Category: Post Visit

————— 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!

When learning of Nancy’s hospital stay, one of her e-mail correspondents sent a version of the alphabet such as has been used to help children remember.  Such as, A is for apple, and B is for boat.  This one is for seniors and begins – A is for arthritis; B for bad back.

Find it here:    http://wwwwj.net/joke02/j063.html

At the end are two extra lines:

I’ve survived all the symptoms, my body’s deployed,

And I’m keeping twenty-six doctors fully employed !

I thought of this today when Nancy and I were visiting with the cardiologist in the ICU for the day.  He mentioned that later today Nancy would be visited by a hematologist.  Someone could put together a list of all the specialties and post it beside Nancy’s bed for the doctors to place a check on when they visit.  With the rotation of folks through the last two weeks she has been seen by many doctors, but most have been cardio-types.

So why the hematologist?  Apparently the chemical of choice to prevent clotting during open-heart surgery is heparin.  Nancy has developed an allergic reaction to this resulting in the degradation of blood platelets – which corrects itself when the drug is withdrawn.  There are substitutes for heparin including one derived from the saliva of leeches.  Synthetic versions have been developed insofar as leech saliva is not abundant.  I had to leave before the doctor arrived and I don’t think she was going to do much today but believe this will lead to analysis of Nancy’s blood chemistry to advise the growing team planning her surgery.

A is for anticoagulant;

B is for blood

C is for ………………

Oh, Nancy slept well last night and felt better today.  Her voice is returning.

Nancy was doing fine today and from Noon to about 2 o’clock we visited and looked at Christmas cards and she wrote short notes on the bottom of letters I’ll mail to family and friends for whom I haven’t found e-mail addresses.  One procedure, done before I arrived, was the withdrawal of 800 ml of fluid from her lungs via a needle through the back.  Ouch!  The issue is they want her lungs to get better as fast as possible so the valve replacement operation can be done.  Taking out the fluid is the fastest way of helping that problem along.  Her heart seems to be strong enough – as a muscle – but the leaking parts need fixed real soon.

I am in awe of modern medicine.

I am less respectful (rant alert) of some of the ‘stuff’ that happens.

Nancy has had “procedures” in the Catheterization Lab twice.  One and one-half days after the first she was on life-support and fully sedated in the ICU within the same building (I think the former is one floor above the later).  Within two days she received (at home) a letter and survey form wanting her to confirm their high regard for their services.  I sent it back suggesting – to the Director – that their protocol include finding out the whereabouts and health status of the intended recipient.  Her second visit to the Cath-Lab was the night time attachment of the external pacemaker and she is back in the ICU again.  The letter and questionnaire almost beat me home from the hospital.

But wait, there’s more.  The dear patient (or Nancy as we call her) gets a second letter.  This one advises her that she is pre-scheduled (what’s the purpose of the “pre” here) for a ‘pacemaker check’ at 2 PM on January 6^th 2010 and failure to appear could cost her $100.  Okay, they provide a number to call to alter this.  Hello, hospital!  She is in the ICU.  She is going to get a permanent pacemaker on Monday.  The one this letter is about – we’ll send it back in a plastic bag for you to check.  (Rant off.)

Finally – if you are still with me – the ICU discourages visitors.  In Nancy’s case she is quite able to have visitors but people in nearby rooms are very seriously ill.  If it were not for potential problems with the heart valve they would likely move her out and if they need the room, they will.  So, no visits, please, as requested by the ICU nurses.

There was heavy fog today.  They closed I-82 for a time but I apparently passed the exit they were to set up at before the police got there.  When I came down off the last ridge into our valley I could see the flashing police car lights blocking the south-bound lanes.  There was only one short stretch where the cars and trucks slowed to about 60 mph, and keeping a respectable distance between us, we sailed on through without a glitch.