“The time has come,” the Walrus said,
“To talk of many things:
Of shoes–and ships–and sealing-wax–
Of cabbages–and kings–
And why the sea is boiling hot–
And whether pigs have wings.”
–Lewis Carroll, “The Walrus and the Carpenter”
Cardiac Artery Bypass Graft (CABG, pronounced cabbage) is not a term one thinks about while riding one’s bicycle. Indeed, the association is with elderly, out-of-shape American males who have been indiscriminate in diet and lax in activity. However, all of those things are cumulative over time, leading eventually to atherosclerosis in the elderly of both sexes who haven’t succumbed to some other infirmity. Somehow, though we don’t feel “elderly” at 70, we do fit the demographic age group, are overweight, and exercise in spurts.
So, after a decade of daily bicycle commuting, near the end of which a cardiac stress test was passed with flying colors, I found myself, in semi-retirement, having some pain on casual, but aggressive riding. “Out of tune, out of shape” seemed a reasonable assumption, and, indeed, the pain vanished with longer rides and more regular riding. This went on for the next nearly five years, with occasional attempts to find answers, and several thousand kilometers of training and touring.
However, the persistence of some pain, usually at the start of a ride, led to a medical consult before commencing on our 2013 self-supported bicycle tour. GERD (Gastro-Esophageal-Reflux-Disease) seemed a resonable solution and, indeed, a round of the popular treatment Omeprazole seemed to alleviate the symptoms, and off we went on tour, with no adverse affects during the 700-Km tour, riding up to 70Km per day over several weeks, towing a heavy (45Kg) trailer full of gear.
After the tour, however, the symptoms resumed, and eventually could not be reconciled to either poor choice of food before or during the ride (though cold weather was once thought to be a factor). A second round of Omeprazole was ineffective, though a switch to the more preventive treatment, Ranitidine, seemed to help some. Rides became shorter, as pains returned soon after the start of a ride, and required a stop to subside. And, multiple stops, on a 30-km ride around Payette Lake in Idaho.
Yet another medical consult, this time insisting on a cardiac stress test. We had registered for a week-long inn-to-inn bicycle tour at the end of July and were woefully behind in training for it. After waiting more than a week for a referral, we took matters into our own hands and contacted our HMO’s cardiac unit directly, the closest in-house cardiology department being in Tacoma, rather than Olympia, where we usually go for specialty care. Yes, we could get in Friday afternoon. Meanwhile, the referral through our primary physician came through, too, though we would not have been scheduled until at least the following week.
On Friday, the stress test started normally, though my pulse rate went up quickly and blood pressure had been abnormally high during the last few doctor visits (abnormal for me, but apparently not for the average 70-year-old in poor health). As soon as the test went to the next level at three minutes, classic angina pain set in; every reading spiked as pulse and blood pressure headed for the 200 mark, and the EKG readout looked like the audio track from one of our grandson’s heavy metal rock recordings. The test was immediately terminated. The cardiologists had gone home for the day, so I was prescribed a cocktail of nitro and heart regulators and sent home for the weekend, cautioned to “do nothing.” Of course, I did tidy up, package, and upload my latest code project to the NIH, so as to justify my time and possibly leave behind something useful…
Monday was a consult with the cardiologist, who, with one glance at the EKG result, announced “serious blockage,” and muttered “time bomb” while scheduling a cardiac catheterization for early the next morning to plan the next step.
Cardiac catheterization is a minimally-invasive look at the heart’s arteries with a scope inserted into a groin artery, through which also the blocked artery might be opened without surgery using a balloon and a mesh expander called a stent. The procedure is performed at an ambulatory surgery center, in this case, at the Franciscan Cardiac Unit at St. Joseph’s Hospital in Tacoma, 80Km from home.
On awakening, I was shown the result: two of the three major arteries supplying blood to the left ventricle (the big one) were blocked over 90% and the third one compromised. The blockage, at the junction of the arteries, was not fixable and would have to be bypassed. I had been minutes from a fatal heart attack every time I had felt a twinge in my chest over the past at least 200Km of riding, or even while taking out the garbage. In these cases, the patient is not released, but scheduled for open-heart surgery at the next available opportunity.
Fortunately, there was a procedure in progress and the team agreed to put on a second procedure (an open heart surgery for bypass or valve replacement takes four to six hours or more). I was sedated once more and wheeled off to the surgery suite.
I have been told that the prep is quite involved. First, they paint you orange from head to toe with an antiseptic solution, attach various plumbing to manage bodily fluids, stuff your nose with anti-MRSA goop, then chill you to preserve the meat for what comes next, which is both terrifying and a miracle.
To get at the heart or lungs, sometimes surgeons can work between the ribs, or cut through only a few on one side. But, for most, it is necessary to open the thorax completely, which means cutting the sternum from top to bottom. I will have a scar about 25 cm long from my collar down.
Next, the blood flow is diverted through a pump and diffuser to oxygenate the blood and keep it flowing through the brain for next hour or so. And the heart stops, the old definition of The End.
Working quickly, the surgical team takes sections of veins harvested at some point in the process from the legs and chest and sews them into the main arteries and the blocked arteries to create a new pathway. Fortunately, with bicycling, I had lots of nice leg veins from which to choose, leaving a rather large scar behind my left knee. and an area that will remain numb for at least several months.
With the two bypass channels secured in place, and the seams checked for leaks, the heart is restarted and the massive wounds reclosed, stitching bone back together with heavy-gauge wire, and super-gluing external tissues together.
Finally, at nearly midnight on a day that started before 8:00 with the first injections of sedatives, I become aware of what seems to be a vacuum cleaner hose stuffed down my throat, which is being pulled out with the most unpleasant sensations. Amazingly, the tortured vocal cords still work, but it hurts. I immediately begin coughing up a sticky clear fluid and foam that is trying to fill my lungs, a process that continues, nearly two weeks later. Deep breathing exercises are supposed to help the expectorant process, but the ribs and chest hurt, and the lungs don’t seem to expand all the way, possibly due to two rubber tubes stuffed in the sac with them, that are draining fluid and blood away into a container under the bed.
But, the important part is, I am still alive, and probably wouldn’t have been had I not sought treatment when I did or had persisted in “riding through the pain” the last couple of months when we aborted rides that were especially painful.
Before long, I get bundled out onto a high-rise walker with hooks and racks for oxygen and aero-bars for a cruise around the ICU station, two laps. Before leaving the Intensive Care Unit, the various tubes get yanked out, and off I go down the hall to the Progressive Care Unit, where I have to get up to the bathroom. Often. Meals are delivered, but the food is inedible, some beef-eaters idea of “vegetarian” cuisine as boiled-to-mush starch and green paste. I manage a few pieces of melon and occasional bowl of cream of wheat or oatmeal, and beg a snack pudding from the floor nurses the last day.
After I spend two nights in the PCU, get my cardiac jumper cables snipped (they are supposed to pull out, but hang up somewhere) and demonstrate the ability to climb a long flight of stairs without aid, Judy arrives with my clothes (sans personal cell phone, which disappeared somewhere during the personal effects transfers) and I am out the door, four days nearly to the minute that I was wheeled into the operating room for prep, and climb a bit unsteadily into the car for the 80-Km trip home, via the pharmacy. I am now officially labeled with Cardiac Artery Disease, and must take several medications daily for whatever time remains to me.
Adapting to the residual diuretics, laxatives, and pain killers is part of the post-op/post-hospital period., and brings its own set of horrors. Judy has bought me a La-Z-Boy chair, electrified, in which I will spend the next few weeks until I can lever myself in and out of bed without putting weight on my shoulders/elbows, etc. No pushing, pulling, or lifting more than 4Kg until the cloven sternum is fully knitted under its metal lacing. The lung fluid continues to collect, now without a built-in vacuum, but I learn to spit into a cup without leaving slug trails everywhere, mostly. Sleeping in the chair elevated to aid breathing and coughing leaves me with a painful kink in my neck (hence the title).
Sleep has eluded me since waking festooned with tubes, with the constant need to clear my airway of slime. I am expected to get 8 hours of sleep, but it comes in 10 and 15-minute snippets. The food is better, as Judy learns to cook what I usually prepare. Melon continues to be a favorite, but I am soon eating well, then sleeping longer and longer as the flow of slug slime from my lungs diminishes. It is hard to remember to use the “Incentive Spirometer” gadget they send home to build up your lung capacity and help clear the fluid. The indicator is set at 750ml: I started past 1500ml in the ICU and peak the device at 2500 by the time I am home, leaving me to nearly turn blue waiting for the device to reset itself. I still need to remember to practice deep, cleansing yoga breathing several times a day.
Finally, I manage to get in at least four hours of sleep, in 30-minute chunks as the diuretics work to dump the remaining 5 liters of fluid pumped into my system during the surgery by the heart-lung machine. This works too well, and I am soon 5Kg below my check-in weight by the time the pills run out. I also had dropped the narcotic pain killers, opting for plain acetaminophen instead, so I spend most of the next day fuzzy and depressed, nose dripping, like a street junkie down on his luck.
Six days after returning home, I am ready to venture out: first mission, replace my lost phone. A trip to the mall 30 Km away in the rain is mostly pleasant–I am not allowed to drive for six weeks while the bones heal–but then, done with the diuretics, the accumulated laxatives win the battle for fluid. Dizzy with low fluid levels, I stumble from one restroom to the next as we finish our shopping and head for home. Still, I am alive, and moving under my own power. Life is good.
At last, down to my normal lifetime medication list and the lung output continuing to drop, we can plan the rest of the recovery. The glue lines start to itch, tapes begin to peel, walks around the yard become less tiring. Back and forth up and down the sidewalk; breathe, fall into an even cadence, faster, further. There are trails yet to ride.
Acknowledgements:
Dr. Roger Chamusco and P.A. Bjorn Larsen, Group Health Cooperative, who treated my symptoms as an emergency and acted promptly.
Dr. Susan Hecker and her staff, Franciscan Cardiothoracic Surgery, who stayed overtime after a long procedure to perform mine, tired, but steady.
The ICU and PCU staff at St. Josephs Hospital, who put up with me through my recovery and discharge.
And, of course, Judy, who put on her nurse’s hat once more to see me through transition to convalescence at home and was there for me throughout my ordeal, and who said “Stop!” when I pedaled to the edge.
