Two thousand and nineteen. The end of a decade, and for me, much else. 2019 was the year I endured anastomotic dehiscence, a post-operative complication in which a re-sectioned part of the colon comes apart and the contents of the large intestine empty into the abdominal compartment. I survived the subsequent sepsis and peritonitis, both extremely serious. It is not an overstatement to say that I only narrowly escaped death. Indeed, parts of me did die. The anastoma on my descending colon was necrotic in parts and the whole section had to be defunctioned; my transverse colon was formed into a stoma during life-saving emergency surgery.

During the subsequent months of recovery in an NHS hospital I also got to witness first hand the devastating effects that austerity politics had obviously had on the service at the point of use: lack of basic medical supplies, scarcity of staff across all sectors, inconsistency of staff provision and communication, wildly fluctuating staffing levels and sourcing, dire oversight of record keeping and documentation, a mind-boggling hyper-vigilance over a series of micro-budgetary issues — atomised to the point of hindering the delivery of care… the list of issues I saw being played out is literally too long to convey in any prosaic manner. The consequences, however, were in every case a massively noticeable variation in the quality of medical care available to myself and other patients.

A long stay in hospital, during which you meet many others, provides you with many stories to tell, of experiences directly witnessed, professional exchanges overheard, and anecdotes: stories of relatives called at home in the middle of the night in order to bring in medical supplies the ward had run out of; of night staffing levels so low that medications supposed to be delivered to patients by bedtime are still outstanding by morning; of first-time privately outsourced night-staff being asked to flush drainage bags and having to ask the patient how to perform the procedure; of doctor’s recommendations delivered on ward round which no member of the perpetually fatigued, overworked and ceaselessly rotating ward staff have any tangible record of; of whole nights spent sleeping in A&E on trolleys for lack of beds; hours spent shivering on cool corridors outside radiology departments on seemingly abandoned trolleys or in ancient wheelchairs; of bedside whiteboards left indicating nil-by-mouth and other conditions weeks after a patient’s situation no longer called for them; of student nurses working double duty as care assistants just to afford their rent; again, the personal stories are only the sharp end of huge systemic problems rooted in the economic management of a hospital and ultimately the service itself, and will endlessly multiply the longer the stay and the more patients you talk to. It’s always too late, too long and not enough: not enough staff, not enough resources.

For me personally there was always the nagging question of whether my elective surgery — the removal of a colovesical fistula — would have had less catastrophic results if it had been conducted under a less austerian economic regime. As it was, I was siphoned into the procedure through the involvement of a third-party ‘advanced recovery’ team whose programme claims to expedite the healing process and minimise the length of post-operative stay in hospital. What it amounted to in practice was the issuing of a ‘best friend’ personal spirometer, a long repetitive boot-camp lecture on post-operative self-care, and the (by traditional standards) early entrance of physiotherapists into the intensive care ward to drag me out of bed once a day. All of which would, to any observer with enough critical distance to see the bigger picture, look like a way not only to minimise hospital stay by the shock of jump-starting my post-operative metabolism, but of securing an all-important empty bed much earlier. In my case, however, no amount of huffing and puffing and hobbling around was enough to adequately oxygenate the anastoma on my colon (where the fistulated section had been removed) for early use. Initially, the ‘advanced’ recovery techniques looked to be working brilliantly, and ICS staff were impressed enough with the process to send me to a normal ward. After six days however, the later of them increasingly active and eating normal-to-large amounts of food, the anastoma burst apart and organ-failure scoring accordingly shot up. I must have entered some kind of semi-conscious state because I only fuzzily recall a team of doctors breaking apart the staples in my abdomen to inspect the contents, with much apology to me, and my consultant surgeon hurriedly informing me that I would require immediate emergency surgery. After a countdown to unconsciousness I awoke back in the Intensive Care Unit, where nobody looked sanguine to see me again, now with two drainage outlets, a wound outlet, and a stoma to maintain — in total four bags I would have to eventually reduce down to a single colostomy appliance before I could be deemed well, many many weeks thereafter. But the trauma was not over, by far, because now I had to deal with the aftermath of an anastomotic leak: weeks of critical illness and the cycle of many intravenously administered antibiotics, most of which proved ineffective. In short, more bags. Lying there in my bed, my body open to so many tubes, I contemplated my extended existence as some kind of multi-tentacled cephalopod; and for many days and nights that was about the limit of my sense of self. As I began to recover, I discovered to my dismay that the second round of surgery, the unelective one undergone within mere days of the first (already a major procedure), had not only probably saved my life, but left me with peripheral neuropathy (burning pains and loss of sensation in the hands and feet) — a condition I am still being treated for today, and am unlikely to ever recover from.

So had the outsourced ‘advanced recovery team’ aka bed-emptying agenda helped or hindered me? It’s hard to say, and I’m much too involved to give anything but a deeply subjective view of the matter. This series of journal entries are entitled 2020 hindsight with the utmost irony. The surgery I initially underwent is by no means risk-free to begin with: during pre-surgical consultations I was cited a 3% chance that there would be intestinal damage. It was also emphasised that one of the key elements to the successful re-sectioning of the colon is the oxygenation of the anastomic site. It certainly wouldn’t have harmed my chances that the advanced recovery programme concentrates on increasing levels of respiration. But from my perspective, I did feel rushed and hurried to recover, and especially so with regards to eating. I feel that I was being fed too early, and overfed with respect to what I would be expected to move through my system. There seemed little to no oversight on this matter, and in my morphine-induced happiness and disinhibition on the ward I was left to consume what I liked without any apparent restrictions. I was supposed to be going home at the end of the week, after all. In hindsight, that all seems ridiculous to me; a week for recovery from major surgery? No, the advanced recovery regime is way too optimistic and demanding, even if it works a lot of the time. What happens when a patient has undiagnosed asthma or COPD, or other complicated and invisible factors come into play? What happens when your expectations of a patient’s recovery are based not on medical observation or evidence in the first instance but on economic considerations, and evidence for your programme’s success rate is actually your second basis, and then only cross-sectionally and not by longitudinal study? Does it matter if your regime is evidence-based if there is only short-term evidence available? If, as a third party, you exist in the first place because of economic considerations, is your intervention even a medical one — does it merit that association? Needless to say, after the first week I have never once heard from the advanced recovery team — no follow up, no questions, no interest. So whatever evidence-gathering system they have in place, it has no interest in the long term picture of my health.

My own suspicion is simply that the advanced recovery model is a passing fad, a policy-based intervention for which evidence has been effectively cherry-picked using a short-term analytic. After all, you could ask me how I was doing on any of the first five days after my elective surgery and I would have cheerfully told you that I was doing better than I had expected and was even looking at the prospect of going home after the weekend (I have to add, much of this was performative and attitudinal; I’d been drilled by the advanced recovery training to consider myself in exactly these terms). But then, on the sixth or the seventh day, I would have been unable to do anything but cry, sweat and faint as my blood pressure plummeted, temperature spiked and pulse raced. Naturally enough, no one from the advanced recovery team was around at that point, and they would have been less than useless if they had been; their whole application seems based on an assumed picture of recovery embedded in an economic mentality that does not admit the existence of any emergency outside of the overarching disaster capitalism of austerity. Health is not just its mandate, therefore, but its underlying imperative. “We’re only really for the healthy”, it might as well admit.

David J Smith
djs@theriomorphous.org.uk

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