Category: Post Visit

Nancy continues to do well.  We’d like her to eat more real food but at the moment she is not much inclined to do that.

She got a big red heart-shaped pillow for her new year.  I didn’t know about these things until last night.  The gentleman homeowner who hosted the potluck last night asked if Nancy had gotten her pillow?  He had multiple by-pass surgery in the same hospital a few years back.  When I said I had no idea what he meant, his wife brought out a large red pillow in the shape of a heart.  This had an image of a heart on it and over that someone had drawn each of the by-passes that had been done inside his chest.  Also, about a dozen people had signed it – doctors, nurses, and family.

I got home to find an e-mail asking the same question?  “Did Nancy get her special pillow?”  I’m I the only one that didn’t know of these?

Well it seems that when your chest is split open and then closed again that in the weeks to follow you have an urge to cough frequently.  So as to keep it from opening again when you cough, you are told to hold a pillow tightly against your chest.  A stuffed teddy bear is sometimes given but any pillow would do.  It seems the red heart-shaped ones are the “special” ones – it could be considered a badge of courage and a statement that one survived.

Much of the very high-tech equipment was gone from Nancy’s room today.  There remained a gizmo on the floor at the foot of her bed making the sounds of a little stream tumbling over rocks.  This is part of a ‘chest drain’ and its purpose is to allow any fluid, blood, or pus to exit the ‘pleural’ cavity by way of a long tube.  Translated into English this means ‘from the hole in your body where they were working.’   Seems to me the original meaning (now said to be side or rib) has gotten lost somewhere along the path from Greek to Latin to Middle English to the World Wide Web.  A wine maker would recognize this as a “water sealed fermentation lock” with a vacuum assist through the water causing the bubbling sound.

Each of the two doctors on the floor visited briefly today and listened to her heart and lungs and pronounced her in good shape – for the shape she is in.  Many times a heart patient in the ICU will only encounter one or two doctors during a stay of a few days.  Today was Nancy’s 36^th day there and she is on their (the doctor’s) third or fourth rotation.  Somewhat uncommon we were informed.

I’ve heard that the first day after heart surgery is the most painful for the patient.  Although Nancy was awake today she was being given several drugs of one sort or another and still was experiencing pain.   When I arrived she still had an intra-aorta balloon pump going and was still on the ventilator.  She was frustrated that she could not yet speak and her nurse was not happy that my presence was causing that frustration.

The surgeon was there and showed to me 2×3 inch pictures of Nancy’s mitral valve – both old and new.  Quite interesting but I would like to see them full screen on my monitor at home along with one from a healthy human.  No such luck.  As part of the operation he also did two by-passes but I didn’t learn anything about that.

There was too much going on in the ICU today –and not just with Nancy.

Based on the readings they were getting from her heart they felt it was time to take out the post-operative balloon pump, so shortly after 1 P.M. they chased me from the area while they did that.  By the time they allowed me back in I felt compelled to leave for home because they were wanting to shut down the ventilator and remove that also and I didn’t have the inclination to set in the waiting room watching the Weather Channel for a second hour.  I already know that the atmosphere over the Northern Pacific is about to clobber the west coast of North America.  Washington State is in between the two major thrusts, one south and one north of us.  We get a mash-up of snow, rain, and freezing rain beginning sometime tonight.

I told Nancy I would come back at 7 P.M. but the driving conditions are suggesting otherwise.  Fog is really thick in the low places and the tops of the ridges are at or below freezing.  I drove through patches of thick fog on the way back north and at home I can see only a short distance.  At dusk, while I was feeding and running water for the horses, I noticed a ‘silver frost’ had formed, and was still forming, on the trees.

I have plenty of pictures of such trees. This is not my picture but it is a rather nice image: http://www.flickr.com/photos/joka2000/2258434451/

“Silver frost” seems to be a Pacific Northwest term for this ice. . .

I did not find it here: http://en.wikipedia.org/wiki/Frost

I apologize for all the weather stuff.  I don’t have anything else.

————— One: waiting

Nancy is still in the operating room as of 2:15 P. M.  Because of the allergy to heparin other anticoagulation chemicals are being used and these apparently prolong the time needed.

Yesterday I wrote that the operation was scheduled for 7 A. M. but that is the time they began preparations with her.  They wheeled her out of the ICU at about 9 A. M. and at this point I do not know exactly when the doctors actually started.

—————  Two: news

The news is good.  An operating room nurse called about 3:30 to say the surgeons were in the process of finishing the ‘closing’ and Nancy would soon be back in the ICU.  They do not expect to have her off the ventilator and awake until Wednesday morning.

The nurse has promised to write a short English-language version of the operation for me to adapt and post here.  That may take a day or so.  A general idea of such operations can be found on the Web, and so, in case you are curious — below are two of the many pages I have looked at.

The Texas Heart Institute has web pages that provide descriptions of heart surgery.  This first is an overview:

http://www.texasheartinstitute.org/hic/topics/proced/

About half way down in this long page you can find a link to “Valve Repair or Replacement Surgery” (just below where “stenosis” and “regurgitation” are explained.  Nancy’s problem was regurgitation.  It is easier to click on the link on the page, but below is the page you are going to:

http://www.texasheartinstitute.org/HIC/Topics/Proced/vsurg.cfm

Here’s to a good tomorrow.

The last couple of postings indicated the remarkable change in Nancy with the insertion of the intra-aortic balloon pump.  This was the hoped for result because it shows that improved heart function will likely bring adequate oxygenated blood flow to Nancy’s body.

The nature of this artificial assist is such that it cannot be continued indefinitely – although it can be in place for more than a few days.  The issue is that while Nancy needs open heart surgery she is in poor health.  A few days with the balloon pump assist and good nutrition makes sense but a prolonged delay provides additional time for more complications from the already compromised heart.

The surgeon who will perform Nancy’s operation had reviewed her case and visited her yesterday while she was sleeping.  During my mid-day visit today, he met with the two of us.  This was a general discussion about the issue of valve leakage and the effects on heart and body health.  A few months ago we obtained a book on heart valve surgery and I’ve taken a lot of material off of the Web, and so we are not unaware of the material discussed today with the surgeon.  For someone in Nancy’s state of health, open heart surgery is dangerous.  There isn’t an alternative.

The team of doctors includes the surgeon, a cardiologist, hematologist, pulmonologist, and anesthesiologist – maybe more. These folks will meet early next week to consider the pending surgery.  As of Noon today neither the meeting of “The Team” nor the surgery have been scheduled.

After our meeting with the surgeon Nancy had another ‘high nutrition’ drink and went to sleep.

The improvement Nancy has shown in the past 24 hours is astonishing.

She was talking and joking with us and scarffing down high protein power chocolate and vanilla shakes – 4 of the 8 oz. size by 2 PM.  That’s more than a day’s supply of a couple of dozen nutrients and, I think, more than she has gotten except when she was on the brown-drip-food or the intravenous stuff.

Except for a slight tilt to her upper body she is prone.  Critical parts of the apparatus have to be at the same elevation as her heart for everything to work and record properly.  All the high-tech equipment comes with a meter (or yard) stick and a carpenter’s level.  I thought someone was going to hang a picture frame when I saw those two items!

I don’t know what is next but “The Team” hit the ball out of the park with the Thursday afternoon insertion of the intra-aortic balloon pump (IABP).   The doctor that performed the insertion visited Nancy this morning but before I arrived.

Over the past few days certain tests were showing minor improvement even while Nancy did not seem better.  She was not eating much, her speech was more labored and difficult, and she continued to require a smallish amount of supplemental oxygen.  Eating grapes, yogurt, water, and a few bits and sips of other things isn’t much nourishment regardless of the good stuff the kitchen sends to the room.

The team of doctors contributed in various ways to a meeting this morning to examine evidence and plan a corrective course of action.  They reflected on the Friday morning (11/27) heart attack and the following cardiopulmonary collapse on Saturday.  The reason for this has not been known but they now think it was part of the heparin allergic reaction (I’ve previously discussed).  This collapse landed Nancy in intensive care fully sedated and on life support for eight days.

When the ventilator and the rest were removed this was a sign that things were improved and likely to continue.  But, she was never able to function without some small amount of supplemental oxygen.  Studying this situation the team collectively believes Nancy’s system took a big  ‘insult’  from the heparin-induced thrombocytopenia (HIT) (low platelet counts) leading to the condition she is in and the inability of her body to heal and strengthen.

So, they are going to try to help things along by inserting an intra-aortic balloon pump. This device consists of a cylindrical balloon threaded through an artery and into the aorta – the main artery that brings oxygenated blood to all parts of the body.  The connected apparatus inflates/deflates this small balloon in a timing sequence with the beating heart such that there is a greater supply of oxygenated blood being generated and sent to the body with less of a demand on the heart.  This should effectively mimic a more healthy heart not unlike repairing leaky valves.

Thus, they are going to try to cause improvement in her cardiopulmonary functions and, simultaneously, get a clue as to improvement expected from valve replacement and/or repair.  They will also supplement her food intake, especially with the protein necessary for better kidney function.

The pacemaker is of no relevance in all of the above as her heart has not needed it – so any change there is on hold.

While the intra-aortic balloon pump is in place Nancy will have to be fully reclined (flat on her back).   [ WHY?  I didn’t ask. ]

I left at about 2:30 when a 3-member-team from the catheterization lab swept in to take her to their home roost.

I’ll see her again at 7 PM.  A later post tonight is unlikely.

Here’s to a great Christmas Eve!                                                                                                              (it’s 4:57 here)

Really, today was just like yesterday.

I’ve got some things I need to do today and early this evening and so won’t add anything else.

Tomorrow may be just like today.

Well, it will be Christmas Eve.  That will be different.

Not a lot to report today.  Her general condition is changing slowly now so just ‘when’ I visit may mask anything else.  Maybe she has just had a short nap or maybe she has been awake and just had several pricks, prods, or questioning staff of one sort or another.

Yesterday afternoon was the ‘handoff’ of the day shift from doctor to doctor.   So Dr. X was around to hear from Dr. Y about the patients – Dr. Y having been involved for 4 or 5 days.  Thus, this morning Nancy essentially was being seen by an unfamiliar doctor and attended to by an unfamiliar nurse.  When this happened ten days ago the newly arriving doctor told me he had just spent 1 ½ hours reviewing Nancy’s file and he, in fact, already knew her and her background.  I have no doubt that these folks know what they are dealing with.  The nurses are smart, well trained, and experienced also – they wouldn’t be in an intensive care unit otherwise.

Still, this morning, Nancy felt a little miffed at the new team.  I figure if you are feeling well enough to notice the difference you might be recovering.  Just a thought.

The implantation of the pacemaker is tentatively scheduled for Wednesday morning.  Again, this is dependent on the clotting time to fall to a safe number.   The modern measure is standardized so that regardless of the particulars of the testing a number is reported that can be compared to other test results.  This is called the INR or International Normalized Ratio.

The appropriate range for a non-ill person is an INR between 0.8 to 1.2.  Nancy’s number has been much higher in recent days and was still at 2.7  on the latest test.  They are hoping for about 1.5 tomorrow morning.  From yesterday in a chat with the doctor I got the impression they would wait for it to adjust on its own rather than add platelets filtered from donated whole blood.  Note the word ‘impression’ in that line.  I could have misunderstood and/or they may change their minds.

Today Nancy showed me how to find an e-mail address book on her laptop within Mozilla’s Thunderbird mail application.  I’ll start going through that list and sending news of this site out to folks – so, if you found your way here via someone else, you may get an e-mail from me soon.  I’ll put a Christmas/New Year’s greeting on the top and you can ignore the rest.

Today was a no-go on the pacemaker implantation.  Instead they substituted a CT brain scan.  Both decisions were based on caution.  A TEE was also done.

Nancy’s blood’s coagulation characteristic did not reach the level appropriate for the small incision and threading of the lead to the heart.  The anticoagulant mentioned yesterday is cleared quickly by the body so the problem seems to have been that the blood platelet decline had not resolved from the previously used harapin.

There is the fact that she could be losing blood somewhere, and there was none in the urine or otherwise noted, so the possibility of bleeding in the brain triggered the CT scan.  That was negative.

She was more mentally playful today than yesterday – this, I think, because the adjustments in meds to prepare for the pacemaker allowed her blood pressure to come up some and so she felt better.  They started fussing about her at 4 AM so by 2 PM she needed a nap.  Interestingly, because she is getting supplemental oxygen her blood is oxygen-saturated and short of carbon dioxide.  Sleeping in this case allows her to relax and because it is the carbon dioxide in one’s system that triggers the breathing mechanism she will stop breathing for many seconds.  It sounds scary but we are told not to worry.  Easy for them to say!

Above I mentioned the TEE or Trans-Esophageal Echocardiogram done today.  For this exam an ultrasound transducer (sound source) is guided down the patient’s throat into the stomach and rests just below the heart.

The TEE provides a close look at the heart’s valves and chambers without interference from the body, ribs, or lungs.  Prior “echo” exams for Nancy where all done in a conventional way – the transducer was outside the body.  Today’s pictures were sharp enough that the doctor believes the bacteria infection last May/June was established on her tricuspid valve.  We’ve know since August that both the mitral and tricuspid valves are damaged.  This is one of the tests –because of its sharpness—that the surgeon wants to see before planning on what will be done during an operation.  [That is not currently scheduled so I look for this TEE exam to be done again – when the time comes.]

And speaking of time, today was the winter solstice in the northern hemisphere at 9:47 AM in the Pacific Time Zone.  Here’s to longer days and a brighter future.

I found out that the tech-staff in the hospital begins work early so that their results will be available when the day doctors and nurses come on duty at 7 A.M.  Thus, they may wake you up at 5:30 to take an x-ray or a blood sample.  This happened to Nancy today as they make plans to implant a permanent pacemaker on Monday morning.

They had given some meds to lower blood pressure and control her heart rate, among other things.  When I got there about 11:45 she was worn out, sleepy, and not in her usual upbeat attitude.  I helped with lunch and ate part of it.  She was ready for a nap and was nodding off, so I woke her up to say goodbye.

Today they were trying Argatroban (ar GA troh ban) as an anticoagulant.  As these things go it is relatively new and people seem not to develop the allergy to it as they do with heparin that leads to low platelet counts – if so inclined, look on the web for heparin-induced thrombocytopenia (HIT).  For any of these things there is a lot of info on the web but a nurse said to me “Remember they tell you way too much.”   Indeed, they do.

The pacemaker implant procedure is scheduled for late morning on Monday.  Apparently, Nancy will receive drugs so as to not feel or remember any of this, unlike when doing the temporary one.  There will be nothing to eat from midnight until she is reawakened.  Bummer!