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My triple bypass

Dr Steve Iliffe's triple bypass was a lesson in how the after-effects of a major operation

can be harder and more frightening for the patient than the surgery itself

I knew something was up when I could not sleep.

At first I thought it was due to a cervical disc prolapsxe (an old friend) and took some paracetamol.

But when the pain in my left arm spread across the chest and triggered nausea, I decided it was angina and woke up my wife.

Even while waiting for the ambulance I was not scared, because I knew what was happening and what needed to be done. Fear comes from not knowing what things are, or what to do.

Medical training makes us all action-oriented, so that we can distinguish significant symptoms from background noise, and know what to do and how to do it. The paramedic's relieving GTN confirmed my diagnosis, and the whole process of being bundled up as a cardiac case was reassuringly familiar.

I had not bargained on the lessons to be learned on the receiving end of NHS care.

As I was transferred out of the A&E holding ward at 5am into the coronary care unit ­ a cluster of beds at the end of a general and mixed-sex ward ­ I watched an old woman with moderately advanced dementia taunt and antagonise the staff, who in turn deepened her disorientation with a

textbook example of malignant social psychology.

For a moment I wondered whether I should detach my monitors and calm them all down. But the inner patient took over from the outer doctor, and instead I took advantage of the nurses' distractions to use my mobile and leave messages at work and the offices of a friend or two. As far I could see nobody's cardiac monitor was switched off by this violation of the telephone rules, but I felt like a novice Good Soldier Schweik, staying close to the combat only because that is where the field kitchens are.

When the cardiologist came on duty it was the one I'd been referring my patients to for 20 years. He was very pleased to see me and it was all very jolly.

But the angiogram proved there were three blocked arteries, instead of the one predicted, and surgery was scheduled for that very evening.

The interesting thing about being in hospital is the immense calm it produces in you and I never expected to be so cool before major surgery. I was very impressed by the care I received. The nurses were attentive without being irritatingly fussy.

After surgery though, it was quite a different story. We all know about pain from sports injuries and home accidents, hammered thumbs and pulled muscles, but there are two other sorts that I can now talk about with patients ­ white pain and sub-clinical (or painless) pain.

White pain is not pain at all, it simply occupies your entire being and discourages breathing and movement. I remember not wanting to blink in case it hurt.

Fortunately it is abolished by opiates, and rapidly downgrades to the recognisable

pain of a sternal scar that pulls sharply when you cough and sneeze. Preparation for surgery is notoriously bad and professionals underestimate the experience of pain, so a personal insight might help convey the post-operative feeling and validate the patient's sense of being taken over by something alien.

My sub-clinical pain was too trivial to warrant analgesia, until I realised how irritable I was and how badly I was sleeping. I will never again doubt those older patients who tell me that two paracetamol give them a good night. Their self-medication obviously takes away the pain they do not know they have.

I also have lots to say now to those patients who see medication use as a moral fault ­ it is very important not to be mean with yourself.

For long periods of immediate post-operative time I thought of nothing. Clearing my mind was not a problem, refilling it was. Conversations stopped in mid-sentence, and I struggled to grasp the meaning of the supper menu presented to me. This is the nearest I will ever get to being a Buddhist, I suspect, and like white pain it too faded. I enjoyed the peacefulness of it but felt the frustration of not thinking and welcomed the return of reason.

I knew that what I experienced was not brain damage, but brain recovery from surgery and analgesia. But not everyone has insider knowledge, and may fear the worst, assuming that their confusion prefigures a stroke, madness or a loss of faculties.

I realised fairly quickly that specialists are doctors who have fallen off the ladder of generalism. This dawned on me while the causes of my acute coronary syndrome were debated. If being a lifelong militant anti-smoking demi-vegetarian, with a serious cycling habit (I sometimes do home visits by bicycle), is not protective, what is ?

The genial and soberly optimistic cardiologist dismissed genetic risks and talked about an inflammatory process, possibly post-viral, and I became peeved because this is my line, woven into countless discussions to explain odd symptoms in anxious people

The more you know, the easier the process is. People who log on to the internet to find out what might happen to them are quite right to do so.

Nothing like this had happened to me before and I had little idea of the pace and pattern of recovery. The rehab nurse talked about important milestones, and when she got to 'resuming normal sexual activity' I had to suppress my adolescent urge to ask about restarting the abnormal sort!

I was back at work a week later doing university work, writing grant applications and papers but did not see patients in my practice for another three months.

In that time I made a note of two things my colleagues did:

· they all felt compelled to give their own explanations of my condition, stress being the favourite.

· they all told me off for doing anything.

Six months on from my operation I have returned to 'normal'.

The difference is it is a new 'normal'. I can still do the everyday activities I used to but I know my fitness is only 80 per cent of what it was and I do not yet have my old level of physical stamina. It will return.

Steve Iliffe is a GP in Kilburn, north-west London, and reader in general practice, University College London

What my illness taught me

· The more you know the better

· There are different sorts of pain; patients can make sense of these and control them

· Surgery can scramble patients' thinking but it's temporary

· You can reduce heart disease risks, but you cannot abolish them

· Encourage patients to get back to normal as fast as they can, but also advise them that recovery will probably be slower than desired

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