First published in St. Mary’s Medical Foundation.

“Every time a patient becomes a client an angel dies.” Many years ago I read those words when glancing through my husband’s old college magazine. It must have been an article on a commencement address for the young graduates of Johns Hopkins medical school. There was a small picture showing a darkened room, an attentive audience all turned to the stage. A spotlight shone down on the podium. A diminutive figure stood, head bowed reading from his notes. He was speaking in warning of the medical business model that was spreading with the speed of a fungal spore after the first autumn’s rain, growing over the art and profession of medicine. He was speaking of when science would pressure the hospitals to spend more money on machines than nurses. He was prophetic and health care as it was in the first and middle of the twentieth century changed with increasing rapidity.

Orthopedic replacement surgeries have evolved in technique and grown to become highly beneficial procedures for both patients and hospitals. There is a call from the young athletes who have beaten their body early into a freezing standstill, the middle-aged overweight person whose joints are strained beyond weight-bearing capacity, and the elder population, living longer but with a brittleness to their bones which cry out for smooth lubrication. Orthopedic procedures are physically tough, requiring precise mechanical finesse. However, the surgeon is but the pinnacle of a pyramid of care. He must be supported by others; good doctors, nurses, therapists and a smooth running institution which, though it moves such patients through its system with the utmost efficiency, never, ever, leaves them feeling like a business client. Such a hospital is St. Mary’s in San Francisco.

It had begun simply enough. A month of twice-weekly walks with a friend. By wearing the wrong shoes I had displaced the navicular bone in my right foot which then strained my left knee. Surely a little rest and ice would take care of the problem. But I didn’t get rest or ice. Instead I took a flight to Europe, and spent three hours on a high bar stool in Paris. I couldn’t walk home… Three days later, I played in a golf competition in England. One doesn’t cancel in a partnered competition. The fifteenth hole saw my game and my knee give out.

As an ‘old’ nurse, longtime wife and mother of four, life has given our family many occasions in which to engage with the modern American health care system. We have come to accept that when we call to make an appointment the first question asked by a medical receptionist is “What health coverage do you have?” The answer to this question will direct the path you will follow. Luckily for me I ‘passed’ the question and was allowed to make an orthopedic appointment two months later. Dr William McGann’s office was full, bustling with a sampling of San Francisco city and Bay Area folk sitting patiently in various states of lameness. Some were old, ‘rode hard and put away wet’ as a cowboy would say. Some were young, crashed out and shocked. The two receptionists behind the glass counter were unflappable, rolling back and forth on their chairs as they moved us through their system. Again I marveled at how calm doctors’ assistants are in the face of America’s medical insurance web.

Once settled in the room the young RN physician’s assistant, Angela, came to say hello, ask questions, listen some and then started moving the offending knee this way and that. It didn’t take her long to figure out what was going on and to catch that the MRI I had brought in didn’t actually have my name on it. We were pretty sure it was mine but – you never know –

To Angela, Kim the X-ray tech, Pete the orthopedic tech and Dr. William McGann mine was a pretty straightforward knee gone wonky. There was some floating “crab meat” from where I had torn my meniscus and then the tell-tale signs of arthritis closing the medial gap of the knee joint. Some quiet chatter, pros and cons of what could be done and an easy discussion of the surgical procedures available. But then, Dr. McGann, with Pete’s assistance took off fifty cc’s of synovial fluid and popped in a little cortisone. Suddenly there was no pain. No pain, no surgery as far as I was concerned. This led me out the door, trying to fix things without the surgery. It took me a further seven months to admit that a knee replacement was no longer an elective procedure but a necessary one if I was to regain a functional level of living out the last third of my life. Going up the stairs in our old farm house, as I now was, on all fours was not an acceptable option.

For old nurses, (and by that I mean those of us who remember being measured for our student uniforms so that the hem lines were no more than eleven inches from the ground,) knowing that we are to enter a modern hospital brings to the surface our repressed fear and curiosity; fear of what we know can happen and curiosity towards the unknown. The stiff white cap and apron may be gone but not the attitude that goes with it. Our eyes are quick to find what medical and hospital procedures have been improved since ‘our day.’ In North America, more than any other country, science, economy and the necessary efficiency are the driving impetus to health care. Medicine has married pharmacology and surgery cleaves to anesthesiology allowing for quicker office visits and shorter hospital stays. In many hospitals’ medical services, efficiency and economy have risen to stand ahead of patient care and outcome. No wonder those of us who ‘remember when’ are apprehensive at the thought of any engagement with today’s medical and surgical teams.

By the week prior to surgery it was time for one last doctor’s appointment and X-ray before heading to St. Mary’s hospital third floor for a pre-surgery check in. And there to be met by the first of St. Mary’s angels. Mahesh, quick. spry, and smiling. He knew that a morning spent being prodded and pictured before leading into an afternoon on the hospital admitting floor for more of the same leaves a lady in deep need of a cup of tea. By the time Mahesh said, “Follow me please, My Lady,” I replied “I’ll follow you anywhere.” Just knowing that one such human being was working within this system gave me hope and courage that I could make it through too.

The night before The Day a phone call came, “Do you want the 7. a.m. slot? There has been a cancellation.” Well why not? 7.30 a.m. first one into a clean OR room is not to to be sneezed at. My husband and I were up early driving through the last of the dawn fog to the city. I wondered what do we all feel, accepting such an event, even when narrowed into that choice by our broken bodies.

Up to the third floor once more. I changed into the hospital gown of choice. We put my clothes all away into my bright, cheerful, purple weekend bag. Then there was the discussion about rings. ‘They’ want the rings off. It is not so much any more about hands swelling as it is about defibrillation and burning. For some women to be ring-less is the final nakedness. When my mother died, I had taken her wedding ring and slipped it onto my finger. That was seven years ago. It had never been off since. Now my husband put my rings in his pocket and then back on my fingers before I woke up.

The anathesiologist, aptly names Dr Goode, came in. Bright and cheery in manner he informed me that I was about to undergo the most painful procedure there was – and that he was here to help me. ‘Thank you so much,’ I replied. After the insertion of a large IV needle meant to last for days, fluids and drugs began entering my body.

The sound of the gurney wheels squeaking along the corridor. ‘That’s a good sound,’ I remembered thinking, ‘where is my recorder? Oh, it is in my bag now getting transported to my room, just as I am being transported to where?’ A friendly face or two. There the young resident whom I tease, an OR scrub nurse hung out on the railing of my gurney. She brought calm,comfort and connection. We shared the same birthday making us both feisty. Dr. MCGann comes by to say hello and write his initials, WM on the offending knee. He hands my husband the pen, a cheap, silly, little marker that I have kept in a table drawer ever since. That is the pen with which – all memory is erased.

They say I was coherent and chatty after surgery. I have no memory of the remainder of that day or night. Somewhere in there I made the acquaintance of Sal, my physical therapist, to whom I was assigned throughout my stay. A sweet and gentle young man with an old soul who knew from his own experience of a football injury early in life, the price of the wound and the source of the soul. In all our time together I felt only his total attention, encouragement and support.

Nurses came and went. Each with a smile, a knowing concern and the ability to care. Nurses love the extra autonomy the day’s end and darkness gives them on the evening and night shifts. For this time the patients are ours. And now I was theirs. At shifts change the nurses came into the room in pairs, passing report from one to the other in front of me. I listened attentively. Smiling gently one asked, “Are you a little hard of hearing?” “Certainly not.” I replied. “My hearing is just a little less acute than it was.” We all laughed and somehow they made that notation in such a way that I never had to ask, “pardon” or “what was that?” with anyone again.

Nurses kept my nights pain free and brought companionship and warm wash-cloths at dawn. To watch day break from a hospital is a slow miracle. For as nurse or patient we know that for some this new day has not dawned. From my bed I could see the the tower of the Church of Saint Ignatius. Down below were the cloisters of the nunnery of St. Mary’s. The nuns remained hidden but one sensed their presence and prayers for us all.

Family, friends, physicians and therapists kept my days busy. Pain became more attentive and so did Sal with his physical therapy. He was joined by the occupational therapists. They brought all those accouterments, handy dandy tools – for old people – that I had to grudgingly accept.

Humor returned, to the expense of the young resident, Patrick. “You are going to be a doctor?” “I am a doctor.” He would reply, keeping his temper admirably. On my next to last morning he came in, early as usual. He found me gown-agape trying to get back into bed. We laughed, ‘Good morning,’ before he said, “Come on. Lets go for a walk.” And so we walked, up and down the corridor, just a little bit more than before. Like a nineteenth-century gentleman he returned me to my bedside, then taught me a trick with my legs to get into bed by myself. “It’s been a long time since a young man has taught me something new to do with my legs in bed.” We shared more laughter as I thought, Yes, now you are a doctor.

That night would be my last in the hospital. It was time to go home.

The longest journey home. The heaven of a familiar bed. The friendship of young women texting hither and yon until Dana brought Megan’s ice machine and the news that her husband, who had the same operation a year ago was away surfing in Indonesia this week. Food and companionship entered the house in the gently wispy haze that binds communities together. Daughters came with granddaughters. Card games of Fish and Snap were played with one granddaughter while the other took me on more adventurous excursions up and down a step to the back garden in search of caterpillars and lady bugs. In those times, pain bowed down and away. Nurses and Physical Therapists came to the Farm, watched over me carefully, checking this and encouraging that.

Restless nights gave way to busy days. It took two weeks before I began to believe that doing the surgery was a good idea. Slowly but steadily healing took place. Progress was measured by the discarding of those fearful and embarrassing accouterments. First out went the commodes. They were soon followed by the ‘sock putter-oner’. Then it was the turn of the walker. The grabber and the crutches stayed a little longer. After three weeks the visiting nurse and physical therapist stepped back and signed me off. I, my knee and my bowels were on their own. Physical therapy continues at home and twice weekly in a Stinson Beach studio. A simple wooden cane has taken over for walking in public. On the farm a pitchfork or broom work better. Yesterday I dug a row for the autumn peas in our garden.

At the end of next month there is one final visit to Dr. McGann. He will, I am sure, make happy talk about my knee and my progress and I will sing the chorus of gratitude. But, as a nurse, a woman and a farmer I will ask him to those questions we all need to have answers for:

How soon can a lady shave her legs after coming off of coumadin?

And he can tell me how soon I can drive my tractor again. It has been two months now and the grass in the apple orchard is tall and dry, and waiting for me.