A Reflection on Day 11: Normal

 As I was preparing for my surgery, one of the things doctors said (both my own doctors and the material I read, both in print and on line) to be upbeat was, “You should be back to normal activities in [some period of time].” Oh, don’t lift too much, and don’t plan on driving too soon, but both of those were, as I heard it, relatively short term issues. “You should be back to normal activities by….”

Each time Karen and I heard that, we couldn’t believe it. We would stop and say, “That’s too optimistic. My normal activities include moderate hiking on uneven trails, maybe stopping to harvest mushrooms; or fighting through brush to lay out a trail; or, depending on the season, heavy gardening or tree work. I don’t those things professionally or for more than a couple of hours a day; but it still seemed (it still seems) unlikely that I would be back to those activities in the times the doctors suggested.

Oddly enough, for most of the written sources the standard for “normal behavior” was golf. Now, golf is a fine activity, but I’ve never been a golfer. It seemed an oddly specific choice.

I found myself thinking about this again last week. I found myself willing to help feed our pets. Suddenly I had a whole different perspective on “normal activities.” I realized there were a lot of small things that Karen had done that I hadn’t been up to after surgery. I had the catheter to adjust to, and at times a bag to carry. I had been told to be careful what I picked up. We had cold weather, and even a few days of ice and snow after surgery, so I hadn’t risked stepping outside. It took me a few days to be ready to feed the animals, or to feed myself, or even to get in and out of bed by myself. These were “normal activities” that it did take me time to get back to, sort of within the time frame of at least some of the doctors’ statements.

So, why did both Karen and I jump to sort of a maximalist understanding of “normal activities?” Perhaps those were where I feared the greatest loss. My biggest concerns were related to two questions: how long would it take my abdominal and back muscles to be back to strength; and how long would it take me to regain continence? I hadn’t really thought about what I would be able to do around the house starting with the easiest tasks. Perhaps I should have. In this first week those are the tasks that have taken the greatest toll on Karen. We do things together, and share household chores; and it’s only in the last few days that I’ve been able to take some of those tasks back.

Part of the answer had to do with the muscle strength part of things. I had abdominal surgery using laparoscopy and robotic assist. That made for more, smaller incisions. It could have required standard surgery, requiring a big incision. In addition, to make the laparoscopy work they inflated my belly with carbon dioxide. In either case, muscles were cut and stretched, and it was going to take a while to be functional again. As I hadn’t had abdominal surgery before, I had no personal experience about how long and how much pain relief it was going to take to reach “functional” - and how functional I actually had to be to do anything. With good pain management, each day I’ve been able to do a little more. Before I left the hospital I had walked several hundred feet. After a day or two at home I was sitting up in the front room for a while and taking my meals there. Now I can pick up light things (say, the box of oatmeal, or some clean laundry), and I can help with feeding pets. I can take the dog out, as long as I don’t use her leash: if she pulled I wouldn’t be strong enough to hold her. (Fortunately, she’s a very good girl!) These small tasks have come back gradually, and, really, pretty quickly.

Now, really, the continence issue is also about strength: certainly, abdominal strength, but also the strength of my pelvic floor. I can work on both, but only so quickly. That’s why the issues of continence take longer. There’s also an issue of ego strength: how willing am I to be out of the house in specialized undergarments? All three of those issues are part of getting back to “normal activities. I will be doing Kegels, and walking more. How well my Kegels can control my sphincter, and how well my abdominal muscles can resist pressure on my bladder, contribute to regaining continence. Those can improve over time (and, really, the ego issues with them). I won’t be at my maximal “normal activities” for a while, but with time and exercise I can with time get stronger and stronger.

To give credit where due, I have realized that golf was a good model. I don’t golf, but I have watched golfers. Biomechanically, they do a lot with the abdominal and back muscles. They bend, twist, crouch, and rise again. They walk and, often, carry their clubs or pull them behind them with a cart. That doesn’t sound exactly like my bushwhacking or my hoeing and digging, but it comes close to my hiking and my mushrooming, and some of my garden work. I suppose that many doctors think of golf as a broad set of abdominal activities that many of them also participate in; but it still does make a decent model of which muscles need to get stronger.

In thinking of all of this, I also thought of something I often heard about from colleagues at the Center for Practical Bioethics. Over the years they would note studies that suggested people who set some clear lines in healthcare directives would, as they aged, appear to relax those lines. As people gradually experienced more limitations, they gradually adapted: they adjusted what limitations they were willing to live with. That is absolutely less abstract for me. I’m not yet certain of getting back to my maximal “normal.” I have good reason to hope, but I’m not so arrogant as to be certain. 

And if I don’t? I will adapt, too, I expect. I will also grieve. I will also remember (at least try to remember) that all the sources encourage patience, a recognition that this is a process and not simply a single achievement. And the more energetic activities are goals. I like, as I tell Karen, “going to the trees.” I like hiking, with Karen or just me and the dog. I like harvesting mushrooms and digging sassafras root. I like making and grooming trails and pruning trees. I will need to work back to those things, taking the time I need, and making the adaptations I need. And in the meantime, I will find myself returning to more and more different “normal activities.”