of competitiveness. She is ambulatory and fully with it. The only deficit I have ever noted is her memory, but not in the way you would think. I am curious about the world she grew up in. What music did she dance to? Does she remember the first time she saw a moving picture? An airplane? A television set? What was her wedding like? She might remember Armistice Day in 1918. My late mother, who was born in 1910, remembered it. But Georgie floats like a cork on life. She says, “I don’t remember any of those things. I just get up every morning and say my prayers to thank God that I am here. I take one day at a time. I don’t worry.” That’s as deep as it gets. Maybe Georgie knows the secret of life. If so, I am not going to survive to 102.