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.

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.