I'm Not Dead... Yet! (60 page)

Everyone who came into the ICU was a bit blown away by how talkative I was; how coherent I was. I could see the surprise on their faces. My sister laughed and said, “Robby hasn’t talked that much since high school!”

Now it was my turn to prove that all of the past three surgeries had taught me something. I asked for the breathing machine—and the ICU doctor was a bit surprised that I asked before he gave it to me.

I used that inhalation plastic toy as if it were the Superbowl of all events. I used it every few minutes. I got used to the maximum chest pain as fast as I could. I checked how it hurt when I leaned to the right; to the left, when I used my stomach muscles to try and sit up; when I pretended to cough.

I knew that pain was the main obstacle that most open-heart patients try and avoid and in avoiding it, they stay motionless, which is the worst thing you can do after surgery. Within reason, you must begin to move your body parts. And, the way I deal with pain is that there is a pain I call the definitive, ultimate pain. I try and go hunting for it as soon as I can. It’s a safari for pain. Once I make up my mind and find what I believe to be ‘the worst possible pain,’ then all of the other pains are relative.

I find that pain is only a minor part of a patient’s unwillingness to help themselves: it’s the
unknown
that is really the culprit: how much worse is this pain going to get? For me, once I find that supreme pain situate, I’m ready for some football!

Later in the day my mom, dad and sister came back into the ICU to say goodbye. They were flying home. I know they saw me in my actual room, but I only remember shadows…

I made it to my room pretty fast—not in record time for me, but still pretty fast. I was now on Lasix, a drug they give to horses to reduce swelling and it stops the horses from retaining fluids. As a guy who grew up around horseracing, I felt a silly delight that I was on the same drug that many of the horses I had bet on also used. (I usually lost…) I learned that the more surgeries one has, the more scar tissue and the more liquids and fluids build up in the system. They need to be removed with Lasix and through the infamous tubes coming from my abdomen, which drain the fluids into a bag hanging on the side of my bed. I stared at the see-through heavy plastic bag. It was a pinkish color. Because of the Lasix I had to urinate like… well, a racehorse.

There came a time when I asked if they would take the Foley catheter out of my bladder, through the urethra and out of my damn penis. “I’m tired of abusing my penis.” (I made the nurses laugh.)

They had to wait a while for two reasons: 1) the bag that was collecting my urine was taken to the lab and they were checking on things like electrolytes, infection, muscle breakdown and kidney function; 2) they wanted to be sure that I could walk to the bathroom—and in doing so, be able to collect all of my urine in a device that looks like a plastic prototype that didn’t pass muster with the company that makes pitchers for lemonade.

Each nurse that I had was
exceptional
. All of them cared about my well-being but also cared about helping Karla, Lyric and Zephyr, too.

Little by little my body was cleaning out the amazing drug cocktail of anesthesia that put me to sleep and then made my ICU stay like a vacation in a science fiction film where you feel great—even when you hurt. Now I just hurt. The only thing on my mind was when and how are they going to pull out the drainage tubes? Then I realized, I only had
one
drainage tube. That was an innovation since my last surgery six years ago, and from what the nurses were telling me, removing it didn’t hurt like the old days.

They gave me Metoprolol, a beta-blocker to help the heart heal. I never did well on beta-blockers so after a few days, they switched to an alternate medicine and I never even knew it. I just felt better. There was someone constantly coming into the room to take blood. For some reason, I had a high white blood cell count.

At the time, I was on a myriad of medications: Simvastatin which is in the class of statins which lower cholesterol, but since my cholesterol counts were in the good range, I was taken off this medication when I left the hospital. Omeprazole, 20 mg capsules were given to me by mouth. This is a medication that treats ulcers because if I had to be on a blood thinner, I definitely didn’t want bleeding in my esophagus or lining of my stomach. I was given one baby aspirin a day to also thin the blood. It was 81 mg. Very small but strong enough to do the trick. They prescribed a Lidocaine patch (700 mg) for my wound as added pain relief, but I found it to be uncomfortable. They knew, from my second surgery, where I woke up in the ICU feeling something was wrong (and it was), I might require anti-anxiety medication post-op, so I was prescribed Lorazepam tablets at 0.5 mg. It was comforting to know they were available if needed, and that they actually listened to my prior medical history.

Because of the pain meds and the anesthesia, our bowels seem to ‘go to sleep’ and it is very important to have bowel movements without grunting and putting pressure on the newly-wired sternum, so Sennosides at 8.6 mg. tablets were given to me orally, twice daily. This medication is derived naturally from Senna, a natural herb extract that is safe and is a time-tested laxative. Along with the laxative they gave me a stool softener called Docusate sodium at 100 mg. Even though it can be the subject of many good juvenile jokes, this is an extremely important medication, believe it or not.

Finally, they gave me Warfarin (Rat poison! I find it ironic that the first three letters in this medication spell
war
) at doses beginning at 5 mg. but with pills that were 2.5 mg. doses. Warfarin or Coumadin, is basically going to keep me alive.

I got up as soon as I could and we’d put the drainage tube bag on the I.V. pole so I could walk the halls. The hallways were great places to walk and I saw other patients doing the same.I faced my moment of truth again: the dreaded removal of the drainage tube. Two kind nurses were talking to me; I was sitting up and knew it would come any second. Their ability to take my mind off of the ‘pulling of the drainage tube’ would never work with someone like me—whoa, it’s out!

It hurt a little. Was that really it? Then, with a smile, the nurse removed my pacemaker wires. Okay, it wasn’t fun—but remembering back to my other surgeries, those procedures were the stuff of nightmares. But not here, at The Cleveland Clinic.

It was over.

We all had made it.

Valuable Life Lessons?
Life
is a Valuable Life Lesson…

Finally, after the longest stay
I had ever had in a hospital, nine days, I was released on Thursday, June 3—and I don’t count the day I was released because… I don’t want to! (Or as my dad once said when my mom told him he was being a little cranky, “I’m 80 years old. If I want to be cranky, I’ll be cranky!”)

We had been living at The Cleveland Clinic for over a month and knew the hospital almost inside out. It worked like a clock.

What is necessary is acknowledging the team, from Mustapha the man who met us at the airport, to Dr. Koch who was on the phone with me and Karla immediately after we told our friend Steve Popovich that I needed another open-heart surgery.
It was all a team effort
.

Dr. Brian Griffin, my cardiologist, was as intelligent a man as I had ever dealt with but more importantly, he immediately made Karla and me feel
safe
. Dr. Griffin didn’t waste time with us; he would just stay until he was sure we understood what was happening inside my chest, and what would happen in order to fix it. And, he is a gentleman. A
gentle
man. In every sense of the words.

Dr. Griffin had a young assistant, Dr. Krishnaswamy who was a great help to us as well. He would explain things in terms of sports so that I could understand it better—but never in a condescending way. When I returned to The Cleveland Clinic for my post-surgery follow up tests, I ran into him in the hallway. He is such a force of goodness, there was no way of missing him, even in a crowd.

We learned what our new life-adventure with Coumadin was going to be like from Dr. Mike Roizen,

who is the hospital’s wellness expert and is also the best-selling author of the “YOU” book series with Dr. Mehmet Oz. I discussed the effects of cardiac depression with Dr. Leo Pozuelo.

Our discussions were honest and frank—but again, there was a
respect
that he and everyone at The Cleveland Clinic exuded. He invited us to attend a conference about the effects of cardiac depression on the patient, the
2010 Heart-Brain Summit
. In his mind, as with so many others, there is no secrecy at The Cleveland Clinic; it’s a pool—a pool of
knowledge
—and everyone, even the patients, were encouraged to participate.

From past experience I understood that surgery is more than a medical procedure; it is an art form. Dr. Gosta Pettersson is an artist who performs his art under life and death situations. He is also co-author of the book,
You Have Touched My Heart,
with Johannes Mollehave.

I had the opportunity to ask him about certain issues I didn’t understand, the first being the Ross Procedure (where the pulmonary valve is removed and put in the aortic position and a cadaver valve replaces the pulmonary valve).

Dr. Pettersson began by saying, “Let’s elaborate about the Ross Procedure. The Ross Procedure to begin with is a simple principle where you take the best valve the patient has and put it in the most important position. We take it out of the pulmonary position and put it into the aortic position. The valve goes from a low-pressure position and goes into a high-pressure position.”

“This principle has two weaknesses. One, you take it from the low pressure and put it into the high-pressure position. Not all pulmonary valves can stand up to the high pressure. The majority do fine in the aortic position. Before we are born, the pressures in the two ventricles are in essence identical; they both serve the systemic circulation, and it’s really first at birth that they separate—the right side becomes the low pressure and the left side becomes the high pressure—so it’s really a wonderful operation. The weaknesses are the low pressure to high pressure and how the valve reacts; and the second issue is we have to use a cadaver valve in the pulmonary position—and that has a limited lifetime. If you’re lucky the failure mode is such that it’s really non-consequential; and if the rest of the heart is perfect and normal, you can live with a bad valve or even no valve in the pulmonic position.”

“Many people have invested a lot in trying to save the pulmonary valve in the aortic position. The idea of reversing it or trying to fix the pulmonary valve in the aortic position is understandable, but I have operated on enough patients, and you have the risk of having two bad valves in your heart. I have been less impressed with how good these failed pulmonary valves are in the aortic position—I have been able to repair some, but these failed pulmonary valves in the aortic position have not been as good and as reliable as I would like them to be to take a fairly high risk of needing another operation down the line.”

“The Reverse Ross Procedure comes out of experience with many other operations. For example, human cadaver valves in the aortic position is a fairly common operation, but that also results in re-operation; it has a limited lifetime. So what we used to do for those patients is put the valves inside the existing failed human cadaver valve. That didn’t turn out to give the patient a very good valve—they got a small valve in a bad conduit—so I started to take this failed human valve completely out. Then I learned how to take the whole root out, very nicely and safely, and to clean everything out and go back to the original pathology. So the Reverse Ross came as a consequence of a lot of experience with re-operations.”

We discussed the art of being a surgeon and he literally blushed and said, “Whatever you do is imperfect… prosthetic valves aren’t perfect, so you have to find good compromises, and I think the older you get, the more important safety becomes to you… the
safety
of the
patient
… and to do, what you are, deep down inside, convinced is the right thing to do—what I would do to myself if I were operating on myself or to family members. Safety.”

“Actually, there are very simple rules. And when you violate those rules, you go home with a conscience that is not perfect. With this job, there is always concern… you always have ‘bad conscience’ because you’re never quite perfect. You try so hard to be, but we’re never quite perfect. And remember, nobody ever calls a surgeon with good news. When I get a phone call, it’s always about… bad news. Someone needs me to help them. It’s very hard for me to sleep because I go over each part of the operation, since I first began, always asking myself, ‘Did I really answer this question correctly or did I perform this part of the operation perfectly and what should I have done to make it better.’”

I was fascinated with the part of the operation where they cooled my body down so that they could work on the ascending aorta.

I asked Dr. Pettersson if he could describe the procedure for me:

“What we do is to cool down the patient completely so that the brain metabolism almost stops. It doesn’t stop completely—there is still a time-dependent damage that you do to the brain—the time you have available to stop the circulation without brain damage is about four minutes. That time goes up as you lower the temperature of the body, and when you come down to 16 or 17 degrees (Centigrade; the conversion is 61-63 degrees Fahrenheit), you can say you have 30 to 45 minutes—and I only need 12 to 15 minutes of time, so it’s very safe.”

“Is the heart ever out of the body?”

“No,” he smiled graciously, allowing us to learn at whatever speed it took. “The heart is never out of the body. The heart is stopped with an ice-cold blood base solution that has a high concentration of potassium that paralyzes the heart. There are a few blood cells in this solution so it can oxygenate the blood. We can stop the heart for four or five hours and it’s in essence as good as when we started after a couple of minutes of recovery.”

The most important question I had for Dr. Pettersson had to do with the heart-lung machine, which he says is very, very safe in today’s world.

He continued, “You get the slow activation of the blood. The white blood cells for instance. The white blood cells respond to injuries in the body—and they get a little confused. (He began to laugh at the simplicity of the discussion, but he loved that we were interested and was so happy to explain things to us.) They know, the white blood cells know that something is going wrong. They understand that something bad is going on and they become activated, but they don’t know where the problem is. So these activated cells get deposited everywhere in the body and they release their enzymes and toxic substances—and that’s why you get this, what we call ‘general inflammatory response’ to the heart-lung machine. Not necessarily linear but more exponentially time-related. How bad your response to the heart-lung machine is also age-related; so the older the patient, the worse they tolerate the heart-lung machine and the more difficult it is for them to reverse this effect afterward. You can see that afterwards you are a little mentally impaired, your lungs are not so good, your liver is not so good, and your kidneys are not so good—but if it’s a short operation you will recover quickly. There will be minimal permanent damage.”

I asked Dr. Pettersson if he visualized his work before he began his operations, the same way many ‘jocks’ might visualize athletic moves—even winning—before each game.