Getting back to normal

Your rehabilitation after heart surgery begins immediately and continues for an indefinite period of time. This period of time is very variable, and depends upon your speed of recovery and return to a normal way of life. Each person is different and may have individual problems. Rehabilitation should also consider the needs of your family and friends, and care is taken to keep them informed every step of the way. During the operation itself, your relatives are very welcome to stay in the hospital, but it is normally a better idea to go home, because you are likely to be asleep for at least ten hours in total. They will be informed about any changes, and told of the earliest time to come and visit you. It is understandable that many people may be concerned, and want to come and visit you after your operation. You will be extremely tired after it, and visitors are surprisingly hard work, so it is advisable just to see your immediate family and closest friends for the first few days. The ward staff will notice if you are getting very tired and may ask some visitors to leave. It is important that they do not get upset about this, as it is all in the interests of your recovery.
Immediately after you have been extubated, an oxygen mask will be placed over your nose and mouth. You will be aware of a loud hissing noise that this mask makes. Do not worry about this, because it is only the oxygen being moistened, or ‘humidified’, before you receive it. You will also receive the attentions of a physiotherapist, who will help you to take deep breaths and practise coughing. If you have been a smoker, you will receive extra attention and ‘bullying’ from the physiotherapist, because there will almost certainly be a lot of ‘muck’ on your chest that needs to be brought up.
You may feel very dry, and want a drink. This is fine, but your anaesthetic drugs may make you quite nauseous, so it is advisable to take only sips for the first couple of hours.
You may also find that it hurts to swallow, so be careful. If drinking does make you sick, don’t worry, because you will be getting plenty of fluids through your drips, and the nursing staff will give you some anti-sickness drugs.

PAIN RELIEF

This is, quite rightly, one of the main concerns of most patients, and the staff will make your comfort a priority. On the ICU, you will automatically be receiving strong painkillers directly into your bloodstream through one of your drips. The dose can be adjusted according to your needs, but may make you feel quite sleepy. You will continue receiving your painkillers in this way, i.e. intravenously, until after your return to the ward and until your pain can be controlled adequately with tablets.
How much painkiller is needed varies enormously between individuals, so take what you need and not what other people tell you that they took. The amount that you need is that which will allow you to achieve all your rehabilitation targets, and this is particularly important after you get home.

BACK ON THE WARD

Although it may not seem like it at the time, your return to the ward is a sign of progress. You will probably feel sleepy most of the time to start with; this is a combination of your painkillers and the fact that your operation takes a lot out of you. You will find that, on the second day after your operation, you feel much better, and you will be encouraged to get out of bed and start walking. Initially, the ward staff and physiotherapist will help you, especially getting in and out of bed. Your chest, back and shoulders may feel stiff, and early mobilisation will help to ease much of this stiffness and other aches and pains. You will receive instructions on gentle exercises for your shoulders and arms.

SUPPORT STOCKINGS

If you have had CABG, involving the removal of vein from your leg(s), you will have to wear special support stockings during this period. These stockings help to reduce swelling of your legs and ankles while the wound heals, and also protect against the formation of dangerous blood clots in your calves (deep venous thrombosis). You should not cross your legs as this encourages clot formation. Wear your stockings during the day for about four weeks after the operation, unless told otherwise by your doctor. You should make sure that there are no creases or wrinkles in the stockings because this defeats their purpose. Before you are discharged, you may be given some advice on foot and leg exercises. These are helpful in avoiding stiffness, and should continue for several weeks.

HYGIENE

Once again, just for the first few days, you will need help from the staff for some normal, routine things. As soon as they feel you are ready, you will be able to have a shower or bath under supervision. You may find this surprisingly tiring initially. You might also find that shampooing your hair, brushing your teeth and shaving cause your arms to ache and feel tired. You should not try to rush these tasks early on, and sit down or take a rest if you need to.
Showering is probably easier than bathing, but a stool is useful, particularly to rest and to wash your feet. Try not to have the water too hot, as this may make you feel dizzy or light-headed.
For the first few days, there may be a small amount of blood or fluid discharging from your wounds. This is normal but the ward staff will keep a close eye on their progress, and ensure that they are kept clean, dry and well-dressed. You should also expect some amount of bruising around your wounds. It is quite safe to allow your wounds to get wet, but make sure that they are nice and dry when you have finished washing. The best way to dry your wounds is by ‘dabbing’ at them, rather than rubbing, and this is also more comfortable.

EATING AND DRINKING

You may notice that your appetite is reduced during the early recovery period, and you may feel nauseous as mentioned earlier. It is probably more important to have adequate amounts to drink during this period, and your fluid intake will be carefully monitored by the ward staff. It is inadvisable to have too many fizzy drinks for the first few days as you may feel ‘bloated’ anyway. If your bowel habit changes, do not be alarmed. Constipation is common, and results partly from the anaesthetic drugs and painkillers. A gentle laxative tablet is usually all that is required.
Many people benefit from advice on how to eat a healthier diet after heart surgery, because a poor diet may have been one of the factors that contributed to your getting heart disease in the first place. Your GP can give you this advice or refer you to a dietitian and there are plenty of booklets available on healthy eating.

DEPRESSION

It is a very common event suddenly to feel quite depressed about four or five days after your operation. This contrasts with the feeling of happiness and euphoria that you may have felt after ‘getting through’ the surgery. Tears are not uncommon, and you may experience uncharacteristic mood swings. Rest assured, this will not last, and you will be back to normal in a very short time. It sometimes helps to talk to other patients, or staff who have had a lot of experience of this.

DISCHARGE

You and your family will usually be given a couple of days advanced warning about a proposed date for discharge. There is usually a ‘pre­discharge’ meeting with the nurses and physiotherapists, so that you or your family can ask any questions.
You will usually have some routine blood tests, an ECG and a chest X-ray performed a day or two before you are discharged. Any non-absorbable stitches or pacing wires are also removed the day before you leave. If there are any stitches that must stay, or if your wound is still a little ‘oozy’, arrangements will be made for a district nurse to come and visit you to take care of this.
In some instances, and for a number of reasons, you may not be ready for home but you are too well for hospital care. In such cases, you may be transferred to a convales­cence area for a short while, until you get your strength up. This is carefully arranged for you well in advance, and is usually somewhere close to your home.
It is important to have a relative or friend to look after you to begin with when you do go home. Your GP will get a letter on your discharge, so should be aware that you have had surgery and are back in the community.
Any problems that you may have can initially be referred to your GP, who can take care of most things. Any specific problems that the GP cannot deal with should be referred back to the team that did your operation. The GP will usually make this referral after seeing you, but if there is a major problem, or you cannot get hold of the GP, remember that there is always somebody in the hospital who can answer your questions over the telephone.

MEDICATIONS

On discharge, you will be given one week’s supply of whatever tablets you are taking. You will find that many of the drugs you needed to take before your operation have been stopped, because you don’t need them any more. Your GP will receive a letter when you are discharged, and will need to write you a prescription for continuing doses of your drugs.

GOING HOME

In preparation for your journey home, a soft towel or small pillow may reduce seatbelt discomfort. You may feel a bit anxious when you first arrive home after leaving the safe environment of the ward. This feeling isn’t at all unusual, and soon disappears. It is a good idea to have a member of the family or a friend at home with you for the first few weeks until you have readjusted.

EXERCISE

Before you go home, you will need to be able to walk unassisted up and down stairs. The physio­therapist will help you with this, and assess your abilities. You may find that short walks of five to ten minutes are best during the first few days. Initially, take walks in familiar environments such as your house and garden.
When you first leave the house, it is best to have company, and to keep the house in sight. As the days progress, you will be able to walk longer distances, and for longer periods of time, even when you are on your own. You shouldn’t try walking up hills until you are stronger. You’re likely to feel a little short of breath or tired during the early days. You may also feel some discomfort along the shin bone, and in your legs in general.
Your exercise programme will realistically take four to six weeks until you reach a significant level of ability. Your physiotherapist will have given you guidelines and goals before you left hospital, and these will have been tailored to you as an individual. Walking is one of the best forms of rehabilitation at this stage. Try to maintain a good posture, and keep your shoulders down and back. It may help to swing your arms gently or clasp them lightly behind your back. Beware of exercises that may cause the sternum to separate, such as press-ups.
Your physiotherapist will also give you instructions on a range of exercises for your shoulders and arms and it is important to continue these when you are at home. Muscular aches across the shoulders and aching in the upper arms are both common. Gently circling your shoulders, forwards, backwards and upwards, will maintain suppleness. Before you attempt any of your exercise routines, it is a good idea to take your painkillers.
Do not be over-ambitious during the first few days or weeks. You will tire easily, and become frustrated. The most common ‘rehabilitation’ exercises are walking, swimming and cycling, and many people continue these for life.

SLEEPING

Do not be tempted to move your bed downstairs. Your physio­therapist will ensure that you can manage stairs before you leave hospital, so there is no need for this. If you have been taking sleeping tablets in hospital, try to ease yourself off them as soon as you can. You are allowed to sleep in any position you like: find the one that is most comfortable for you. It is up to you whether you share a bed with your partner during the initial period after surgery. Some people prefer a separate bed to maximise uninter­rupted sleep. Many patients continue the hospital practice of an afternoon nap, but as your night­time sleep improves, the need for this should decrease.

YOUR WOUNDS

There will not usually be any problems with the healing of your wounds, but in the event of any of the following, you should contact your GP:
• Persisting redness
• Redness spreading into the surrounding skin
• New or worsening discharge
• New or worsening pain or tenderness.
The top part of your chest wound may remain quite swollen, interfering with buttons or tie knots. This may take several weeks to settle. A numb or ‘dead’ feeling is also quite common along both your chest wound and your leg wound. This results partly from the unavoidable cutting of some of the tiny skin nerves, but in the case of your chest wound, it is a result of the IMA being taken down from the back of your breastbone. Loose clothing will cause less irritation to these areas until they heal.

DRIVING

Most surgeons will ask you not to drive for four to six weeks after your operation, usually until you have seen them in clinic. You do not have to inform the DVLA if you have had a routine recovery from a routine operation. If you plan to continue as an LGV or PCV driver, you will need to notify the DVLA. It is a legal requirement to inform your insurance company when your heart condition is diagnosed, and tell them details of operations and complications.

YOUR SEX LIFE

Starting to have sex again after heart surgery can be fraught with unnecessary worry. Sexual intercourse is a form of physical activity, but it will not place a dangerous strain on your heart. You need to discuss this with your partner, because he or she may be equally anxious, but both your fears can be allayed. As with any form of physical activity, do only what you think you can comfortably manage. Familiar and comfortable surround­ings help to ease any remaining worries. If you find that you are experiencing problems in resuming sexual activity, you should seek the advice of a health professional recommended by your GP.

SMOKING

Smoking after heart surgery is insanity, particularly if you have IHD. The disease process that narrowed your coronary arteries causes narrowings in the new conduits in a much quicker time and, if you smoke, you will accelerate that process hugely. It will also worsen any breathing difficulties and chest infections you may have had in the recovery period.

RETURNING TO WORK

The timing of your return to work depends upon both you and the type of work. Light non-manual work can be resumed much sooner than heavy manual work. In general, a period of eight to twelve weeks should be set aside for recovery. There will be no problem in getting ‘sick certificates’ from either your GP or your surgeon.

CLINIC APPOINTMENTS

You will see a member of the surgical team in the clinic four to eight weeks after your operation. If you have had CABG, you will then usually be discharged to the care of your GP, but you may also be given an appointment with your cardiologist. If you have had a valve replacement, it is not uncommon to have further follow-up appoint­ments and some surgeons will want to see you every year. Other surgeons, however, are happy to discharge you to the care of your GP or cardiologist. If you have any complications or other problems you can be seen as often as is required, and appointments can be made urgently if needed.
If you have had a mechanical valve replacement, you will also need to attend an anticoagulation clinic to monitor your warfarin therapy. When your warfarin dose is stable, you will only need to attend these clinics every four to six weeks to begin with, then even less frequently as directed by the clinic or your own doctor.