As noted in one of my earlier posts,
Minimalist PT explained, this is intended to be a platform for the sharing of information from both providers and patients. In keeping with this intent, below you will find an article written by a patient regarding heart surgery. It is his personal experience and he very eloquently and with great detail describes the procedure that saved his life as well as his thoughts, experiences and emotions as he went through diagnosis, surgery and then recovery.
Below is the article. This was published in the December 1998 issue of Esquire Magazine. "
You Haven't Lived Until You've Died" by Ramsey Flynn.
WHAT IF YOU PULLED OVER RIGHT NOW, RIGHT HERE IN THE
Beltway’s emergency lane, and just keeled over for good? Relax
relax relax. Is there a piece of paper and something to write with?
What to say to Betty and the boys? How much time do you have?
Easy. Relax. Breathe deeply. What will people think when they
hear police found you here stiff, in such an unpoetic circumstance,
jerked over on this colorless roadside at some random
junction of latitude and longitude? Let’s see now, how best to position
the body? Might there be a way to concoct some ironic
wink from beyond the grave to amuse your colleagues? And why
do they really matter at a time like this, anyhow? Shouldn’t you
be getting ready to meet the Big Cheese? Relax easy relax.
Breathe deeply and slowly.
Why is the steering wheel slippery? Sweat! “Uh-oh.” You
punch off the “calming” Wynton Marsalis CD and fumble for the
window levers. The air rushes in, and you tense up as it whips
your work papers around. The afternoon’s thunderstorms have
left little shreds of trailer clouds on the dark horizon, and a cool
August mist fuzzes the interstate’s hostile sodium-vapor lamps.
The odd taste of iron floods your mouth. Blood? You twist the
rearview mirror to reflect your face, which is more puke-white
than usual. Someone leans into
his horn while passing, because
you’re slowing and angling and
looking for an exit.
Okay okay—easy—maybe
we’ll get a break here. So your
chest ache has radiated into your
left shoulder and upper arm, and
there’s tingling and numbing in
your face and hands. There’s also
a weird flushing in your head. But
your blood pressure has always
been untrustworthy, your migraines
have been behaving ever
more strangely, and you’ve successfully
been disciplining yourself
to breathe deeply and slowly
. . . yes . . . deeply . . . from the diaphragm . . . slowly. . . .
Relax!
At the gas station, you smile at the fine young man behind the
counter. It’s dark outside, and the hellish mating whirs of a billion
insects fill the world beyond the glass entryway.
“May I help you?” he asks.
“I hope so,” you say as undramatically as possible. “I think
I’m having a heart attack. May I borrow your phone?” You smile
again, trying to impersonate a man in full possession of his faculties.
But deep down, you feel like a child who hasn’t properly prepared
for a Very Big Test.
While waiting for the ambulance, you call Betty. You tell her
you think you’re out of danger but will get checked out anyhow.
You’ve both long suspected you’re a walking anxiety factory, and
you sometimes get full-blown panic episodes. You promise to call
her if anything develops.
So now you’ve done it, and now your whole family’s gonna
find out, and, if you live, you’re going to feel embarrassed: There
he goes again, the excitable boy.
At the same ER you recall from all the bloodiest episodes of
your accident-prone childhood, you get all hooked up in the usual
fashion. You study the nurse’s expression intently for evidence that
your tracings portend badness. Nothing. So you’re already preparing
yourself to feel foolish for when they’ll inevitably tell you you’re
perfectly healthy, just as they did when you visited another ER a
year ago (albeit without flashing lights and siren); they’ll tell you to
avoid stress and caffeine while sending you home, their eyes secretly
rolling skyward as you sheepishly gather your things.
Your blood pressure was 210 over 90 in the ambulance; now
it’s down to 170 over 105. Your numbers might be dangerous if
there weren’t the presence of mortal fear to explain it away. When
the fear fades, so will the hypertension. Your heart’s beating seventy-
five times a minute, headed toward its normal sixty-something.
With the nurse’s permission, you temporarily unhook the
monitors so you can walk to the ER bathroom. You turn to
the right to check out a flurry of activity and spot your brotherin-
law, the district-court judge, accompanying a gurney as it’s
wheeled past the nurses’ station.
“That’s your brother,” says Darrell to the rumpled shape beneath
the sheet.
“Who?” says the rumpled shape, now unraveling a small pile
of red hair to reveal the face of one of your five sisters.
“Kick!” you say cheerfully to Kathleen. “What are you doing
here?”
“What are you doing here?” she demands.
In moments, your gurneys are placed next to each other, and
you’re trading black-humor
quips. The basic theme is that
you’ve long had a pseudo competition
over which of you was
the family’s smartest, and now
you would compete to see who
could be first to the grave. The
ER workers find the whole scene
a hoot, if a tad bizarre.
Kathleen is also suffering a
mysterious heart problem, which
you’re inclined to dismiss because
she’s a premenopausal woman.
Which is curious, because she’s
dismissing your problem because
she knows you’ve previously
been checked out from head to
toe and pronounced healthy as a horse. You’re thirty-nine; she’s
forty. Both of you were born in the same calendar year, which
means you’re Irish twins. And, strictly by appearances, you’re both
too young to die from heart problems. But she’s in midsentence
when, suddenly, she slips into one of the fainting episodes that have
alarmed her throughout the day. It looks like a slow-motion
windup for a sneeze, except her face slackens as her head tilts. You
alert the nurse, who races to Kick’s side just as her consciousness returns.
To aid in the cause of reassuring calm, you smile again, think
of quipping, bite your tongue, and fall silent as the nurse verifies
that your dear sister’s heart just stopped for seven seconds. Suddenly
black humor feels very unfunny. What if her heart won’t restart
the next time? Does she know how much you love her?
Later, in the dimly lit echo lab, you watch your own murky
heart movements on the video screen. The rhythmic sound of
blood squirting through valves fills the room, as if the room itself
were being stalked by some hyperventilating sea creature
with a throat obstruction—tshe-uw! tshe-uw! tshe-uw! The
soft-spoken tech acknowledges that the red streaks on the
screen indicate valve leakage. As she applies more lubricating
jelly to your chest and moves the microphone device away from
your breastbone, the red streaks grow larger.
“I suppose I don’t have much frame of reference for these
things,” you say, “but isn’t that a pretty big leak?”
Bingo!
96 E S Q U I R E D E C E M B E R 1 9 9 8
DAV I D C O LWELL
Eve of surgery, October 16, 1996, 8:00 P.M.:
Betty, William, and Ramsey Flynn.
Six years ago, doctors told you they’d detected “a slightly dilated
aortic root” above your heart. They couldn’t explain how it
got there, but weren’t particularly alarmed. They said you might
have to deal with it in about twenty more years.
You learned that a healthy aorta is the size of a garden hose.
You had written the following data on a Post-it note: “Normal
aorta: 1.25 inches. My aorta: 1.75 inches. Danger zone: 2 inches.
Dead: 2.5 inches.” That data applies mostly to very tall, basketball-
player-type bodies suffering a condition called Marfan’s syndrome.
You’re only five feet seven inches and 150. You figured
your oh-shit number would probably be two inches.
Now you’re at 2.25 inches, the proud father of a screaming,
bouncing aneurysm aching to blow a hole in your chest.
Meanwhile, Kick has been diagnosed as having a grape-sized
aneurysm in her brain’s frontal lobe that’s dangerously pressing
on a critical nerve that controls her heartbeat.
UPON MEETING THE MAN WHO WILL BECOME PRINCIPALLY
responsible for your earthly fate, you and Betty are instantly taken
with his confident smile and warm handshake. Johns Hopkins’s
Dr. William Baumgartner congenially guides you through some
preliminary discussion while outlining the procedure. Dr. Vincent
Gott sits in as something of a gray eminence; he is one of the procedure’s
unassuming pioneers and has come back from retirement to
bless the hospital’s aortic program with his quiet wisdom. He produces
a sample of the artificial aortic graft that will replace the
blood vessel you’ve trashed. It’s a white, three-inch-long, finely corrugated
Dacron tube with a black artificial aortic valve attached to
one end—two hinged flaps made of diamond-hard carbon.
He lets you hold it. At first, it feels suspiciously fragile. Odorless.
Taking one end in each hand, you test its strength lengthwise;
it flexes but seems unfazed by the abuse. You insert both index
fingers into one end and pull in opposite directions; same
response. You suddenly wish to retract all the awful things you’ve
ever said about polyester.
“It’s very strong,” says Dr. Gott, adding that it has a half-life of
several hundred years. “It’ll last longer than you will. Over 750,000
of these valves have been implanted.Without a single failure.”
Your surgeon is the quintessence of The Right Stuff: Dr. Baumgartner
does about two hundred hearts a year, many the riskiest
sorts of cases, and typically loses only six. Of course, most of
those cases are less ambitious than yours. But there’s something
about his personality that creates an instant bond. Does he get
this friendly with hopeless cases?
You secure an agreement that the doctors will try to preserve
your natural aortic valve. You hear the artificial ones are noisy and
require a lifelong addiction to blood thinners. They agree to try.
You pull out your calendars, and the moment feels about the
same as when you schedule an important business meeting. You
settle on Thursday, October 17.
You stare at the date on the calendar. October 17. Quite possibly
your date of death.
ON A THURSDAY, YOU MEET KICK AT A DOWNTOWN BAGEL
shop. She works as a real-estate-investment lawyer just a block
from your office, and you marvel together at how seldom you actually
get to rendezvous. You’re impressed to learn you’re both holding
up well. Both of you have recently seen a CT scan of her
aneurysm, which is nesting ominously amid a cluster of major arteries,
scorpionlike, alive, poised to strike with the slightest annoyance.
She describes an “eggshell feeling”; she doesn’t want to do
anything that will risk provoking the aneurysm. Like sneezing. Or
laughing too hard. You know exactly what she means.
You both profess a surprising lack of fear, now that you’ve had
time to dispense with the initial death jitters. You’re fervent believers
in God and God’s mercy. You personally have always had
a powerful leaning toward the essentials of the whole Jesus story,
including the intellectually unfashionable Resurrection and forgiveness
parts, but you also extend the broad Christian ideas
across the world’s other principal belief systems like an umbrella.
Kick believes in God in a more generic sense. You’re both hoping
heaven’s gatekeepers grade on a curve, and you’re more concerned
about how the prospect of your sudden departures would
affect other family members, especially the kids.
With Kick, it’s a more critical issue. She’s got a bad case of supermom,
with four kids under ten and a brutal work schedule.
She tells you how, twelve days before her surgery, she’s staying
awake concocting elaborate lunch and clothing and activity
schedules to get Darrell and the kids through her absence.
The one thing you don’t express is that you find the idea of her
upcoming procedure much more menacing than your own. You,
after all, are merely getting your plumbing rearranged. Crucial
plumbing, but somehow it feels less personal than having your
frontal lobes, the very seat of your mortal being, probed with a
very sharp knife. No matter how smart the knife.
“I’M GONNA SCREW THIS PICTURE UP,” YOUR SISTER EILEEN
laments to your other sisters. She’s in something uncharacteristically
low cut and cocktailish; the others are post-Catholic.
You and Kick have hatched this plan for a formal family portrait—
something you suspect your other family members might
have wanted to do but were hesitant to ask for—just in case either
of you isn’t around by Thanksgiving.
The mood is okay, considering. While your friend the photographer
sets up a backdrop on the front lawn of your parents’
house, your parents’ fourteen grandchildren wheel around,
though the older ones are restrained.
Kathleen’s skull will be opened up in about twelve hours, but
tonight she’s all business. She’s got your last will and testament,
just as she promised. She’s also got your power of attorney and
your living will, in case Betty needs to pull the plug if you’re a lost
cause. (Miraculously, you took out a $250,000 life-insurance
policy just before all the trouble started, signing the document
during a break in a basketball game.) Now, sitting in the kitchen
while the photographer tries to keep everyone on standby outside,
Kick guides you through a few particulars, you both trade
bad jokes, and you sign.
Later, you catch a glimpse of Kick in the foyer, her briefcase
perched on her knees, revising chapter-and-verse childcare orders.
In the morning at the hospital, you get a few preop moments
with Kick. You’re in business attire; she’s in one of those congenitally
dorky hospital gowns. You’d like to say something inspired,
D E C E M B E R 1 9 9 8 E S Q U I R E 97
IN THE WEEKS LEADING UP TO THE SURGERY, YOU AVOID HEAVY LIFTING
AND HEAVY EMOTIONS. YOU TAKE YOUR SON’S HAND: HOW
SMALL AND SOFT IT FEELS! YOU’LL NEVER BE OKAY WITH LETTING GO.
but the basics are all you can manage. “Good luck, kid. You’ll be
fine.” Though no one in your family has ever been particularly
touchy-feely, the two of you hug for an unusually long time.
At work, you can’t keep it out of your mind that your dear sister
is meeting her fate while you conduct a staff meeting.
Forty-eight hours later, on the eve of your own moment of truth,
you abruptly depart work and visit Kathleen again. (When the surgeons
got in, they’d discovered that her bulging aneurysm had already
begun to bleed.) She’s in her room alone, head wrapped in a
skin-toned gauze turban that covers her eyes, her facial features distorted
with swelling. She’s asleep, unaware of your arrival.
None of your family members has reported anything about
her brain function, and her apparently conked-out state means
you’re not going to get any indication, either. Maybe she has essential
brain function, but what about the exquisite laser wit that
makes Kick Kick?
Suddenly she rolls over and grabs the phone from her bedside
and blindly dials her home number. She asks the baby-sitter to
connect her with her youngest son, Brendan, who turns three today.
“Happy birthday, Brenny-den-den-denny! Did you get the
cake I left in the fridge?”
One down, one to go.
AS DINNERTIMES GO, THIS SIX
o’clock event is earlier than usual.
For the last three years or so, your
normal arrival time has been between
eight and ten. It’s still daylight
as you settle in over carryout
pizza, yours without the cheese.
Betty is holding up but does not
feel chatty. She is beautiful, her
unlined face still as magically luminous
as when you met ten
years ago. Her voice remains one
of the most pleasant sounds in
your life. She’s thirty-four now,
too young to be a widow.
One-year-old Hunter waves a hunk of pizza crust from his
high chair, smiling at you as he chants, “Da-da-da-da-da-da.” He
pauses, seems to understand that the sound somehow connects
with who you are in his life. He smiles again, looking vaguely expectant.
If you die anytime soon, he’ll have no lasting memory of
you whatsoever.
And William. Oh, boy—William understands just a little too
much about what’s going on. At four, his bursting curiosity has
allowed him to collect too many little signals, despite your best efforts
to shield him. If you don’t wake up from tomorrow’s operation,
he’ll probably have a few lasting memories of you, but could
also be much more seriously injured by your sudden departure
than Hunter. Still, you can’t lay it all on the line for a four-yearold.
With William sitting on your lap at the kitchen table, you
keep your arms around him and explain the coming event with
the same gravity as you would a business trip. “Daddy’s got a big
bubble in his chest, so he’s going to the hospital to get it fixed. I’ll
be home soon. Okay, my lumpkin?”
“Okay, my daddy,” he says in his most angelic voice.
Before bed, you shower with the surgical Betadine solution,
according to orders. Its sensations propel you across the medical
threshold. It’s the color of rust, smells generically astringent, and
has the approximate viscosity of gasoline. Toweling off, you regard
your sternum closely in the mirror, knowing you’re seeing it
whole and young looking for the last time. You run your fingers
along it slowly and try to hear the sound of the jigsaw that will cut
through it in the morning.
IN THE PREOP AREA, YOU ARE SWADDLED IN YOUR POLYESTER
gown as the anesthesiologist briefs you and Betty and your parents,
and a nurse interrupts to ask for the removal of your rings and your
glasses.Andthen it’s time. There is a quick round of hugs. Before being
wheeled away, you stand and hold Betty, whispering in her ear.
Rolling toward the operating room, you have a curiously
cryptic private talk with God. Instead of giving one of those
clichéd spare-my-life-and-I’ll-do-anything appeals, you nevertheless
risk insulting God with the promise to zealously attend to all
the unfinished business the two of you have discussed for most of
your conscious life.
And then, a very odd, prosaic feeling: You’ve been a worldclass
insomniac all your life, and you’re now eagerly anticipating
the profoundly deep sleep that comes with general anesthesia, the
closest feeling to eternal rest. For the next ten hours, no more
worries, no risk of the noise of consciousness.
Your arms are strapped to the outstretched limb supports of
your operating gurney in the proper position for crucifixion. Or
lethal injection. You’re so nearsighted
that you can’t distinguish
the few folks cloaked in surgical
scrubs and milling about. Wait,
you think, shouldn’t there be introductions?
Which one of you is
Dr. Baumgartner? Oh, well. You
surrender peacefully as the mask
is lowered onto your face.
YOUR GOWN IS REMOVED, AND
you are splayed naked. A physician’s
assistant wet-shaves your
chest and legs—the legs just in
case they find clogged arteries
in your heart and have to go
rooting for replacement veins—
and begins slathering your torso liberally with alcohol and Betadine,
which begins dripping down your sides and groin. Your
body wobbles with his handiwork.
With your upper torso now hairless and sterilized, the assistant
spreads a Betadine-coated glassine plastic sheet across your chest,
pressing parts of it into the small canyon of your sternum and tucking
it along your sides like a bronzing SaranWrap. You look like a
basting whole turkey taken from the oven twenty minutes too early.
Blue surgical fabrics are strategically arranged to leave a rectangled
opening for the principal surgical site, much the way
metal plates are placed around a street-work area before the
backhoe moves in. A mobile metal table is positioned so it hovers
over your head, shading it from the glaring, cold lights. The
bat wing, as Hopkins surgeons call it, gives the doctors something
to lean on, protects the endotracheal tube in your throat,
and is arrayed with cardiac tools like locking needle holders,
clamps, long forceps, and the pencil-sized Bovie, an electrocautery
device destined for a lot of action today.
To most of the people in the room, you are essentially a medical
Rubik’s Cube to be solved. Gott and Baumgartner, anesthesiologist
Lester “Lex” Schultheis, and circulating nurse Brenda Pittman
will suffer the added burden of having met the man beneath the
bat wing, as well as his family, and therefore must attach actual
faces and feelings to the consequences of today’s actions.
Dr. Baumgartner tends to other duties during the preliminar-
98 E S Q U I R E D E C E M B E R 1 9 9 8
DAV I D C O LWELL
10:00 A.M., October 17, 1996:
Gillinov and Baumgartner
examine the aneurysm.
ies, and his trusted senior resident, Dr. Marc Gillinov, will start.
Gillinov motions to Schultheis. “Okay to make skin?” asks Gillinov.
Schultheis nods, and Gillinov uses a number 10 knife, a surgically
refined version of a common X-Acto, and makes a smooth
single incision along your sternum. It’s 9:07 a.m.
At 9:09, Dr. Gillinov tests the miniaturized jigsaw, the air-powered
Stryker. It sounds very much like the garage air drills used for
removing bolts from car wheels—brzzewww! brzzewwww! Its
blade resembles a razor-clean metal cutter with fine serrations.
Its two-inch cutter is protected by a rigid housing to keep it from
ripping into the soft tissue below the sternum. “Saw up,” says
Dr. Gillinov as he maneuvers into position. “Lungs down?” he
asks Schultheis, verifying that there’s little risk of the saw blade
contacting an inflated lung.
Dr. Gillinov places the saw blade at the south end of the exposed
sternum and squeezes the trigger. Brzzzzzzzzzzzzzzew! Just
like that, smoother than a carpenter ripping through a sheet of
plywood. There is no bone dust; the material is too moist to become
friable. The sternotomy is done in less than ten seconds.
Dr. Gillinov and the physician’s assistant insert their latexsheathed
fingertips into your freshly opened chest cavity and lean
their body weights away from each other, spreading the maw of
your chest open for its first contact with the outside world, which
at the moment includes a controlled room temperature of 65 degrees.
They insert a rack-and-pinion device called a sternal retractor,
cranking your chest halves to a fixed six-inch opening.
“What’s the cautery set on?” asks Dr. Gillinov.
The cautery pencil buzzes and sends up delicate curls of smoke
as Dr. Gillinov works through cobwebs of fibrous tissues until he
comes to the tough pericardial sac that serves as the heart’s protective
shroud. He parts the sac’s glistening surface as if it were a dollhouse
curtain, using retraction sutures to attach the flaps to the
walls of your open chest. He continues cutting toward the neck to
expose the aorta. He works his fingertips into an area adjacent to
the aortic space, trying to maximize his visual access to the bulge in
your aortic wall. And then, there it is. Freed from its strictures, the
evil thing balloons with each beat, until it takes up an area on your
chest surface as big around as an orange. With the doctor’s surgical
magnifiers doubling the size of everything he sees, it looks like a fatted,
pulsating white leech angrily quaking at getting caught in the
act of rotting a young father’s insides out. “Wow,” says Dr. Gillinov,
leaning away from the emerging alien. “Look at this!”
A number of OR workers peer in, variously echoing the doctor’s
exclamation. If you were conscious right now, you’d probably
feel a little proud.
The aneurysm has made what Gillinov thinks of as a grand entrance.
It dominates the surgical field as three bright spotlights
are quickly trained on its full glory. Dr. Gillinov is already sizing
up what portends to be a larger technical problem.
“Brenda, call Dr. B.,” he says. “This is paper-thin, and I think
he wants to be here before we do anything else.”
Dr. Baumgartner arrives and looks over the bat wing, pokerfaced.
“I don’t believe it,” he says flatly. “This is not what we
were expecting. This is an atherosclerotic aneurysm. Brenda, see
if you can find Vince.” He walks away shaking his head. He
scrubs in for a long pull.
Dr. Vincent Gott arrives. “Golly,” he says in a soft, boyish voice
that belies his thirty-five years in cardiac surgery. “That’s a big one.”
The two senior doctors probe the monster with forceps, remarking
on its papier-mâché-thin spots, which ache for bloody
release. Other areas of the bulging surface are thickly calcified
with layers of plaque.
The surgeons now know their adversary is much more threatening
than they’d hoped. And all of them wonder: How could such a
young man with only modestly high cholesterol develop such
severe aortic disease?
YOU WERE AN EXCITABLE BOY. ALARM CLOCKS ALWAYS STARtled
you, racing your heart. Your father’s military-style commands
kept you on edge. You couldn’t stand being tickled. Sometimes you
were so sensitive to the world around you, it seemed as if you could
feel every speck of dust settling in the room. On humid days, you
could feel the tickling of all your body hair as each one pulled away
from your sticky skin. You imagined it as the curse of having too
many dendrites per square inch. You felt too much.
The hypertensive surges started five years into your career, with
your first hostile boss. No one called them panic attacks then.
Doctors said you were getting “worked up” and told you the effects
were benign. You never believed them, and all along suspected
your dilating aorta was a direct result. That the aorta was also
corroded with atherosclerotic barnacles never seemed far-fetched
to you, either, but various doctors dismissed such a prospect. Your
cholesterol has always hovered at about 240, but with unusually
low HDL, the protective good stuff, which seemed stuck at 30.
Strictly by the math, it seemed obvious you’d be a plaquer, but cardiologists
discouraged your dark folk theories.
Sustained surges of hypertension are known to cause lesions
on the insides of arteries. To bad blood fats looking for a place to
settle, these roughened areas are fertile ground. Once the beachhead
is established, other erstwhile renegade blood fats gather
and bloom. And there goes the neighborhood.
In any case, you’ve long thought the surges would fade if you
could only find the proper mother lode of “psychic income” that
would inevitably arrive on the heels of your first career home run,
which would give you all the esteem you’d campaigned for so
fiercely, opening the floodgates to the pent-up reservoirs of endorphin
hormones meant to make you feel good.
But having so committed yourself to looking for love in the
wrong place, all of the people who should matter to you the most
keep getting further away. You’re losing touch with your wife
and kids, your larger family, your supposedly lifelong dearest
friends, whose phone calls continue to go unreturned. With benign
and then headlong neglect, they’ve been heaped upon the
altar of your sacred career.
With your heart closing against the very things that should
give it life, you have earned the present reality of needing to have
it opened with brute force.
CARDIOPULMONARY BYPASS NOW ESTABLISHED, PLASTIC
tubes carry blood past your heart and into the aortic arch beyond
where it’s pinched off with the cross-clamp. Your heart becomes
flaccid, shrinking to a third of the heart cavity’s space. In thirty-
D E C E M B E R 1 9 9 8 E S Q U I R E 99
YOU ARE ABOUT TO BE RENDERED CLINICALLY DEAD. YOUR BODY
WILL BE DRAINED OF ALL ITS BLOOD. YOUR LUNGS WILL STOP. YOUR
HEAD WILL BE WRAPPED IN ICE, AND BRAIN ACTIVITY WILL CEASE.
nine years, this is its first rest. To Dr. Baumgartner’s latex fingertips,
the deflated heart feels like a slippery beach ball without the
air. The team realizes it has an important mystery to unravel:
How far up into the aortic arch does the aneurysm go? Has the
disease already gotten a foothold in the dual takeoffs of the carotid
arteries that feed your brain?
The delicate aroma of heart surgery surrounds the operating
area. The mix of saline and tissue fluids and small traces of blood
blend into something that resembles primal pond water, a kind of
eau de slime, as though it had been heavily occupied by busy amphibians.
The conversation of the surgeons is like the easygoing
murmuring between fishermen pausing to tie flies.
Probing farther than they’d expected to, Baumgartner and
Gillinov feel along the aortic arch until they find a complete tapering
of the balloon. It goes to the lower half of the upper arch, right
beneath the carotids. This is another bad surprise; the carotid
blood flow will have to be shut off. The operation is now committed
to a high-stakes turn.
“Lex,” says Dr. Baumgartner to Schultheis, “this thing goes
into the arch. I think we’re going to have to arrest him.” Then he
turns to the perfusionist. “Cheryl, let’s start to cool.”
“Brenda,” says Schultheis to
nurse Pittman, “let’s get the ice.”
In the old sense of the term,
you’re about to be rendered clinically
dead. Your body will be
drained of all blood. Your lungs
will stop, and no oxygenating
device will take their place. Your
body temperature will be taken
down to 58 degrees. Your head
will be tilted down at a 30 degree
angle to ensure that deadly
air bubbles will not enter your
skull but will escape harmlessly
into the OR air. Your head will
be wrapped in ice, chilling your brain as if it were cocktail
shrimp on a party platter. Cerebral activity will cease.
In recent years, doctors have experimented with how long an
organism can survive in this semi-cryonic state: forty-five minutes?
An hour? The phenomenon has forced a redefinition of clinical
death:You can’t be properly dead now until you’re warm and dead.
Where is your spirit at a time like this? In suspended animation?
Vaguely residing somehow in this now-inert hunk of protoplasm
that could once run like a high-performance sprinting
machine? Does it work like an alarm clock zapped by a thunderstorm,
with a 1.5-volt battery keeping track of the time until the
real electricity returns to light up the LED display? Is now the
proper time for your out-of-body experience?
Out in the waiting area, Betty watches the clock pass the forecast-
update time. Your other loved ones are oblivious. Betty stares
at the clock, as if debating a teenage child’s failure to return home
by midnight. They’re too busy to call. No, something is amiss. But
surely they’d call if something were wrong, wouldn’t they?
While waiting for your body to cool, Baumgartner and Gillinov
decide to examine your aortic valve.
“Okay,” announces Dr. Baumgartner, “we’re going to open this
aneurysm now.” He clasps his fresh number 11 non-serrated-blade
scalpel between thumb and forefinger, aims it at the monster’s herniated
belly, and makes a gentle thrust. Bright red blood flows into
the surgical well created by the pinned pericardium tissue. He inserts
scissors into the nicked hole and cuts up toward the clamp, occasionally
feeling a subtle crunching from the calcified spots.
Then, cutting back down toward the heart, Gillinov and
Baumgartner get their first look at the crucial aortic valve to see if
they’ll be able to save it. The disease has beaten them to it; the
valve’s three leaflets are thinned and furled.
With most of the aortic arch’s lower half now cut away, Dr.
Baumgartner can see the openings of the ascending carotids.
Clean and clear. Lucky break.
He cuts the far end of the Dacron hose at a 45 degree angle,
much the way a skillful florist cuts stems. This is so it will run under
the arch in a bevel. Both doctors take turns suturing, reinforcing
each suture with a rim of felt and cerulean-blue 3-0 Prolene stitches.
The normal patter that would surround heart surgery is absent.
There is no radio, just an eerie, concentrated silence.
“Time, Brenda?”
“Twenty-eight minutes.”
Outside, the horizon sharpens as the morning mist gives way
to a light wind, and the temperature climbs toward the mid-70s.
At your home, the baby-sitter puts Hunter into the stroller. She
takes your boys for a walk.
In your downtown office, the sun filters through your window,
which is streaked with some of the thickest bird shit ever to
grace a Baltimore office building.
The message light on your
phone glows red.
AS THE DOCTORS BEGIN CLOSING
procedures, they take stroke-prevention
precautions, rinsing vessels
to remove stray particles,
leaving a tiny hole in the polyester
hose so they can suck out air
bubbles with a syringe.
It’s technically an impossible
job; the rogue particles could be
anywhere. It’s an archeological
dig full of ancient traces of burgers,
fries, and an irrepressible ice cream habit. As your jerryrigged
heart is shocked back to life, the unclaimed detritus gets
carried away like sand on the beach under a crashing ocean wave.
They insert a temperature probe into your esophagus. It takes
a half hour to wean you off the bypass machine, observing your
function and cauterizing the spots of bleeding.
“Ready for wires?” asks Dr. Gillinov, and the physician’s assistant
opens the package of heavy-gauge sternal wires, each
about ten inches long, each tipped with its own two-inch needle.
Dr. Gillinov manually forces them through the thinner bone of
your sternum and laces it closed like two halves of a hiking boot.
They’ll also have to insert crude chest tubes to drain your upper
body of any excess blood after the closing, so they make room
between your rib cage and lungs by repeatedly sweeping away the
fatty layer between them with the cautery pencil. The burning of
fat tissue fills the room with a strangely aromatic smoke, much
like an indoor barbecue.
Meanwhile, the rogue microplaques are scattering throughout
your body like destructive bits of flak. Some pass your brain-feeding
carotid arteries at the top of your new aortic arch and continue
down your descending aorta, where they’ll find harmless resting
places in your internal organs and limbs. But a few will also enter
your carotids and head straight for the one organ in your body
where they are least welcome.
One scrambles up through your posterior cerebral artery,
bouncing about chaotically until one of the smaller branching arteries
allows entry, up to a point. A small sector of your occipital
100 E S Q U I R E D E C E M B E R 1 9 9 8
DAV I D C O LWELL
3:00 P.M., October 17, 1996:
Cardiac-surgery intensivecare
unit.
lobe, which detects and interprets visual data from both eyes, begins
gasping for breath. At most, this sensitive bundle of neurons
has eight minutes to live. Stroke number one.
Another errant bit of flak travels up the anterior cerebral artery
and diverts into one of the branching vessels that feed the bit of your
prefrontal lobe that initiates motor activity. Stroke number two.
Meanwhile, the fissure that crosses the top of your brain from
ear to ear, separating areas of motor function from sensory function,
begins to choke in two spots, one spot in each hemisphere.
The damage spreads in dime-sized areas that straddle the fissure,
in what doctors call a watershed pattern, because such areas of
damage typically resemble the shapes of reservoirs formed by the
damming of rivers between ridges.
Even if your conscientious caretakers could track these events,
medical technology in the late 1990s provides them with approximately
zero remedies. This happens before you exit the OR, but
makes no outward announcement. “Post-op complications,” jots
Dr. Gillinov in your chart. “None apparent.”
Dr. Baumgartner emerges from the OR with his hair mussed
from removing the surgical garb. As he rounds the corner, he sees
Betty and smiles victoriously, but then notices she looks scared
and tearful. He tries to reassure her that, despite the operational
difficulties, he’s confident you’re going to be fine.
AT 3:30 P.M., WHILE MOST OF YOUR LOVED ONES ARE RECOVering
from the day’s tense vigil, cardiac nurse Thomas Richter
lifts your eyelids and shines a penlight into the pupils to test their
constriction. He jots in the notes that your pupils are moderate in
size but sluggish in their speed of constriction, not altogether unusual
for a patient who’s still heavily sedated. He further notes
that your skin is cold, dry, and puffy and that your nail beds are
pink, showing good capillary refill.
Just before 5:00 p.m., Richter notes an increase in the “ST segment”
of your continuous EKG tracing. He calls cardiac intensivist
Dr. Nauder Faraday, who orders the medications readjusted
to maximize your declining blood flow.
When Dr. Faraday visits at about 5:30, you are shivering,
which is fairly common, but the other indicators of your heart’s
strength—tallied up in a bottom-line figure called the cardiac
index—are slowly heading south. “This is abnormal,” says Faraday
to Richter. “Keep an eye out.” But Dr. Faraday, who is
technically responsible for all fourteen heart patients in the
cardiac-surgery ICU tonight, virtually camps out at your bedside.
Nurse Mary Catherine Dyke joins the watch at about 6:00,
and together she and Dr. Faraday interact with you while you’re
in a semiconscious state, asking you to move individual limbs on
their command. They note that you have a general right-sided
weakness, suggesting some sort of trouble with your brain’s left
hemisphere, which controls language and speech.
“Great,” says Dr. Faraday sarcastically. “This is just great.”
Then, as they watch, your heart tracing becomes erratic. “Let’s
call the eleven-oh-nine,” he says.
The 1109 is a mythic figure in the culture of Hopkins cardiac
surgery. The number refers to a pager code for the senior cardiac
resident on call, who by decree has virtually unlimited powers to
gather whatever resources he or she needs to save a patient’s life.
Tonight, the 1109 is Dr. John Liddicoat, who has just been
told the patient in 5B is suffering an acute heart attack. He and
other cardiac-ward heavies begin “loading the boat,” an expression
for a full-scale alert to get everyone involved so that, if the
boat sinks, no one will go down alone.
Your case cardiologist, Dr. Thomas Traill, is alerted to get to
the cardiac cath lab stat. “Oh, shit,” he says at the news, uncharacteristically
abandoning his British reserve. Dr. Jon Resar begins
preparing his lab for an emergency cardiac catheterization.
Gillinov and Baumgartner are just wrapping up their second
surgery of the day—which was seriously delayed by your earlier
bad behavior—so nurse Dyke is dispatched to deliver the news
to their OR.
Dyke knows and adores Baumgartner—as do most people at
Hopkins—and she typically refers to him as “Saint Dr. B.” because
of his unfailingly gentle manner, a rare trait among surgeons. She’s
not happy telling him the bad news about the Flynn case, but begins
her grim report while accompanying him out of the OR.
“I don’t understand,” he says. “It was the perfect surgery.”
In the cath lab, Dr. Resar inserts the probe into your right
groin and begins threading it up to your heart muscle. By 10:00
p.m., he has his diagnosis: Your left anterior descending artery,
the one cardiac surgeons playfully call the widow-maker, is 99
percent blocked and not responding to nitroglycerin.
JUST AFTER 11:00, BETTY IS GETTING READY FOR BED. SHE HAS
comforted herself with the idea that you’re stable. Over the sound
of the water running in the sink, she hears the phone. It’s a Dr. Liddicoat
from Hopkins. He begins briefing her, but she can’t hear the
words; his grave tone gets in the way. She feels the earth slip out
from under her. She numbly dials your father and can barely speak.
Your mother is simultaneously placing a status call to the hospital
and is learning from junior resident Dr. Pierre Theodore that
her son is suffering an alarming setback. She switches to the other
line in time to catch the tail end of Betty’s talk with your father.
“We’re on our way,” he says.
Concerned neighbors gather at the front of your townhouse as
the baby-sitter arrives. Betty hustles into your parents’ backseat,
and in moments they’re speeding down I-83. Your father is outwardly
composed, but inwardly feels his irrepressible optimism
crumbling. Your mother is silently praying the Lord’s Prayer, pausing
after the words “Your will be done.” But not yet! she adds. Betty
wants to get to the hospital before you die.
YOU’RE AWAKE. NURSE DYKE ASKS YOU A FEW SIMPLE QUEStions,
and you nod appropriately, unable to speak because of the
tube in your mouth. On her request, you move all your extremities.
You appear alarmed by the cath-lab scene, and your blood
pressure shoots up. She resedates you in preparation for an emergency
bypass and takes all your vital signs. She tallies up your revised
cardiac index as 1.3. This number, as doctors would say, is
“incompatible with life.” It means your body is cycling only two
liters of blood per minute and must triage in favor of your most vital
organs—your brain and heart. If you’re left in this state much
longer, your other organs will begin systematically shutting down.
The key heavies from your first
D E C E M B E R 1 9 9 8 E S Q U I R E 101
THE DOCTORS TAKE STROKE-PREVENTION PRECAUTIONS, BUT IT’S
FUTILE. THE ROGUE PARTICLES COULD BE ANYWHERE, ANCIENT
TRACES OF BURGERS, FRIES, AND AN IRREPRESSIBLE ICE CREAM HABIT.
[continued on page 162]
Y O U H A V E N ’ T L I V E D U N T I L Y O U ’ V E D I E D
surgery are gathered
in the OR, and Dr. Baumgartner apologizes
for the re-call. As your gurney is
wheeled in, Baumgartner and Gillinov realize
they have to act before Schultheis can begin
anesthesia. “We’ve gotta get moving,” says
Dr. Gillinov. “I need a staple remover.”
He rapidly removes the metal staples from
your chest and untwists the wires to redivide
the sternum. In moments, he is harvesting your
mammary artery from its convenient site right
under the rib cage. This is the most favored replacement
vessel for a cardiac surgeon in a hurry:
It’s like a spare tire—clean, clear, long lasting,
and no more necessary to a modern man’s
anatomy than the vestigial appendix.
With your loved ones regrouped in the
waiting area, there’s a general suspicion that
you may be buying the farm. They persuade
an OR operative to wrap a Marian scapular
medal around one of your legs.
WITH FILTERED MORNING LIGHT BATHING
your surroundings, you awaken to the pleasant
feeling of Betty’s hand on your leg. “You
made it, baby,” she says.
But of course, you think, and soon drift
back to sleep, secure in the knowledge that
everything’s going to be okay.
But it’s not. By early afternoon, the strokedamage
watch quietly gears up. Cardiac nurse
Caitlin Nass notes that your right arm is virtually
lifeless and that your pupils have finally
surrendered their protest to the fulminating
distress inside your skull; for ten hours, your
pupils were lopsided, the right one constricted
smaller than the left. But now the brain swelling
is about to begin in earnest, the natural outcome
of a general trauma to the brain from two long
go-rounds on the cardiopulmonary-bypass machine,
which is notorious for destroying a certain
percentage of red cells with each cycling.
In the wee hours of Saturday morning,
nurse Nass writes that you are “agitated, crying
out.” She ups your dose of morphine and writes
further that you don’t know where you are or
why. She gives you the answers and then asks
the questions again, and you again fail the idiot
test. Mechanically, you’re able to sip water.
At 10:24 a.m., your heart rhythm slips into
atrial fibrillation, beating at 145 beats per
minute. You respond to simple questions but
do so in two words or less. You pull at your
lines and begin murmuring the word ow repeatedly,
raising both legs and thrashing back
and forth. This goes on for hours.
Betty arrives, and she becomes distressed
by your obvious downturn. She senses you are
in some sort of extreme pain. Various medical
types say that it’s not as bad as it looks and
that you’ll likely not remember it.
When Betty returns on Sunday, she watches
as cardiac nurse Deborah Formella asks you if
you know your wife’s name. You understand
the question and its intent but are so consumed
with discomfort that you find the prospect of an
inquisition intolerably taxing. You keep rolling
your head from side to side, chanting “ow-owow”
in a continual rapid-fire string. Formella
persists with the question, hoping it will reassure
Betty, but you get angry at not being left
alone. You desperately want the nurse to stop.
“I don’t care,” you snap, resuming your “ow”
incantation without skipping a beat.
Later, Betty attaches a photograph of your
two beautiful boys to a monitor next to your
bed, just to remind the caregivers that this
blithering idiot has a lot to live for.
The following morning, a CT scan shows
multiple stroke spots and areas of unresolved
bruising. Neurologist Dr. Hyder Jinnah studies
the scan and visits you. He finds your
speech surprisingly “fluent,” that you score
five out of five on a name-recognition quiz,
that you’re oriented to person, place, and situation,
but that you think the year is 1989. He’s
not sure whether the date confusion is the result
of stroke or of postoperative delirium.
On a Sunday afternoon, in the hospital’s
step-down unit ten days post-surgery, you’re
trying to nap through a quiet conversation between
Betty and your father. Your father has
his cell phone out, and the two of them want to
call Kick at home. As they try to remember her
number, you get frustrated listening, because
they’re way off base. Finally, you blurt it out:
“Three-three-seven, nine-one-eight-seven.”
Betty and your father exchange glances.
Your father’s eyes well up as he dials.
Jeez, you’re thinking, did they really think
I was that bad off?
STEP FORWARD POWER ENGLISH.
It’s the first of November—two weeks
post-surgery—and you’ve been trying to work
through a profound lethargy. You’re dozing in
a state-of-the-art cardiac-rehab ward at Sinai
Hospital, and this gibberish keeps cycling
through your head. What the devil?
Step forward power English.
The sheer oddness of the apparently random
association of words befuddles you, and
you feel yourself puzzling through them for
some shred of rationale. The working of your
brain rouses you slightly, but you manage to
stay in the delicate margin between deep sleep
and drowsy wakefulness, a dreamy place
you’ve often practiced lingering in for
terrifically extended periods.
At seventeen, you were having one of your
most vivid dreams of flying high above the earth
when you slipped into a remarkable clinical detachment
from the delightfully mystical experience.
You practiced whirls and loop-de-loops
until you felt as if you were beginning to master
gravity-free movement, and then suddenly
something snapped and you hurtled at warp
speed back to earth. You felt your bed bouncing
as you awoke wide-eyed, your heart racing.
Now you feel vaguely as though you’re returning
from just such an experience and that
these four words are some accidental leftover
from your unconscious mind, a souvenir. Step
forward power English?
All you want to do is sleep, and you keep
searching for some psychic spark plug. As you
turn the phrase over in your mind, it slowly
blossoms into a visual manifestation of a basketball
layup. It starts with you gathering the
will to step forward, then to marshal enough
power to leap into the air, and then apply the
precise amount of English to spin the ball off
the backboard and through the hoop with
sublimely perfect control.
IT’S BEEN TWO YEARS. YOU’RE SITTING IN THE
basement, your so-called catacomb. The room
is utterly quiet, quiet enough for you to hear the
clicking of your valve, which sounds like some
distant underwater tapping. The valve sound
has faded during the course of an absurdly remarkable
process: Inside the once-naked polyester
hose in your chest, your arterial tissues
have “endothelialized” through the alien vessel.
You have grown a new aorta, but with a spaceage
wrapping that will last well into the twentyfourth
century.
All your doctors swear any remaining bits
of plaque are likely now shrunken to inconsequentialities
by your nightly cholesterol-lowering
pill, and they keep saying with perfectly
straight faces that you have a normal life expectancy.
One cardiologist said it would be
okay to bench-press pianos if you felt up to it.
As it is, your right arm is about 90 percent of
what it used to be, which is more than satisfactory,
because you happen to be left-handed.
About four times a week, you take a long run
through the neighborhood with three-pound
hand weights, and you lift William and Hunter
over your head all the time. You spin them
around whenever they ask. You are much more
inclined now, in fact, to cater to their every
whim, most recently serving them toasted and
buttered super-cinnamon bagels and juice as
they perched in the two saplings on your front
lawn. Friends and coworkers frequently remark
on how you’ve changed. You now laugh
at things that formerly would have spiked your
blood pressure. You often wonder where you
went during your death, whether your newfound
serenity is the result of something you
glimpsed there. You sometimes recommend
your surgery as a palliative for anyone with an
attitude problem. And you’re only half-joking.
You think of your wife and two sons upstairs
in their rooms, sleeping, and of your sister,
Kick, who has retained 100 percent of her
mental agility and resumed juggling a jet-setting
career with motherhood, and has somehow
managed, in the process, to modify her
schedule so that she now goes to sleep at bedtime,
like a normal person.
You sit there alone in the basement room of
your quiet house, and suddenly you notice your
valve’s timing is in perfect sync with the room
clock’s second hand, which means your resting
heart rate is a perfect sixty. And then you notice
a third tapping sound: Ice is melting from the
roof and dripping onto the basement window
frame, the drip-drip-drip matching the tick of
the clock and the click of your valve, and you
drift off, smiling at the ridiculous notion that
you are still moving at the speed of life. ≥
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