Thursday, April 21, 2011

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.