Something Happened!

"I'm feeling strange, she said". I glanced across from the road in front. She looked agitated, and her voice became slurred, as if slightly drunk. I froze for a second and then asked her to smile for me whilst stopping the car. I put on the hazard lights and looked at her carefully."Lift your arms and close your eyes", I said. She did it. I got out of the car and went around to her door and opened it. She then said in a normal voice, " my arm's a bit numb and my leg too". I asked her to smile again, stick her tongue out and raise and lower her arms. She complied immediately. I got her out of the car and helped her stand. "Walk", I said, and slowly she walked at my side and we turned and went back to the car. "It's on the other side now and my cheek's tingling". "It's changed sides!" I said. She concurred; it had.

I was gripped by fear. The signs although small and transient were nonetheless bad. I did not want to admit it, but the woman I loved was possibly having a stroke! I needed to act and fast, just in case it progressed. I got her into the car went to the driver's side, got in and turned around, heading, not without some trepidation to that hospital, the scene of our past trials at the hand of the NHS. My car screamed it's way through the Friday afternoon traffic, headlights on to try to clear a path. It was 4.30 pm and busy. It was also August. The new intake of FY1's would be there to greet me no doubt, anxious to contradict the view that they were presiding over a another 'killing season' as August is aptly named in A&E, and that's just by the doctors.

I made remarkable time, all the time hoping I would wake up and this would be just a bad dream. It wasn't of course, it was real life. I parked illegally by the Ambulance bay and helped J', who was not very ill just very scared, into Reception. Taking grasp of the situation, I shouted that my wife was probably having a stroke and to help me. That worked. They got her onto a trolley straight away and pushed it into the Department and then left us! And so the waiting began.

I stood at the side of the trolley, holding her hand and trying to assure her that she would be fine. She still had some 'tingling' sensation in her right cheek and was extremely frightened, but little was happening and the floor was filling with patients on trolleys. It was more than an hour before we were taken to a cubicle and a nurse (well a nursing assistant) said she needed some 'bloods'. As she said J' may need some IV medication she would insert a cannula. I was about to protest but J' stopped me. I do not believe in invasive procedures 'just in case' and there was no way she was going to be infused with anything without considerable evidence of need, but I held my tongue. She was also completely useless at the task, took many tries and caused considerable bruising in the antecubital fossa.

A Doctor eventually showed up after some two hours and conducted tests; the usual smile, open/close your eyes, lift your arms etc. He also tried the resistance tests (pushing/pulling against his hands). He then departed and shortly after the ECG/EEG trolley was wheeled in and a nurse applied the twelve leads and conducted the test. I don't have too much knowledge of this procedure, but sufficient to see there was no atrial fibrillation, which was a relief. She went away again saying that a doctor would come and interpret the test results, but before this could occur they came to take J' for a head CT scan. I went with her; they sure as hell were not going to separate us this time! She was not in there long and when I asked the nurse she had no idea of the dose rate of radiation she had received. But, I knew it to be 2 mSv or about 20 chest X-rays and because it's the brain we're scanning that's a lot. Again we were told that a Doctor would be along to give us the results.

Well, we waited and waited. They had left the charts and I checked for obvious problems. Her BP and pulse were very high and blood sugar too at 8.5 mmol/L, although the stress of it all and the natural protective measures of the human body would have been responsible for this I was certain, although even so 190/95 seemed high for someone who regularly records 120/70. Then, over three hours into the event we saw a Registrar who basically said that nothing on the test showed any abnormalities and he went through the routine tests again. I said I thought it was time to go as J' was becoming agitated and the situation was becoming more harmful than productive. As the 'event' had crossed the mid line (changed sides) I was pretty certain it was not a stroke or TIA (trans ischemic attack) and voiced this opinion. He agreed, although was somewhat guarded but did think J' would be discharged quite soon, to my care.

As it was August I suspected he had just been 'made up' to this position and was not really confident in his decisions and he went away saying he would return soon. He didn't. Yet another nurse arrived to say J' was being taken to the Stroke Unit on the other side of town! And of course she had to go by Ambulance, not with me, unless I abandoned my car. I reminded her to remove the cannula which she did reluctantly and I said I would follow the Ambulance. I talked with driver while he waited for his partner to collect the paperwork. He told me to follow him out and he would ensure we did not get separated, which he truly did, slowing down if I got caught at traffic lights. It was nonetheless a nightmare, with me anxious and extremely stressed at the separation from J' as I did not trust the NHS or any Doctor I had seen thus far. I was also bemused as to what had occurred and hated once more the prospect of being caught up in the 'machine' that passes for Medicine today.

We arrived twenty minutes later and J' walked in accompanied by me and the driver. After a couple of minutes I was then allowed to be with her on the ward. They had given her a bed! BP and Pulse were taken together with blood glucose and oxygen levels. If anything BP had increased, to 201/95 and I was a beginning to feel the place we were in was more to blame for this than anything else. I wanted us to leave, but I also wanted to be sure that in so doing I was not putting J' in jeopardy.

 After an hour or so a nurse appeared who seemed to be in charge. She had decided to do a 'swallowing test' which apparently gives some indication of Stroke/TIA if the patient cannot swallow sips of water from a spoon. As the nurse was holding the spoon J' gagged a bit, which I found unsurprising and as she had already taken sips of water from a cup earlier, (which apparently she should not have done) I thought it was useless as a test. She also apologised for the delay in seeing anyone (but her) due to an emergency. Ah well, I thought that's triage for you.

By this time it was well after 10 pm and we were some five and a half hours into the event. And here's me thinking the first three hours were critical in stroke diagnosis! We sat there for another hour, with a sense of dread coming over both of us. J' was all for going anyway by 11.30 and said she felt fine in every way and just wanted to escape the clutches of the NHS which by this time we felt were just trying to cover their collective arse's. Just as we were about to do precisely that, a Doctor arrived.

He was quite affable and at least not patronising, recognising that we were not average punters and at least gave us some respect. He went through all the procedure again and also allowed J' to sip and then gulp water from a cup, which she did without problems. He said he thought an MRI would be useful together with an ultra sound of the neck to check for plaque in the arteries. He also said it would not be possible for this to occur now as the facility was not on line. Whether this was because it was the weekend or for some other reason he did not allude to, but after conducting a 'stress test' comprising J' blowing a stiff sheet of paper until it bent, for a whole minute, he decided he would discharge her to my care. Not before however, she was coerced into taking 300 Mg's of soluble aspirin and a promise that she would continue with this regimen until an appointment could be made for the tests by 'phoning them on Monday of the following week.

I discussed with him the likely cause of the event and that it did not seem to fit into the pattern of a stroke or TIA and he at least admitted that he was baffled. But he said until he had seen more test results he would not pass judgement and for safety's sake we should keep up the aspirin protocol and be prepared for other interventions such as Clopidgrel. Not on your life mate, I thought, aspirin, enteric coated at 75 Mg's maybe, but not that awful stuff! But at least we were able to escape, clutching a sheet of paper with advice about TIA's we exited the building as fast as possible, in case they changed their mind! It was gone midnight and we had been in their care for more than seven hours and still no real diagnosis!

We reached the car and I opened the door. I held J' in my arms before she could take her seat, grateful that she was still with me. It was a long moment before I let her go; I never really wanted to let her go ever again but I did and we traversed our way to the entrance and sped off back to the 'hovel' both emotional but relieved to have escaped, relatively unscathed from the NHS and the events of the day.

At home we were both agitated and bemused. We had no idea of what had occurred or its reason. I know Diabetics are more prone to any sort of stroke than the normoglycemic community but all other factors were not present. She maintains good control of her diabetes's with HbA1c of the low 6%. She has excellent low BP to the tune of 120-130/70-80. She does not smoke, takes regular exercise and her clotting factor was low normal. If we ignore the 'drivel' about cholesterol (her non-fasting total is 6.5mmol/l total lipoprotien) but most scientists know that in a women this is viewed as 'protective' rather than indicative of any danger. So what may have caused this? Obviously the Neurologist did not know because he said as much. It would be rare, even if there was some plaque formation that it would cause a bilateral blockage almost simultaneously, but that would have to be determined for certain by MRA/MRI. So we would have to wait for this determination before reaching any conclusion. And of course that would not be until Monday.

We spent a somewhat agitated weekend, with me watching her like a hawk, not letting her drive and giving her a daily dose of enteric coated 75 mg aspirin, just in case there was any possible problem, to be reviewed in the light of further tests. Aspirin is not a drug I like and cannot take myself due to a past ulcer, but J' has a very strong stomach and never even gets heartburn, ever, so I was confident that a few days intake would likely do little harm. Long term use was not something I wanted to contemplate (yet). I did increase the dose of Omega 3 capsules to 2.10 gms (in 3.30gms of capsules) as this is a fairly benign anticoagulant,( from its previous 1.40 gms), although I knew it's effect would take some time to be realised. I also took her BP and pulse regularly and as sure as predicted, it returned to usual levels within 24 hours of the event, in fact by Saturday night it was 118/71 and the pulse was 76!

Monday came and I 'phoned up about the appointment the Neurologist said would be made first thing. They hadn't even heard of us! They promised to call back. They didn't. At 12 noon I rang back once more and was told that it was now too late for that day but 11.30 Tuesday was the time they had arranged. So that was another day wasted, and so much for the urgency of the tests the Doctor had said were essential, and had to be undertaken that day!

After another fitful night, whilst we were preparing for the day, we then had a call from the Hospital. They had a spot available as soon as possible, could we come in straight away? Obviously we agreed, fools that we were. We got there and after another bout of form filling were ushered in to see the duty Neurologist Dr. W. Without an doubt whatsoever he was dick! Uninterested, remote, rarely looking at the patient, he said very little, asking a few questions and making a very short examination. Just the pulse, wrist and carotid and the usual tests for stroke. He conveyed no view when I asked him about the symptoms crossing the mid line just stared at his screen. He did say J' should have an immediate MRI of the brain together with an MRA with contrast dye, of the neck, no doubt to check for any plaque in the Carotid.

He then told his female assistant ( a trainee) to arrange this and we were dismissed. We sat outside awaiting the news and the young woman came and told us she could not arrange it until 1 pm, which was some two hours away! Not enough time to go home and then struggle back across town and find a space again in the immensely expensive car park, which was half a mile from the unit. She then said she would need to install a cannula for the dye infusion, so we would need to come back to the unit for this before we went to the imaging unit for the MRI/MRA.Why they had not already arranged a test  when it was obvious that it was a need, and the entire reason for our visit, escapes me, but obviously our time was of no matter and theirs at a premium, despite the fact that they would be hard pressed to arrange an orgy in a brothel.

So we went into the Hospital and tried to obtain some food and drink. Well there was coffee, of a sort. The food was all 'junk food', all very high in carbohydrates and totally unsuitable for a diabetic, and frankly it was all highly processed rubbish. We took a further walk through the grounds back to the unit and the trainee then came to insert the cannula for the dye infusion. She seemed different now the boss wasn't around and told me she had researched the dye side effects whilst we were away and attempted to assure us both that it was relatively benign. I discussed her training whilst she was at work on the antecubital fossa. She had just completed FY2 and was now a GP trainee and knew a number of my friends in research and emergency medicine. She was also excellent at inserting cannula's, with confidence, gentleness and expertise that produced no pain or bruising. So we trotted off to the MRI facility half a mile away.

I was stunned when I saw it. It was a brand new building, in the grounds and provided on a 'contract' basis by a private provider; more cash for the private sector! Anyway, after a minor altercation with the 'prick', who drives the machine, J' went away to return fifteen minutes later, sans cannula and in no distress from the dye infusion which said she hadn't felt. We had been told we would get a 'phone call later with the results after they had been evaluated by Dr. W. In fact his secretary rang about 5 pm to tell us that everything was normal and that nothing at all had been found! I'm sure the sod's always get their underlings to provide this sort of information just so you can't ask questions, because we both had many, but for lack of anything else we could do, we would have to wait for the letter they would send.

We had a long wait. After four weeks I rang the unit and spoke to said secretary who informed me that we were not getting a letter but one had been dispatched to the GP some weeks ago. Upon further probing I found they had sent this to our GP of five years before and not to the current one, despite the fact I had filled forms in with the correct information; twice! She did say she would ask permission of Dr. W  for us to receive a copy. I was almost choking with anger by then. "You mean that we are not allowed to see what has been determined about my partners event, but you, our GP and anyone with the access password can?". I said I felt it both insulting and patronising that such should be the case and I would complain in the strongest terms if this was not rectified. She promised to do what she could and I left it there. I explained it to J' who responded with a few expletives,somewhat worse than any in this post.

We did get that copy after another week, and it simply said that J' was healthy without any evidence at all of any abnormalities and, curiously, 'the rest of her history is non contributory'. What! The trauma surgery your colleagues botched, the diabetes they missed, the keto-acidosis, the fact she cannot take vigorous exercise, because the hemiarthroplasty starts to hurt after half a mile, and the chances of revision surgery succeeding or her surviving it, recede with every passing year!

It's also interesting that at no time was J' asked to give any informed consent, written or verbal, for any of the investigations, nor was anything ever explained in any detail until I pressed those involved to do so, and was able to demonstrate knowledge and qualification. Even then, they spoke over J' to me, or directly at me. Bunch of patronising misogynist prats. I really shudder when I think what may have occurred had I not been there to fight her corner. And what is my take on the event? I do not really know, although I suspect it may be microscopic particles of debris (plastic/bone/metal) from the hip implant momentarily lodging in the brain. We are at the stage when the joint will be producing quite lot. Active people can wear them out in five years. J's active and that's next June.

This, dear patient reader is the reason why my blogging has been somewhat curtailed of late. These events have had a profound effect on us both, highlighting the fact that our grasp on life is at best tenuous. But that can be said of us all. But, wherever possible we should all keep away from hospitals; they're full of sick people and not all of them are patients.

The Constant Patient

Loss of Innocence-It Goes On.

I left the saga last with J' having gained control of her Diabetes and progressing to a more 'normal' lifestyle, but of course once the NHS has it's claws into you it never wants to let go. Between us we decided that we did not want to participate in any of their 'educashun' (sic) programmes for Diabetes, nor did we want to return to that hospital for any tests for osteoporosis, or X-rays or indeed for anything. Whilst both of us had a jaundiced view about DXA scans for bone density, on balance we thought it was justifiable to have at least one done to determine whether any such condition really existed. As a consequence we decided to pay for one at another location. So we did.

The results were pretty much as predicted; her hip and spine were slightly less dense than optimal and she was defined as 'osteopenic', which is pretty much what any post-menopausal woman is likely to be, especially in our Vitamin D deprived country with it's aversion to sunlight, love of sunscreens and paranoia about cholesterol. All these, for those who do not know, contribute to the density of the human skeletal structure or rather don't, if you employ any of the above.

A year down the line from the accident we also saw a 'new' Consultant who X-rayed the hip in which the prosthetic 'lurked' to ascertain the extent of any acetebular erosion or protrusion. There wasn't any; well not that could be seen, but frankly a normal X-ray is unlikely to show any until progression was reasonably advanced. It did provide some assurance however and the Consultant was at least honest and didn't treat either of us like children, probably because I talked the 'language' of his profession, in that I utilised medical terminology. In the meantime, we had both changed to a new (for us) GP practise. Because J' was now a registered Diabetic she then began to receive constant entreaties both in the mail and on the 'phone to attend for this test, that vaccination, sundry assessments most of which were largely pointless, or were largely encompassed by our own protocols.


Out of interest, we eventually gave in to a 'diabetic assessment' more out of curiosity than anything else. Of course it was undertaken by a Diabetic Nurse, which presumably did not describe her condition (it was a woman) but her vocation. Looking as she did I was prepared to revise that view because she embodied the 'don't do as I do, but as I say', philosophy in the NHS of appointing those who look sicker than their patients to advise them of the error of their ways. She looked as if she had been a Diabetic herself for many years, bordering on obese, with a florid face and that constant frown, common in those that have little understanding of  what they are doing because they have no idea of why they were doing it,  (I think she probably drowned puppies for a hobby).

She took J's blood pressure (132/65), weighed her, which was the same as it always was (now) took some  bloods for analysis including for a 25(OHD) that I had requested and laid her on the couch and prodded her feet with a short bristle device. As she weighs herself weekly, I take her blood pressure, and often 'tickle' her feet (it makes her jump) it all seemed pretty pointless to be frank, but she did suggest we come along to the 'club' they have for Diabetics, and also a training session where we would have likely had the virtues of low calorie/low fat dieting, extolled in glowing terms and of course be told that there was no need to 'test' constantly (because test strips cost money and the NHS doesn't have any). We declined I'm afraid. She looked crestfallen at this news, but we had seen the pictures on the leaflet and certainly did not want to emulate any of the antics therein portrayed (watching paint dry seemed more attractive).We left then to await the blood test results which were to be available in about 5 days.

Four days later, whilst we were whiling away the time at the 'hovel' counting the cobwebs on the ceiling, the 'phone rang and lo' it was the lead partner in the GP practise wanting to speak with J' about the test results. As we did not have them as yet I found this curious, but not wanting to prejudge the situation, I put her on the 'phone and listened in on the speaker. After praising J's HbA1c result, of 6.3% (the achievement of which he had no hand in, but would be rewarded anyway on the Quality Outcomes Framework) he raised the question of her Cholesterol level of  7mmo/L and suggested she take a statin. J' then asked me to respond to this so I took over the conversation after she gave permission to the Doc' on the 'phone. I pointed out to him that there was no evidence to support such a protocol for any woman, and that it would likely be injurious to her health, along with a few choice references that supported my view, and perhaps he might do a bit more research? At that point he fell back on the "I am only carrying out orders" defence and then told me how the QOF meant he had to do things that he did not always agree with, just to earn a 'crust'. Forcing back a tear, I expressed my heartfelt regret at such appalling treatment meted out by the PCT Commissars and we left it at that, after he promised to let me have a copy of all the test results.

What then are we to make of this? Well, GP's are paid to monitor Diabetics under the QOF protocols and ours had earned 44 points by undertaking the Diabetes examination and recording the findings. This includes achievement of some points from blood pressure, HbA1c and certain levels in the blood of various components, all of which he had no hand in at all! But of course that is never enough. We already had refused the tests for Retinopathy, because our Optician included it in J's annual eye test, the annual flu' vaccination, because it's counterproductive and now of course we had refused statins'. One gets the idea that curing sick people is merely an adjunct to the more important task of fulfilling certain criteria within QOF that invoke payments. Is this what Primary Care has become? Well err... yes.

Diabetics are treated very poorly by the NHS, and outcomes continue to worsen, mainly I believe because the diets, drugs and lifestyle advice is founded upon poor science, dogma and the touching (but wrong) view that 'Pharma' is a benevolent edifice, searching endlessly for cures and life enhancing drugs to make the lot of Diabetics as 'normal' as possible.The truth is that they only want to 'treat' the condition and symptoms with a cocktail of their products, in ever increasing number and volume to make a profit! Virtually all of the evidence that backs their products as efficacious is funded by them. Diabetes UK is heavily dependent on their largess as is the US equivalent the ADA.

It is not inevitable that Diabetes is progressive and life shortening unless the 'mainstream' treatments are pursued. Many know this and either overtly or covertly follow their own agenda and are considerably healthier as a result. When J' gets a day when her three times a day tests, all come out as normoglycemic purely by gist of diet, a little exercise and a few supplements, it is a cause for celebration. It can be difficult some days, there are pitfalls in many foodstuffs that are not evident at first analysis but by testing rigorously they are soon found. But if you are not taking a hypoglycemic drug they are not funded by the NHS. So you have to buy them yourself. So you save the NHS lots of money by being responsible for your Diabetic destiny and the mealy mouthed idiots then penalise you for so doing. Crock of s**t or what?

I will continue to post the continuing saga as and when it happens. J' is somewhat handicapped as a Diabetic because her piss poor prosthesis is not conducive to vigorous exercise and that is a useful protocol for any diabetic to lower insulin resistance and 'burn off' excess glucose. So she has been doubly damned by the arrogance and stupidity of a system that is incapable of factoring in individual needs in treatment. Thank you NHS for making sure the law of unintended consequences rules!

Loss of Innocence (Part One- Addendum)

It was my intention to move straight to my second instalment of the saga of J's treatment at the hands of the NHS and in particular the part played by the 'Orthopod's'. However, the intervention of the furore relating to prosthetic hips has given me the opportunity to vent my spleen about the ridiculous situation that exists in the treatment of those unfortunate enough to need any form of hip surgery.

You would think that in view of the large number of procedures undertaken in the NHS that the science would be driving the procedure, when in fact it is more custom and practise tinged heavily with vested interests and hubris. Orthopods (Orthopaedic Surgeon's) are generally viewed by Medicine, even other Surgeons as lacking in subtlety and intelligence. My view is somewhat more colourful and I view them as 'butchers' more than surgeons. Sure, it's a hard job, requiring physical strength and endurance, almost as much as skill because of the need to saw, hammer, drill and slice, with instruments more akin to a construction site and a butchers shop than an operating theatre. And the repair (or often not) of damaged hips epitomises this more than any other procedure. Dealing with hip trauma is probably the most difficult and dangerous procedure any surgeon undertakes. It is important then that the patient is paramount in the evaluation of which path to pursue as regards the protocol that is most efficacious.

It is not beyond my purview that many 'orthopods' are failed Rugby players, not that I attach any significance to that, except to say that their adherence to scientific evidence as a tenet of their professional conduct is perhaps somewhat lacking.  It may sometimes be evident that their judgement of certain medical devices might be coloured by the presentation they last 'endured' in Barbados about the latest implantable device from one of the many makers of such engineering masterpieces (sic). One of these, of course is Depuy, a subsidiary of Johnson and Johnson (a family company). They make the 'Pinnacle' implant, which is a MOM (metal on metal) device using cobalt chrome, and this has been indicted as being subject to early failure. And more importantly, (I feel) of causing the migration into the bloodstream, bone and other tissues, of wear particles that are potentially life threatening in a number of ways.

The BMJ in conjunction with Newsnight undertook a study recently that highlighted this problem that is faced by a number of  'younger' patients who have been ill served by the installation of this design of prosthesis into their acetabulum. In truth the BMJ article is somewhat more comprehensive in it's condemnation of the device than was Paxman in the interview with the head 'honcho' of the MHRA who, it would seem had full knowledge of the 2010 recall by Depuy of it's ASR implant (Pinnacle) but seems to have done little about it. Nonetheless I did enjoy Paxman's taking Kent Wood's to task about the fundamentally supine attitude of his organisation when it comes to 'approving' medical devices, which essentially amounts to a review of the specification provided by the makers, because there are few if any clinical trials undertaken, except using the patient cohort as 'guinea pigs'.

As an engineer first and biologist second (but linking the two), I cannot understand how anyone would recommend the installation of any ball and socket device, in the human made from cobalt chrome that will be subject to metal on metal wear or indeed any frictional wear. The cobalt element of the  material does have high strength, coupled with excellent corrosion resistance, but whilst it's salts are used by most animals especially ruminants, at high levels it can be toxic and it's compounds have been responsible for cardiomyopathy (heart muscle disease) in humans. Chromium is also quite toxic in its (VI) form except at very low levels and is a known carcinogen as well as being responsible for damage to the kidneys, liver and blood cells. Having said that, if this material had only been utilised for non-frictional component parts it is unlikely that there would have been a problem, but friction in metal to metal bearings throws off metal ions, eroding interfaces which increases gaps in mating surfaces thus introducing 'free play'. This is of course exponential, so the more wear the more the acceleration of that wear. The consequent contamination of the tissue surrounding the acetabulum and femoral stem and migration of these metal ions into the bloodstream promotes high levels of bone loss, cement collar erosion, cartilage damage, and many other toxic side effects that have yet to be fully evaluated.

When you introduce any 'foreign' body or substance into any living organism you have to be very sure that by so doing you are not making matters worse, but obviously this did not seem to impinge upon the corporate 'psyche' of J and J. Greed seems to have been the driving force and don't forget this company had last quarter earnings of $16.3 billion despite having to pay out $3 billion for the Pinnacle debacle in the US.

This design of implant was targeted at the younger audience and was sold as a 'low wear' prosthetic so as to avoid the need for revision surgery because this cohort tends to be physically very active. Activity promotes wear in any joint be it in humans' or in machinery, unless you can regularly lubricate that joint. There is some value in the concept of synovial fluid performing this function (the hip joints natural lubricant and hydraulic 'cushion'), but as this 'capsule' has effectively to be 'burst' during surgery for access, it is unlikely to function as it was designed by nature thereafter. The simple truth is that in our haste to address the increasing needs of an ageing and increasingly joint challenged society we have lost sight of many of the needs attendant upon the production of manufactured  joints for implanting. And sadly it is not just in the metal to metal prosthetics that we have a problem.Many different materials have been tried over the years, especially plastics, sintered metals and ceramics. If one views success as being a bearing surface that does not wear out at all, and what wear does take place as being entirely benign, manufacturers have failed. Failed miserably in this context because all arthroplasty components have a finite life, so except in elderly patients, they are unlikely not to need revision at least once and in young patients possibly more.

UHMWPE has been the material of choice especially the newer 'crosslinked' varieties, for the manufacture of joint surfaces for some years now. Ultra high molecular weight polyethylene displays admirable self lubricating properties together little moisture absorption and considerable strength. But combinations of both this, ceramics and other metals have been tried, to come up with this goal of the perfect implant. None, including UHMWPE is devoid of particulate contamination of the tissue and blood of the recipient, although this last one is probably more benign than others. None are entirely so, and all wear is at a rate in proportion to the amount of use. So active people wear their implants out quicker.

As regards the NHS; well they invariably go for the cheapest they can get away with, THA (total hip arthroplasty) using cemented stems and UHMWPE bearing surfaces is usually the type most will get for either trauma repair or elective surgery, generally for osteoarthritis of the hip. Except for non-displaced or slightly displaced fractures, when the waters become extremely muddied. This is because of the payment system that prevails in trauma care which is based on a tariff for the most expensive treatment involved in a hospital 'stay', and the desire to keep the costs low, avoid re-admission and get rid of you as soon as possible. Trauma patients 'bugger up' the system, take up unplanned beds and play havoc with operating lists and theatre time allocations. If you aren't fixed quickly it costs more than the tariff. If they do something that's possibly short term, even if it's in your best interest as a patient, it's likely not to happen. If you are re-admitted for something that's a result of your initial admission, they won't get paid for it, so you are a burden.

This has resulted on many occasions in the almost complete lack of hip repairs in trauma patients because of the incidence of failure. This is despite the fact that preservation of the native acetabulum and femoral head is the ideal solution. Failure rates of hip repairs are the subject of much conjecture but they are only about 25% in reasonably healthy people up to 65 or 70 years. They are also quick to do, much less traumatic, and can be undertaken, often without general anaesthetic, and sometimes without incision. Generally this requires nails or screws to fasten the joint together which are then left in place. If this fails, then you can go on to have a full procedure at a more leisurely pace and not as an emergency. But it won't happen, because if it fails, the Hospital involved will not get paid for the subsequent and much more expensive procedure to fix it because the 'system' attributes the blame to them. You will also have a longer recovery time as your leg will not be load bearing for some time, but you will be in possession of the best hip joint there is; your own! What you will likely receive for trauma, even if the fracture is so slightly displaced as to seem much like a 'crack', is the Hemiarthroplasty; the worst of all prostheses, because it's cheap, has a short operating window, and is likely to last five or six years, so they will be beyond the date whereby failure would not be paid for under the tariff.

The NHS likes this implant despite it's short life because it also has a lower dislocation rate, can be installed by relatively lowly surgeons and through the side of the hip. This is despite the fact that more damage to the muscles and cartilage ensues in this approach. In addition as this implant simply is a metal ball, sometimes with a plastic floating cup (bipolar version) which is literally 'pushed' into the acetabulum. It also brings in some cash from the Primary Care doctors for monitoring X-rays that have to be taken to check up on wear of the bony cup that is the acetabulum. It's almost beyond belief that anyone would consign a patient to receive a big metal ball 'stuffed' into a bone socket that's absolutely certain to wear away and cause pain in quite short order as it articulates with movement. Metal on bone; it doesn't take a scientist to work out which will wear first, especially in a younger, active patients, now does it? Alright, for the 85 year old with little in the way of exercise and a number of co-morbidity's, it may, just maybe justified after a fall, but as a first line treatment for most it's a cynical manipulation of guidelines and flies in the face of good practise and the welfare of the patient to reap the reward of the tariff.

Hip joints are one of the wonders of nature. They are a 'ball and socket' certainly, but one that has an interference fit that has a regenerative liner of cartilage and a fluid cushion that acts like the hydraulic fluid in a shock absorber, being 'squeezed' out and in as you walk and load the joint. As engineers we haven't even got close to this model nor are we ever likely to. There's no demand, well not from the medic's, the NHS and certainly not Big Pharma's devices wing. The patients, well we're the last people they care about, so long as the 'gravy train' keeps rolling. J and J's rubbish prosthesis is symptomatic of the 'device industry' and the final irony, as I keep hammering on about, is that most of these devices are implanted in women, because the female hip has much more 'articulation' than that of men to enable child birth, rendering their hips more liable to breakage. So women, often elderly women or those viewed as elderly by the NHS are the main recipients especially of 'hemi's', often when they and their peers see them as 'mature'. More misogyny, heavily tinged with ageism. Well there's a surprise!

Loss of Innocence ( 7 days in June).

(Part One)

For one of quite some age such as I, it was strange to lose my innocence. The events were so profoundly life changing that I was caught up in a whirlwind of doubt, dysfunction and misery. My career, what was left of it, my control of events and even my very life became threatened by a calamitous and traumatic sequence of events that came to pass, at the hands of the NHS.

I had until that time had some respect for that bastion of Healthcare, probably because I had used it infrequently and when I had, my expectations were quite low because that which was wrong with me had little in the way of a cure. Osteoarthritis, glaucoma and cataracts can be ameliorated but completely cured, no. I never expected it and Healthcare did not let me down, especially when it came to the cataract, that was made worse by lens implant. Posterior Vitreous Detachment it was called, made all the worse by that short window before it's occurrence when I saw real colour's for the first time in years. Such a revelation; the world was so bright and vivid, well for 48 hours anyway. Then it hit, and from that day and henceforth, life was to be viewed through a mist; a fine net curtain, obscuring detail and it's recognition.

I was already quite depressed at that time, with my life already falling apart at the domestic level, as it had been for years, but I had ignored it by immersing myself in an arduous routine of work and more work, not wishing to address the pain because that way it wouldn't hurt. I did decide that any further eye surgery would likely be counterproductive so I settled down to live with what was left, and then tried to address my life before the remainder slipped through my fingers.

And I did; I found a sort of happiness, that gradually replaced the pointlessness I had felt that slowly swelled and for the first time in more years than I remembered, plans started to form. The NHS; well they had made a mistake, but it wasn't life threatening and we all make mistakes after all. I didn't bother complaining very much and accepted the explanation that PVD was always possible when ultrasound is used to remove the old lens. Pity no-one had informed me it was possible, but hey-ho them's the breaks.Then,one summer day in June I learnt that the NHS's hubris (and mine) had consequences that can reverberate throughout your life, and that colossal mendacity is practised daily, along with cognitive errors that can only be judged as incompetence (or stupidity).

She, with whom I will end my days, was off in front, pushing on up the hill, pedals whizzing round, whilst I paused, foot on the ground, gasping for the air that effort had stolen from my lungs. Then, with graceful ease, almost in slow motion, she fell from the bike and landed heavily on her side. With increasing fear, I dropped my cycle and staggered over to her, my breathlessness no longer from effort but panic. She was white with pain and emitting low screams. I tried to help her up but the pain was too great. I made her as comfortable as possible with my jacket under her head. Her pulse was racing, breath coming in short pants; she was definitely in shock. Fumbling with the damn (not so) 'smart phone' I cursed it's stupid step logic, but finally got through to the Ambulance Service and told the story almost screaming for help. It seemed a lifetime in arriving and all I could do was to keep her warm and still and feel inadequate.

I suppose I knew already what was wrong. Foot turned out, unable to move her left leg and in great pain, it had be a femur fracture and worst; probably at the top, the dreaded hip fracture. It took three of us to get her into the ambulance using a crude device of a blanket to help immobilise the joint and with blue's and two's slowly drove down the hill (yes that hill) to A&;E. All throughout the journey I found myself praying to a God I didn't even believe in, for her to be alright, that it could be a dislocation, that she would be home tonight or tomorrow at worst. I was of course wrong, and no God was listening to my prayers, as always.

At last ensconced in a cubicle, her ordeal began. It took nearly three hours for an X-ray, just after she got some Paracetamol (Acetaminophen; as if that was going to be of much use). More than four hours to even see a 'doctor' (some FY1 child), who didn't really say much, partly because her English was somewhat poor, and partly because she was out of her depth. The notes got lost, then they were the wrong ones, as I pointed out that J' was not a teenage male with a broken arm. This caused some consternation and after that I never saw any notes in evidence. Some four hours in, she was given IV morphine but not until (apparently) she had an ECG; this came to light only after perusal of the notes some six months later, but as neither I nor her witnessed any such event I very much doubt it. Also she had a 'ghost' chest X-ray, of which she has no recall as no machine was placed over her chest only her pelvis, but again that only came to light much later.

After some six hours from admission, some nurse or other (we had seen a few) informed us both that J' had a broken hip which by this time the cleaner could have diagnosed. What type she did not say. She did say that an operation would be needed to 'fix' it, but again did not say what type. So ill informed and bemused we were shown up to a ward. Through what seemed miles of corridors and one lift journey we arrived and I was placed on a chair at an unlit corner of the nurses station to ponder and stress about what was to come. My brain was racing through the likely short and long term outcomes and I was searching my memory for long forgotten learning of the human anatomy and biology from nearly fourty years before. I filled in the admission form for J', ensuring I noted her problems (she had a 'stiff' arthritic left knee from a riding accident from twenty years before) and intake of any med's, which was only a high Omega 3 supplement. An hour later, which seemed forever, I was summoned to her bedside through the darkened ward bay and into the curtained area that surrounded her.

She was in tears. Without me there to support and question anything; J' is primarily an Accountant, with no knowledge of anything remotely related to Medicine or Health, she was confused and distraught. And yet I had been excluded whilst some Surgical 'on call' FY2 had explained some of what was needed for her operation and had asked for a signature of consent. Being presbiopic and without her reading glasses she had then requested my presence, which is likely the only reason I had been called at all. She asked for my help and passed the form to me to peruse. I clearly recall it as being one sheet of paper simply requesting consent for anaesthesia and little else, this was to turn out to be critical but by that time 2 am, with no food and little water, up since 6.30 am the previous day, we were both somewhat 'punch drunk'. The very young (and very beautiful) black woman who faced me explained in halting English, what was to occur in the morning. It was garbled, almost incoherent but the word 'hemi' kept coming out. I didn't have a clue. After some patient questioning by me it transpired she meant that J' needed a half hip replacement which was some sort of repair. Thinking, in my orthopaedic ignorance, that half was better than whole I suggested that we had little choice than to concur and J' signed.

I then spent half an hour with her, before they decided to kick me out, clinging to her, not wanting to say goodbye, with a sense of doom coming over me. I left my contact details with the nurse on duty and took the number to contact the ward stating that they must let me see her before the 'op'. I know how capricious a general anaesthetics effect can be, but despite my advice J' had said she did not want to be 'awake' when they sliced her thigh open. I explained she would not be awake as such as she would be liberally plied with tranquilisers as well as the regional anaesthesia but she would have none of it. That, I had to admit made me a little resentful (sic), but it's her body and I knew she was quite squeamish, so I pressed her no more.

I wandered through the long corridors and found an exit eventually. I found the car I had illegally parked in the empty disabled car park, with my Police ID prominently displayed on the dash. The parking Gestapo had consequently ignored it and I made my escape; well I tried to. I was so wound up, so preoccupied (and knackered) that I went round the perimeter road twice before I found an exit to the real world; where people could walk, laugh and get drunk, which is what I wanted to do, right then, more than anything.

I entered the empty flat and went straight for the Rum. I hardly diluted it at all, just tipped a small slug of Cola into the half full glass. I sat in the window, with it wide open, staring into the night, or what little was left of it. An impending sense of doom was all I could feel. Thus far my experience of the Hospital was one of confusion and incompetence; like a ship steering through a storm with no-one at the helm. I was frightened that my sight of J', in that bed might actually be my last. And I now had little confidence that the outcome would be good, whatever happened. I felt like the last man on the Planet, and I was scared, no terrified, that I could be losing her after years of letting her down. Had I let her down again? In the next few days I was to find that was the least of her problems. Because the NHS was much more adept in that than was I. And what was that the paramedic had said, "how do you control your diabete's?", what the hell was that about?

Note to reader; this is too hard for one instalment, even after three years. It would also be too long. You will find some of it so unbelievable that I could not make it up. 'On the Ward' will be posted soon.