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November 6, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 10:38 pm
     Paul Jason
 

 Chapter 16:      The Wonder Drugs (continued)
    

Having described my regimen of post-surgical drugs in the last installment, my commentary on that subject would be incomplete if I failed to address the one last “wonder” about these drugs: their cost. 
  

 The monthly retail cost of these medications is over $200.00 (a little less if your pharmacy has a “senior citizen” rate).  By far the most expensive medication of the group is Lipitor. Fortunately, my medical insurance plan covers a significant portion of these expenses so that my actual out-of-pocket cost is less. Of course, the plan costs me over $5,000 a year in premiums and covers me alone.  Is it any wonder that so many moderate-income, retired and elderly people are desperate to receive financial deliverance from the impossible costs of their life-preserving prescriptive medications.
 
I find it incredible that any individual in the United States who can afford to own his/her own home is entitled to deduct every penny that he/she pays in interest on his/her mortgage loan, thereby receiving a subsidy towards the capital appreciation of the value of that property,  but that no individual can deduct the cost of his life-saving or life-preserving prescriptive medications unless they, together with his medical and dental expenses, exceed 7.5 % of his/her annual adjusted gross income.
 

 Thus, for example, in spite of the relatively expensive health insurance plan that I pay for, the out-of-pocket co-payments that I am generally obligated to expend for medical services and prescriptive medications amounts to an additional  $2,500.00, more or less. I am unable to deduct one penny of that expense on my income tax return.
 

 Can there be any question why these inequities engender outrage amongst many Americans, both young and old?  If Congress has assisted some citizens to achieve the American dream, it has also condemned others to suffer the American nightmare.  It is a national disgrace, and Medicare Part D is not the answer.
 

Finally, I would be remiss if I did not comment on the fact that in spite of the reality that these wonder drugs have been proven to reduce the necessity of hospitalizing patients suffering with episodes of congestive heart failure and myocardial infarction (the pharmaceutical companies claim that for every dollar spent on prescription drugs $3.65 in hospital costs are avoided; that 50,000 heart-related deaths could be prevented each year in the U.S. if high-risk patients received statin drugs; and that deaths attributable to heart disease and stroke have been reduced by 50 percent in the past thirty years due to drug therapy), such hospitalization is essentially covered by Medicare, while the drugs are an added expense.
 


Congress’ efforts to provide drug coverage at prices the average American can afford has  been inadequate at best. I subscribe to the notion that the medical/drug needs of the American people will not be properly served until they receive the same coverage their elected representatives, the members of Congress and the President, do.  I challenge you to name one other milieu in which the employees (our elected officials) receive better health care benefits than their employers (the voters).

To be continued…

 

September 19, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 12:32 pm

   Paul Jason

Chapter 15:                                         The Wonder Drugs
   

I guess it’s common knowledge that advances in medicine have managed to increase life expectancy in the United States over the past hundred years.  In 1900, the average American lived to the age of 48 years .  By 2000 , that life span had soared to over 70  years (80.0 for white females, less for others;  74.5 for white males, less for others). Of course, part of that increase is attributable to the manipulation of numbers.
 
Early in the last century, diseases like tuberculosis, pneumonia, dysentery, influenza and diphtheria stole many young lives, thereby skewing the statistics.  Even then, men and women lucky enough to advance beyond their adolescence and ultimately reach the ripe age of 50 years had a fairly good chance of surviving to the age of 70.  Now, thanks to major advances in immunization and child care in general, the number of infants who survive their twentieth birthdays has vastly improved.  Thus, the average life expectancy has risen accordingly.
 

But, that is only part of the story.  Modern medicine has also learned how to deal much more effectively with the ailments which accompany advancing age.  Today, many people are alive who would have succumbed to their illnesses if we turned the clock back twenty or thirty years.
 

The critical issue has become, however, not whether modern medicine can keep us alive, but rather, what kind of quality of life can we expect from modern medicine if we are allowed to remain alive through the benefit of incredibly sophisticated surgical techniques and “illness-specific” drugs.
 
As I mentioned in the Preface, during the ten-year period prior to my bypass surgery, I used prescription medication to reduce my total serum cholesterol level, which in 1989 was discovered to be 254 mg/dl (milligrams per deciliter).  In 1987, authorities in this field had announced that the maximum acceptable serum cholesterol level was 200 mg/dl, regardless of age or sex.
 
My Primary Care Physician at that time prescribed the medication Lopid to accomplish that goal.  I also read Robert E. Kowalski=s New York Times bestseller “The 8-Week Cholesterol Cure”.  Kowalski scared the hell out of me and had me baking my own low fat oat bran muffins and eating them by the gross which, at times, was “gross”.  However, my own body was simply manufacturing too much cholesterol and Lopid and oat bran together could only bring my level down to around 220 mg/dl.  And that, in spite of the fact that I walked, as I discussed previously, nine to twelve miles a week during approximately seven months out of the year.
 
To make matters worse, my “low-density lipoprotein cholesterol” (LDL, the so-called “bad” cholesterol) was always too high, and my “high-density lipoprotein cholesterol” (HDL, the so-called “good” cholesterol) was always too low.  The end result was that the ratio between my total cholesterol and my HDL always exceeded the number that Kowalski said was critical:4.5.


 

Thus, when the newer medication Zocor came onto the market, I discussed with my physician changing to that medication.  He advised me that there was, at the time, a dichotomy within the medical community as to whether or not Zocor should be taken together with Lopid, or whether it should be taken alone.  His position was on the side of the dual medication; therefore, sometime in 1993, I began a regimen of both Lopid and Zocor.  That combination brought my total cholesterol level down to around 200  mg/dl, the level deemed to be the absolutely maximum acceptable level.  However, the ratio between my total cholesterol and my HDL remained unsatisfactory.
   

Of course both of these medications had side effects and I had to have my blood drawn and tested periodically to confirm that I was not experiencing any negative liver function disorders.
 

Also, somewhere along the way my doctor suggested that I commence ingesting a quarter aspirin (81 mg) every day as a heart attack preventive.
 
Then, in mid-1998 , I heard about the newest cholesterol drug, Lipitor.  I questioned my new Primary Care Physician about it and he agreed that I should try it and see what positive (and possibly negative) effects it might have on me.  Thus, in October, 1998,  I ceased using Lopid and Zocor and began using Lipitor. The effects turned out to be all positive.  My total cholesterol dropped to around 180 mg/dl and the ratio between my total cholesterol and my HDL improved as well.
 
Nevertheless, as you now know, all of the progress I made in my battle against Coronary Artery Disease as a result of these medications did not prevent the necessity of my having to undergo quadruple bypass surgery in April 2000.
 
In the years leading up to Y2K the only regular medications prescribed to me were Lopid/Zocor/Lipitor, which I took together with one-fourth dose of a regular non-prescriptive aspirin.  Since the surgery, on the other hand, I have been on a regimen of six prescriptive medications, plus aspirin.
 

Let me give you the names of the drugs first and then I will describe them and their side effects in greater detail.  I do not mean to imply that all post-coronary bypass patients take these same medications or even any of them; I only mean to tell you that my physicians, in whom I have confidence, have recommended this menu of drugs for my short and long term welfare.
 
The drugs, in alphabetical order, are: Altace , Atenolol ,  Colchicine , Folic Acid , Furosemide  and Lipitor.
 

All of these drugs (including the aspirin) are “wonder drugs”: it’s a wonder that I can remember to take all of them every day (except for the Furosemide, which I take every second or third day); it’s also a wonder that I can keep track of when each prescription needs to be re-filled, since I seem never to be able to get all of the prescriptions to expire on the same day of the month.


 

My pharmacy encloses a computer-generated sheet entitled “Patient Prescription Information” every time I have a prescription filled.  The sheet provides the common brand name(s) for the drug; how to use it; its side effects; precautions; drug interactions; and actions to take in the event of an overdose or missed dose.  Using that information, and with the aid of some additional research, I thought I might attempt to give you some insight into some of the medications used by post-bypass patients.
 
Enzymes are a group of specialized protein molecules that control biochemical reactions in the body.   Altace is a member of the class of drugs known as ACE inhibitors,  which are designed to inhibit certain enzymes in the body from narrowing the blood vessels, thus helping to lower blood pressure.  The good news is that it seems to work very efficiently to accomplish its stated mission.  The bad news is that Altace seems also to have the ability to produce rather undesirable side effects like dizziness, headaches, diarrhea, constipation, nausea, fatigue and/or dry cough.  The user may also develop chest pain, tingling of the hands or feet, yellowing of the eyes or skin, persistent sore throat and/or fever.  In the event the user turns out to be allergic to the medication, reactions could include rash, itching, swelling, dizziness or trouble breathing.  Sounds like fun, doesn’t it?  I began with a dosage of 5 mg per day (one small capsule).  After a year, that dosage was reduced to 2.5 mg a day.
   

Aspirin (acetylsalicylic acid) has been available commercially for over one hundred years.  But it was not until the early 1970s that it was discovered that aspirin inhibits the body’s production of hormone-like substances called prostaglandins,  which assist in the contraction of vascular smooth muscles and the dilation of blood vessels.  Thus, aspirin can prevent blood clots by preventing platelets from releasing  thromboxane, a member of the prostaglandin class, which causes the platelets to clump together in a blood clot; that is, aspirin serves as an anti-coagulant.
 

In 1985 the U.S. Food and Drug Administration approved the use of aspirin to prevent heart attacks in patients who had either suffered a previous heart attack or suffered from unstable angina.  Aspirin may also serve to reduce inflammation in the blood vessels.  Current research indicates that blood vessel inflammation can lead to hardened and narrow arteries, thereby precipitating heart attacks.
 

However, with long term use, aspirin can have some unintended side effects.  Even at low doses, aspirin can cause gastric irritation, increased occult blood loss and, occasionally, serious gastric bleeding.  There is even a relatively minor increased risk of cerebral hemorrhage from sustained use of aspirin and, at high doses, dizziness, ringing in the ears and vomiting has been known to occur.  To counteract some of these side effects, it is recommended that the aspirin tablet used be of the coated variety, designed to eliminate stomach distress and/or damage.  My cardiologist instructed me to take one 325 mg (full strength) Ecotrin tablet every day, indefinitely.  Ecotrin is an enteric-coated aspirin.
       


 

Atenolol is part of a group of medications known as Beta Blockers.   Beta Blockers can control angina (chest pain), high blood pressure and irregular heartbeats.  Atenolol slows down the intensity of the heart=s contractions and reduces its oxygen requirements and the volume of blood it has to pump.  It also serves to increase the diameter of the blood vessels, thereby reducing the pressure needed to move blood through the vessels.
   

Atenolol can cause the user to experience dizziness, lightheadedness, drowsiness and/or blurred vision. Because it reduces blood circulation to the extremities, the patient’s hands and feet may become more susceptible to cold temperatures.  In addition, the patient could experience easy bruising or bleeding, swollen hands or feet, confusion, depression or sore throat.
 
Allergic reactions to Atenolol may include rash, itching, swelling, dizziness and difficulty in breathing (difficulty in breathing!!).  Women are cautioned that this drug should be used during pregnancy only after consultation with their physicians regarding the possible risks involved.  I started with a dosage of 25 mg per day (one tablet).  After one year, that dosage was reduced to 12.5 mg per day.  The only problem is, there is no generic 12.5 mg tablet on the market.  Therefore, every month I bring home thirty 25 mg tablets and diligently cut each of them in half.
 

Colchicine  is  used  to  prevent and/or  treat gout, a  condition characterized  by the sudden onset of severe pain in  the joint  of the big  toe, or, sometimes, in the ankle,  wrist,  knee or elbow.  The pain  intensifies and  the joint becomes very sensitive to  the  slightest
external pressure.  As I explained in Chapter 6,  I experienced gout for the  first time in  my life  during those few days I spent in the hospital prior to my surgery.  I suspect it may have been precipitated by the introduction of thiazide or a thiazide-like diuretic into my IV as a blood pressure medication. Thiazide diuretics are recognized as a cause of hyperuricemia which, in 70 to 95 per cent of all cases, is the result of the underexcretion of uric acid rather that the overproduction of uric acid.             
 

Colchicine has the ability to produce the following side effects: nausea, stomach pain, vomiting, diarrhea, yellowing of the eyes or skin, sore throat, easy bruising or bleeding, muscle aches, numbness or tingling of the arms or legs, fatigue, rash and/or itchy skin. Oh, and one more happy note: alcohol can decrease the effectiveness of Colchicine, so the patient should “limit” alcohol consumption while taking this medication.  I take one 0.6 mg tablet every day.
 

Folic Acid is a vitamin.  It is found naturally in leafy green or yellow vegetables, beans and orange juice.   Folic Acid helps to regulate levels of homocysteine in the blood.  A high level of homocysteine is an independent risk factor for arterial disease.  A usual dosage of Folic Acid, contained in many non-prescription vitamin supplements for example, is 400 mcg (micrograms). I consume two 1 mg tablets a day.  That’s 5 times the amount of Folic Acid contained in the vitamin supplement.  At 1 mg  (the standard therapeutic dosage), it requires a prescription. Fortunately, Folic Acid has minimal side effects; but some patients do suffer allergic reactions like rash, itching, swelling, dizziness or trouble breathing.
 


 

Furosemide is a member of that group of drugs known as “water pills” or diuretics.  It is a potent diuretic , which means that it acts to decrease the amount of water retained in the body by increasing urination.  Thus it counteracts edema (fluid retention and swelling of the hands and feet caused by heart failure or other diseases) and high blood pressure.  Its side effects are interesting, if not familiar by now: dizziness, lightheadedness, increased sensitivity to sunlight, blurred vision, loss of appetite, itching, stomach upset, headaches and weakness, muscle cramps, pain, nausea, vomiting, dry mouth, thirst, unusual bleeding or bruising, rash, yellowing of the eyes or skin and/or ringing in the ears. 
 

And whereas the effectiveness of Colchicine is decreased by the consumption of alcohol, the side effects of Furosemide may be intensified by the intake of alcohol.  Women are cautioned that this drug should be used during pregnancy only after consultation with their physicians regarding the possible risks involved.
 

During the first year after my surgery I took one 40 mg tablet of Furosemide every other day.  After one year, I reduced that intake to about every third day.  During the first six hours or so after ingestion, the drug induces sudden, strong urges to urinate.  This will occur repeatedly during that time frame.  It is a highly unpredictable phenomenon.  Needless to say, you will want to be sure that a toilet will be accessible and available to you at all times during that six hour period once the pill has slid down your throat.  If you don’t follow this advice, then don’t say I didn’t warn you.
 

Finally, Lipitor is one of the statin group of drugs which are being used to help reduce cholesterol and triglycerides (fats) in the blood.  It works by inhibiting cholesterol synthesis in the liver. Lipitor, too, can produce some of the nasty side effects I have alluded to above: headache, nausea, diarrhea, constipation, gas, stomach upset, joint pain, muscle pain, weakness, fever, unusual tiredness, chest pain, swelling in the arms or legs, dizziness, yellowing of the eyes or skin, dark urine, vision problems and black stools.  As if that wasn’t enough, allergic reactions can include rash, itching, severe dizziness and/or trouble breathing. Frequent ingestion of alcohol may increase the possibility of serious side effects.  Also, as with all statin drugs, liver function must be monitored periodically through blood tests to be sure the medication does not have a negative impact. 
 

Lipitor does have one idiosyncracy, however: you cannot eat a grapefruit or drink grapefruit juice while using this medication.  I don’t know why; you just can’t do it.
 

Finally,  this drug cannot be taken during pregnancy since it may cause fetal harm.
 

There, that’s the whole of it.  Based upon an orderly cataloging of the side effects I have described, you may have surmised that I walk around lightheaded; am unable to focus on the world around me; run to the bathroom at least once every hour; have yellowed eyeballs and rashes all over my body; appear slightly swollen; am prone to nausea, with ice cold hands and feet; given to scratching myself in the most intimate of places; chronically tired, slightly feverish, possessing no appetite and complaining constantly of muscle cramps.
If that’s your conclusion, I’m here to tell you that you are . . . wrong (. . .or at least I think you’re wrong!).

To be continued…
 

August 8, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 6:20 pm
  Paul Jason  

Chapter 14: “Get Out and Stay Out”
 By the fourth day after the surgery, Saturday, April 8, 2000,  I could get on and off the hospital bed myself, but with great difficulty and pain.  My left leg was swollen to a girth one and a half times the size of my right leg, from the inner mid-thigh down to the ankle.  My breathing was shallow, and my wired chest was very unstable.
 
You may remember that I said in an earlier chapter that the thoracic surgeon told me that, barring unforeseen complications, I would be discharged from the hospital four and one-half days after the surgery. Well, on that fourth day one of my physical therapists came to visit me. She said that her mission was to be sure that I could walk, and that I knew how to negotiate steps.  She explained that since my left leg was temporarily incapacitated, I would have to go up and down steps one at a time, leading always with my stronger right leg.  So, for example, if I were to go down a flight of stairs, I was to descend from step to step by lowering my right foot to the step first, and then bringing my left foot down.  Conversely, to mount a flight of stairs   I was to ascend to each level by stepping first with my right foot, and then bringing my left foot to that level. Sounds easy enough (a child can do it), until you take into consideration the feeble breathing, general weakness and aching chest factors.
 

I believe that it was sometime during that fourth day that a PA (Physician’s Assistant) appeared in my room and announced that he was there to remove the tubes that were still protruding from my body.  I had tried to ignore them during the past couple of days, while the inevitability of their removal buried itself within the recesses of my mind. Moreover, they were camouflaged amongst the millions of little surgical strips that covered my wounds.
 

To the best of my recollection, I still had two tubes right below my breastbone which had served to drain the fluid that collects around the heart after this surgery, and a third tube located just below and to the left of my breastbone, in the rib cage area, to drain any fluid which collects in the chest cavity.  What these tubes drained into I cannot tell you.  In fact, that’s the very point: there are so many things hanging from your body during those first days; so many debilitating things going on with your body and mind; so many thoughts and pains darting back and forth,  that simple, probing questions that curious minds usually entertain, such as where those drains empty, are blotted out from conscious thought.   
 

Up to that moment it never occurred to me that anyone other than my surgeon would be removing from my body anything that had been inserted during surgery.  But that PA was on a mission and anything I had to say on the matter was of no concern to him.  Not knowing whether I should brace myself, I asked him if this was going to hurt; “Not much” he replied. Easy for him to say.  I was laying on my bed. With aplomb, he grabbed hold of one of those tubes and started to pull. I couldn’t look.  From the sensation it felt like he withdrew two feet of tubing, although I’m sure it was much, much shorter. Then he went on to the second tube, and then the third.  I couldn’t believe what was coming out of me.  He dressed the wounds and left. The whole procedure probably lasted five minutes.


Well, it was becoming apparent that they really were determined to discharge me on the next day.  I couldn’t believe it.  Could I really function outside the confines of this hospital so soon?  Given the state of my mobility, I questioned how I would be able to get home and into the house.  My “significant other” was making arrangements to come to the hospital with a friend and to drive me home.  How would I get to the car?  How would I get into it?  How would I get out of it?
   

Sunday morning, April 9, 2002,  it started to snow.  That’s right, snow. A little late in the year for snow in New York City, but you can look it up.  I limped out to the hallway window (remember, the dividing curtain in the center of the hospital room was never drawn back,  so I could never see the room window) and watched the flakes coming down… slowly at first, and then more frequently.  By 11:00 a.m., snow was beginning to accumulate on the ground.
 

“They’ll never release me on a day like today,” I thought to myself.  “How can they expect me to go outside, as unsteady and unstable as I am, and travel home? What happens if the car gets stuck in the snow?  I’m not physically capable of maneuvering myself out of any  situation.”  These thoughts raced through my mind.
 
My significant other had the same thoughts, and she called me to express them.  Should she drive the long distance to the hospital in this weather?  Should I be exposed to such harsh weather so soon after such critical surgery?
 

I hobbled to the Nurse’s Station and made inquiry regarding my impending discharge. “Oh, yes” I was advised, “you are scheduled to leave the hospital as soon as your cardiologist arrives to examine you.”  My cardiologist?  Well, thank God . . . I can’t imagine that he’ll let me out in this weather.
 

How wrong I was. In fact, it was not my cardiologist, but one of his partners, who appeared that day.  I expressed my concern as he was examining me.  He declared me fit for discharge, downplayed my fears, and told me to go home.  He wrote prescriptions to be filled at an outside pharmacy that day, wished me well, and left.  Boy, I wished I was as optimistic as he was.
 

I guess the moral to the story, if there is any, is that modern American medicine is controlled by the insurance companies, HMOs, managed care services, etc., and that, short of a catastrophe, my post-operative days in the hospital were pre-ordained and carved in stone.
 

The “Discharge Plan/Instructions” sheet that was delivered to me by an RN indicated that my blood pressure was currently 102/60, my body temperature was 99.4 degrees F. and my pulse was 84.  All of my medications, their dosages and frequency of ingestion were listed there.  It also advised me to call for medical assistance if I experienced chest pain, palpitations, dizziness, redness or discharge on my incision sites, fever, “etc.”  In case of an emergency, call 911.  An emergency?  How the hell would I know what an emergency is.  To me, this is an emergency!!!


Tired, weak and faced with the inevitable conclusion that the insurance company bean counters would dictate my exit from this medical facility, I phoned my significant other, told her what had happened, and asked her to please come and get me.

To be continued…

July 28, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 6:55 pm
  Paul Jason

Chapter 13:   ” Sponge Bath . . . What Do You Think This Is, a Spa ?”
  

 

The remaining days and nights of my hospital stay prior to discharge were filled with restlessness, discomfort, loneliness, apprehension, fatigue and depression. Various members of the “medical team” dropped by intermittently to examine me, but most of the time I was left to contemplate my condition and cope with my pain. 
 

I found that unless I asserted myself, little attention was devoted to alleviating my pain.  For example, from the moment the endotracheal tube was removed the morning after the surgery, my throat was sore - - - very sore.  They had given me ice chips to suck on soon thereafter, but nothing further.  The soreness persisted over the next days.  It was not until the fourth day, when I was complaining about the situation to a nurse I had not seen before, that she offered to bring me some lozenges to suck on.  Lozenges?  “You mean you have throat lozenges to alleviate the pain?”.
 
 ”Nobody offered them to you before?”
 

“Well, no.”
 

Sure enough, the lozenges were numbing and soothing.  Why hadn’t anybody brought them before?  After all, every surgical patient who has had general anaesthesia has had an endotracheal tube shoved down his/her throat.  The throat and windpipe react to the intrusion and irritable soreness inevitably results.  Why not provide lozenges as a matter of course?
 

Nevertheless, it is this sort of general indifference which undermines the hospital experience.
 

Lozenges, of course, are just a small indication of this indifference.  Another one of my pet peeves is the fact that once that aide in the CCU had gently cleansed me the day after surgery, no one else ever washed me; no one ever offered to wash me.  As I have described in a prior chapter, lying in a hospital bed can be a perspiring experience.  My ability to get on and off the bed was somewhat limited, and painful.  The first couple of days I was using a bed pan, and I didn’t have enough solid food in me to require use of the toilet.  But, surely, I needed to be washed down, if not for my cleanliness, at least for my dignity.  I always thought that patients in my condition received “sponge baths” in or at their beds.  But there were no sponge baths to be had.  I guess they’re no longer part of the union contract!!
 

Fortunately, my domestic partner came to visit me every day and she washed me down using  wash cloths that she commandeered from a nearby corridor supply closet. (This is but one very small example of what I was talking about in the Preface when I said that  I could not imagine the hardship one would undergo to face this ordeal alone.)
 


Also, by the fourth day, I was able to struggle off the bed by myself, shuffle over to the bathroom a few feet away (when it was available, there being, of course, two other room occupants to share it with, and more when there were visitors), and attempt to wipe myself down with the wet corner of a towel.
 

I understand that there is a nationwide nursing shortage.  I also know that my experience in one hospital cannot serve as the basis of a generalization.  However, I have now taken the time to speak  to other people who have been hospitalized in the New York metropolitan area, and their comments have been similar to mine. Comments to the contrary have been the exception rather than the rule.  And, after all, The Motel Monte is not some backwoods infirmary; it is a major player on the metropolitan New York medical scene.  And it doesn’t require the services of a registered nurse to sponge bathe a post-surgical patient.  Something is wrong, terribly wrong, and I suspect that not enough is being done to address the matter.
 

In a similar vein, I discovered that no one was particularly concerned about the pain I was experiencing.  Unless I persisted in my requests for pain medication, I received no attention or sympathy in that regard.  Now, don’t jump to the conclusion that I’m some pampered wimp, incapable of tolerating a little pain and, therefore, was whining for relief every five minutes.  Quite the contrary.  As one example of my pain toleration, a few years ago I had a lower rear wisdom tooth prepped for the installation of a crown . . . without any anaesthetic.  However, that pain lasted for an hour and then subsided.  This pain would last, unabated, for several days.
 

Since the surgery, I have read about hospital-based programs in pain management in which patients are given limited control over the introduction of pain medication into their bodies.  Whatever the status of those programs, and the medical philosophies that buttressed them, was in April 2000,  in my experience The Motel Monte was not implementing them.  Certainly this is an area of care that requires more consideration, and every prospective surgical patient should make inquiry regarding the status of pain management in the hospital of his/her choice.
 

When I first organized an outline for this book, I considered naming two of the chapters  “You Have Throat Lozenges?” and  “May I Have My Pain Medication Before I Die?”  This was reflective of the anger I felt during the recuperative period whenever I contemplated the hospital experience.  Ultimately, as you can see, these individual ideas became melded into a more generalized statement of dissatisfaction.

To be continued….
 

June 3, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 7:48 pm
   Paul Jason
    

  Chapter 12:   “Whoops!  We Have a Visitor”
 
Approximately thirty hours after I left the operating room I was wheeled on a gurney up to the “Intermediate Cardiac Care Unit” on the sixth floor.  Unlike my first visit there (prior to the surgery), I was now placed in a semi-private, as opposed to a private, room.
    

It was after midnight when I was wheeled into my new room. The overhead lights were out.  The light on the wall behind the bed was turned on and I was assisted from the gurney onto the bed with considerable pain and discomfort. At my request, the nurse brought me a couple of pillows to prop me up in the bed. My IV was checked, I was hooked up to some monitors, the light was turned off and I was left to my own devices.  The hallway lights, peering into the room, created an eerie environment. 
 

It was a standard type of room that I had been in many times before as a visitor. Upon entering, on the left, was a bathroom.  Beyond the bathroom was the bed reserved for me.  A movable curtain separated that bed from a second, parallel bed, which itself was parallel and adjacent  to the windows. At this time the curtain was drawn, and I could not see who occupied that other bed.  This was probably going to be my roommate for the next couple of days.
 

The ability to find a comfortable position in which to rest abandoned me and I spent the next couple of hours restless and perspiring. . . perspiring so much that I finally felt impelled to ring for the nurse and to request that my bed sheets and hospital gown be changed.  Whether this was precipitated by the emotional anxiety generated by my relocation from the CCU, or the sheer physical exertion of that transition, was unknown and not particularly important at the time.  The fact that I was wet enough to feel very uncomfortable was enough.
 

One of the things that you come to recognize after laying on a hospital bed for a short while is that vinyl liners reside immediately beneath the bed linens.  I’m sure they are there for sanitary reasons; however, they also serve as unwanted captors of body heat and are capable of fomenting linen-drenching perspiration in patients whose body temperatures can fluctuate continually for any number of reasons.
 
Of course the mere changing of bed linens became for me another exercise in pain and discomfort, requiring as it did that I shift myself around the bed to assist in the process.  Nevertheless, having temporarily achieved a drier sense of myself, I managed to fall in and out of sleep repeatedly as the next few hours passed.
 

Then, all of a sudden, at what I estimated was perhaps four or five o’clock in the morning judging from the quietness of the hallways,  the separation curtain rustled, and a short, squat figure appeared from the far side of it. The figure walked right past the foot of my bed, headed straight for the bathroom, and never even looked at me.
 


At first, in the dim light, I couldn’t decide whether I had just seen a man or a woman. A woman? I didn’t know they have co-ed hospital rooms.  I mean, I know that many colleges have had co-ed dormitories since my kids went to school.  But, even then, that sometimes means that alternating floors within a dormitory building are designated for girls only and for boys only and, at other times,  that rooms occupied by girls are located on the same floor as rooms occupied by boys.  I never heard of situations where one girl and one boy are assigned to the same room.  Hmmmm.  But, then again, in those college dorms, on those co-ed floors, I also know that some (maybe all) of the bathrooms in the hallways are co-ed.  Hmmmm.   But, I still didn’t think that hospitals have co-ed rooms.  Never heard of it; never saw it. 
        

The bathroom door opened, the figure trod back in front of my bed, never looking at me, passed to the other side of the curtain and got back in bed.  This time I was convinced - - - it was a woman!
 

And then another thought hit me.  This person was walking without any difficulty. How could that be?  I was in the ICCU.  I had to presume that all of the other people on this floor have undergone some type of cardiac procedure.  When that happens, you walk around with an IV dangling out of you, or some sort of monitor hanging around your neck, or bent over from the stitches they put in you, or something like that.  But this person had none of those impediments.  What is she doing here?
 

Before I could ponder the situation much further, I fell asleep again.
 

I was awakened by soft voices.  As I became coherent, I realized that the voices were coming from the next bed.  I looked towards the bed, but the curtain was still drawn.  However, the sun was starting to filter through the windows and the opaque separation curtain, and I knew that I had made it through the night.
 

The voices were Spanish voices.  Soon there was rustling again and the short, squat figure appeared, dressed in a bathrobe.  She plodded past my bed without a glance or a word and disappeared into the bathroom.  After some time, she emerged and then disappeared behind the curtain. 
 

Again, Spanish voices.  Now the curtain rustled a second time.  A man, dressed in a different bathrobe from that worn by the woman, appeared this time.  He glanced at me briefly as he passed my bed, but said nothing.  He, too, entered the bathroom. After a few minutes he  retraced his steps, and went behind the curtain.  It sounded like he got back into bed. Back in bed?  Wait a second . . . I didn’t know they had double beds in here!!  Curiously, as with the woman, there was no IV dangling out of him, and he wasn’t bent over either.  What’s going on here?  Who are these people?
 

Shortly, a nurse entered the room to check vital signs and the daily hospital routine began.  The woman reappeared from behind the curtain dressed in street clothes and went out into the hall.  Neither the nurse, nor anyone else, as far as I could discern, said anything to her.
 


The nurse checked the man in the next bed; there was some language difficulty.  He spoke very little English, and she spoke very little Spanish.
        

When she finished, I fully expected that the curtain would be drawn back so that I could not only see my co-habitant, but so that a little daylight be allowed to shine into my side of the room.  However, my expectations were dashed.  In fact, from the moment I entered that room, until the moment I checked out three and a-half days later, that curtain was never drawn back.
 

And with good reason. This couple had set up housekeeping in that portion of the room.
 
I have good reason to believe that the food service department delivered two meals to that bed at every meal.  The woman spent most of each day there, and slept there every night, sharing the bed with the man.  They spoke only Spanish to each other, so I could never understand anything that they said.  They never demonstrated any interest in speaking to me.
 

I can tell you that no matter how many visitors you have while you are a post-operative patient, there will be many hours in each twenty-four hour day when you will feel alone, isolated and depressed - - - depressed, even if you don’t know it.  Spending those moments in the confines of a private hospital room may provide the sanctuary in which to cope with your inner thoughts and to contemplate the future. But spending those moments within a semi-private room provides the opportunity to share your misery with a fellow human being who is faced with the same feelings of self-doubt.  However, being confined in a semi-private room occupied by three people, as I have described the situation, is demoralizing and demeaning: it lacks the quietude of the first alternative, and robs one patient of the camaraderie inherent in the second.
 
On my second day in that room,  one of their visitors asked me, in English, how I was doing.  I used the opportunity to pursue my natural curiosity.  It turns out that the man had been admitted to the hospital about two weeks earlier to undergo coronary bypass surgery.  However, he had other neglected health problems which rendered him a high risk candidate until they could be controlled.  Therefore, he had been laying around the hospital receiving some medications, being visited by his primary care physician and other doctors, and waiting to be told that the surgery could be performed.  Thus, his wife had moved in with him.
 

Also, by the second day in that room, I was starting to use the bathroom.  Now, instead of sharing it with one other patient, I was sharing it, on a full-time basis, with a non-patient as well. The room began to feel, well . . . crowded.
 


To my surprise, and chagrin, no one on the staff seemed to be concerned about the situation. Not the Administrative Nurse Manager; nor the Associate Administrative Nurse Manager; nor Patient Care Coordinators; nor the Registered Nurses; nor the Licensed Practical Nurses; nor the  Nursing Attendants; nor the Clinical Care Coordinators; nor the Monitor Technicians; nor the  Attending Physicians; nor the Residents; nor the Interns; nor the Physician Assistants; nor the Nurse Practitioners; nor  the  Unit Secretaries; nor the Service Associates; nor the Unit Manager.  No, not even the Registered Dietitian cared.  Nope, not one of them was concerned that three people were co-existing in a semi-private room designed for two patients . . .  and one was a very sick post-operative patient.
 

And so the old saw addressed to good-doers everywhere was visited upon me: “Let no good deed go unpunished.”  This was my fate. Voluntarily leave the CCU one day early, at the request of my surgeon, and join a menage-a-trois!!
 

My reaction to this scenario turned from negative to very negative. I felt as though I were trapped  in some fictional tawdry roadside motel of yesteryear, where rooms rented for one wound up being occupied by two, with curtains drawn and  profiles kept low in the hope that no one would say anything. Befitting the administration of the place, as viewed from my vantage point, I decided, right then and there, to dub it “The Motel Monte” and to use that descriptive name as the title of any document I might later generate about my hospital experience.

 

 

 

 

May 2, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 2:04 pm

 Paul Jason

Chapter 11:  You Want Me to Volunteer to Do What?
     

The exultation which accompanied  the confirmation of my continued existence on Planet Earth was soon replaced by the reality that I hurt.  I mean every part of me hurt.  As soon as I was released from the restraints that had prevented my earlier movement, I discovered that my body ached.  My left leg felt very swollen and weak.  My back felt sore.  My chest felt like an eighteen-wheel truck had run over it.  An IV and a urine-collecting catheter were hanging out of me and I suspected that a few other tubes and/or wires were projecting also. I was sure the IV was feeding me pain-killers, as well as some saline solution.  In addition, a nasal prong was inserted into my nostrils to supply oxygen and assist my breathing.
 

To tell the truth, I wasn’t too anxious to survey the damage.  Dealing with blood and bloody wounds has never been one of my strong suits.
 

After the endotracheal tube had been removed, a nurse brought me ice chips to suck on to alleviate the soreness in my throat.  That soreness would continue for the next two or three days.
 

Some time thereafter, a young woman appeared at my bedside and announced that she was a physical therapist and that she was there to assist me from the bed onto the floor.  I retorted (with whatever energy I could muster) that I seriously doubted that she, at  about one hundred pounds, was going to be able to sit me (at about two hundred pounds and feeling like a dead weight) up in bed and then assist me into a standing position.  I guess she had second thoughts because she  left the room for a few moments, only to  return with a second one hundred pound young woman.  Well, I thought to myself, at least we have improved the odds.
 

Their first attempts to get me into a sitting position on the bed were filled with agony (for me), fear and a little disbelief.  I hurt in all directions.  Additionally, I learned for the first time that my dissected chest was very unstable.  At the least little movement, it felt as though my breastbone would pull apart.
 

I knew, prior to the surgery, that the patient’s chest is pried opened.  But, to tell the truth, I never understood the full reality of that statement.  My dismantled breastbone was literally held together with wires. It was unstable and would not begin to recover its stability for eight weeks or so.  To make matters worse, the surgery had very quickly depleted the major supporting muscles of their tone and strength, and I felt something like a marionette dangling loosely on its strings, incapable of creating assertive motion.
 

Nonetheless, these two young women were determined to get me out of bed, like it or not.  So slowly, and very painfully, they propped me into a sitting position, then maneuvered my feet and legs over the side of the bed, held me under the arms and lowered me to the floor.  There was not much that I could do to assist in the process and, as my feet hit the floor, I felt my rib cage quiver.
 


But the agony was not over.  After getting me to take a few assisted steps, they sat me down in a hospital armchair (the firm, vinyl upholstered, wooden arms type).  During these few moments, I discovered three other things: one, my left leg felt stiff and it was not working very well; two, it hurt just as much trying to sit down as it did trying to stand up; and three, I couldn’t breathe very well.  My breaths were short and shallow.  The anaesthesia was still working on my lungs. Every attempt to draw in air was resisted by a pair of protesting lungs and a protesting chest, both of which felt as though they were about to explode.
     

Coughing had become an excruciating experience.  I had learned, however, from cardiac patients I knew or had previously met, that CCU patients are generally given a “security blanket” to hold onto, and to hug against their chests, as assistance in those moments when unexpected coughing or body turning becomes inevitable.  In some hospitals, this companion comes in the form of a large-size Teddy bear, or some facsimile thereof.  Often it is decorated by the nurses with words of encouragement, the patient’s name and/or the date of the operation. When I asked for one at this hospital, what I got was a blank white pillow case stuffed with some bedsheets!! . . . my “security pillow”.  I knew right then and there that I was either dealing with a very dispassionate nursing staff, or a nursing staff that was undermanned and/or overworked and/or undersupplied.
 

I believe it is worth digressing at this point to mention that the American Nurses Association has been saying for years that most hospitals are understaffed.  Often these institutions supplement their regular nursing staffs with temporary nurses who may be unfamiliar with all of the particular facility’s routines, mission statement and medical staff.  We’ve all heard about this nursing shortage, but I believe that most of us don’t pay much attention to it . . . until it directly affects us.
 
I also believe that people become nurses for the best of reasons and intend to provide the best possible care for their patients.  I, therefore, gave my nurses the benefit of the doubt.  Nevertheless, when you are overwhelmed with post-surgical despondency, you really are not in an appropriate frame of mind to rationalize  why some RN is seemingly ignoring you in your time of need.  .
 

To overcome the breathing problem, I was soon introduced to a diabolical little plastic lung-exercising device, sometimes referred to as an “incentive deep breathing exerciser.” It consists of three enclosed vertical cylinders, five inches in length, each holding a small plastic ball.  The three cylinders are attached to a base which has a projecting flexible tube, at the end of which is a mouthpiece. The goal of the device is to get the debilitated, anxiety-ridden patient to suck on the mouthpiece hard enough to make the balls rise in succession to the tops of their respective cylinders.  Thus, on the first feeble attempt, the patient may be able to get the first ball half way up its cylinder while his lungs scream for relief. Sooner or later, the patient will hopefully improve to the point where all three balls will rise to the tops of their cylinders. With this surgery I immediately knew that it would not only be necessary for my lungs to improve, but my chest would have to heal as well.

 

This breathing exerciser was to become my nearly-constant companion for the next six or more weeks, until my breathing resumed its pre-surgical norm.  However, during that initial introduction to it,  I was convinced that this device had been created solely for the purpose of becoming my personal nemesis - - - my sworn enemy.
     

While these seemingly exhausting activities were going on, and in no particular order, an aide came into my room and announced that she was going to wash me while I was sitting up in the armchair.  I had detected earlier that my left leg and most of my chest was swathed in bandages, and my body had the telltale signs of various fluids (antiseptics, blood, etc.) all over the portions I could see.  Ever so gently, she began the first post-operative clean-up and I was most appreciative of her efforts.  While I thanked her profusely at the time, I never saw her again and was never able to fully express my gratitude for her kindness in momentarily returning to me some sense of dignity.
 

Later in the day a handful of relatives came to visit me.  Of course, visiting hours in the CCU are limited, but their presence was a psychological reaffirmation of my existence.
 

Also, the two physical therapists returned.  This time they got me out of the chair, assisted me while I shuffled twenty excruciating feet up and down the hallway, and got me back into bed, IVs, hanging tubes, wires, and all.
 

The inability to walk was psychologically devastating for me.  Walking had been my primary form of exercise during the prior twelve years; and I don’t mean strolling.  Sometime around my forty-eighth birthday I had set a goal of four-mile one-hour walks as a yardstick for measurement of my physical well-being.  Every time I went out onto the streets (and that averaged three times a week during the approximately seven months of agreeable weather in New York) I would aim to walk four miles in less than an hour.  I had devised a series of measured routes in my neighborhood so that I could walk with abandon, enjoy the scenery, and be assured of the distance I was traveling.  All I needed was a pair of sneakers and a wristwatch.
 

After awhile, the routine became sacrosanct and, to memorialize it, I decided, in celebration of my fiftieth birthday, to establish the “Paul S. Jason Annual Fifth Avenue Four-Mile Walk.”  I invited some friends and family members to join me at 8:00 a.m. on a Sunday morning in the Fall at 86th Street and Fifth Avenue in Manhattan.  We then proceeded to walk down Fifth Avenue (with the cross streets empty of most vehicular traffic at that hour on a Sunday morning) to the Washington Square Arch, a measured four miles.  This was not a race; but I encouraged all walkers to set a goal to walk the distance in one hour or less, if possible. Then, when everyone reached the Arch, I took them all out to breakfast.
 

I chose a walk in Manhattan because I was born and raised in New York City and I wanted to simultaneously celebrate my life and my lifelong attachment to this city. I chose Fifth Avenue because (i) it runs in essentially a straight line for the required four miles, (ii) it is lined with a great array of wonderful New York landmarks, and (iii) it concludes with a very visible goal line, the Washington Square Arch.


 

By April, 2000, I had already conducted ten of these annual events with a somewhat varying group of participants.  And, always, I had  managed to complete the walk in less than one inspiring hour.  Thus, it had become a source of joy, renewal and friendship for me.  Would that now be jeopardized forever? I had no way of knowing.
 
I forget whether or not I ate any solid food that first day. I was receiving nourishment intravenously.  I did, of course, slip in and out of sleep.
     

One of the other lessons I learned that day (I guess I should have known this before) is that hospital gowns are designed so that the patient’s rear end pokes out every time he gets out of bed or rises out of a chair.  No article of clothing has yet been devised by the mind of man to more quickly rob a middle-aged man (or woman for that matter) of his dignity than the hospital gown.   As my two young, female therapists assisted me with my first, feeble steps I didn’t know whether to cry (from the pain) or to feel embarrassed.  But I learned very quickly that when the body is broken and in pain, dignity dissipates straightaway and survival takes over.  For the balance of my hospital stay I was never again concerned with personal modesty; practicality ruled at all times, and that’s all I have to say about that subject.
 

Eventually, night settled in and I was thankful that I had survived the initial post-surgical trials and tribulations. My body ached, but somehow I knew I was going to get through this passage of my life.
 

Then as I lay in my bed, just minding my business, my surgeon suddenly appeared.  It was about 10:30 at night and I was surprised that he was still in the hospital since I was under the impression that he operates during the day time.
 

“Mr. Jason, I have come to ask a favor of you.”
 

(”A favor of me.  What could I possibly do in this condition to assist anyone, let alone a cardiothoracic surgeon?”).
 

“We have a critical emergency case who is being rushed into the operating room.  When the surgery is over in a few hours he will have to be moved into the CCU, and we have no available beds for him tonight.  Of all the patients in the CCU you are in the best condition to be moved . . .”
 

(”Best condition?  I’m half dead.  I’m just glad that my heart is still beating . . . and I can hardly breathe.”).
 

“I’m hoping that you will volunteer to leave the CCU tonight to make room for this patient.  If you agree to do so, you will be moved to the sixth floor ‘Intermediate Cardiac Care Unit’ tonight.”
 


 

(”Tonight?  I thought I was supposed to be in the CCU for two days after my surgery. I just had a quadruple coronary bypass operation. Should I question the evaluation of the man who, ostensibly, had just saved my life?”).
 

Well, now I was not only physically debilitated as never before in my life (and clinically depressed I might add), but I was being presented with a moral dilemma.  Do I respond to the doctor’s request as a decent human being concerned about the welfare of others less fortunate than myself, or do I play the role of the very sick patient and plead my own cause?
 

I don’t think that anyone appreciates having to deal with a moral dilemma, under any circumstances.  But I do think that this was a special circumstance. . . a time when I was not operating with all of my reasoned faculties.  Yet, to my subsequent amazement, my spontaneous reaction was to agree to the proposition that was presented to me.
 

To this day, I still mull over in my mind whether that request was ethical or not, and whether my response was emotional or rational.  In hindsight I can see that I suffered no ill effects from that decision; but, at the time, I had no way of knowing what the outcome of that precipitous action might be.  
To be continued….

April 10, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 10:42 pm

  Paul Jason

Chapter 10:  Help!!!  I’m Drowning and No One Can Hear Me
   

I was in the operating room for six and a half hours.  It was in the CCU, about nine hours after I was wheeled out of the operating room, that I learned that I had survived the operation and remained a mortal being on Planet Earth.  However, I didn’t know that immediately.  My first recollection of a conscious moment occurred  when I opened my eyes and realized that I was laying in what felt like a horizontal position, perhaps a little elevated, and everything around me appeared to be white.  I couldn’t see too much because I couldn’t really turn my head to the left or the right.
 
 ”My head must be propped in place”, I thought to myself.  “And I don’t seem to be able to move my arms or my legs.  It feels like there’s some kind of tube inside my throat, and I can’t swallow.  That must be the tube I heard about that assists your breathing during surgery.  But, I thought they take it out when the surgery is over. God, I don’t even know how I’m breathing. I can’t talk … I can’t even call out.  Help, someone.”
 

It’s not dark in here, but I feel paralyzed, and everything is white.  Oh, my God, maybe I’m dead and I don’t know it.  I can’t hear anything.  But wait, there is one thing I can see that isn’t all white - - - right on the wall directly opposite me.  It’s a clock - - - and I can see it, even without my eyeglasses on. I can read the numbers, and I can see the hands.  It says 3:30. 3:30!!  Is that a.m. or p.m.? What day is this? The surgeon told me the operation would take between six and seven hours.  They wheeled me into the operating room at about 11:30 a.m. on April 4th.  That would mean that I left the operating room around 6:30 p.m . on that day.  Is it now past midnight and into the wee hours of April 5th??  I can’t tell in here - - - wherever I am  - - - there doesn’t seem to be any natural light.”
 
“Wait a minute.  This is crazy.  I don’t even know if I’m dead or alive and I’m worrying about the time. Maybe this is a delusion.  I can’t move any of my limbs; I can’t talk: I don’t hear anything. How do I know I’m alive?  Maybe I’m in a suspended state of being, floating somewhere in the netherworld, somewhere between Heaven and Hell.  The clock.  Maybe it’s not real; maybe it is symbolic.  Maybe the time that I see on its face is illusory.  Maybe it’s there just to force me to come to grips with the fact that my time on Earth was but a  fleeting moment in the eternity of the Universe.”
 

My mind continued to race with thoughts of mortality, and then, without warning, all conscious thought ended. . . . .
 

“Wait !! - - - I’m conscious again.  Was I gone for a moment, an hour, a day, a week, a year?  I still can’t turn my head; my arms and legs still feel like they have heavy weights on them.  That damn tube is still stuck down my throat.  And the clock is still there on the wall - - - and it says 4:05.  I can hear voices in the background, but I cannot comprehend what they’re saying and I can’t yell out to them.  Oh God, am I dead or alive? Help, someone.”
 
And then, from out of nowhere, a thought occurred to me - - - if I am floating in the netherworld,  then this is all an illusion.  If that’s true, I shouldn’t be able to feel anything tangible.  But, there is one portion of me that I can move - - - and that’s my fingers.
 

  

So, I scratched at the whiteness around me and felt my fingernails rake the starched crispness of the bed linens.
 

“God, I must be alive.  I can feel the nub of the sheets and hear the frantic sound of my  fingernails digging into them.  I must be alive.  This is no illusion!!  This is tangible, and every fiber of my brain is telling me that I’m alive.”
 

And then, just as quickly as I made this discovery, I slipped back again into unconsciousness. . . . .
 

“Wait.  I’m conscious again.  And that clock on the wall says 4:35.  Why doesn’t anyone walk over to look at me?  I can still hear their voices out there.”
 

“Wait a second. Something’s wrong.  I think I’m alive, but I still can’t move anything but my fingers - - - and I can’t call out to anyone because I have a damn obstruction shoved down my throat.  And something is happening to that tube . . . that hose.  It feels like there’s something dripping down that hose. Drip, drip, dripping - - - with no let-up.  Oh, no. That post-nasal drip I inherited from my mother - - - the drip that comes and goes at its own whim - - - the one that never gives me serious trouble - - - but just enough trouble that I feel impelled to clear my throat, or cough, or blow my nose, to alleviate it . . . even take over-the-counter medication sometimes to dry it up real fast . That same nasal drip has just decided, at the most inopportune time in my life, to start acting up.  And its discharging mucous right onto that hose - - - and I can’t clear my throat (for God’s sake,
I can’t even swallow with that hose stuck down my throat); I can’t blow my nose; and there’s no way that I can communicate to anyone that I’m in distress.  What am I going to do?  How come no one warned me about this possibility? I feel like I’m going to choke.”
 

“Wait a minute: I’m not going to choke - - - I’m going to drown!!!  I’m going to drown right here in this damn hospital  - - - right here in this damn Cardiac Care Unit. I’m drowning and no one can hear me . . . and nobody’s going to know about it until I really am dead.”
 

“Don’t panic.  For God’s sake, don’t panic!!”
 

Unconsciousness. . . .
 

“I’m awake again.  The clock says 5:10.  Well, at least time isn’t standing still.  It must be 5:10 a.m. on April 5th.  But I can still feel that mucous dripping. . . dripping . . . down the hose in my throat. God, how big is that hose anyway?  It feels like a garden hose.  It must be  an inch in diameter. I really feel like I’m going to drown.”
Damn, I’m sure the nurses are checking on me periodically.  Why is none of them ever standing by my bed when I’m conscious?  Even if one of them were standing right there, I don’t know if I could communicate my anguish.  Oh God, is this the final retribution - - - allowing me to survive that horrendous surgery (itself a testament to the intelligence and creativity of man), only to allow me to ironically succumb to the lowliest of man’s ills? . . .  Unconsciousness.
 

Consciousness.  “The clock says 5:50.  I’m still alive. I didn’t drown while I was out, but I can still feel the mucous drip, drip, dripping down that hose. Voices.  Female voices.  Sounds like two nurses standing right outside my room.”  I hear one of them say: “John will be here soon.  As soon as he gets settled in, he will remove the tracheal tube from this patient.”
 

“Soon.  How soon?  Every moment feels like an eternity and that damn dripping isn’t stopping.   I hope I haven’t drowned by the time John gets here.  Wait.  Here comes a nurse. She’s coming right here to the bed.  She’s looking right at me.  She sees that my eyes are open.”  She says: “Take it easy, Mr. Jason.  Someone will be here in a little while to remove that tube from your throat.  You’ll feel better then.”
 

“Then?  When is “then”?  Can’t you see the terror in my eyes? . . . .   I guess not.  You’re walking away.” 
 

I doze off again.
 

“I hear voices again.  This time it’s a man and a woman.  The same nurse who told me that someone would be coming in a little while.  I can see that it’s 6:20.  My God, it must be morning, and the morning shift is coming on.  That hose must be in my throat at least since I left the operating room almost twelve hours ago.”
 

John and the nurse are exchanging some pleasantries, and he’s telling her about his social activities of the prior night.  “Oh God, don’t they understand that I”m about to drown.”  The seconds feel like hours. “I hope John is wide awake this morning and ready to go.”
 

Then, suddenly, John is at my bedside, doing just what he is trained to do.  Before I know it, the hose is removed and I really begin to feel alive.
 

Alive . . . Alive!!!

To be continued…
     
 

March 29, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 5:42 pm
  Paul Jason
 

Chapter 9                    Anesthesiology and Anesthesiologists
 

Tuesday, April 4, 2000, was the big day.  It could be my last day if things didn’t go well in the operating room. I know that they were feeding me tranquilizers intravenously.  Otherwise, I would have been bouncing off the walls.  
 

At 9:05 a.m., an aide came to my room to get me. I was transferred to a gurney and brought to a holding area on the surgical floor of the hospital.  The holding area was cool and I felt cold.  A nurse put a blanket on me.
 

At first, the staff couldn’t find my surgical consent form.  But soon it was located.  A Physician’s Assistant came by to check my chart.
 

And then . . . a female physician with an Eastern European  accent came.  She told me that she was the anaesthesiologist.  The anaesthesiologist??   What happened to whatshisname??
 

Oh, God!  Is this a bad sign?  A part of the team has been changed and we haven’t even started yet.
 

Again I expressed my apprehension, and requested that I be rendered unconscious before being brought into the operating room.
 

“No problem.”
 

Now, for the first time, I began to think about the paradox created by the fact that I had chosen my thoracic surgeon, but  I apparently had no say in choosing my anaesthesiologist.  What if my operation was about to be performed by the best cardiosurgeon  in the hospital, assisted by the worst anaesthesiologist in the hospital?  Why is it that patients get to pick their surgeons, but they don’t get to pick their anaesthesiologists?
 
Obviously, I didn’t have time to resolve that dilemma prior to my surgery.  The tranquilizers were kicking in.  Why hadn’t I thought about this before?
                                                                             
Anesthesiology is apparently one field of medicine (similar to obstetrics) that lends itself to group practice.  I don’t know the history, the economics or the politics of this situation, but it is a fact.  As I indicated earlier,  I tried to interview two anesthesiologists after the surgery to get some answers to this and other questions.  Perhaps, had they been willing to grant those interviews, I could be speaking from knowledge, rather than conjecture.
 


It appears that anesthesiology groups contract with one or more hospitals, providing services on an as-needed basis. It seems logical, therefore, that every time a surgical procedure is scheduled at a hospital, an available anesthesiologist from the contracted group is designated to cover the operation.  Whether one or more anesthesiologists are in attendance during any one surgical procedure is unknown to me.  Also, whether anesthesiologists specialize (e.g., in head surgery, thoracic surgery or obstetrical procedures), is also unknown to me.  What I do know from speaking to people, however, is that most patients do not get to choose the anesthesiologist who will assist their selected surgeon.
     

In my case, the surgeon was recommended by two of my attending physicians.  Additionally, as I described elsewhere, I was encouraged by the recommended surgeon and by my cardiologist to obtain a second opinion and I did receive that opinion, regarding both my condition and my surgeon, from a cardiac surgeon affiliated with another major medical institution in New York City.
 

However, at no time during the pre-surgical process did anyone inform me that I had any choice whatsoever in the selection of the anesthesiologist.  I repeat my earlier question: what if my surgeon is the best cardiothoracic surgeon at the hospital, but is being assisted by the worst anesthesiologist in the group providing services to that institution?
 

            I knew that I would be subjected to general anesthesia during my surgery.  But, what exactly is “general anesthesia”?  Does it simply mean that they would “put me to sleep”?  Obviously a general anesthetic state is much different from sleep.  I can’t imagine anyone being able to remove or repair one of my body organs while I am simply asleep. 
 

Actually, general anesthesia is about as different from ordinary sleep as a snooze is from a coma. It is essentially composed of four elements: hypnosis (unconsciousness), amnesia (lack of memory), analgesia (lack of pain) and muscle relaxation.  Not every surgical operation requires all four elements.  On the other hand, no one drug or technique can address all four elements at the same time. Therefore, being able to choose the correct combination of drugs and techniques is at the core of anesthesiology.  Dosage, of course, is also important.
 

Amongst the drugs used to achieve the desired results are barbiturates, narcotics (opioids), volatile anesthetics, anxiolytics and muscle relaxants.
 

Barbiturates produce hypnosis and are used to induce unconsciousness.  They provide virtually no analgesia, amnesia or muscle relaxation.
 

Narcotics or opioids, on the other hand, provide potent analgesic effects, but are not effective in producing either hypnosis or amnesia.
 
Volatile anesthetics are liquids that vaporize and are administered through breathing apparatus.  They are very effective in producing hypnosis and amnesia and, at some dosages, produce good muscle relaxation.  However, they provide no significant analgesia.
 


Anxiolytics are used to relieve anxiety and are usually given to patients prior to surgery to calm them.  They are also helpful in ensuring anterograde amnesia (i.e., lack of memory regarding events going forward in time).  They produce hypnosis only at high doses and do not provide any analgesia or muscle relaxation.  Versed, which I discussed in conjunction with my angioplasty, is an anxiolytic.
     

Muscle relaxants do exactly that.  Therefore, they are never used alone.
 

In a typical surgical procedure, an intravenous infusion is established and an anxiolytic drug is introduced to calm the patient and to induce amnesia.  In the operating room induction agents are introduced through the IV to quickly establish the anesthetized state.  Most of these agents are short-acting.  They are utilized to allow the placing of the endotracheal tube through the patient’s mouth, past the vocal chords and into the trachea (windpipe).  Once this has been accomplished, the anesthesia for the surgery is begun by introducing combinations of the  barbiturates, narcotics, volatile anesthetics, anxiolytics and muscle relaxants discussed above.
 

Interestingly, muscle relaxants, when they are used, are not selective, i.e., they weaken all of the muscles of the body, including the muscles used for breathing.  That is one of the reasons the endotracheal tube is used.  It provides a means of assisting breathing by connecting the patient’s respiratory system to an external, mechanical ventilator.
 

The anesthesia is continued until the completion of the surgery, at which time introduction of the agents is discontinued and the effects of the muscle relaxants are reversed with intravenous medications.
 

Most persons are awake enough to be responsive shortly after they arrive in the recovery room, even though they cannot remember these moments.  The sensation of “waking up” occurs when the patient’s memory returns (the ebbing of the anterograde amnesia), even though he may seem, from all outward appearances, to be awake before that time.
 

Are there risks associated with general anesthesia?  Of course there are, and we have all heard about them in some general way.  A human being, with human frailties, will be making critical decisions regarding our lives while we are defenseless to fend off his or her  errors. The number of potential complications are extensive.  One source I came across claims that death, as a direct result of anesthesia, occurs about two or three times out of each million anesthetics.  However, I wouldn’t take too much comfort in that statistic, assuming that it is true, because the emphasis is on death, as opposed to permanent damage to some body organ or system.
 


Another issue I had never thought about before is the possibility of waking up in the middle of the operation.  I assumed, as I would think most other laymen have assumed, that once they put you to “sleep”, you stay asleep until the surgery is completed and you’re in the recovery room.  Up until very recent years, while it was an exceptional occurrence, there were recorded instances when exactly that worst nightmare happened. To understand how it happened, one must appreciate the distinction between unconsciousness (lack of awareness) and amnesia (lack of memory).  An inebriated person, for example, is not unconscious, but he could be amnesic.  Therefore, in spite of the fact that his speech and motor coordination may be impaired,  he can still be aware of his surroundings, although he may not later remember anything that occurred while he was in that state.
 

Are patients unconscious from the time that the initial sedation sets in until the surgery is over.  Not necessarily.  They may have no memory of the events that occurred while they were under the influence of anesthesia, but whether they were unconscious at all times is sometimes hard to tell.  There have been some studies that suggest that many patients may have awareness, at least for sound, during anesthesia.  It appears that very few have any recall.
 

During the surgery, as I discuss in the next chapter, the patient’s vital signs (pulse, blood pressure, etc.) are closely monitored.  If there are any signs that a patient is beginning to awaken from the anesthetic, the anesthesiologist is alerted to this fact by telltale signs such as increases in blood pressure and heart rate, changes in respiratory patterns and a variety of other vital signs.  Therefore, action can be taken to remediate the situation. Nevertheless, there have been cases where patients have actually experienced recall of events which occurred during anesthesia, even though above average doses of anesthetic agents were introduced or because their bodies failed to signal the telltale changes in their vital signs.  Again, variable factors such as  differences among individuals regarding their tolerances to medications can result in unexpected events.
 

The worst possible case scenario could occur when muscle relaxants are used. In that event if the patient becomes aware or feels pain during the surgery, he is incapable of communicating that to the operating team because he is essentially paralyzed. 
 

Fortunately, however, in 1996 a new technology known as the Bispectral Index (BIS)  became commercially available.  It is a noninvasive monitoring system consisting of a sensor attached to the patient’s forehead and a monitor. It can directly measure the effects of anesthesia on the brain by analyzing the brain waves recorded in the electroencephalograph (EEG), translating them and producing readings on the monitor ranging from zero (no brain activity) to one hundred (the patient is fully awake).  By continually indicating the patient’s level of consciousness during the surgical procedure, the anesthesiologist is able to adjust the amount of anesthetic agent the individual requires.  The result is that there are fewer cases of under-sedation or over-sedation and patients are waking up faster after the surgery.  I do not know if this device was used during my surgery.

To be continued next week…

March 13, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 8:37 pm
  Paul Jason    

  

Chapter 8:      What Did You Say Is the Difference  Between a Medical  Resident and a Physician Assistant?
  
One of the things a hospital inpatient must try to adjust to is the liberal use of the word “doctor.”  Most laymen are familiar with the terms “intern”, “medical resident” (or just “resident”) and M.D. (Medical Doctor).  They are all “physicians”, aren’t they?
 

In New York State, to satisfy the requirements for obtaining a license as a physician, the applicant must present evidence that he/she has completed sixty semester hours of college study from a New York State registered program or its equivalent, and satisfactory completion of a medical program registered by the State Department of Education as license-qualifying (or accredited by the Liaison Committee on Medical Education or the American Osteopathic Association) and received the degree of Doctor of Medicine (M.D.), Doctor of Osteopathy (D.O.), or the equivalent.
 

In the alternative, graduates of non-accredited medical programs can show satisfactory completion of four academic years in a medical program recognized as an acceptable educational program for physicians by the appropriate civil authorities of the country in which the school is located, and receipt of the degree of Doctor of Medicine, Doctor of Osteopathy, or the equivalent as determined by the Department of Education.  They must also satisfactorily complete a proficiency examination, such as is certified by the Educational Commission for Foreign Medical Graduates.
 

Applicants who have graduated from a registered or accredited medical program must then complete at least one year of postgraduate hospital training in an accredited residency program.  All other applicants must complete at least three years of postgraduate hospital training in an accredited residency program.
 

According to the American Medical Association (AMA), newly graduated MDs generally enter into a residency program that is three to seven years or more of professional training under the supervision of physician educators.  The length of the residency training varies, depending on the chosen specialty - - e.g., general surgery requires five years.  The first year of residency is sometimes referred to as an “internship”; however, the AMA no longer uses that term.  “Fellows” receive one to three years of additional training if they chose a subspecialty.
 

Many physicians choose to become “board certified”, as an  indicia of their expertise in their chosen specialty. Certification is optional and voluntary.
 

And then we get to the Physician Assistants (PAs) who appear to be pervasive in today’s hospitals.  In my experience, I believe that I had more contact with (or, perhaps more accurately, they had contact with me) Physician Assistants than with Residents or Interns. So, what is a Physician Assistant?
 


According to the official literature, a Physician Assistant is a person over the age of twenty-one who has completed a four-year course of study in a secondary school approved by the New York State Board of Regents (i.e., a high school), or has passed an equivalency exam, and who has completed a program for the training of Physician Assistants that is approved by the State Department of Education, or that is determined by that Department to be the equivalent of such a program.  The program consists of at least thirty-two credit hours of classroom work and forty weeks of supervised clinical training.
 

There is no minimum work experience required for licensing as a Physician Assistant.  All applicants, however, must pass the Physician Assistant National Certifying Examination, a computer-administered exam.
 
A PA may perform medical services under the supervision of a physician, and only when such acts and duties are within the scope of the medical practice of the particular physician. That supervision is supposed to be “continuous”, but is not deemed to require the physical presence of the physician at the time and place where the PA=s services are being performed. And while a physician may not employ or supervise more than two assistants in his/her private practice, hospitals may employ PAs who are supervised by physicians, but the 2 to 1 ratio is specifically waived.  I wonder if this is based upon sound medical judgment, or does it signal the final triumph of the MBA bean counters?
 

The National Commission on Certification of Physician Assistants offers a Surgery Examination (consisting of one hundred eighty multiple-choice questions) designed to evaluate the knowledge and skills of individuals who conduct or have been trained to conduct a variety of health care functions related to surgery. Exactly what those “functions” are is still not quite clear to me.
 

What I do know is that there were two PAs in the operating room during my surgery.  What their functions were, and whether they laid hands on or in my body, is unknown to me. I have reason to believe though, that it was a PA who harvested the vein from my left leg.  That vein was cut into pieces which were used as the by-passes. I have no idea who stitched my leg back together again, but whoever it was I think he/she did a great job.
 

And one final question for the inquisitive: What is the difference between a Nurse Practitioner (NP) and a Physician Assistant (PA)?? The distinctions in their required training and authority appears to vary from one state to another.  I tried, without success, to get an intelligible answer (for you, dear reader, or for me). 

To be continued next week….

 

 

 

 

February 28, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 8:57 pm
  Paul Jason
 

 

Chapter 7:   Can I Get a Second Opinion?  

One of the things that I discovered during my illness is that people that you least expect to give you support and assistance take on roles which are truly astonishing.  One such person is a client of mine who is a real estate builder/developer.  He called me at the hospital a few hours after I checked back in, when he discovered from my secretary what had happened.  After I described  my current condition to him, he asked me whether or not I was going to have the surgery performed at Montefiore Hospital and, if so, who the surgeon would be.  When I gave him the name of the surgeon who had visited me, he exclaimed: “That’s the doctor would performed triple bypass surgery on my father over fifteen years ago.  He’s great.  My father is almost eighty years old now and the bypasses are still holding up.”
 

Truly comforting news.  But I still knew I had to get a second opinion. And I didn’t know who to get it from.
 

My client told me that he had had extensive business dealings with a well-known philanthropist, who had given generous endowments to several metropolitan area hospitals.  This philanthropist had heart problems himself, and had an outstanding thoracic surgeon.  Within an hour, my client called back and said that I should arrange to have my film delivered to this surgeon at his office near Columbia-Presbyterian Medical Center in Manhattan at 10:00 a.m. the next day, a Friday.
 

The arrangements to deliver the film the next morning were made. Before 10:30 my bedside phone rang.  It was the thoracic surgeon.  I was startled, and thankful, that he would take the time, on such short notice, to review my film and to call me.  I guess that’s why he’s in the “Castle Connolly Guide: How To Find The Best New York Area Doctors”  also.  He confirmed the severity of my arterial blockages and said that I was not a good candidate for angioplasty and the insertion of stents.  He agreed that a quadruple bypass operation should be performed.
 
Then I asked him whether he thought that I should remain at Montefiore and have the recommended surgeon perform the procedure.  His answers to both questions were in the affirmative.  He opined that Montefiore has a very good cardiac program, that he knew the surgeon at Montefiore, and that this doctor was a very competent cardiothoracic surgeon.
 

Whew, what a relief! I had lucked out: without leaving the hospital, I had received my second opinion and professional guidance as to where and by whom the surgery should be performed. The die was cast.  The only remaining questions were: when would it happen, and would I survive?
 

 I then called the surgeon’s office, advised his staff that I was still a patient at Montefiore, and had decided to have him perform the surgery.  Since the weekend was fast upon us, they advised me that the procedure would occur the following week, as soon as the doctor had an “opening.”  (A double entendre?).


Needless to say, my anxiety began to build over the weekend.  And, somewhere along the line I’m sure they started to introduce sedatives into my IV.
         

I forget who first said it, but “into every anxiety a little misery must come.”  In my case, the misery came in the form of gout.  The classic gout symptom is sudden, severe pain in the joint of the big toe, although it may also occur in the ankle, wrist, knee or elbow.  The pain ordinarily intensifies and the joint becomes very sensitive to the slightest pressure applied to it or the surrounding skin. My left big toe started to kill me.  I guessed, just from general knowledge, that it was gout, but I had never before experienced it . . . why now?
 

Gout, I later learned, is a type of arthritis, and it occurs when uric acid accumulates in the body and forms crystals in a joint. It is known that a gout attack can be precipitated by injury, surgery, the consumption of large amounts of alcohol or protein-rich foods, fatigue, stress or illness.  Hmmm.  Gout is also associated with high blood pressure, and the chance of an attack increases when the victim is taking the blood pressure medication “thiazide”.    Hmmmm.   Had they introduced thiazide into my IV?
 

All I know is that the attack came suddenly and within one day I could hardly stand up because of the pain in my left toe. What a predicament!!  Here I was on the verge of open heart surgery, during which I knew  they  were going to remove a vein from my leg . . . and I couldn’t even stand up.  If I couldn’t stand up prior to the surgery, what would it be like after the surgery?
 

I advised the medical staff of my affliction and the diagnosis of gout was confirmed. Some medication was introduced and, impressively, within a day, the symptoms were under control.  After another half day they were gone altogether.
 
On Sunday I was advised that the operation would not occur on Monday, but would probably happen on Tuesday
.
On Monday a young man walked into my room and advised me that he would be the anaesthesiologist for my surgery.  He asked me a bunch of questions and then asked if I had any questions.  Of course I couldn’t think of any pertinent questions because I had not been under general anaesthesia since I was twelve years old.  That had been a horrendous experience, but I had every reason to believe that things had changed since then.
 


The one thing I did tell the anaesthesiologist was that I was terrified; that I had no adult surgical experience; that I didn’t know what to expect; that I was distraught over the idea of being wheeled into the operating room while I was still conscious.  I asked if I could be rendered unconscious before I was brought into the operating room and he said “Yes.”  This served to allay a good part of my apprehension, for I felt that if I were rendered unconscious prior to entering the operating room, I would be totally oblivious to anything they did to me.  If I survived, no one could truly prepare me for the ordeal of recovery; only someone who has experienced it can have any valuable preparatory information, and, even then, each person’s body reacts differently.  I knew several by-pass patients personally, so I had some idea of the immediate effect of the surgery.  But, at least if I survived, I could look forward to the  restoration of my life; and, if I didn’t, I wouldn’t know what happened.
 

Monday night, April 3rd , a nurse’s aide appeared in my room and advised me that he was going to shave me in preparation for surgery the next day.  Now, there’s shaving, and there’s shaving.  The aide proceeded to remove all of my hair, from my nose to my toes, front and rear.  I had grown a full, but trim, beard more than thirteen years previously.  I had watched it turn from a reddish-brown to salt-and-pepper gray.  Three years prior, I had decided to remove the sides of the beard and retain a mustache and goatee.  In fact, I had grown rather accustomed to, and fond of, facial hair. As a result, when he finished, I felt like a naked ape.
 

Talk about shock!  This was the first time I had seen my clean shaven face in all those years. For the first time I had to acknowledge Nature’s brutal ability to change us  imperceptively  as we wander through life.  I peered into the bathroom mirror at the strange face staring back at me.  God, I hadn’t realized how much my face had changed over the years.  After looking at myself in the mirror every morning and night for thirteen years - - - that’s about 9,500 times - - - one sort of gets an image of what one looks like.  Was that really me?
 

It surprises me that in moments of great stress, the human mind can occupy itself with such trivia.  It must be a natural defense mechanism.   

To be continued next week….
 

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