TUESDAY — plugging the holes

The chest drain is gone and the hole sutured shut.  That is a sort of milestone, I suppose, indicating the reduction of danger from open heart surgery.  However, the sutures will have to come out in about two weeks and so – in my mind – when that happens I will think of the heart surgery episode as having closed.  I’m thinking here in terms of danger level because I know there is still a long healing processes.  It will be a major step down in terms of stress – not actually an end.

Today also marked the beginning of a more aggressive plan to get Nancy moving and back on her feet.  A physical therapist arrived about 2:15 P.M. and I left for home.  Such folks have been coming daily but the doctor and the operating room nurse were both in today to indicate the stepped up activity.

The Advanced Care Unit (ACU) has been asked to make a room available and to insert an extra nurse into the schedule.  ACU did not have an empty room today but Nancy will be kicked upstairs (4th floor) soon, possibly as early as tomorrow.

The fourth floor rooms are directly off the hallway and visitation is easier in contrast to the 2nd floor ICU rooms which are configured on the periphery of a central personnel station.  Thus to get to an ICU patient you have to ask over a phone to be allowed in and you walk through the work space of the doctors, technicians, and nurses.  Once inside that space there may be a security guard when required, patients may be wheeled in or out, coming from or going to operations, or, in fact, if there is a lot going on you won’t be allowed to enter.

I suspect some such thing happened recently because Nancy woke to find a balloon and candy “Get Well” package in her room.  This seems to have been purchased at the downstairs gift shop but the clerks there this afternoon don’t recall selling it and have no way of determining to whom it was sold.  So, ‘thanks’ to the person or persons responsible.  Nancy will thank you in person if the mystery guest signs in, please.

(If you are under a certain age you probably won’t recognize the television connection to this last phrase.)

MONDAY — might have been

The only news today is that there may be news tomorrow.  It is quite likely the chest drain will come out tomorrow.  That will be followed by a move out of the ICU and up to the fourth floor.  The move could be on Tuesday or Wednesday.  Plans are not set yet.

It is increasing clear that Nancy is having no problem recovering from the surgery.  I wonder “what might have been” had she gone into the hospital for an elective operation that relied on heparin?  The initial use of heparin was with the Friday after Thanksgiving heart attack – not a seriously invasive procedure such as cutting one’s chest and heart open.  I wonder if she would have survived both the surgery and the heparin allergic reaction?

Having gotten the explanation of the operation posted last night I’ll not do any more now but hope to have something to report on Tuesday.

UNDER THE SAW AND KNIFE

This will be a short description of Nancy’s open heart surgery.  I’ve used notes from the surgeon and information taken from the internet.  I’ve changed most of the medical terms to simple English and in the process reduced the accuracy.  I’ve added links where I’ve found helpful drawings and information.

When the operation was completed Nancy had a new valve and two replaced sections of artery leading to parts of her heart.

This link shows the location of the parts of the heart.  Note the location of the ‘left atrium’ because that is how one approaches the mitral valve.

http://en.wikipedia.org/wiki/Mitral_valve

The heart needs oxygen rich blood that is provided by arteries and when these become narrowed by disease the muscle of the heart suffers or dies.  Two arteries needed to be replaced.  One of the larger heart arteries is called the “left anterior descending” (LAD) coronary artery.  Its location is shown on this page:

http://www.texheartsurgeons.com/cad.htm

From the main arteries are branches or “diagonals” and one of these also had reduced blood flow from clogging.

To get to these arteries and the mitral valve Nancy’s chest had to be opened.  This is done with a reciprocating saw with the same basic design of a wood worker’s tool you buy at the hardware store.  The design is more refined and the blade is short – it only has to be slightly longer than the breast bone (sternum) is thick.  The location of the sternum is shown here:

http://en.wikipedia.org/wiki/Sternum

A photograph of one brand of sternum saw is shown here:

http://www.terumo-cvs.com/products/ProductDetail.aspx?groupId=6&familyID=114&country=1

You will sometimes hear of “breaking” the chest bone but the instrument of choice is a saw and not a hammer.  Here is a link to a video that shows the chest being opened.  There is some blood, but not a lot, and you get a look at a beating heart.  If you feint at the sight of blood skip this or sit down in a comfy chair.

http://www.youtube.com/watch?v=r7RsB0BA4EI

Once the surgical team gets the chest open the blood flow to the body is maintained by bypassing the heart with a “heart lung machine.”   The concept is shown here:

http://biomed.brown.edu/Courses/BI108/BI108_2004_Groups/Group03/HeartLungMachine.jpg

And here is a picture of the real thing.

http://heatherwritesablog.files.wordpress.com/2009/06/heart-and-lung-machine.jpg

Much more complex.  The issue is to take the heart “off line” and repair it while maintaining blood flow to the rest of the body.  You can read about it here:

http://en.wikipedia.org/wiki/Cardiopulmonary_bypass

An issue in all of this is that you do not want the patient to get blood clots while doing the surgery so an anticoagulation chemical is necessary but you then need to put the parts back together with sufficient clotting ability in the blood so that they don’t leak around every suture.

Nancy managed to complicate this already complex issue because of her serious allergic reaction to heparin, the anticoagulant of choice.  For her they used a chemical called Angiomax.

The next issue is that the heart will be stopped and disconnected from the blood supply and both the patient and her heart will fare better if all this is done at a lower temperature.  So she was cooled from a normal 98.6o F. to 86o F. (37o C. to 30o C.).

Her heart was stopped by using cold blood (with added potassium) put into it by way of both the main artery and vein and kept cold by repeating this every 10 minutes.  This is called “cold potassium blood cardioplegia” with the last word meaning “paralysis of the heart.”

A vein from near the surface on the  inside of her left leg, above the ankle, was “harvested” and used to replace the “diagonal” artery.  The vein used is called the “saphenous” vein (clearly seen) as it is close to the surface of the body and can be seen under the skin.  When the body is too hot the body shunts blood from the deep veins to the superficial veins, to facilitate heat transfer to the surroundings.  Normally this vein doesn’t get a lot of blood volume and so can be removed without harm.

Next the “left anterior descending” or LAD  was bypassed.  For this they used an artery found within the chest cavity called “left internal mammary artery” or LIMA.  There is also one on the right side.  These unique blood vessels run along the inside edges of the sternum, sending off small branches to the bones, cartilage, and soft tissues of the chest wall. For unclear reasons, the IMAs are remarkably resistant to cholesterol buildup and thus a good choice for replacing an important heart artery.  Read more about the IMAs here:

http://www.hsforum.com/stories/storyReader$1491

To replace the mitral valve the left side of the heart has to be opened.  This is called “left atriotomy” —  meaning cutting open the upper chamber on the left side of the heart (the atrium).  Nancy’s mitral valve was in need of replacement and (apparently) dead bacterial ‘vegetation’ from last summer’s endocarditis was also found there. The attachments that make the valve work were shaved some to make them work better.  The old valve was cut out and a replacement from a pig (a 33 mm Hancock II porcine prosthesis) was set in and sutured into place.

With the new valve in place the surgeon than had to close the opening in the heart.  As they worked their way back out of the chest cavity they re-warmed Nancy’s entire body and sent warm blood back into the heart.  Her heart came back to life with a single electrical shock.  It started with a normal rhythm, which in medical terms is called “sinus rhythm” but the use of the term ‘sinus’ likely derives from a mistaken idea and so has only historical context for its continued usage.  She was on the heart-lung machine for 100 minutes.

On a normal patient the surgery would be about over at this point.  But for Nancy there was a long wait ahead.  The blood thinning issue meant she would stay in danger of excessive bleeding for some time.  With all the major and minor cuts and sutures in her chest cavity there were lots of places for something to leak.  So they waited.  First they waited for 3 hours with an open chest, watching and monitoring the instrumentation, and testing the clotting time (ACT = activated clotting time). Then they closed the chest and stayed with her in the operating room for another hour.  She spent from 9 in the morning until about 4 in the afternoon with the operating team.  Then she was returned to the ICU, a room full of instruments, and watchful nurses.

The operation was on a Tuesday.  Watchful waiting lasted into Thursday.

Then the ventilator was taken away and slowly other sensors and monitors were removed.  About Friday Noon the ever-vigilant nurses started to relax.

Nurses from earlier days, doctors, and many others started coming by, standing at the foot of her bed, smiling, and giving her 2-thumbs up.

SUNDAY — drainage reduction

I’ve mentioned the drainage coming from Nancy’s chest.  From just after her operation until today the rate of discharge has steadily decreased and is now just half of what it was.  It still seems a lot to me but the surgeon thinks that it will soon be time to remove the tubes.

The pleural space is the space between the inner lining and the outer lining of the lung.  A drawing can be found here:

http://www.nlm.nih.gov/medlineplus/ency/imagepages/9968.htm

A tube, usually about as big around as a small finger is inserted in the pleural space. This tube is sutured into place and the skin around the tube is sutured. This tube can be hooked to suction to facilitate drainage.  The function of this set up is to help get the serum or fluid out of the body without allowing fluid, air, or organisms to enter.

You can learn a bit more about this by visiting the following site.

http://web.mac.com/kieran.mcmanus/Chest_drains/Chest_drainage_systems.html

There is a simple drawing showing three bottles and the basic set up.  Scroll down to see the 3-chamber plastic unit such as is being used for Nancy.  This is not shown in use here but continue scrolling down and there is a photo of a plastic unit (a Portex bag) showing the color of the initial fluid being drained from Nancy.  Over time this color has become more pink and transparent.

The pleural fluid allows the pleurae or membranes to slide effortlessly against each other during the breathing process.  The fluid is produced and reabsorbed continuously.  The decrease in volume and the change in color indicate the improvement taking place within Nancy’s body, especially the chest cavity.

Soon the sutures holding the tubes in place can be removed, the tubes pulled, and the holes closed – then her lymphatic system will have to take over the absorption of any excess fluid.

SATURDAY — food, therapy, fluid

Everyone seems to be in agreement that as Nancy consumes better food and starts to move more (as in physical therapy) she will speed her recovery.  The doctor is pushing the food aspect and indicated he is currently keeping the chest drains in especially to prevent any pressure on her lungs.  When I arrived today the physical therapy team was completing a session with her and then later the nurse brought a padded chair and propped Nancy’s feet up to lessen the pressure in her legs.

Her heart rate, breathing, and oxygen saturation (without supplementation) were all in good range today.  All signs that the repair of her heart has worked as planned.

A few days ago the ICU was a bit quiet.  Not so last night and today.  We never know who is there or why but it is easy to tell when patients in serious need are there.

One of Nancy’s new “friends” following along suggested a tattoo on Nancy saying “No Heparin” and seems like a good idea.  The question is where to put it.  A medical bracelet was/is a good idea also.

I’ve thought of getting a sweatshirt listing all the things she has endured in the last year – something like

“2009 was a great year –

I survived

and then the list”

We’ll need a big sweatshirt or tiny print.

FRIDAY — counting nutrients

Yup.  That is all that is new today.  At a time when many open heart surgery patients would be home Nancy still has a chest drain and holding excess fluid, mostly in the lower body.  As her arms have been freed up and she has been able to move them and exercise her hands, these have taken on a normal look.

The surgeon requested of the ICU nurses that they record what part of her meals Nancy actually eats.  Then the nutritionists can calculate the nutrients she is ingesting.  The nurses just love to do this!  Yeah, right!  Having enough of the proper nutrients is essential to cell recovery and lessening the edema.  With her refurbished heart doing well they feel it is time to focus on this other problem.

At 2 P.M. a crew of two from the physical therapy staff showed up to work on Nancy.  I left.

Nancy seems to have had very little trouble from the open heart surgery.  Rather, her entire body has suffered from the allergic reaction to heparin – the anticoagulant.  Over the weekend she will stay in the ICU, then on Monday she will likely have the chest drain removed (or maybe not) and move to the fourth floor.  There they can be more active about getting to work on the lower body therapy which she badly needs.

While we are now counting nutrients we are not yet counting down the days to the end of the hospital stay.  It does seem that we will soon be doing that too.

THURSDAY — go for a ride?

After I arrived today two nurses came with a wheel chair for Nancy.  Then Nancy, a nurse, and I left the ICU, went down the elevator one floor to the main level and went to the front entrance.  We told Nancy we were going to escape!

Actually, on either side of the main entrance there are large windows and one can look off toward the hills east of downtown Yakima.  The temperature was cold outside and it wasn’t a really pretty day but it was the first view of the world outside of hospital rooms Nancy has had since Thanksgiving.  For four of those days her rooms had windows but there was nothing to see and she was not in shape to care.  The ICU room has a tall, thin window that lets in fuzzy light and looks at another section of the building.  That one is behind the bed so it isn’t useful either.  This was the first chance Nancy has had to become orientated – both where the ICU is within the building and where she is relative to the city.

She will stay in the ICU over the weekend it seems.  She talked to the surgery team’s nurse about not wanting to be moved because she is so weak and because there is less constant and immediate care in the Advanced Care Unit (ACU) where she was for the two 2-day periods when she was not in the ICU.    Nancy thinks a move just before a weekend is a bad idea.  I surely don’t know, while she might.

Her refurbished heart seems to be doing fine.  She is not up and around but by the time she is, about two weeks will have gone by since the surgery.  Currently she indicates there is no pain associated with the upper chest area but neither is she coughing with a pillow held closely as we were told to expect.  Her lungs are being helped to clear without that.  I think if she were more vertical then coughing might be more normal.  Nothing is normal about this though – not only is her heart healing but damaged lungs, kidneys, and liver (and her whole body) are also along for this ride.  That is why hers is a special case and why she is still in the ICU.

WEDNESDAY — day 8

Nancy was getting doses of Robitussin© today with emphasis on the expectorant potential.  It seems to be working.  She is still in the ICU.

This is post-op day 8.  A regular (if there is such a thing) open heart surgery patient would likely be out of the hospital on day 5 or 6.  Nancy’s back road’s way of getting to this stage included heart attack and cardiopulmonary collapse from heparin-induced thrombocytopenia (HIT).

http://en.wikipedia.org/wiki/Heparin-induced_thrombocytopenia

I now have a single-spaced 3 page transcription of the operation as dictated by the surgeon.  I’ll work to summarize it and post that later this week.  Given my lack of medical knowledge, such a summary would not be possible without the resources on the internet (or WEB or Cloud, or whatever it is called this week) and a relatively fast connection (DSL via phone company for us out in the county), nor would this manner of providing updates on Nancy’s progress.

TUESDAY — new parts & spare parts

Nancy is slowly being transformed into a bionic woman.  Some years ago she had intraocular lenses inserted to replace the natural lenses of her eyes.    Now she has a porcine valve in her heart and, using her own donated tissue, some new plumbing for her blood.

Today the team decided she need no longer have the external pacemaker that has been with her for some time.  It has been turned off for a couple of days and she wasn’t needing it for a time before that.  So the wires were clipped and the ends leading into her heart were given a few gentle tugs.  One came out very nicely.  The other one seemed more securely anchored and so it got to stay.  It was stretched out ever so gently, clipped off, and allowed to retreat beneath the skin.  Truly, a spare part.

Otherwise, for Nancy, this was an uneventful day.  We are again talking about (but not having) a timeline for leaving the ICU and going to a skilled care facility.  A comment was made today that “there is light at the end of the tunnel.”  True, but it has turned out to be a very long tunnel.

MONDAY — not much

New today is a ‘midline catheter’.  I wonder why they don’t call it an MLC?  Almost everything is known by acronym.  It’s maddening.  And I think it should be a mid-length catheter – but I didn’t get to name it.

Catheters are short or long tubes that can be inserted into the body, in this case Nancy’s, for the injection of fluids.  Thus, she gets one poke that will do for many days rather than multiple pokes.  The down side is that you have the end sticking out and taped to your skin – often in an awkward place.

The midline catheter usually goes in on the arm near the elbow joint and runs up into the area just short of the axilla or near where the arm connects to the shoulder.  I’ll get a look tomorrow.

Nancy had a PICC line (peripherally inserted central catheter) inserted last summer.  That story began in April and you can search for endocarditis to catch up.  Nancy had four different bacteria in her blood and the protocol was for 28 days of injections of about 30 minutes.  That line went from about the same location near the elbow into the artery near her heart and so the medicine was released close to where it was needed.

Today, I was there for lunch and visits by a nutritionist and a social services case manager. The case manager gave us a large 3-ring binder with reading material designed to guide us through the recovery period, especially that time after Nancy leaves the hospital.  There is also a section on pre-operation instructions and one on how to quit smoking.  I’m thinking of buying a parakeet so I’ll have something to do with those pages.