Tuesday 28th July. A charity board meeting, then Hash night!

Today I have two real reasons to get out, but I decide to take it easy on the exercise, walking at a reasonable pace, not trying to elevate my breathing or pulse.  I know that even sitting and concentrating, whether in a social or other situation, is itself tiring and it is going to be a long evening.

First I head off to tower Hill for an Arts4Dementia trustee board meeting.  Shortly before I discovered the heart problem I had applied for the role of Treasurer (and Trustee) of this small, but incredibly productive, charity. While I had had a couple of meetings with the charming CEO and her brother, and helped them in some small ways, I had to cancel an all-important meeting with one of the trustees as part of their due diligence around my appointment. Now I will have an opportunity to meet them all.  The meeting is lively and educational for me and I was appointed subject to some due diligence, which I think means checking my cv is legitimate and I am not on any police lists of "bad boys".  I don't think I am.

Afterwards I have a drink (softie) with a few of the Trustees and make plans for some meetings in the next couple of weeks.  Looks like I am getting my normal life back, but still need to take it easy.

But if you know anyone affected by dementia (including Alzheimer's), whether people with dementia or their carers or family, please have a look at the website, which points to lots of activities across the UK that can really help.  And of course consider supporting them.  This is a small charity that promotes game-changing ways to improve the lives of both people with dementia and those around them.


Tuesday Night is Hash Night (even though I am not running)
 Then a short walk to Monument where City Hash are running from the Loose Cannon, EC4R 3UE.  This is the Hash Oscars night, with awards given for the last 12 months (best trail, best fancy dress etc..).  The pub has an amazing space under the arches of Cannon Street Railway bridge, big enough for a party of 1000 I should think.  Unfortunately for me, the trail is short (5k) and the pack has already returned and eaten all the free food.  On top of that the chef has gone home so I cannot buy dinner!  If only the board meeting had finished in 90 minutes as I had been promised!  Nil desperandum,  Condor (a hash name) buys me a half of Guinness and I grab a few handfuls of garnish from the plates!

The awards make change from the usual circle.  The RA, Lexy looks very sexy in his gangster outfit, and his glamorous assistant Bent Roy a little less so in a floral print dress.  The  awards themselves, made by the hare from old trainers spray painted and mounted on painted wooden stands, are amazing.  Imagine my surprise when i am called up to receive an award for the best (or worst?) misdemeanour on a run, which apparently was having a heart attack and still finishing the trail (the truth is stretched a bit, but I did have angina, without realising what was happening!).

And here it is!

Saturday July 25th. Adapting a runner's training programme for cardio rehabilitation

Today it is just under 3 weeks since I left hospital and I walked over 80 minutes up and over Parliament Hill and on to Kenwood.  Am I doing too much exercise?  According to the standard instructions I was given in the hospital I am, but I don't think so; I felt fine during and after the exercise and my greatest fear is losing all my muscle mass by doing too little.  I have decided to take the advice of one of the hospital physios who was also a runner.  He said that so long as I listen to my body I could do as much as I felt comfortable with.  No running of course for at least 6 weeks, until my sternum has healed.

The standard instructions clearly assume patients are overweight, unused to exercise, old or very unfit.  Starting at just 5 minutes exercise a day in week one (after leaving hospital), exercise increases by 5 minutes a week.   Effort is measured on the "Borg" breathing scale.  I should keep my breathing in the scale range 2- 4 which means from light to moderate-severe (the scale is 1-10 with 10 being extremely severe).  Unfortunately no one has explained what "moderate-severe" feels like and in any event if I only exercise according to the instructions I would never reach these levels anyway.   So on the basis that the scale is somewhat subjective, using terms like moderate and severe begs the question "severe for whom?") I have interpreted the scale, based on my experience running, as follows:

The TOB-interpreted Borg scale
1. No exertion (resting)
2  Slight effort - no noticeable increase in breathing
3  Slight effort - steady breathing, increased effort apparent at rest.
4  Moderate effort  - steady breathing 3 paces in/3 paces out
5  Moderate/Severe - Steady Breathing 3 paces in / 2 paces out
6 
7  Severe - 2 paces in / 2 paces out
8
9  very Severe - faster than 2 in/ one out
10 Uncontrolled breathing (gasping).  Probably standing still (ie: cannot continue exercising)

Borg is not enough
 
Just relying on the "Borg" breathing scale to assess my effort does not seem to work mainly because there are too few hills long enough to push me much past level 3.  So I am taking a leaf out of the runner's approach.  Running coaches talk of 4 different types of training (eg: see @letsgetrunning's guide "going through the gears" ), which encompass long slow runs for endurance (aerobic training), faster sessions to strengthen the heart and develop aerobic capacity, and speed sessions or intervals to train anaerobically.  I have adopted a similar approach in my exercise plan with three main elements, monitoring pulse as well as breathing.

1.  endurance:
Long flat/gentle hill walks typically at a high pace (6 kph) get my breathing to Borg level 2-3 and pulse in the range 90-110.

2. Threshold / cardio / aerobic capacity:
Moderate hills (average grade 4/5, probably only 3-5%, but can be steeper sections) at a high pace (5kph).  Breathing Borg 3-5, pulse can reach into 120-140 range on steeper sections. It is difficult to find hills that are of a consistent gradient and sufficient length to count, so usually shorter ones are interspersed with downhill or flat sections.

3.  Anaerobic:
Fast stair repeats (2 story repeats * 6- 10, walking down for partial recovery).  Borg 4-6 and pulse 120-140.

My programme will include a couple of each of these each week.  I am thinking of adding a stationary cycle (which does mean reinstating my gym membership) as an alternative threshold session.  The advantage of this is that I can sustain a desired level for a longer period which walking cannot do as there are no hills in London big enough.

I have no idea if I am doing too much, but if I monitor outputs and still feel good at the end I hope that I am at least doing no harm and will be in a better place to start training more quickly when I can get back to running.   Lets hope so! 

NB: this programme is for me, and is not a recommendation for anyone else.  You should do what is right for you, given your underlying fitness, medical condition and the advice that you have reeived from professionals.  

Friday 25th July. Subscribing to Netflix and watching box sets.

Over a week since my last post.  The fact is that there is not much to write about on a day-to-day basis; one day is pretty much like another.  We get up late, drink tea and read the paper, check twitter and facebook, breakfast, shower, go for a walk, lunch, waste time on the PC, prepare and eat dinner, watch TV (or write a blog).  A couple of times a week friends visit and bring lunch with them.  Today Martino and Bill come laden with goodies and cook a lovely fish and pasta dish which is washed down with a delightful Maconnais (with a Cremant de Loire rose as aperitif, though I am of course watching my alcohol intake which leaves more for everyone else!).  This is delightful and and passes away the afternoon.
 
Actually we are not watching a lot of TV in the evenings as, being laid up is an opportunity to catch up on series 2 and 3 of the US House of Cards, so I have registered with Netflix.  Not bingeing you understand, just watching 1 or 2 episodes each evening (we saw series 1 on the way to and from China last year). 

I am also catching up with a few other series including The Saboteurs, Humans, The Interceptor.  The first two are on Channel 4 and it is very annoying to have to watch 15 minutes of adverts every hour.  It seems there is no way to skip them unless I record the programmes first on Tivo, which means I can skip through them.

Netflix of course has no adverts.  On line viewing may be de rigeur when the government gets rid of the BBC.


     

Wednesday 15th July. Social life is picking up!

Yesterday (Tuesday) I was supposed to go to the GPs where there is a weekly blood test clinic.  I forgot and had breakfast instead, by which time, since the tests should be fasting, it is too late.   

Jane comes to tea, loaded with goodies from M&S.  Lots of people have been really nice helping Helen at home and visiting the 'halt and the lame'.  Yesterday Anne came also loaded with goodies.  She has a great retirement job training on risk and crisis management for the U.S. State Department that takes her to the corners of the earth.  I am quite jealous.  

Tuesday is hashing night and while I am not ready to run just yet, Helen announces that City Hash is at the Oak and Pastor near Archway.  She is getting cabin fever and we decide to go to the pub after the run and see how well she can walk.  It takes 15 minutes to get to Tufnell Park station, so we head for a bus stop.  The bus drops us just outside the pub and we arrive during the circle.  I am called in and, along with Marxist, another CAGB survivor, am given Down Downs.  However fortunately I was allowed to nominate someone to drink the beer.  Still everyone was extremely nice and seemed surprised and happy that I was up and out so soon after the op.  But then perhaps not so surprising because so am I!

Back to today, I set off for The Whittington where bloods are taken every day.  It is a 22 minute fast walk, and I am very comfortable when I arrive.  Unfortunately  there are 53 people in the queue in front of me, but after 90 minutes My number comes up and I am quickly out of there.  I walk home again.  That's 2 * 20 minutes and the exercise programme says 10 minutes a day.  I am tired though and sleep for two hours after lunch.  Nevertheless I think that's progress. 

In the evening Jeremy, my best man, who now lives in Dartmouth but was in London on business, visits and we indulge in an Indian takeaway.  Indulgence!

Sunday 12th July. Phase II physio begins.

Daily postings are very unlikely now as I am in to recovery Phase II, with progressively more exercise over the next 5 weeks, starting from very low levels. One day is pretty much like another with small changes taking on greater meaning than they probably should.   For example in week 1 I should be walking 5 minutes a day with my breathing at "Borg level 2-4" (Borg is a scale of measuring breathing from no impact being one, to extremely severe at ten).  But this is too easy and I  walk for 10 minutes at 6kph on the flat twice a day, still only reaching Borg 2.  Clearly most people were pretty unfit before they became ill and are still unfit now.  It occurs to me however that the instructions to use the Borg scale may mean that I overdo things in other areas.  Should I be monitoring my blood pressure and pulse?

On Thursday I have an area of hot red swelling on the front of my left leg.   I am concerned that it might be a thrombosis, but decided this was a normal side effect of the operation.  By Sunday I decide there is clearly something wrong but the GP is now closed.  I call the hospital and speak with a nurse.  He in turn calls the surgeon and an hour later calls me back.   The surgeon says it is probably an infection and I should go to my GP and get some antibiotics.  I decided however that if I am to start antibiotics then I should do so as soon as possible, so rather than wait until I get an appointment with the GP some time on Monday I get a taxi to the local A&E.

A&E is busy. I wait two hours and, along with the other clients, were entertained by a man on probation with a curfew ankle-strap.  He is drunk and has taken too many paracetamol and wants attention before his curfew time of 20:00 hrs.  Despite being noisy and using extremely ugly language he is polite to staff and eventually gets a letter that will prevent home from going back to jail for breach of parole conditions, but leaves without treatment anyway!

Eventually I see a doctor who gives me the antibiotics and I go home around 21:00 hrs.  The Doctor suggests next time I make an appointment with the out-of-hours GP service, also located in the A&E department.   That will have saved time, but the GP will only provide a prescription so you still have to find a pharmacy to dispense the drugs, which is not easy on a Sunday evening, especially if you are not mobile!

this blog are going to become the exercise programme is going great guns.  My only worry is that I am doing significantly more exercise

Tuesday 7th July. Free at Last!

This is the day I go home from hospital.  Not that the process is simple.  I still have two stitches out (the last ones), all dressings removed and Mr Shipolini to review the echocardiogram prepared yesterday to ensure there was no liquid around the heart.  He arrives and says he is happy to sign me out, assuring me that once I get home "it will be a whole new ball game".  I am not sure whether this is good or bad but look forward to giving it a go.

Of course getting out of hospital, even a private hospital, is not all that easy.  Lots of waiting around for drugs, for the nurses' discharge letter, spare elastic stockings and goodness knows what.  Eventually, I leave in the middle of the Djokavic "one set quarter final", which I was really looking forward to. 

When I get home it is clear that the excitement and taxi journey are too much for me and I need a lie down.  Despite this by 2000 hrs, shortly after dinner I make my excuses and retire, for the next few weeks at least to the spare room as I don't think with my night time bathroom antics (peeing every 60-90 minutes) and with Helen's plaster cast we are made to sleep together in the marital bed.  hopefully that will change and things will be back to normal!   

Monday July 6th. When will I get my Exeat?

Sunday was uneventful other than visitors. Oliver arrived in mid-morning with the good news that he has landed what sounds like an amazing job as an economist with a firm of Canadian solicitors.  It sounds just up his street and he is quite bouncy about it.  Hope he keeps them onside.

A new physio also popped in yesterday.  It turned out that he was a runner so he appreciated my desire to get back to fitness again asap.  After we did a couple of quick laps of the floor and 2 flights of stairs he said I was doing very well, recalling that it is only day +5.  Surprisingly he thought the programmes offered by the hospitals would not meet my needs; most of the patients are not as well as I am and his advice was really quite vague; just be patient but each day/week do as much (more) as you feel capable of.  He said I should not try to run until after I see my cardiologist, in a month. But the recommended static cycling as a good way to get the lungs and heart working without putting strain on the wounds. His colleague qualified this slightly today (Monday) as she thought I might only be doing 2 - 5 minutes, so unless I had one at home already it was unlikely I would find going to the gym practicable.      

Helen arrived just after lunch and we watched tennis together before both deciding to have a bit of shut-eye.  Almost immediately after, Andy (a CABG veteran) and Xiao.  Conversation remains quite tiring and after 90 minutes I was dropping off so they left. 

Fast forward to today, I feel much better getting up in the morning, enjoy a two egg omelet and toast for breakfast before taking a shower.  Dressings are all replaced and the pacer wires are removed from my heart.   This must be done before I can leave hospital.  The process is not painful (though involves removing some stitches) but I can feel a slight heart "flutter" as the wires are withdrawn.  I then go for an echo-cardiogram to check if there is any fluid around the heart, which there is not.  I wait with excitement for Mr Shipolini to arrive but he may not be here until the evening.

Tony arrives at lunchtime and we chat about the CH3 2015 Weekend away in Canterbury, which I missed.  He said people enjoyed it.  Check out the website and if you like it come out one Tuesday in London (we run from a pub in Tube zone 1 or 2 somewhat after 1900 hrs).  Tony joins me on my laps and stair walks and is impressed as there are some people he knows who cannot keep up with him when he walks at this pace.  I do find an hour or so of talking to a visitor quite tiring so after an hour or so I ask him to leave.  Fortunately no one takes this personally (so far).

I am also surprised by a loud banging (Shock!), a creepy opening of the door (Horror!) and the appearance of the lovely Wendy who helped make Helen's 60th into a real party (Delight!).  We also chatted for an hour and did a couple of laps before I thought it best to retire to bed.

At last Mr Shipolini arrives around 2000 hrs - presumably another emergency has held him up - and he gives me the good news that I can go home tomorrow.  He will be back at non with a letter for the GP and for the Whittington Cardiologist, Dr Susannah Hardman.  Apparently it is quite possible she has been told nothing and thinks I am still at Barts awaiting a procedure!

I go to bed excited, though first I must watch last night's episode of "Humans" (about Androids) on All4 catch up TV.

What does the UK spend on Healthcare and does it spend enough?

The UK spent 9.3% of GDP on health services in 2012, or on average USD 3,289 per person.  So is this a lot, enough, or too little? 

We always read in the press that the NHS is strapped for cash. The OECD publishes tables showing cost per head and as a percentage of GDP.  Rich countries are of course more likely to be willing to spend more on health than poorer ones simply because they can afford it.  However the figures of course indicate situation is a lot more complicated.  Germany and France spend over 2% more of GDP on health than the UK and Italy spends roughly the same as the UK.  Their nationalised health systems are organised quite differently, but do they deliver equal quality of care, better or worse?  Those who have experienced all seem to have different experiences.  But money means something, so lets just look at the figures.

The UK's GDP per head has broadly mapped that of the OECD as a whole.  Our spend % of GDP is also the same as the average for the OECD , which includes countries like Indonesia, Portugal or Greece with significantly lower GDP than the UK.  We are also at the bottom end of the range of the G7 richest countries in the world. 
 
The USA not surprisingly has a significantly higher health spend that any other country.  This contrasts with the expected life span numbers and morbidity (the likelihood of death from serious conditions, a better measure of health outcomes).  This probably reflects the well-known fact that the US system spends an awful lot on a insured and rich people (because insurance is usually capped, if you want the best treatment you must have cash to hand) at the top end, while outcomes at the bottom end amongst the uninsured or those depending on state funding, are much worse.

The question is why is there such disparity in effectiveness and cost between different countries in what is essentially an applied science?  The reality is surely that those countries that spend less may have chosen to spend less, though they may be trying to be more efficient.  And those countries that spend more do so because either they are incredibly inefficient or have chosen to build redundancy into their system to enable them to respond to emergencies and to address high-cost cares.

Perhaps the detailed figures present some other questions and answers, but at least we should know why the government thinks 9.3% of GDP is enough. 

2012 (unless otherwise stated) Data from OECD via Kings Fund,

			Average age at death
	USD per head	% GDP	Male	Female
USA	8745	16.9	76.3	81.1
Germany	4811	11.3	76.3	81.1
G7 average	4656	11.3	78.7	83.9
Canada	4602	10.9	79.3	83.6
France	4288	11.6	78.7	85.7
Sweden	4106	9.5	79.9	83.8
Japan	3649	9.5	79.4	85.9
OECD average	3478	9.3	77.5	82.8
UK	3289	9.3	79.0	83.9
Italy	3209	9.2	79.8	84.8
Notes: G7 = the listed countries excluding Sweden.
The OECD consists of 34 countries including all listed. The UK's GDP per head has been very similar to the average  for the OECD as a whole.  Countries such as Indonesia, Greece, Portugal lie significantly below the average.
NB: C2Morbidity (likely death rates from various medical interventions are probably a better measure than average life spans