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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….
 

February 14, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 7:16 pm

  Paul Jason

Chapter 6:   Our Cardiac Care Menu Today Features . . .
   

What is it about hospital food that makes it so unpalatable?  Is it the presentation, the quality or the flavor?
 

Now, I’ve been told that some hospitals (precious few by most accounts) do, in fact, serve reasonably attractive, tasty meals.  Most, unfortunately, do not.
 

Why the American public, otherwise blessed with such a diversity of quality, succulent food choices, is willing to tolerate the unappealing nature of hospital food is beyond me.
 

After all, food is one of life’s pleasures.  It is, and has always been, in virtually all societies, an essential cornerstone for celebration, camaraderie, thanksgiving and comfort. And, certainly, there can be no more critical time for the individual succor and comfort that well-prepared food can provide than during the course of a generally depressing hospitalization.
 

Some people eat to live; others live to eat. I have always enjoyed food.  To me, it is tangible evidence of God’s bounty, not to be taken lightly; a simultaneous source of sustenance and pleasure, best enjoyed in the company of family and friends, but satisfying enough even when consumed in solitude. Although I had, during the past ten years, subjected myself to a low-fat, low-sodium diet, I nevertheless continued to thoroughly enjoy flavorful, well-prepared food.  The appearance and smell of good food, combined with its taste and “mouth-feel”, creates an undeniably pleasurable experience.
 

Talk about smell.  How come hospital food smells like no other cuisine that we encounter in the multitude of our other worldly activities?  It remains a mystery to me.
 

Lastly, there can be an inexplicable quality to well-prepared food that transcends the mere ingredients. People in some cultures, and individuals throughout the world, believe that foods can impart more than the nutrients contained within them  – - that they can bestow a spiritual energy effused from the preparers. In recent years the film “Like Water for Chocolate” conveyed in classic fashion this mysterious side to the aura of food.
 

In any event, here I was, in the days leading up to my surgery, a virtual captive to the culinary artisans of Montefiore Hospital.
 

Now I can understand that some people are admitted to hospitals in a state of acute distress, and that, as a result, food is the last concern on their minds.  And other people enter hospitals already severely limited to medically-prescribed, restricted diets.  But most of us are not that curtailed, until such time as the medical staff renders us so.
 

Here I was, not in any particular pain; nor was I incapacitated.  I was, so-to-speak,  nervously awaiting a life-saving surgical procedure. If ever I was in need of some healthy, savory, comfort food, it was right there and then.


 

But no relief was in sight.  Instead, I was inundated with the relentless, uninspired cuisine of the unimaginative and the mundane: lumpy hot cereal; chicken boiled to oblivion; milk served in a little waxy container; little squares of red Jello; hard-boiled eggs with solid yolks (wait a minute – - – I thought this was the cardiac floor?).   Help!  I must be trapped in some elementary school student cafeteria. I think the airlines do better, even at thirty thousand feet.
   

Now I know that the culinary efforts at hospitals can be better. Perhaps they don’t want to make it better on the theory that every patient is entitled to a complete hospital “experience.”  But I happen to have a brother who is a graduate of the French Culinary Institute in New York City.  Ten or more years ago, writing on behalf of Weight Watchers International, he was able to create a whole bunch of pasta recipes, for example, that were relatively low in fat and sodium, and were easy on the palate.  Recipes such as “Sicilian-Style Pasta with Califlower”, made with extra virgin olive oil, red onion, pines nuts, low-sodium chicken broth, basil, parsley, grated cheese, black pepper, garlic and raisins.  Each serving contains 384 calories, 11grams (or 25%) from fat, and 385 mg of sodium.
 

Or “Pasta Puttanesca”, made with olive oil, onion, garlic, canned low-sodium tomatoes, ripe olives, ground red pepper, water-packed tuna and black pepper.  346 calories per serving, 6 grams (or 15%) from fat, and 293 mg of sodium.
 

Or “Penne with Grilled Vegetables”, made with red and yellow bell peppers, eggplant, onion, zucchini, mushrooms, olive oil, garlic, rosemary, thyme, sage, grated cheese and parsley.  274 calories per serving, 6 grams (or 19%) from fat, and 58 mg of sodium.
 

He was also able to create non-fat Brownies, made with egg whites, prune butter (yes, prune, but you don’t taste it in the final product), vanilla, Dutch-processed cocoa, all-purpose flour and a little salt (instant espresso powder is optional).  Delicious!!   And I’m not kidding.
 

I think you get the idea.  But if you’re interested in a few more flavorful recipes that
other health-oriented chefs have been able to invent, read on.  The following is just a sampling:
 

“Mushroom Barley Soup” made with onion, garlic, olive oil, fresh mushrooms, dry sherry, reduced-sodium soy sauce and dill weed. 590 calories per serving, 17 grams (or 26%) from fat, and 700 mg of sodium.
 

“Orange-Jicama Salad” made with jicama, oranges, coriander, orange juice, balsamic vinegar, olive oil,  black pepper and a dash of salt.  107 calories per serving,  3.5 grams (or 29%) from fat, and 100 mg of sodium.
 

“Dill-Poached Fish Fillets” made with cod or Dover sole, fresh dill weed, fresh lemon juice, water, black pepper and a dash of salt.  71 calories per serving, 0.5 grams (or 7%) from fat, and 100 mg of sodium.                                                                                                                                                           


 

“Oven-Fried Potatoes” made with fresh lemon juice, olive oil, rosemary, garlic, black pepper, vegetable cooking spray and a dash of salt. 158 calories per serving,  2 grams (or 11%) from fat, and 100 mg of sodium.
 

“Apple Crisp” made with green apples, fresh lemon, raisins, brandy, brown sugar, cinnamon,  whole wheat pastry flour, old-fashioned rolled oats,  toasted wheat germ, salt, light olive oil and maple syrup.. 244 calories per serving, 7.5 grams (or 27.5%) from fat, and 140 mg of sodium.
*                                                           *                       * 
I am unconvinced that food served in a hospital has to taste like “hospital food.”  And it certainly doesn’t have to smell like “hospital food.”  Maybe . . . just maybe . . . improvements in this area of hospital administration might make a difference in the perception of concern and caring, and the reduction of stress, that patients so desperately need during their hospital stays. I find it disconcerting that hospital administrators appear to be so oblivious to this glaring inadequacy. Aren’t they ever patients in their own hospitals?
 

Instead of incorporating the serene and spiritual value that nature’s bounty has to offer towards the healing process touted by their institutions, they shortsightedly concern themselves solely with its minimal nutritional value, all to the detriment of the patients. Low in taste and, I suspect, low in cost, such food brings the spirit down rather than lifting it up.
 

So I’ve come to this conclusion: It’s time to get rid of the greedy bean counters and bring in the gourmet bean cookers.

To be continued next week….
 

February 6, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 8:22 pm
   Paul Jason

 

                                             Chapter 5 
 

The balance of the day on which my cardiac catheterization was performed was spent in a private room on the sixth floor of the north wing of the hospital, officially known as North 6, and designated as the “Intermediate Cardiac Care Unit”.  This is a cardiac monitoring unit, also known as a telemetry unit.  Patients in this unit wear a telemetry box which is a cardiac monitor.  The functioning of each patient’s heart is monitored at a central station twenty-four hours a day.
 

 

Now  things started to get a little complicated in this unit.  I had always thought, in my experiences as a visitor to sick patients, that the central core station in each section of a hospital was manned by RNs and an intermittent  flow of MDs (that’s why it’s referred to as the “Nurse’s Station”, right?).  I was also aware of orderlies roaming the halls and rooms cleaning up this thing and straightening out that thing. In the catheterization lab there had been a physician, a physician’s assistant, a registered nurse, and, I believe, a  technician.  But here, at North 6 there is a Roster of personnel sufficient to boggle the mind of a Pentagon bureaucrat.
 
First, according to the Roster pamphlet I discovered,  there’s a nursing staff composed of Registered Nurses (RNs), Licensed Practical Nurses (LPNs) and Nursing Attendants (NAs). The Registered Nurses are divided into five categories: an Administrative Nurse Manager (who “oversees the overall functioning of the entire unit and staff and assures that  “quality care and services are delivered to the patients”); an Associate Administrative Nurse Manager (who assists the Administrative Nurse Manager, what else?); Patient Care Coordinators (each of whom has the responsibility to “coordinate staff and unit activity for a particular shift”); Staff Nurses (I guess these are the fabled “angels of mercy”); and Clinical Care Coordinators (who identify and facilitate “options and services to meet the individual health care needs of patients and their families”).
 

The LPNs are responsible for “delivery of appropriate nursing care under the supervision and direction of a RN” [emphasis added].  NAs assist patients with daily living activities such as eating, bathing and walking, as well as “carrying out other specific duties delegated to them” by an RN.
 

In conjunction with nursing services there are Monitor Technicians, whose primary job is to keep an eye on  the central cardiac monitors and alert a nurse if a problem arises.
 
Then there’s a medical staff composed of Attendings, Residents, Interns, Physician Assistants and Nurse Practitioners (more about these categories later).  There are also  Unit Secretaries, who have “clerical responsibilities which include maintaining [patient] records.  They usually are the ones who respond to your call-bell when it rings on the intercom in the nurses station” [emphasis added].
 

Of course there’s the Service Associates, whose responsibilities include housekeeping for the unit (Oops!  I think I referred to them as orderlies), transporting patients  to other parts of the hospital for tests, and serving meals to patients.


There’s also a Unit Manager whose job it is to supervise the unit secretaries and service associates, besides being responsible for maintaining unit supplies and equipment.
    

In addition, the following people are available for consultation:  Registered Dietitians, who evaluate and oversee patients’ nutritional needs and can develop a diet plan “tailored” to an individual patient’s needs (if only they could master the art of making the stuff look wholesome and taste good!!); Home Care Nurses, who make determinations regarding the services a patient may require after discharge from the hospital and arrangements for the same; Pharmacists, who “review the appropriateness of patients’ drug therapy, including drug dose and interaction”; and Physical and Occupational Therapists, who evaluate the condition of patients and help develop customized activity treatment plans.
 

Whew!! Multiply all of those categories by the number of daily work shifts, and a virtual army of personnel is passing in and out of a patient’s room, and in and out of a patient’s life, faster than most sick people are emotionally or physically prepared to comprehend or deal with. On paper it all seems organized and logical.  In practice, however, it is a whirlwind of strange faces, most of whom the patient cannot distinguish by rank or category.  Was that a Resident, a consulting MD, a Nurse Practitioner or a Physician’s Assistant who just left my room??? The confusion is exacerbated when you have a fever and/or you have a cardiac monitor hanging around your neck and/or you have an intravenous tube hanging off your arm and/or you are receiving medications which dull your awareness and/or your eyeglasses are in the drawer of the night table next to your bed.
 

But, I digress.  Sitting in bed all day is not the type of regimen I’m  used to.   True, I had suffered ventricular fibrillation (perhaps even cardiac arrest) awhile ago, but I felt better after a few hours and  my mind was alert. Therefore, I decided to look through a book that, fortunately, I had borrowed from my secretary and brought to the hospital that morning.  The book is entitled  “Castle Connolly Guide: How To Find The Best New York Area Doctors” (Third Edition) and is designed to be  a consumer‘s aid in choosing a doctor.  In it, you can find out about a doctor’s medical school education, his residency training, his fellowships, board certifications, hospital appointments, etc.  Thirteen hundred pages of information. The book is organized so that you can find a physician by name, by medical specialty or by the county in which he/she maintains an office.
 


To find the best doctors in the New York Metropolitan Area, Castle Connelly says that it “randomly selected 20,000 board certified doctors from over 55,000 doctors” in that geographic area and mailed them a form requesting that they nominate the best from amongst their peers, with emphasis on “excellence in patient care”.  Additionally, Castle Connelly communicated with 6,000 nurses in the region, and 3,000 health care professionals in major medical centers and hospitals, all randomly selected, and asked for their input.  This process resulted, they say, in the nomination of over 17,500 doctors.  Their research staff then went through the tedious task of verifying information and undertaking thousands of personal telephone calls to corroborate the recommendations.  The list of nominees distilled down to a little more than 6,000 doctors, deemed to be the “best of the best” in their respective specializations.  Each of these doctors was then apprized of his/her nomination and was requested to complete a professional information form.  This data constitutes the basic information in the Guide.
    

I was quite satisfied to find that three of the five physicians in my cardiology group were in the Guide, including the doctor that I had consulted.  The other two physicians, the youngest members of the group, were not; and, one of these had been the doctor who performed the catheterization that morning.
 

Of greater importance, for the moment, was the fact that both recommended surgeons were in the Guide.
 

The Guide also contains profiles of some of the major hospitals in the area drafted by the hospitals themselves.  Major medical centers included are Beth Israel Medical Center, St. Luke’s-Roosevelt Hospital Center, The Long Island College Hospital, Montefiore Medical Center, The Mount Sinai Medical Center, The New York Hospital-Cornell Medical Center, Columbia-Presbyterian Medical Center, NYU Medical Center and Saint Vincents Hospital and Medical Center.  Listed, also, are specialty hospitals such as Calvary Hospital, Four Winds Hospital, Hospital for Joint Diseases, The New York Eye & Ear Infirmary and St. Francis Hospital-The Heart Center.  Finally, there is information on a group of regional medical centers and community hospitals.
 

In its promotional information section, Montefiore Medical Center announces that its “cardiothoracic surgeons perform over 1,400 heart surgeries each year, including coronary artery bypasses and valve repairs.”   Also, their  “interventional cardiologists perform more than 4,000 catheterizations.”
 

Well, that was reassuring.  At least I was in a hospital that had extensive experience with people suffering from my malady.
 

The next thing I did was call my cardiologist.  I told him that I was contemplating having the surgery performed at Montefiore and that his partner had recommended two cardiothoracic surgeons.  He asked me for the names, opined that both were excellent surgeons, and offered his choice of the two to perform my surgery.  He said that he would contact that doctor and ask him to visit me so that I could meet him and ask  any questions that I might have.  I agreed that that was a good idea.  He also said that the surgery should be performed in the next week or so.
 

Later that day the surgeon did appear at my room. He was a man in his 60’s, plain, calm, confident.  He  examined  me  briefly  and  then  explained  the  nature of  the
proposed surgery, assuring me that my overall health indicated that I was a good candidate for this procedure.  He suggested that I get a second opinion and decide if I wanted the surgery to be performed at Montefiore.  If so, he was prepared to accommodate me, and told me to call his office to schedule the surgery.  He said that the operation would take between six and seven hours, and that barring any complications I would be out of the hospital four and one-half days after the date of surgery.  Four and a half days?  Boy, some bean counter must really have this down to a science!


He, too, said that I could leave the hospital (!!!) to get the second opinion and make my decision; but, the surgery should be performed in the next week or so.
    

Immediately upon his departure I went back to  Castle Connelly and rechecked his credentials.. He is a board certified thoracic surgeon, having done his residency more than years ago.  He had a fellowship in general vascular surgery,  and is a Lecturer in Surgery at the Albert Einstein College of Medicine. His area of special interest is cardiac surgery.
 
So it was, that approximately twenty-four hours after my catheterization, on Thursday, April 30th, I prepared to leave the hospital, go home and contemplate when, where and by whom I should have my by-pass surgery performed.
 
By  11:00 a.m., I notified the nurses’ station that I would be vacating my room in a little while.  I dressed in street clothes and was just about to walk out of the room when the telephone rang.  It was my son, the lawyer.  The conversation went something like this:
 

 ”Hi. Dad. How do you feel?”
 

 ”Okay, I guess.”
 

 ”What are you doing?”
 

 ”Oh, I’m just about to leave the hospital and go home.”
 

 ”Go home?? Don’t do it!!  I’ve been speaking to some doctors that I know and they say that you should stay right where you are.  The weekend is coming up.  What will you do if you have a cardiac problem over the weekend?  Especially if you’re not at home.  You might wind up, if you’re lucky enough to survive, in a hospital that you don’t want to be in, under the care of a doctor not of your choice.”
 

 Well, I guess all of that schooling paid off after all.  He’s probably right, I thought; I should stay here until I decide what to do. I’ve already experienced fibrillation.  What if I have a heart attack?
 

Within five minutes after I finished my conversation with my son, the phone rang again.  This time it was my daughter, another lawyer.  The conversation went something like this:
 

“Dad, I’ve been speaking to my brother, and I’ve also consulted a doctor that I know.  The consensus of opinion is that you should not leave the hospital unless you have an immediate contingency plan so that you are not at risk.”
 

 ”Okay. I guess you’re both right”.
 


As a layman, I was torn between the advice of my attending cardiologist and surgeon on the one hand, and the informed concern of my family on the other.  I was not equipped, by education or experience, to evaluate this situation.  After a few moments I decided to follow the best instincts and advice of my loved ones. 
 

I went out to the nurses’ station, and checked myself right back into the hospital.  I returned to the room,  got undressed, and  climbed back into bed.

To be continued next week…

January 30, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 5:38 pm
 
Paul Jason

Chapter 4.
  
Nine  unnerving  days after  I learned  that I had some type of  as-of-yet unnamed cardiac
problem, on Wednesday, March 29, 2000, at 7:00 a.m., I appeared at Montefiore Medical Center in The Bronx for the cardiac catheterization. I fully expected to be back home sometime later in the day, and back in the office the next day, as I had cheerfully advised my secretary.
 
I knew several people who had undergone this procedure, including my older brother, and they had each indicated that it was virtually painless and uneventful.  I was still having second thoughts about having canceled the Costa del Sol trip.
 

Basically, cardiac catheterization consists of a procedure in which a long, flexible tube called a catheter is inserted into a blood vessel (usually in the groin area, sometimes in the arm) and guided towards the heart. A local anesthetic is administered at the insertion site, the patient is sedated but remains awake during the entire procedure. The doctor watches the catheter wend its way through the body on an x-ray video monitor. If the patient is curious, the patient can watch the monitor as well.
 

When the catheter reaches its appointed destination, an x-ray contrast fluid is injected through the catheter and allows any blockages of the coronary arteries  to be recorded on film (“angiograms”). The coronary arteries are blood vessels that wrap around the surface of the heart and supply it with oxygen-rich blood.  Any interference with that flow of blood caused by the buildup of fatty plaque in the lining of the arteries is referred as atherosclerosis.
 

Other tests can be performed during cardiac catheterization as well.  For example, x-rays can record the pumping action of the chambers of the heart; measurement of the blood pressure in the heart’s chambers can be determined; abnormal heart valves can be detected.
 

Additionally, certain types of treatment can be undertaken during cardiac catheterization.  Amongst those most familiar to the public are angioplasty and placement of stents.  Angioplasty is a procedure in which a catheter with a small balloon at the end is positioned in an artery where a blockage has been discovered. The balloon is inflated and deflated several times to compress the fatty plaque against the artery wall, thereby restoring a more normal flow of blood at the site.  The catheter is then removed. 
 

Balloon angioplasty is not appropriate for everyone.  For example, patients with blockages in three or more coronary arteries are generally not good candidates.  They require bypass surgery.  However, they may subsequently undergo balloon angioplasty to reopen a bypass graft if it begins to re-close. 
 

Implantation of stents (small metal coils or mesh tubes) is one step beyond angioplasty.  Having compressed the plaque buildup against the arterial wall, the physician inserts another balloon catheter holding the stent.  At the site, the balloon is inflated, causing the stent to expand. The expanded stent  further compresses the plaque against the wall of the artery. The catheters are withdrawn. With any luck, the stent will permanently keep the artery open and help slow the rate of further plaque buildup.
         

When I arrived at the hospital for my cardiac catheterization, someone took my medical history again. As directed, I had taken one Prednisone tablet every six hours on the day before the procedure, and one again that morning.  Prednisone is designed to suppress any inflammation during the procedure and to reduce the body’s antagonistic/allergic response to the introduction of foreign substances (the catheters and the contrast fluid).
 

I removed my clothing and placed it into a plastic bag and I was prepped for the procedure. As with all of these procedures, I was asked to sign a consent form stating that I knew that there are potential risks involved with the procedure, including the possibility of heart attack or stroke.  What I didn’t know (according to some of the literature I have subsequently read), and what nobody bothered to tell me, is that five (5%) percent of the patients undergoing cardiac catheterization suffer cardiac arrest or stroke during the procedure: that’s one out of every twenty patients.
 

My records indicate that I was given Benadryl, a sedative and antihistamine, orally.  The doctor spoke to me and told me that after the catheter was inserted and guided to my heart, a contrast fluid would be introduced into my body; that I would feel a hot flush throughout my body; and that I should not be concerned about it.  In this case, as I later learned, the contrast used was Hexabrix.
 

I entered the catherization lab (to me, it looked like an operating room; but, then again, what experience did I have to distinguish a “lab” from an “operating room”?) and was placed on a table.  The cardiologist was present, together with a Physician’s Assistant, an RN and a technician.  My groin area was numbed and the catheter was inserted.  I didn’t feel a thing.  Then the doctor advised me that I could follow its progress on the monitor.  Now, that isn’t exactly my idea of a video game, so I declined.  In any event, I didn’t feel the movement of the catheter inside my vessels. 
 

At one point, the doctor asked me to move my head to one side; to me, this was proof positive that I was conscious.  Then he said: “I am going to inject the contrast now; remember, you are going to feel a hot flush throughout your body.” 
 

Moments later I felt the hot flush… followed, it seemed to me, almost immediately by a strange, strong erratic beating of my heart. A fibrillation? Then . . I fell into a black hole.
 

This was not like the hallucinatory nightmare produced by the ether when my broken wrist was repaired at age twelve; nor was it like the unconscious dreams I experience every night.  No, this was simply a black hole; a space of absolute darkness.  I do not know how  long I wandered in that nothingness.
 

The next thing I remember is the sound of the doctor’s voice telling me that the procedure was over.  I asked what happened and he said that he would discuss it with me outside in the holding area.  Almost immediately a nurse came to me with a jar containing some type of ointment.  She began applying it to my chest when, for the first time, I noticed two large “burn” marks on my chest.  It looked as though someone had placed two hot clothes irons on my chest. 
         

When the doctor approached, I asked him what had happened. He told me that my heart had gone into an arrhythmia and ventricular fibrillation and that they had restored my normal heart beat through direct current cardioversion, using the so-called “paddles” (defibrillators), He didn’t tell me how long I was in that condition.
 

When I recovered from that news, I asked him what he had found with regard to my coronary arteries.  He said that he had found four blockages.

“Four blockages? Did you put stents in to open the blockages?”
 

“No.” 
 

“Why not?”
 

“Because you are not a candidate for stents.”  (Not a candidate for stents???  Me, the ascetic who years ago foreswore the sweets and delicious, succulent fats of my youth and have tried mightily to conscientiously pursue a  wholesome, low-fat, low-salt diet?)
 
(Me, the self-disciplinarian who, through a combination of diet, medication and exercise, brought my total cholesterol level down from 254 to less than 200?)
(Me, the cautious Virgo who  for years had engaged in long, rapidly-paced walks,  watched my weight,  visited my doctors regularly, and  ingested multivitamins and minerals,  multi-carotenes, vitamin E and selenium on a daily basis?)
 

These ideas raced through my mind, as quickly as the contrast fluid had raced through my bloodstream.
 

Help: there must be some mistake!!! I should have been leaving for Costa del Sol tomorrow.
 

“Well”, said the doctor, “there is no mistake.  I found four blockages in your coronary arteries: one at 75%;  two at 90%; and a fourth at 100%.  They are of a magnitude that does not lend itself to a long-term, successful placement of stents.”
 

“What comes next, doc?”
 

“You require quadruple coronary artery bypass surgery.”
 
Bypass surgery?  This can’t possibly be happening.  Not to me.  That kind of surgery is for fat people who never exercise, eat fast food cuisine three times a day, never go to a doctor and smoke four packs of cigarettes a day. 
 

Help!  I must have climbed out of that black hole into a hallucinatory nightmare and this is not really happening.  Or, just maybe, I’m really dead and this is the other-worldly Twilight Zone.
 

The doctor brought me back to reality quickly enough by drawing a sketch on a piece of paper showing me where the blockages were and what needed to be done.
 

“You will have to make a decision as to which surgeon you want to perform the procedure and in which hospital.  Meanwhile, you will be held overnight on the cardiac care floor.”
 

“Are there any surgeons in this hospital that can perform the surgery?”
 

“Yes.  There are several, but I would recommend two of them especially and I will write their names down for you in case you decide to have the surgery done here.”

to be continued next week…

January 24, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 5:54 pm

   Paul Jason

                                                               Chapter 2
 

So, my stress test was conducted on Friday, March 17, 2000, St. Patrick’s Day. The written report of the test (which I didn’t see until months later), showed that I walked on that treadmill for 9 minutes and 50 seconds, entering the 4th stage of the Bruce Protocol and reaching a MET level of 12.9.  MET stands for “metabolic equivalent”.  It is a unit measurement of the amount of oxygen consumed by the body at different levels of activity.  This activity caused my body to use 12.9 times the amount of oxygen it otherwise uses when I am lying down at rest.
 
I also achieved a maximal heart rate of 105, which was 66% of the predicted maximal heart rate for a person of my age and general condition. My blood pressure rose from 140/80 to 200/90.  Symptoms of the chest pain were first noted at 4 minutes and 20 seconds, while I was at a heart rate of 101, and dissipated within 2 minutes after I got off the treadmill.  I terminated the test due to leg fatigue and increasing chest pain. The “Conclusion” at the end of the report says that I had a “good level of cardiopulmonary fitness”, but that the electrocardiographic portion of the test was “positive” for myocardial ischemia (insufficient supply of oxygenated blood to the heart). 

Myocardial ischemia is a transitional phase in the development of coronary artery disease in which the heart tissue is slowly starved of oxygen and other nutrients.  When blood flow is completely blocked to the heart, ischemia can lead to a heart attack.  Unfortunately, ischemia is not always symptomatic.  It can be silent as well, and silent ischemia places its victims at a high risk of experiencing a heart attack without warning.
Symptomatic ischemia is epitomized by chest pain called angina pectoris or, simply, angina.  The pain can vary from a tight, squeezing, heavy pain located beneath the breastbone or generating into the throat, jaw or arm, to a sensation of heaviness or tightness, to a feeling similar to indigestion.  Stable angina occurs during exertion, but quickly dissipates by resting, or by taking nitroglycerine. It usually lasts between three and twenty minutes. Unstable angina, on the other hand, occurs more frequently, lasts longer, is more severe and disturbing, and can occur even during rest or light exertion.  
Many readers may be familiar with some of the risk factors associated with myocardial ischemia, but they bear repetition,  just to be sure.  First, there is heredity.  If your parents have (or had) coronary artery disease (CAD), then you are more likely than the average American to develop it also.  Moreover, African-Americans are at greater risk than the population as a whole.
Second: smoking. It  increases the chances of developing CAD and, once developed, the chances of dying from it.

Third: high blood pressure, which makes the heart work harder.
Fourth: high blood cholesterol.
Fifth: age, particularly for men over forty-five years of age and women over fifty-five years of age.
Sixth: sex.  Men are more likely then women to experience heart attacks; women, on the other hand, are more likely to suffer with angina.
Seventh: high levels of fibrinogen and homeocysteine,  which are involved in blood clotting and arterial plaque formation.  Blood tests can check these levels.
Eighth: diabetes.  This disease seriously increases the risk of developing CAD.
Ninth: stress and anger, both of which increase the heart rate and blood pressure and can injure the lining of the arteries.
Tenth: obesity.  Quickly becoming a national crisis in the United States, obesity serves to increase the general strain on the heart. It also increases blood pressure and blood cholesterol and can lead to diabetes.  It increases the risk of developing CAD even if none of the other risk factors is present.
Eleventh: lack of exercise, plain and simple.
 

Oh, and as I previously mentioned,  before a nuclear stress test is administered, the patient is asked to sign a “consent” form that contains the following language, in one form or another:
 

“I consent to voluntarily  engage [emphasis added] in an exercise test to determine the state of my heart and circulation and to evaluate the ability of my heart to respond to stress. The test will be performed on a treadmill, with the amount of effort I must expend increasing gradually.  The increase in effort will continue until symptoms such as fatigue, shortness of breath or chest discomfort appear and indicate to me that I should stop the test. I understand that the possibility exists that during the test I could experience abnormal blood pressure, fainting or heart beat irregularities.  I further understand that there is, in a rare instance, the possibility that I could suffer a heart attack [emphasis added], or an even remoter possibility that I could die [emphasis added].  However, I am advised that emergency equipment and trained personnel will be available to deal with any unusual situation which may arise. Notwithstanding the foregoing, I agree to proceed with the test and not hold the diagnostic center or the personnel involved responsible if subsequent  life-threatening events or injury results.”
 

Amen.

to be continued next week…

January 18, 2008

A LAYMAN’S PERSPECTIVE OF CORONARY BYPASS SURGERY

Filed under: By Paul Jason — Administrator @ 6:36 pm

   Paul Jason

Chapter 1: Every Journey Has a Beginning
It was a clear, dry March day in New York, the type so much appreciated as the cold of Winter begins to recede into the warmth of Spring.  After a light lunch, leisurely eaten at my desk as I surfed the Internet to learn the latest world and local events, I grabbed my attache case and began the two-block walk to my car.  I was on the way to an appointment that afternoon and the case, together with the documents contained within, weighed about fifteen pounds.  A two-block  walk carrying a fifteen-pound attache case was a non-event for me prior to that day.  But, on that particular day, as I walked towards my car, I began to experience a sensation that I can best describe as “slight indigestion” in my upper chest, which I immediately recognized as being unlike any other indigestion I had ever experienced.  It wasn’t located in the abdomen (isn’t that where upset stomachs are supposed to strike?).  And it  wasn’t a sharp pain in the chest (isn’t that what heart attacks are supposed to feel like?) No, this was different, and I knew it.
Upon reaching my car, I placed the attache on the rear seat, and sat down in the driver’s seat.  Within a minute, the unusual sensation was gone.  Cause for concern?  I didn’t know.
My appointment was uneventful – - I negotiated the short distance to and from my parked car with no difficulty; but, when I returned to my hometown, parked my car in its usual spot, and began the two-block walk back to my own office, I once again experienced this unusual upper chest sensation.  And, once again, when I sat down for a minute, it went away.
Much to my chagrin, I experienced that sensation several times during the next few days, each time while carrying relatively light objects.
Thus I decided it was time to visit my primary care physician to investigate further.
Now, my doctor is, I believe (based upon recommendation and experience) a  competent and concerned internist.  At the time of our first meeting in September, 1995, he wrote down in great detail not only my medical history, but the medical histories of both of my parents and my three siblings.  In the approximately five years that he had been attending to my health needs, he had demonstrated genuine concern  for my  welfare, and undistracted attention to my medical complaints.
 
On this occasion, he conducted a rather thorough examination, including  blood pressure, pulse, reflexes, electrocardiogram (ECG), and drew blood for lab tests.  At the conclusion of the exam, he advised me that he had found nothing out of the ordinary compared to my prior records.  However, he indicated that based upon my family history of heart disease he thought it advisable to have a cardiologist examine me. I was quickly referred to a local, recognized cardiology group.
 
I had never before met the cardiologist with whom I consulted, although I was casually familiar with one of his partners. The group of five doctors had a good reputation, and this particular physician was pleasant, direct and professional.  Looking lean and fit, this forty-something young man, a graduate of the Albany Medical College, with specialty training at  Mount Sinai Hospital and Montefiore Medical Center, both in New York,  took a medical history from me and proceeded to conduct a physical examination similar to the one I had received from my internist.  One of his staff assistants also performed an electrocardiogram. At the conclusion, the cardiologist stated that he had not detected anything significant, but that my family history was sufficient to merit further investigation. He indicated that his preference was to have me undergo a non-invasive test before recommending an invasive one.  Therefore, he scheduled a nuclear stress test for me, to be conducted right there in his suite of offices, within a matter of days.
The purpose of a stress test of the heart is to ascertain whether the heart muscle receives sufficient blood when it has to exert itself.  A normal heart is capable of increasing its output (measured by the volume of blood pumped per minute) to several times its usual output when it is stressed.  The goal of the test is to provoke the heart to boost its output.
  
The “nuclear” part of the test refers to the use of either thallium or sestamibi, radioactive substances (isotopes).  When introduced into the bloodstream, these substances collect in those portions of the heart muscle that have good blood flow.  If one of the coronary arteries is blocked or partially blocked, less of these substances accumulates in the portion of the muscle supplied by that artery.
For those not familiar with the procedure, it is a test in two parts.  In part one, the radioactive isotope is injected into the patient and allowed to circulate for about an hour.  Then the patient is placed in a horizontal position while a special camera (it looked like an x-ray machine to me) takes “pictures” of his heart for about twenty minutes from a variety of angles.  These images provide a baseline profile of the blood flow in and around the heart.  This is the “rest” part of the test.
The second  part of the test consists of  the patient  being  hooked up  to an
electro-cardiogram machine and placed on a treadmill or stationary bicycle.  A blood pressure cuff is placed on one arm.  Sometimes a little sensor is clipped onto the tip of an index finger to measure the amount of oxygen in the blood.  The patient is asked to commence exercise and to continue while the energy demands are gradually increased.  The patient is expected to continue for as long as he is capable, or until a predetermined peak heart rate is achieved. Usually, there is a point at which the patient can no longer keep up because of fatigue, or because symptoms such as chest pain, shortness of breath or lightheadedness occur. This is the “stress” part of the test.
At that zenith – - the maximum level of exercise – - the isotope is once again injected into the body and the patient is allowed to come to rest.  Throughout the procedure the patient’s heart rate and blood pressure are monitored.  At the conclusion of the stress portion of the test, images are again taken of the patient’s heart from a variety of angles, allowing for an analysis of the flow during both rest and at the point of maximum exertion. Thus, the use of  thallium or sestamibi greatly increases the accuracy of the stress test in diagnosing coronary artery disease.
The test can also measure the functional capacity of the patient. If, for example, signs of ischemia (insufficient supply of oxygenated blood to the heart) occur at a low level of exercise, the arterial blockages are likely to be significant.  On the other hand, if ischemia does not occur, or if it occurs only at high levels of exercise, the blockages are likely to be less significant.
Since exercise also raises the level of adrenaline, a stress test can be an aid in diagnosing certain cardiac arrhythmias that tend to occur when adrenaline levels are elevated.
The level of exercise to which the patient is exposed is based upon a carefully calculated scale, known as the Bruce Protocol.  Robert Bruce was the developer of the standardized treadmill test for diagnosing and evaluating heart and lung diseases. The Bruce Protocol, a multi-stage test, was first introduced in 1963.  The Protocol consists of seven stages, each lasting three minutes.  During each stage the treadmill moves at a pre-set speed and pre-set elevation, as shown on the following chart:

Stage    1     2     3     4     5    6    7
Speed (mph)   1.7   2.5   3.4   4.2   5.0   5.5 6.0
Grade (%)   10    12    14    16    18   20   22

                                            
It is estimated that about 70% of the millions of stress tests currently performed annually in the United States to evaluate heart function use this protocol.
 

Of course I didn’t know all of this when I had my test.  I did know that the exercise would be performed on a treadmill. And, this particular medical group prefers to conduct the two parts of the test on different days.  This was contra to the procedure followed in the two similar stress tests I had undergone during the prior twenty years (at approximately 10 year intervals).
 

I was surprised, and more than a little concerned, to learn that the treadmill test was to be administered by a Nurse Practitioner, not an M.D.  Of course, I was advised, one of the cardiologists in the group would be present “somewhere in the suite” of offices during the test, but the Nurse Practitioner would actually be the one to conduct it.
 

I wasn’t familiar with the title “Nurse Practitioner”.  I knew that there were Registered Nurses (“RNs”) and Licensed Practical Nurses (“LPNs”) around; but, what was a Nurse Practitioner (“NP”)?   I subsequently learned that a lot of other people are not familiar with the term either.  I wasn’t particularly comfortable with the idea that anyone less than a licensed  physician would be in charge of a test that I knew begins with the patient signing a disclaimer form stating that he knows that there are potential risks involved with the procedure, including the possibility of heart attack or stroke.  Nevertheless, anxiety over a determination of the status of my health prevailed and I submitted to the ministrations of the NP.
 

Later, when I had the time to make inquiry I learned that she has more experience and ability to administer that test than most cardiologists do.
 

But I must return to the stress test itself, which was conducted on Friday, March 17, 2000: St. Patrick’s Day. (Whatever happened to those St. Patrick’s Days when I celebrated with corned beef and cabbage, boiled potatoes, lots of mustard, Irish soda bread and just enough beer to wash the whole, happy meal down???).  For a few minutes, with the NP and a young RN present, I seemed to be doing well.  Then, my worst fears were realized;  I began to feel the same discomfort in my upper chest that had brought me to this moment to begin with.  I immediately advised the NP and the “stress” portion of the test was terminated shortly thereafter, but not before the isotope had been introduced into my body. Afterward, with the aid of that isotope pictures of my heart were taken from a variety of angles. I was advised to call the cardiologist on the following Monday afternoon for the results.
 
Needless to say, I spent a very apprehensive weekend wondering what, if anything, was wrong with me.  Afraid to exert myself lest I unintentionally trigger a heart attack, I nevertheless continued to mull over in my mind my actions over the past several years: moderate exercise; low fat/low sodium diet; medication to successfully lower my cholesterol; regular blood tests to oversee all of this; a diet high in fruits and vegetables; and periodic medical check-ups to monitor my general health.
 

At the appointed hour, I called the cardiologist=s office.  He informed me that he detected some “abnormality” from the results of my stress test and recommended that I  undergo cardiac catheterization. He advised me that one of his partners routinely  performed these procedures and that he could arrange to have it performed at either Columbia- Presbyterian Medical Center in Manhattan, or Montefiore Medical Center (Moses Division) in The Bronx.  Since Montefiore was more convenient for me, I chose to have it done there.  The procedure was scheduled for March 29th.
 

In addition to being concerned about my health, I was also very disappointed.  I had been hoping to vacation in Costa del Sol (Spain) for more than five years, but had never  been able to actually schedule that trip. At long last, I was scheduled to leave on that vacation on March 30th.  Ironically, compared to many of my peers, I allowed myself a meager number of days each year as vacation time, and I was particularly looking forward to this trip.  Nevertheless, prudence dictated that I not wait until March 29th to find out if I was in good enough physical condition to leave for Europe the next day.  So, sadly, I called the travel agent and cancelled the trip. Perhaps I could re-book it, after the catheterization,  for some time in April or early May. 

to be continued next week….

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