Brave New World of Medical Technology

Lucky me, I have a pacemaker.  Actually, very lucky as when I was fifty four I was running around the office one day, feeling a little dizzy, but going about my business, preparing to get on an overseas flight to the Frankfurt Bookfair, and my wise wife forced me to see my doctor before we departed (she was going with me). My doctor took an EKG and looked startled, saying that my heart was beating at only 30 BPM.  I should have passed out long ago and he wondered how I was able to get through the day.  So I said, isn't there a pill I can take, I have to be in Frankfurt tomorrow. He replied, the only place you're going is to the ER.  Had I gotten on that plane, ignoring the symptom, I was told I would have died.  So, lucky me, indeed.

After ER, I was admitted to the cardiac unit and they thought I had an advanced form of Lyme Disease, which can attack the heart's electrical conduction system. I was put on heavy duty antibiotics and meanwhile they warned me that if my heartbeat dropped below 30, I'd have to have a temporary pacemaker wired through my neck.  That evening a team of medical personal came bursting into my room, monitors beeping, indicating my heartbeat had dropped to 28-29.  Look, I said, I'm conscious.  Please don't put a temporary pacemaker in unless it drops further.  So they watched me that night and I was at least stable.

After almost a week of medical treatment, and no improvement of my condition, a cardiologist informed me they would be prepping me for a permanent pacemaker the following day.  They had no idea why, at my age, my electrical system was failing.  Lousy genes they speculated (a favorite explanation offered by medical personal when they have no clue). So, into the operating theater I was wheeled and was told I'd be sedated but hazily conscious as the surgeon would have to ask me questions as he placed the leads into the heart.  A representative of the pacemaker manufacturer was present and I remember he and the surgeon joking during the procedure.  The surgeon said this is a piece of cake as he's relatively young and in good shape so I piped up, I ought to qualify for a discount then!  Fat chance he replied.

In any case, I have lived with a pacemaker, now, for sixteen years.  Actually, I'm now on my third such device as when the battery runs low, it's not like replacing a couple of double A's.  A new pacemaker has to be inserted in my chest. 

I know, it's an awful looking picture, but that's what my chest looked like five days after getting the last one.  It actually looks worse than it felt.

My third generation pacemaker is high tech.  The older devices needed monitoring, usually in the cardiologist's office.  But now the monitoring is done remotely, as the pacemaker transmits the information wirelessly to a receiver that sits by our bed, one that is plugged into our phone system, and it dials out the data as I sleep.  Every three months if does a "pacemaker interrogation" the same one I had in the office and transmits the data (it will also send data immediately if it detects any serious irregularity such as a ventricular tachycardia).  Our phone system is now digital, so the information goes out via our cable company's broadband.

But wait, more high tech.  Our telephone answering service is provided by the cable company as well; not only are messages recorded, they are transcribed using voice recognition, and then sent to me via email.

And yesterday I received the following email:

From: Voice Services@-------.com

Sent: Tuesday, January 15, 2013 1:04 PM

Subject: You have a new Voicemail

    "Hello this is your implanted cardiac device clinic calling to let you know we received your follow up data and it looks normal. We look forward to your next appointment. Thank you and goodbye."

Thus, from an implanted pacemaker with a computer chip transmitting on a proprietary band, to a receiver that dials out via broadband to a computer that analyzes the data and, if normal, then places an automated call which is recorded and then transcribed via voice recognition, finally being emailed back to me.  A full circle without human interaction!

Any sufficiently advanced technology is indistinguishable from magic.....Arthur C. Clarke

But there are serious issues with all this technology, both positive and negative.  My pacemaker is transmitting at all times.  Anyone within 10 feet knowing the frequency and having the right equipment, in a public place, can have access to the data which raises privacy issues.  I have no problem with that but it also means that same person would have the ability to reset or even disable the pacemaker.  Pacemaker (and implantable cardioverter-defibrillator) manufactures say that is nearly impossible, but it seems to me that almost any "techno-magic" is feasible today.

Thinking more macro-medical technology, we have the ability to build a national database of medical information, at least for Medicare recipients, that would obviate the endless duplication of medical record keeping for the same patient at multiple health care facilities and doctors' offices.  Again, privacy issues have been a stumbling block, but imagine the significant cost savings (and improvement of data accuracy).  I have less concern about the privacy issues than I do about rising health costs and the burden it puts on taxpayers.  Surely there is a techno-magic means of satisfactorily addressing the matter.

April Fool Anniversary

It is a one year anniversary of sorts for me today. Ironic it should be on April Fool's day, as it was no laughing matter. Some of the details of what I write about below were also covered by the entry I wrote not long after that day but I purposely did not revisit it before writing what follows, not wanting to be influenced and knowing that I would repeat some of what I wrote. But I recall not revealing some of the details and my feelings when I wrote that entry. I was too close to the event.

I had entered the hospital in late March for what I thought would be, yet, another stent, perhaps butting a stent inside one that had collapsed. A tricky operation, yes, but more routine than the dreaded alternative, bypass surgery. In spite of being in good shape all my life, eating healthily (well, at least relatively speaking), exercising, and, even having low cholesterol, my parents both had heart disease and I've resigned myself to being the victim of bad genes. Of course I'm not unique in this regard and I do the best I can.

But surgery did not go well, my returning to consciousness soon after I went under. The nurse in recovery looked somber, saying the surgeon would be in to explain. I knew what was coming. The interventionist cardiologist said he was referring me to a thoracic surgeon, the best in the area, as he could no longer address the widow's maker blockage with stents. Back in my hospital room I met Dr. Katz who was to operate on me.

He said I needed a dual bypass and he intended to do this surgery off the heart lung machine. In other words, on the beating heart. Open heart surgery. Images sprung to mind of his having to work quickly between heart beats, conjuring up a scene from a Woody Allen movie.

"Don't worry," he said, "I've done this before, in fact many times before. But here's the problem, we have to wean you from Plavix before the surgery because of the risk of excessive bleeding. It'll take days to work it out of your system but we can't discharge you as we wait because your artery is so blocked that you could have a heart attack anytime and you should be here. In a sense, we have to balance the risk of early surgery against the one of you having a significant heart event."

Nice euphemism, "significant heart event," not the words one wants to hear. So the wait began. Tests were taken at regular intervals which revealed I had acute sensitivity to the blood thinner so it would take days, how many they didn't know. Finally, on March 31 they said, surgery tomorrow, they couldn't wait and they were hoping the Plavix factor had diminished.

Happy April Fool's day I thought as I was being wheeled into the cardiac surgery theater. All I can remember is the cold, the high tech monitors, and a team of medical personnel ready for a full court press, March madness still being in the air. The thought went through my head that I might not survive this surgery and these might be my last conscious moments of my life, with strangers, in this sterile room. But the human psyche is innately optimistic and I looked at my surgeon and saw how confidently he was orchestrating his team, and I went under.

I woke up four days later.

My previous entry recounts much of those details, but essentially, excessive bleeding and traumatic intubation mandated not only opening me up a second time, it also required that long period of controlled unconsciousness. Ann says at times I wildly gestured to her when she visited, none of which I can remember. Mittens restrained my hands so I could not pull out myriad tubes entering my body, but, in particular, the Tracheal intubation tube down my throat. I was not a pretty sight, as the gruesome photograph clearly depicts. (I'll not post it again, but a link is here).

Did I see my life flashing before me, lights at the end of a tunnel? I don't remember anything of those four unconscious days.

But when I did awaken, I was in cardiac intensive care. Jon and Ann were there. The surgeon visited and recounted the details. My body felt bludgeoned. I was given a "cough bear" -- a little teddy bear to hold to my chest in case I had to cough up anything, something to press on the wires holding my sternum together, more of a reminder not to expand my chest for any reason. I was told that I would be in intensive care for at least two days before I could go to the cardiac wing and as I was in a coma induced sleep for four days, to expect not to be able to sleep during that entire time.

After my family left for the evening, there I was, alone, clutching my bear. I didn't have the strength or the inclination to read. Just trying to get comfortable and minimize the pain was enough of an effort. So I was left with either my thoughts or the TV to pass away the agonizing long hours of the nights. I found my thoughts somewhat depressing. Will I recover and be able to resume my life as if this never happened (it didn't seem possible at the time)? Why me? (I've asked that question many times regarding my heart issues, and blockages and high blood pressure are not the only ones, as I also have a pacemaker; my body's electrical system was shot by the time I reached my mid 50's.)

So, I turned to the TV. Do you have any idea of what is on basic cable channels during the wee hours of the night and early mornings? I had to suppress a laugh watching the numerous ads for mattresses, sleep aids, etc. Those lucky people in the real world who can't sleep only because of insomnia. I'd trade places with them in a heartbeat (no pun intended).

While the TV was on low to keep me company, I closed my eyes most of the time just to pretend a sense of normalcy.

Night "life" in a cardiac intensive recovery wing consists of hearing other patients sometimes moan in pain. I don't think I did that, although the sense of discomfort on the one to ten scale was eleven most of the time. Worse, I heard a doctor and a nurse nearby saying the patient in the next room had just died and to contact his family. Right next to me. It could have been me, I thought.

Then, there was the night nurse from hell. I suppose nurses fall into the bell shape curve like any other group of human beings, there being a few exceptional ones, most merely competent or average, and a few very unexceptional ones. In my case, I would draw the curve with many more on the exceptional end, especially the cardiac nursing staff.

But first, nurse from hell. I don't know her name (AKA Nurse Ratched, "NR"), but she was on duty my first two sleepless nights, the ones when I was in the most pain, and, frankly, most fearful of the outcome of all of this.

NR obviously took enjoyment from her position of power over her patients. I don't want to cast aspersions at the airport TSA personnel, but, face it, some enjoy the same relationship with the travelers they control.

This woman had an acerbic flair for mockery as well. That first night of interminable consciousness, after my wife finally went home exhausted, NR had obviously overheard Ann referring to me as "Bobby," a moniker I don't particularly like, but Ann (I call her Annie though) uses it and therefore some of my closest friends who have been around us a long time, call me that as well.

NR obviously took a jealous aversion to my wife and in the middle of the night I could hear her at the nurses' station (they don't realize that their chatter at night drifts down the hallways a long distance, sort of like being downwind of an anchored boat in the middle of a calm night), mocking "I wonder how 'Bobby's bear' is doing" (meaning the bear I was hugging to keep my chest together). She noted my wife's jewelry (some pieces jangling when she walks, Ann arriving like a brass band) to her co-workers, something that I guess incensed NR.

Then, one of the few times I buzzed the nurses' station in the middle of the night because of the extreme discomfort I was in (or pain, I hardly could tell the difference), and needed someone just to move me slightly to one side or the other (I was incapable of moving myself with all the tubes coming out me, the catheter, etc.), she reluctantly assisted me, but menacingly whispered in my ear, "you ought to back off that buzzer, we have other patients here."

So besides the insufferable but benign TV, I had this real life John Claggart from Melville's Billy Budd to deal with. I really saw her in those terms, not that I was the embodiment of innocence, but I was at my most vulnerable. These thoughts raced through my mind: If I ring for help, might she take vengeance for bothering her? If I report her or tell my wife to report her, what would those consequences be? I was determined to make it out of intensive care alive, and then deal with it. I asked Ann to "dress down," cryptically saying "I'll explain later."

In retrospect, I should have said something then and there, but when you are that vulnerable, your mind works differently, and believe me, in the middle of two sleepless nights, you are really ALONE.

So I clutched my bear and bore it, the sleeplessness and the terror of Nurse Ratched (although the one in the film based on the Ken Kasey novel was a lot more attractive but equally evil). But she was not the only nurse on duty, thankfully; all the others were wonderful.

For instance, on the opposite end of the spectrum was a day nurse who was the model of efficiency and good humor. Why? Because her first comments to me was that she was somewhat dyslexic (just my luck I thought) but, as a consequence, everything she needs to do for each patient is on a checklist (she showed me her personal clipboard). Sure enough, she methodically went through her list each time she saw me and didn't miss a thing, and she had me laughing to the extent that I could.

When I finally graduated to the regular cardiac care unit (and to my first night of sleep), I was greeted by the nurses who I already knew as I was in the cardiac rehab program before my surgery because of my prior stents. It felt like going back to family, all wonderful nurses who are in the unique position of following their patients from the nadir of their hospital stay, to their eventual discharge, to their offsite rehab. I still go to the rehab gym to this day, one year later, to get on the treadmills and the exercise machines, back to form before all these cardiac problems enveloped me. I can't say enough about the help and encouragement of that nursing staff, the higher end of the bell curve I described earlier.

Once out of intensive care, I took my first steps with the help of these nurses, very tentatively, my legs feeling like rubber bands, with their arms around me. They said, "don't worry, every outing will get easier and longer." And they were right.

So here I am exactly one year from the day I went into a four day coma, and a brush with death. To say I am grateful is an understatement, to my surgeon, Dr. Katz., to the young Anesthesiologist, fresh out of medical school I thought, Dr. Carroll, who prepared a checklist for any future anesthesia caregiver in the future, to alert them to my difficult intubation, and the need for a fiberoptic bronchoscope. So I carry this checklist around with me in my wallet to this day and on a USB drive attached to my keychain as a PDF along with other essential medical records.

But most of all I am grateful to the nursing staff that brought me along, and continues to work with me to this day so I can indeed resume my normal life. In fact, with my new "pipes" feeding my heart much needed oxygen, I feel more healthy and productive than I did before. Anyone reading this blog regularly would recognize that as I went on a home repairing spree when we returned from last summer's travels, including painting much of the house myself. Even the scar has pretty much disappeared, although the left part of my chest is still somewhat sensitive because so many nerves were severed and they take a long time to heal.

I did not mean to dwell on the one rotten apple to mark this one year anniversary of my coming back from the nearly dead, but, at the time, she loomed large in my mind. I reported her at the end of my hospital stay so I hope other patients were spared.

My wonderful surgeon, Dr. Katz, is also a gemologist and he has made it a tradition of giving his patients a heart shaped stone specimen of his hobby in their follow up visit, one I had a couple of weeks after getting out of the hospital. You choose one and then he reveals the "story" behind the rock. I choose a very heavy, beautifully polished one.

And the story behind my choice, which turned out to be Hematite, mined in Brazil, is that metaphysically, it is said to be "excellent for calming and relief of stress....a good stone for 'grounding', meditation, dissolution of negativity, and bringing peace and inner happiness," ironically, all my weaknesses, and so I go on hoping it works and grateful for this reprieve. No April fooling.

Conroy's Reading Life

Our good friend Edie gave me My Reading Life by Pat Conroy when I recently entered the hospital, which was supposed to be for a more routine visit than it turned out to be. She knows I love good writing, and she thinks of me as a writer as well. It was a very thoughtful gift. Yes, I write, and I enjoy it, but to be a real writer means to forsake just about everything and dedicate yourself to the craft. It also helps to have an abundance of talent, an omniscient eye and an encyclopedic memory.

I cannot think of any great writer who is not obsessive compulsive about writing. In many ways, I wish I could roll back time and make that choice, but it would have been to the detriment of a publishing career I loved and other avocations such as the piano, studying the machinations of economic markets, politics, and a bunch of other things. Although I started Conroy's work in the hospital, I had difficulty concentrating on it or anything else after undergoing such major surgery. My recovery left me unable to do much but change channels watching awful TV which I can only describe as crap, and if that is emblematic of where American "culture" has migrated, there is no hope for our society.

Once I returned home, I picked up the book again. Conroy achingly cries out in poetic terms for an understanding as to why he writes, why he found refuge as a child in literature, first as a means of connecting with his mother (no, worshiping her) and as a means of escaping his father. I have a particular empathy for literature as a means to understand family, as I wrote in an earlier piece: "What draws me to these writers is families, or more specifically, dysfunctional families. Strong mothers or weak fathers or weak mothers and strong fathers with borderline “crazy” behavior, dark humor and the unpredictable maturation of children from those families. Of course if art mirrors life, it may be that “dysfunctional” is merely normalcy in today’s world."

It was heartbreaking, though, to read Conroy's dedication page. My Reading Life begins with: "This book is dedicated to my lost daughter, Susannah Ansley Conroy. Know this: I love you with my heart and always will. Your return to my life would be one of the happiest moments I could imagine."

So, as in my family, succeeding generations are affected by the tribulations fostered by previous generations. I naturally tried to discover more, and found his comments about the dedication page in an NPR review: Apparently he has been estranged from his daughter since divorcing her mother in 1995: "She has a perfect right not to see me. She's 28 now. But I thought this [dedication] was going to be a last cry of the heart. I would at least try to get her attention and see if I could get her to come back. It has been one of the most soul-killing things to ever happen to me." [Copyright 2011 National Public Radio]

Maybe his daughter will reconnect with her father if she has the opportunity to read this book and understand the undertow of Conroy's maturation as a man and as a writer. He covers a wide range of influences on his writing, first and foremost his mother, who became immersed in Gone With the Wind, continuously reading passages from the novel to her son, beginning when he was five years old. "I owe a personal debt to this novel that I find almost beyond reckoning. I became a novelist because of Gone with the Wind, or more precisely, my mother raised me up to be a "Southern" novelist, with a strong emphasis on the word "Southern," because Gone with the Wind set my mother's imagination ablaze when she was a young girl in Atlanta, and it was the one fire of her bruised, fragmented youth that never went out....It was the first time I knew that literature had the power to change the world."

Then there were the teachers, in particular Gene Norris's English class, and the "anti-teachers" in particular his father, Donald Conroy, the Marine who beat his family. Conroy bore much of this. "From an early age, I knew I didn't want to be anything like the man he was....I was on a lifelong search for the different kind of man. I wanted to attach my own moon of solitude to the strong attraction of a good man's gravitational pull." Gene Norris was that man and he became a lifelong friend and mentor to Conroy and introduced Conroy to a wide range of classic literature.

Then there were people in his life who could have been negative influences, the librarian, Miss Hunter, at Beaufort High School, Cliff Grabart, the proprietor of the Old New York Book Shop in Atlanta, and the cantankerous, but lover of literature, a book representative, Norman Berg, who I met on several occasions at book conventions. Conroy even went out on sales calls with Berg. That was the foundation of the publishing business then.

From each of these people Conroy took away something and bonded with them in his own way. In fact, Conroy was sponge-like in his dealings with people and the literature he read, recording everything, the eyes and ears of a writer on duty at all times. This is what separates mediocre writers from great ones.

He did the ex-pat "thing" in Paris in the late 1970s. "Parisians... relish the xenophobic sport of stereotyping and love to offer an infinite variety of theories on the nature of Americans. To them, we as a people are shallow, criminally naive, reactionary, decadent, over-the-hill, uncultured, uneducable, and friendly to a fault....Whenever Parisians heard my execrable attempts at French, they would cover their ears with their hands and moan over the violation and butchery of their sweet tongue." My own visits to France taught me a similar lesson, my high school French had to be left behind and I sometimes pretended to be Canadian. But maybe the French are on to something, given my captivity by the mindless TV programming during my hospital stay.

Conroy was finishing The Lords of Discipline in Paris, staying at a hotel where he encountered a wide range of travelers, including other artists. As my son is an inveterate traveler, I was fascinated by Conroy's exquisite explanation as to what it is to be an ex-pat, meeting other people on similar journeys: "Because we were strangers who would know one another on this planet for a very short time, we could trade those essential secrets of our lives that defined us in absolute terms. Voyagers can remove the masks and those sinuous, intricate disguises we wear at home in the dangerous equilibrium of our common lives. The men and women I met at the Grand Hotel des Balcons traveled to change themselves, to trust their bright impulse with the hope they would receive the gift of the sublime, life-changing encounter somewhere on the road. There is no voyage without a spiritual, even religious impulse. Each of us had met by accident, our lives touched briefly, fragilely -- then we continued on our own private journeys, and those intense encounters left a fragrant pollen on the sills and eaves of memory."

But to this point, My Reading Life is merely a warm up for what is the main event and influence on Conroy's writing and he appropriately entitles the chapter "A Love Letter to Thomas Wolfe."

It was Gene Norris who gave him Wolfe's classic Look Homeward, Angel in 1961 as a Christmas present. "The book's impact on me was visceral that I mark the reading of Look Homeward, Angel as one of the pivotal events of my life....The beauty of the language, shaped in sentences as pretty as blue herons, brought me to my knees with pleasure....I was under the illusion that Thomas Wolfe had written his book solely because he knew that I would one day read it, that a boy in South Carolina would enter his house of art with his arms wide open, ready and waiting for everything that Thomas Wolfe could throw at him."

I felt the same awe when I read the novel in college, probably at about the same time as Conroy. Never before had I felt that way when reading fiction. The only way to describe his writing is as being concurrently prodigious and poetic, an uncommon combination. And the novel was even larger before publication and luckily for Wolfe his editor was none other than the legendary Maxwell Perkins at Scribner's who also was Ernest Hemingway's and F. Scott Fitzgerald's. Wolfe was in good company.

The publication of Look Homeward, Angel, had, at its heart, detailed autobiographical elements, the same sort of autobiographical elements in which Conroy's own The Great Santini is grounded. Wolfe's work caused an uproar in his hometown, beautiful Asheville, North Carolina. For a while he was banished from the town, but he did return later to write You Can't Go Home Again.

Conroy has made the pilgrimage to Asheville, first with his teacher, Gene Morris, to visit Wolfe's "Old Kentucky Home," the boarding house maintained by Wolfe's mother. Conroy rocked on the chairs where the boarders gathered on the porch. He toured the home which has been so lovingly restored. I wonder whether Conroy has seen the wonderful play about Wolfe's return to Asheville, Return of an Angel which we were lucky enough to experience during one of our visits to Asheville. It brought Wolfe's return to Asheville alive.

We have been to the Wolfe home in Asheville twice and came away with the same feeling of time having been stopped during those years, before Wolfe's untimely death at the age of only 37. Imagine the great works he would have written if he had lived. As Conroy says, "I think the novels of his fifties and sixties would have been masterpieces. Time itself is a shaping, transfiguring force in any writer's life. Wolfe's best novels sleep in secret on a hillside in Asheville -- beside him forever, or at least, this is what I believe." I agree, Pat, and thank you for reminding me of Wolfe's passion, an invitation to reread his work.

Conroy's concluding chapter, "Why I Write" is probably one of the best I've ever read on the subject, setting the serious writer apart from the potboilers that weigh down today's best seller lists. "Stories are the vessels I use to interpret the world to myself...Good writing is the hardest form of thinking. It involves the agony of turning profoundly difficult thoughts into lucid form, then forcing them into the tight-fitting uniform of language, making them visible and clear."

Also in that chapter, he returns to the overarching theme of literature and family, the role of literature explaining who we are and where we came from: "I've always wanted to write a letter to the boy I once was, lost and dismayed in the plainsong of a childhood he found all but unbearable. but I soon discovered that I've been writing voluptuous hymns to that boy my whole life, because somewhere along the line -- in the midst of breakdowns, disorder, and a malignant attraction to mayhem that's a home place for the beaten child -- I fell in love with that kid." And I too fell in love, as much with Conroy's nonfiction as his novels, particularly with My Reading Life, as well as My Losing Season. Such truthfulness and beautiful writing. One can only hope his honesty will lead to a reconciliation with his daughter. It would be just.

.

Widow Maker Redux

There is a reason I've been silent so long. In fact, I am lucky to be around to resume the story I wrote last November when I described my silent encounter with the "Widow Maker" artery. The link gives the detail, but briefly I unknowingly had a 99% blockage in the infamous Widow Maker's artery, the LAD. If it were not for the fact that I regularly exercise, the problem would have gone unnoticed, and indeed my case would have resulted in another widow.

At that time, a cardiac catheterization revealed the blockage and I was given the option of less invasive three kissing stents vs. open heart surgery. Naturally, given the choice between the intrusive bypass, the possible complications, and the long recovery, I choose the path of least resistance. After all, couldn't I undergo the more invasive option if the stents didn't work?

Following that procedure, I began a cardiovascular rehab program, which consisted of 36 sessions. Once again exercise saved my life. I was on my 33rd session when I started to feel some burning sensation in my chest after about 15 minutes on the treadmill (I was doing 30 minutes at 3.8 mph). It would generally pass and I rationalized it was gas, but, here is the value of such programs (one that may become vulnerable to cuts in Medicare): the extraordinarily caring cardio nurses on duty reported it to my cardiologist who called me in for a nuclear stress test. I got through the test, so I went about my business again waiting for results the following week.

In fact, immediately afterwards, boating friends of ours from Connecticut, Cathy and John, visited us and over the next four days we took our small boat out to watch the moonrise over Singer Island, ran the boat up to Jupiter the next day to the funky, fun, Guanabanas Tiki Bar and Restaurant where we could tie up at their splintery old docks and enjoy a little bit of the Caribbean right here in Palm Beach County.

The following day we went to Peanut Island, our favorite destination on our boat, watching Tiger Wood's yacht, 'Privacy' (Tiger put the boat up for sale recently if you have a spare $20 million or so and can afford the crew and maintenance) glide by as Ann and company played Scrabble on the beach. We enjoyed lunch al fresco and later barbecued dinner and left as the sun slowly set.
A possible negative report on the stress test was the farthest thing from my mind, and I went about my normal activities as usual. In retrospect, our friends' visit could not have come at a better time.........the calm before the storm. Life as usual.

My follow up appointment with my cardiologist was the day after they left. Apparently, the stress test, combined with the burning symptoms when exercising, called for another catheterization and, as was explained to me, the sooner the better. The following Monday, March 28, I went into the hospital and had the catheterization expecting, at worst, Restenosis, which usually happens within 3-6 months after stent placement and I was still in that time frame from my previous procedure. I thought I would wake up to still another stent or a treatment of intra-coronary radiation (brachytherapy).

Wishful thinking. I was told my Widow Maker was now more than 90% blocked again (turned out later to be 100%) with another artery 50% and I would need dual bypass open heart surgery. There is a delightful acronym for this surgery as it is sometimes called: CABG ("cabbage"). I was to become a cabbage patient. Luckily for me, one of the gifted thoracic surgeons in the area, Dr. Arthur Katz, was available for the task, and also that I was at the Palm Beach Gardens hospital which is a leading heart hospital.

First order of business was to get as much as possible of the blood thinning Plavix out of my system before surgery. I had been on the drug since my first stent more than six years ago. However, knowing that I had such extensive blockage in the LAD (the LAD coronary artery supplies a very large part of the heart muscle) made it a judgment call of how long we could wait. The surgery was scheduled for March 31 but after a blood test, it was delayed one more day (April Fool's day). Our son flew in from Tokyo (where he had been during the earthquake, but that is another story) to be with me and my wife. His presence made all the difference to Ann who bore the brunt of seeing my struggle and trying to communicate status reports to friends and family via email and phone. My older son, Chris, could not be here but Ann kept in constant touch with him.

Dr. Katz specializes in surgery without the use of a heart lung machine (off-pump, it's called), something I was grateful for as I have heard about cognitive recovery and other issues resulting from that. But as it turned out, my operation was anything but routine. First, endotracheal intubation (the process of placing a breathing tube to protect my airway and control breathing during the administration of general anesthetic), became very difficult because of various anatomical issues unique to me. A fiberoptic bronchoscope had to be used after several unsuccessful attempts at direct larngoscopy and glidescope.

Surgery went well initially, using an internal mammary artery and another artery from my left leg, but then there was increasing difficulty controlling bleeding. I had a number of transfusions. In fact, after my sternum was wired and the chest stapled, there were further signs of internal bleeding so for the first time in recent memory, Dr. Katz had to reassemble his OR team and go back into the wound. This carries a risk of course and it is why surgery is as much an art as it is a science.

Thankfully, he was able to control the bleeding at this point, but I had been through the wringer and back again, and had to have half of my body's blood replaced. As I had so much anesthesia, my recovery was to be equally slow and for four days I had that breathing tube down my throat as I went in and out of consciousness. My throat had been lacerated and was now excessively swollen. Waiting for my throat to return to normal, mittens had to be put on my hands so I wouldn't grab the tube when I had brief borderline awareness. Ann said during those moments I was waving my arms, gesturing with my boxing glove hands and giving everyone the fish eye. No wonder.

When I finally came to, I was in intensive cardiac care, pretty much unable to move, and having been unconscious for four days, would now probably be awake for at least two days. Those nights were the most difficult, not being able to move much, trying to get into a comfortable position, forced to lie on my back. I could hear almost every precious heart beat and sometimes the creaking of my sternum which was wired together. Deep into those nights you are left with your thoughts and fears, regrets and hopes.

I could operate a TV on the wall with a remote. It is not possible to realize how bad late night TV is until I became dependent on watching it all night, unable to sleep. I thought it ironic that juxtaposed to my surgery was all the rhetoric on the news shows about shutting down the government because of the lack of a budget compromise, all the posturing and huffing and puffing by the wolves in Washington, the propaganda about "entitlements" and the inexplicable inability of rolling back some of the Bush tax cuts as one part of dealing with the growing deficit. A subject for another entry, but, this is what I listened to as I was personally benefitting from an excellent healthcare system and no doubt a very expensive one, the very one some of our politicians would like to turn over to the insurance companies.

There is no way to describe everything that had to be done to me and for me to pull through, but I had asked my son to take a picture of me in recovery, thinking I might want to post it if I survived the operation. Warning, it is not a pleasant sight, but I include this at the end of this entry. It puts a "face" on Medicare. In spite of all of the shortcomings of the program, as one of the most civilized countries in the world, such care must be available to all. And of course, throughout all of my 15 days and nights lying in that hospital bed, I was looked after by a revolving crew of highly trained nurses who literarily kept me alive changing vital fluids, making me as comfortable as possible with all the tubes and apparatus attached to me and using all their skills and experience to help me survive my arduous surgery. There is no way I could ever thank them properly enough for their dedication and professionalism.

My breathing tube was gone by the time I came to. The third chest drain was yanked out (yanked is the correct word) by Dr. Katz as he diverted my attention to a discussion of where I grew up and my familiarity with Jahn's, a favorite teenage hang-out in Richmond Hill. Strange to be talking about Jahn's "kitchen sink" some fifty years later while a chest drain is being removed. Finally my urinary catheter was removed as well.

Another complication was a sudden spike in fever when I finally got to the regular cardiac unit, so for the next two days I was tied to massive intravenous antibiotics. No one could explain this spike which disappeared as quickly as it appeared other than it being somewhat par for the course.

So now I have been home for a little over a week and thanks again to Medicare, have been closely monitored by an attentive nurse and physical therapist putting me through the paces in the house. I now have follow-up Doctor appointments and have been given the green light to return to cardio rehab next week. While bypass surgery has relatively good prognosis, the fact that I had complications, new blockages, etc., results in some anxiety. I eat a healthy diet, exercise, have always been active, but as I said in my prior entry on the Widow Maker, hereditary factors seem to preside over everything. Will my therapy and new medications offset this deficit? That is the hope.

To friends and family who might be reading this, thank you for all your heartfelt support, for me, and my wife who has been valiant through all of this. Ann was calling, emailing everyone, coming home from the hospital near exhaustion. Her last email after my second (no, actually third) operation in a week is typical of the kind of attention she gave to everyone, in spite of the late hours she returned from the hospital:

Dear Friends and Family,
It's been a day from hell. All I can say is thank goodness Jonathan was here with me, or I would have lost my mind. In short, Bob was bleeding profusely during and after the operation this morning for the double bypass. We saw him very briefly in the critical care recovery room with a million tubes coming in and out. We were home less than an hour planning to return over the next visiting period when Bob's Surgeon, Dr. Katz, called and said he was going back in again, Bob was still oozing and he was reassembling his OR team. That meant cutting his chest open over the fresh stitches, undoing the wiring on the sternum, breaking it again and taking another look.

I thought Jon and I were going to pass out. Once we started reading all the literature on this procedure and all the risks involved, we were totally freaked. When it was finally over, we saw the Dr. and spent 20 minutes discussing everything.

The good news now is that Bob is stable. No profuse bleeding, holding his own. They can't take out the breathing tube yet, however, because he is still in critical care and because he may have suffered lacerations in his throat when it was originally inserted (with great difficulty) and they're waiting for an ENT specialist to examine him.

To update, Jon and I have just returned from our third brief visit at 9:00 this evening and although we are both bleary eyed, I wanted to send this quick, and I hope reassuring, note to you. He is completely stable, but still heavily sedated and was not aware of our presence. He has a dedicated nurse with him all night who is a gem. The ENT Physician had not arrived but was expected at any minute. His heart is strong now, the lungs are clear, all his other vital signs are good and we are confident that he will make a full recovery. .

Get Over Your Junk

Get over it already! Having an implanted medical device for almost twenty years and having flown frequently both domestically and internationally during that period, I've had more pat downs than Tiger has had lap dances. Furthermore, having endured the indignity of backless hospital gowns and medical procedures on a number of occasions, my being naked on a faceless image of a body scan sure beats being blown to smithereens at 30,000 feet.

Amazing, this "outcry" against thorough airport screenings is exactly the kind of disruption terrorists want and the American public is buying right into it. Instead of just going through this in an orderly way to expedite the process, we conjure up images of our constitutional rights being violated. It will take only one tragic incident in the air to silence these critics, something they are inviting by their protests.

Do I think these rigid guidelines are the answer to combating terrorism in the skies? No, but they are part of a solution, and an easy one if everyone simply cooperates. Ten seconds in a body scanner is not too much to ask. Your "junk" is not so sacred. Stay home and never go to a hospital if you think it is.

The Widow Maker

There is a fine line writing this blog, expressing my views on a number of subjects, but sometimes struggling about how much personal information I am willing to reveal, and this entry is one of those, somewhat crossing the line to recount a recent health issue as a "public service" piece.

I remember when Forbes' Wealthiest 400 List was first published, noting that among the foremost "professions" that led to wealth was "inheritance." I made a mental note to make that my college major in my next lifetime. Being born into such a family such as DuPont or Rockefeller made succeeding generations instant lottery winners!

Here's the connection to the topic at hand: The reverse lottery is being born into a family that has a history of coronary heart disease. Eating a reasonably healthy diet and exercising might delay or mitigate the effects of being dealt poor genetic cards, but last week I found that no matter what I do, I am going to battle this disease for the rest of my life. That is the depressing part of the problem. I have always approached life with the thought I can do something about affecting the outcome. Well, I have no direct control over the progression of coronary heart disease; both my parents suffered from it, in one form or another.

Now other people have been dealt much worse hands on matters of health and cancer has to be among the most cruel and frightening. Coronary heart disease, however, is stealth like and a bigger killer. It develops over years and years. No doubt I compounded my genetic problem as a young adult, smoking by my late teens into my early 30's. My parents both smoked and the rooms of our home sometimes looked like they were in a fog. Also as I kid I ate foods like Wonder Bread ("builds strong bodies 8 ways!") and drank massive amounts of whole milk (which I did into my college years). Meat was also a staple "health" food, and Coca-Cola at 5 cents a bottle was consumed like water.

Over the past summer I noticed that I was having difficulty climbing steep hills during my morning power walks, with a noticeable tightness in my chest. So until we returned home to Florida, I just avoided hills. That was stupid. I should have seen someone immediately, but I didn't think much of it and I was fine otherwise. Once I returned, my Doctor did not like anything I reported, and he said let's skip the usual stress test and go directly to a radial catheterization. Going through the wrist is a newer technique, with faster recovery for the patient. So I went into our local hospital which has an excellent catheterization unit on Monday last week, made a mental note of the time I was wheeled into the cath lab and found myself in recovery less than a half hour later. I then knew there was something wrong. Even if they did merely a balloon angioplasty it would have taken longer than that.

When the Doctor showed up in recovery, he explained I had a 99% blockage in the "Widow Maker" an apt name for the left anterior descending artery which usually gives little warning of being blocked and most who have a heart attack because of that particular blockage die then and there. This blockage could not be addressed with drugs and most interventionist cardiologists would simply refer me to surgery for bypass surgery, an invasive procedure, painful, and with some real risks.

He suggested another option, inserting two drug eluding "kissing" stents where the arteries form a "V." He said it would be tricky, but given my age it might be a better option than a bypass we might have to do all over again in ten years. One bypass per lifetime is enough.

So the next day I was prepped early for a femoral procedure and at 8.00 am was back in the cath lab saying hello to the same technicians and nurses again (we're on a first name basis). I didn't get out until after 10.00 so I knew it was a complicated procedure, but awaited the word from my Doctor about how it went. He explained I received three new drug eluding stents, two in the left anterior descending artery and a kissing one in the diagonal. That makes six total stents in my system and I am now known as a catheterization lab "frequent flyer."

It's been quite an experience. As I said, not half as bad as many people have to go through with their health issues, but bad enough. The message: listen to your body and know your family history.

I am hopeful that I can continue to successfully manage this, but that hope is sort of dependent on being reasonably tethered to my cardiologist and cath lab. In that regard, Dr. Paul Teirstein of Scripps Clinic wrote a reassuring editorial, "Drug-Eluting Stent Restenosis. An Uncommon Yet Pervasive Problem", published online June 21, 2010 in Circulation. His advice for physicians:

Do not underestimate the emotional impact of repeated procedures on patients, particularly the “frequent flyers” who have experienced multiple visits to the catheterization laboratory. These patients often describe significant frustration and fear. They feel a loss of control, mostly due to an inability to plan their lives and predict when a restenosis will occur. It is helpful to reassure these patients by emphasizing they do not have an incurable, lethal disease.... Patients can be told if they stay in close contact with their cardiologist, the risk of death and infarction is low.... It may sound obvious to the physician, but most of our patients are seeking this kind of reassurance.... I also emphasize that recurrences are unlikely to go on forever. Finally, it is worth communicating that they are not the only patient to encounter this problem, and ultimately, patients with restenosis who seek treatment usually have good outcomes.

Potpourri

Towards the end of the week I am going into the hospital for “a procedure” (a minor one to the medical community, a major one to me) so I attribute this posting to some free floating anxiety and an attempt to get some thoughts down on several topics, all suitable for their own entries. I think of them as a bunch of tweets, albeit more than 140 characters.

The first thing on my mind, other than “the procedure” is how quickly we’ve become inured to the major catastrophic saga of the last month: the oil “spill” in the Gulf of Mexico. I present as anecdotal evidence Sunday’s New York Times. “All the News That’s Fit to Print” fails to mention anything on the topic until more than halfway into the first section, although the front page did carry an article on premium prices for a Jon Bon Jovi “concert” in Hershey, Pa.

Why, I wonder, are we not pressing with all the public opinion power at our disposal for some resolution to this disaster? To watch BP, Transocean, and Halliburton in the brief Congressional Hearings was sickening, each pointing to the other to blame in a see no evil, hear no evil, speak no evil routine, finally all pointing to the Minerals Management Service which “oversees” drilling activity. BP says it will pay "all legitimate claims," the operative word being their interpretation of “legitimate,” but that is far from the main issues: why were there no contingency plans in place and how, with all this country’s resources, is there no way to stop this fire hose of black destruction on the pristine waters of the Gulf? Every single one of us should be holding these companies and the federal government responsible and let our justifiable anger be heard.

Maybe I take this personally as we live in Florida and appreciate the natural beauty of its waterways and beaches. But I felt the same way after the Exxon Valdez and it is absolutely stunning that we have failed to learn the sad lessons of drilling in fragile environments.

Then, I shift to another aspect of living in Florida, particularly south Florida that is blessed with some of the finest theatre talent. I’ve written before on the incredible productions at Dramaworks, the West Palm Beach theatre dedicated “to theatre to think about.” Yesterday we saw a concert version of Sondheim’s classic Into the Woods performed by the Caldwell Theatre Company. There we discovered that some of the actors we’ve seen repeatedly at Dramaworks and Florida Stage not only can also sing, but do so at professional levels befitting Broadway. In particular I mention Jim Ballard (who we saw only a few nights before in a Noel Coward reading at Dramaworks), Elizabeth Dimon, Wayne LeGette, and Margery Lowe, and I apologize if I am overlooking others. Also, as a pianist myself, I found Michael O’Dell’s keyboard accompaniment remarkable – almost three hours of Sondheim’s intricate melodies played flawlessly and lovingly. All in all it was a great performance of one of Sondheim’s best works, the lyrics of Children Will Listen reverberating in memory:

Careful the things you say
Children will listen
Careful the things you do
Children will see and learn
Children may not obey, but children will listen
Children will look to you for which way to turn
So learn what to be
Careful before you say 'Listen to me'
Children will listen

We saw Stephen Sondheim last year in West Palm Beach on the eve of his 80th birthday (I regret that Google has removed music uploads from the link). He is a national treasure, our last remaining tie to the greats of Broadway.

Finally, and I’m not sure about the appropriate transition to this topic, but I continue to be mesmerized by Raymond Carver’s writings, including his essay “On Writing.”

From that essay, here is classic Carver as it is exactly what he does: ”It’s possible, in a poem or a short story, to write about commonplace things and objects using commonplace but precise language, and to endow those things – a chair, a window curtain, a fork, a stone, a woman’s earring – with immense, even startling power. It is possible to write a line of seemingly innocuous dialogue and have it send a chill along the reader’s spine.”

Thinking about a friend who admitted he wrote something just to make a deadline and make a buck, knowing he could have written something better if he took the time, Carver writes, “If writing can’t be made as good as it is within us to make it, then why do it? In the end, the satisfaction of having done our best, and the proof of that labor, is the one thing we can take into the grave. I wanted to say to my friend, for heaven’s sake go do something else. There have to be easier and maybe more honest ways to try and earn a living. Or else just do it to the best of your abilities, your talents, and then don’t justify or make excuses. Don’t complain, don’t explain.”

It seems this advice is applicable to everything as we journey into the woods.