Friday, June 21, 2013

Coronary Artery Bypass Grafting

CABG procedure in progress

CABG is a medical acronym that stands for Coronary Artery Bypass Grafting

I have been reviewing my blog posts, and realized that there is a big hole in my blog entries, starting about October 2011 and going forward for about a year.  Sorta like the big hole in my chest that appeared just about that time.

One of the excuses I offer for my lapse is that I had a timeout for a heart attack and bypass surgery.  In medical parlance, they refer to it as "myocardial infarction".  To me it was just plain ol hurtin.

I had the acute heart attack episode in September 2011.  I came home from work that day feeling rather tired, so I tried to lay down and take a nap.  But I had a persistent sharp chest pain, and was having difficulty breathing while laying down.  I had little inkling of just what was developing inside my body, but since laying down proved too uncomfortable, I went to the family room to sit in the big cushy recliner and watch TV.

I live with my mom, but she had been gone on an extended shopping trip since that morning, so I was home alone.  I got more uncomfortable as time went on, but still had no suspicion that I was experiencing a heart attack.

Finally my mom came home late in the afternoon.  She had been experiencing frustrations of her own, with shopping crowds, road construction, her car running out of gas, preparing a meal for a Relief Society assignment for some families in the ward, and a host of other annoyances and inconveniences.   She started telling all about it, while she put Papa Murphy's pizzas into the oven.  She had been planning to fix casserole for the other families, but ran short of time and decided to do quick Take 'N' Bake pizzas instead.

I sat on the couch, immersed in a haze of pain, not paying much attention to her recounting of the challenges of her day.  When the first batch of pizzas were cooked, she left to deliver them, after putting in some to bake for us.

By the time she returned, the pain had increased to an alarming level, though during earlier episodes with health problems I have endured much higher pain levels.   I just didn't understand what was happening.

We sat down together to eat pepperoni pizza, and I was thinking I might feel a little better after I ate something.  So I had a couple of slices of pizza.

After we had dinner, I returned to the recliner.  Eating dinner didn't help.  I got to hurting so bad, I felt like I just wanted to go off to bed, and sleep it off.  But I got in some kind of surreal argument with my mom as I attempted to head off, and finally confessed to her just how awful I was feeling.  She wouldn't let me just go to bed, but insisted that I needed some emergency medical attention, and it turns out she was right.

Dammit, she's ALWAYS right!  Why do I even bother to argue?

Anyway I donned my footwear and she drove me to the hospital emergency room at Utah Valley Regional Medical Center.  I was unhappy to be heading there for yet another hospital adventure, but it hurt me so bad, I didn't argue.

Checking in at the ER

When we arrived, the ER attendant quickly wheeled me in to an exam room, and the doctors and nurses began their probing and prodding and inquisition.  One hitch that I encounter with every doctor visit these days is how I should answer their question about pain.

Numeric Pain Rating Scale

Medical people all ask the same question to evaluate patients experiencing pain.  "On a scale of 1 to 10, how would you rate your pain level, with zero being no pain, and ten being the worst pain imaginable."

Okay, that's clear enough to understand.  My problem is, how to frame my response, because I have in the past experienced a nightmarish raving screaming in pain, such intolerable pain that I was more than willing to die right then to have it stop, bouts of pain that would rise to a crescendo, until finally it would cause me to pass out.  So I can imagine quite a lot.  My past experience kinda tends to make the pain rating scale irrelevant.

The compromise I have arrived at for such situations, which have been all too frequent lately, is generally to report a pain rating level of 7.  I know from experience that this is the level medical professionals consider to justify some kind of medication as intervention for pain relief.

They finally gave me a big shot of morphine, and immediately I was breathing much easier.  Pain drugs are so wonderful!

As they worked on me in the ER, my mom had phoned my sister Cindy, and she came right away with her husband Carl to the hospital.  That was another routine that had become far too routine, but Carl and his son administered a priesthood blessing, which is always a comfort to me in times of distress.

Quite some time passed.  Then the ER doctor made an extended presentation of what they knew so far.  He explained that test results were somewhat ambiguous, indications from blood testing were that I'd had a significant myocardial infarction, but the chest x-rays also indicated some pericarditus.

During a heart attack, heart muscle cells die and release certain proteins into the bloodstream.  The blood tests showed this, but there were other possible explanations for my symptoms.

After some medical deliberation, the doctors brought in the heart specialist.  He recommended that they perform a coronary angiogram, which helps them map blood circulation to the heart,  and allows them to perform angioplasty, and to emplace a coronary stent where they judge it is warranted, to help open blocked arteries.

Soon they wheeled me into the pre-op room, where they prepared me for the catheterization lab.  The guy that was prepping me injected me with something, and I don't remember anything after that for what seemed like a long blackness.

I don't know exactly what they saw in the cath lab, but next thing I knew, I was back in pre-op being prepped for the CABG operation.

Those moments are pretty fuzzy to recollect.  I heard people saying things around me, but they seemed to be very far away, and it was much too difficult to respond.  What I remember mostly is people offering reassurance and encouragement, but I wasn't sure why.  I still didn't realize what was happening.

After that I remember going into the operating room, transferring from the gurney onto a narrow table, laying on my back.  All kinds of people bustling around in surgical gowns with gloves.  Then someone put a mask on my face, and told me to start taking some deep breaths.  That's the last awareness I had for what seemed like a long time.

Apparently, while I was unconscious, the doctors had decided that the angiogram results indicated that there were too many severe arterial blocks to correct with angioplasty and stents.  Facing the possibility of my immanent demise, my mom gave the go-ahead for the doctors to perform the CABG surgery.  The cardiac surgeon apparently told my mom it was lucky for me that she brought me into the ER, instead of letting me just go to bed as I had wanted, because I would not have survived the night with the current condition of my heart.

Heart during CABG procedure
The surgery involved cutting a long incision down the center of my chest.  Apparently then they saw apart the ribs, and use an instrument called a rib-spreader to force apart the rib cage and expose the chest cavity and the still-active heart.

The surgical team

The CABG procedure apparently employs quite a team of doctors and nurses gathered around the exposed heart.  Before they put me under the anesthetic, I noticed a pretty big crowd of people were in the OR.  Everyone is wearing a surgical mask, so even if I knew anyone, I would probably not have recognized them.  I guess some of them mighta just been curious spectators, or even space aliens just dropping in for a visit from another planet, I honestly dunno.

Heart-lung machine

To get the CABG started, the heart is prepared for attachment of the cardio-pulmonary bypass machine, which during the surgical bypass procedure, replaces the normal functioning of the patient's heart and lungs, hopefully temporarily.  Plastic tubes carry blood from the heart to the machine and back.  While passing through the machine, transported by mechanical pump, the blood is oxygenated and returned to the body.

At this point the surgeon administers a cardioplegic agent, which paralyzes the heart muscle and stops the heart from beating, just as in death.   The patient is effectively being kept alive by temporary artificial cardiovascular perfusion.

Prior to the opening of the chest cavity, another team is involved in harvesting veins from the leg or arm to use to bypass blocked coronary arteries.  In my case, the blood vessels to be used in bypass grafts were extracted from my right leg, typically using the "great saphenous vein".  Apparently they utilized some type of endoscopic technique - I'm not certain, but there is no incision scar on my leg.

During the procedure, the cardiac surgeon performed seven bypass grafts on my heart.  That seems like an unusually high number to me - I've heard of double, triple, quadruple bypasses before, but I never heard of seven.  I guess they had plenty of grafting material, so why not go for it?   Maybe I'm just lucky to still be alive.  They don't even seem to have a term in medical jargon for a seven-artery bypass.

So the surgery took about 8 hours of the surgical team working on me.   Obviously they went to a great deal of trouble in my behalf.  My heart was not beating for much of that time, which is difficult for me to imagine.  Perhaps it is fortunate for me that I don't remember any part of it.  But in any case, they performed the CABG, got my heart beating once again, and closed up that huge gaping incision in my chest.

Shocking the heart to stimulate heartbeat
Next thing I knew, I was waking up some time in the afternoon of the following day, in the  cardiac intensive care unit at the hospital, there was a big incision wound sutured down my chest, wires and tubes trailing out of it, with attachments to all manner of devices that I could not really see.  I could hear them, though - beeping and ringing and vacuuming me right on cue, as if to reassure the attendants that I was still alive.

Actually the first shock to me was to realize that I WAS STILL ALIVE!  I think I had prepared myself for dying, but being kept alive hooked to a bunch of machines, seemed like much more than I was ready to accept.

I recall very little about the first few days.  One memory of the attendant assisting me to sit up in the bed.  With help, I swung my legs out of the bed, and just about the time my feet were touching the floor, everything suddenly went black again.  I heard someone saying something like, "He's passing out!", and don't remember what happened after that.  I guess I woke up a bit later.

I was several days in the cardiac intensive care, then they moved me to a bigger room somewhere else in the hospital, I don't really know where.  During that period, I got physical therapy from a whole cadre of people, I don't remember much about.  They encouraged me to stand up, and eventually to walk around the ward, it you could call it walking.  I was also coached about breathing exercises by the cardiologist and a host of others I don't remember too well.

They seemed to have a lot of interest in my capacity for continued breathing.
Apparently that is one factor they encounter lots of complications with in cardiac care.  They gave me a little plastic gadget for measuring my breathing capacity, and I was supposed to exercise with it regularly.  I did the breathing exercises, but I could never tell that it made all that much difference.

A number of people visited while I was there, many of whom I don't recall.  Several notable visits including Dr. Kennedy, my family doctor.   Two ladies from Ability First, where I had been working.  My cousin Randy.  People from my ward.  Several of my sisters.  And of course, my mom.

One of the grossest things in all of this nightmare experience - at least, that I was conscious for - was when I was getting ready to check out from UVRMC.  The whole time I was there, I had a number of "things" attached to me, among other pleasantries, several big plastic tubes trailing out of my chest leading off to some kind of suction pumps.  I guess the object was to remove any excess blood that accumulated in my body's various cavities as a result of the surgical wounds.

When the time came, they just yanked them out, rather unceremoniously, from my perspective.  It was quite horrifying to me, watching these big plastic tubes come slithering out of my body.  I was afraid I would come apart at the seams or something, and all my guts come spilling out across the bed.  Over the next few months I had the uneasy feeling that if I sneezed too hard, or happened to be too roughly jostled, my chest would open up and everything would gush out on the floor.  To make it worse, medical authorities routinely warn those who have had their chest surgically opened to be careful about heavy lifting and reaching overhead. 

Of course the biggest relief of all was having that damned Foley catheter removed.  It never is comfortable to have that thing jammed up one of the most sensitive parts of the body.  I was not capable of urinating by myself for a while, so I guess it was necessary.  But what tortuous hospital appliance could be more undignified, I cannot imagine. 

So after my time in the hospital, they got tired of me, and sent me across the street to a rehab place.   They delivered me in an ambulance, to ride across the street.  How exciting.   I was at the rehab and nursing care center for several fairly uneventful months before they finally sent me home.

Several other issues related to the CABG procedure have come to my attention since I had the surgery.  I believe they are of general interest to anyone involved in such an operation.

My older brother had an artificial heart valve implanted in a similar procedure, and he expressed concern about one of the side-effects popularly referred to as "pump-head", or in medical parlance, postperfusion syndrome.  The syndrome is rather controversial, and is provisionally characterized by a wide array of neurological deficits that are manifested following surgery that involves perfusion.  Medical authorities theorize the syndrome may be caused by tiny debris and air bubbles (microemboli) that enter the brain via the action of the heart-lung bypass machine.  Scientific research has returned contradictory findings.

Am I any more stupid than I was before the surgery?  I don't really know.  There is no objective method for me to assess my own cognitive functions, other than those that use those very functions.  I have no way to distinguish between neurological defits resulting from my strokes and other medical issues and the CABG surgery.   It becomes a sort of recursive question, one that seems to be of much particular interest to no one but myself.
Another standing question from the CABG procedure relates to how the surgery affects people, particularly in ways other than the most obvious.  A number of scientific studies indicate that postop outcomes directly affect many quality-of-life issues.

One of the relative measures of success for post-CABG is referred to as "graft patency".  It expresses coronary circulation in grafted veins, as a percentage of optimum.  CABG veins go through the same occlusion processes that the original arteries are subject to, and the general projection estimates an average of five years of life from the grafted veins.  Then it is expected that CABG recipients who have survived that long will undergo another CABG procedure to replace the old grafts.

In further medical episodes that have been staged in more recent times, I have experienced chest pains and breathing difficulty, with lots of rather disturbing irregular heartbeats.  There have been doctor visits to all kinds of specialists, and not a few trips to the ER.

Most recently I consulted with a cardiologist, and though the outcome of the session was as unsatisfying to me as most other doctor visits, among other things he recommended that I have a cardiac stress test.

He prescribed for me to start taking a very commonly used diuretic, Lasix or generic furosemide, even though I protested that I had tried diuretics before, and the side-effects for me were intolerable.  The good doctor seemed not to hear me.  After trying the drug for one day, and spending most of the subsequent night in the bathroom, I decline to take any more of the stuff.

The cardiologist had also prescribed an additional drug which I never obtained, since the pharmacist informed me, when I requested the prescription, medical insurance would not cover the cost of that drug, therefore decided I really didn't need the drug that the doctor had prescribed all that much.  Another instance of health insurance informing my need for health care.  The last time such a thing happened, I was scheduled by my doctor to get a cardiac stress test, and the insurance company declined to authorize it, because they decided I didn't need it.  By coincidence, the very next day after the test had been scheduled, I had the heart attack. 

I submitted myself to the stress test this time, admittedly without much joy, and went back to the cardiologist a few days later to hear the interpretation of the results.

The only really interesting thing was the nuclear reagent Thallium, which they carried into the room enclosed in a small lead-lined flask.  Then they injected the stuff into ME!  I guess I was glowing in the dark for a while.  It was an amusing picture to imagine, anyway.

Subsequent meeting with the cardiologist was a rather interesting session, more informative than most doctor visits prove to be, perhaps because the cardiologist was accompanied by some kind of apparent doctor-in-training, who listened to his narrative and took copious notes.  The doctor addressed many of his observations to her, but I listened intently.  I did not internalize all of his characterization of the test results, but caught several references that seemed important.

He mentioned one metric they call "ejection fraction", and indicated that mine is less than 40%, which I understand is not good news for me.

He used the term "congestive heart failure" in the particular context of the problems I have been having with edema in my feet, more pronounced in the right foot.  He categorized the edema as "grade 4" in severity, which is the most severe.  He offered the rather obvious observation that circulatory impairment was naturally more pronounced in my right leg, because surgeons had removed a portion of the right saphenous vein in the CABG procedure for graft material.  None of the other doctors prior had ever suggested such an obvious and clear reason for the right leg swelling.  Believe me, I had asked plenty.

He said he was not anxious for me to have another coronary angiogram, even though I was continuing to experience severe chest pain.  I expressed my reluctance also, but perhaps for reasons somewhat different than his.

Anyway, the immediate outcome was that he prescribed a proton pump inhibitor, on the off chance that my chest pain was just a bad case of heartburn manifesting itself.  I've been taking it twice a day, and cannot discern any significant effect, particularly in the incidence of chest pain and irregular heart rhythm.  He scheduled a follow-up for a month later.  We'll see what future developments will follow.

Next instalment:  Everybody Dies

No comments: