Thursday, July 18

Bypass surgery – living to tell the tale

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NOTE: The photograph in this article shows the actual image taken during the writer’s surgery. He is not only grateful to IJN for giving exclusive permission for the surgery to be photographed but also registers his heartfelt gratitude for a stellar job on his heart.

AN insidious burp and it happened again. And again.

It became a regular feature for days, then weeks and months. Though I was not severely distressed in any way, I had that strange feeling the burping was not altogether spewing from my gastro-abdominal system.

Having “read too much into the medical text” while a reporter doing the health and medical beat and being no stranger to frequent press conferences at the National Heart Institute (IJN), I need not be a heart specialist to know the alarm bells were now ringing for me.

Perhaps, the time has come to have my ticker checked and revisit jargons like angiogram, angioplasty, stent and stenting as well as coronary bypass surgery and heart transplant – all of which had rolled off the lips of cardiologists whom I have interviewed before.

I faced interventional cardiologist Datuk (Dr) Rosli Mohd Ali whom I have met during press conferences. This time, it was Rosli who posed the questions and I fielded them.

Rosli, IJN’s head of cardiology, was as usual oozing with his trademark passion for people and their hearts.

Feeling the pulse

“Any chest pain, breathlessness?” Rosli asked, and I said “no.”

“Sweating, palpitations?” and I again said “no.”

“Nausea, pain in the left hand, radiating to the back and throat?”

“No,”I replied.

He then examined my chest with his stethoscope, listening to my chest sounds and like every good clinician, he seemed glad there was no immediate danger. He peered into the X-ray, took a cursory glance at the report and noted the words borderline enlarge-ment of the heart as stated by the radiologist.

“Angiogram,” Rosli declared, adding: “It will give us a clearer picture of your arteries.”

I nodded in agreement. He typed out a referral letter so I could consult a cardiologist at a government hospital and signed me off with a P Ramlee smile.

Over at the hospital in Selangor, I realised, at long last, the time had come for me to know the cold truth. Being a long-term diabetic with four siblings having undergone bypass surgery, the false sense of confidence I tried to create for myself seemed all the more frail and fragile.

Not me

I mentally listed out the reasons why I could not be a candidate for cardiovascular disease. First, I did not experience the classic symptoms of an imminent cardiac event such as chest pain, breathlessness or nausea – all of which are usually experienced by heart patients.

Secondly, as I have been on statins (drugs that regulate cholesterol levels) for more than eight years and my regular blood tests for triglycerides and cholesterol were favourable, I consoled myself I had had a headstart in stopping fatty plaques from percolating in my arteries. And just as I was about to add on the third plus-point, I heard my name being called.

The cardiologist

Propelled back to reality and donning a loose surgical garb, I was wheeled into the freezing large expanse of the hospital’s cathlab. I laid flat on the table, beneath an enormous octopus-like contraption that had X-ray cameras and TV screens fitted to it.

My right hand was firmly plastered in place to allow the cardiologist to insert the catheter. It was also here, I realised cardiologists come in different shapes and sizes, and if I may add, sentiments as well.

The man who was about to push a catheter into the artery in my right hand, till it gets to my heart, and deploy a dye, was in no mood for pre-angiogram pleasantries. He was so upfront and business-like that in my silent thoughts, I decided to nickname him Dr Cold Stone.

“You are going to feel a stick here,” Dr Cold Stone said, at the same time, tapping my wrist to locate a vein.

“Take a deep breath,” he instructed, and then said nothing for a long time.

I only knew he had already injected the anaesthetic, inserted the catheter and also deployed the dye when I felt a hot sensation in my body. He was certainly a fast worker and a silent one too.

Then the TV screen came alive, and there it was – my pulsating heart labouring pathetically. As I viewed the matinee on the screen, with my heart going dub-a-dub, dub-a-dub, Dr Cold Stone spoke again.

Of course, there was no post-angiogram pleasantries either. Just the plain truth, delivered in cold blunt monologue.

“All three coronary arteries are blocked. They are 60-80 per cent blocked. If I have to perform angioplasty, I may have to place six stents. But we don’t usually do that. The better option is open heart bypass surgery for you,” Dr Cold Stone said.

Before I could say anything, he delivered a second recital: “Even if you opt for open heart surgery, it may be a little tricky for the surgeon as your vessels are too small. I will refer you to IJN.”

I was amused Dr Cold Stone uttered all the minus-points without even giving me one little iota of hope. No, I am not complaining. Perhaps he forgot to say something nice. Perhaps he did it his way. Most of all, can I blame him if he had nothing nice to say?

Then he peeled off his surgical gloves and dropped them into the bin and quietly left with the air of a fighter pilot reporting “mission accomplished.”

As he removed his gloves, I caught an image of Pontius Pilate washing his hands off me. My jitters climaxed to a crescendo and just as the words “oh my God” quivered on my lips, the orderly came to wheel me out.

The surgeon

I was back at IJN facing Rosli once again. He was sympathetic and lent some hope.

He said: “At least now we know what is wrong and what we can do to get ahead of the problem.”

Rosli suggested I consult with IJN’s Dr Paneer Selvam, a cardiothoracic surgeon and wrote out a reference for me.

I had an immediate good first impression of Paneer Selvam. He looked confident. He had the kind of confidence that only a very self-assured man will have. He studied my medical notes, asked a few questions and said: “We can do the surgery on Oct 31, any questions?”

“The cardiologist said my arteries are small and they might pose a problem. Will you have any problem during the surgery?” I asked.

“Yes, your arteries are small but we can deal with them,” he said in his typical confident poise.

My next question: “Why are my arteries small?”

“Congenital,”said Paneer Selvam, adding: “You were born with smaller arteries.”

Then he went on to explain the surgery.

“Just like all surgeries, there will be risks and complications. But open heart bypass surgery is a major operation with added risks and complications. The anaesthetist will tell you more,” he said, and left with a subtle “don’t worry” smile on his face.

The anaesthetist injected a dollop of medication which made me drowsy and then everything in the room was a whirl of blur. I must have gone under at this time.

During the surgery, the surgeon and his assisting doctors removed a vein from my right leg. It was a lengthy piece of vein harvested from close to my ankle right up to my mid thigh. This vein was eventually divided into four pieces and grafted into my heart to create “the bypass sections” so that blood will flow through them instead of being clogged up at the diseased arteries which were blocked.

The surgery took a little more than four hours.

Recovery room

I heard voices calling out my name. It belonged to the anaesthetist and her OT nurses attending to me in the recovery room.

“Can you hear me, Joseph … the surgery’s over, open your eyes.”

A bright ray of light stung my retina and I quickly shut my eyes back.

“Oh, he’s fine,” I heard someone say.

I felt my chest and right leg heavily bandaged. Though I was still falling in and out of consciousness, I did one thing I mentally willed myself to do immediately after the surgery. I flexed the fingers on both hands tightly and let them go, repeating the exercise over and over again. Then I flexed both my ankles up and down repeatedly. I was now “personally satisfied” I was in one piece and all my reflexes were working well.

Critical care

I was freezing. I was in IJN’s intensive coronary care unit (ICCU). Here, at any one time, there are only four patients with each having a single nurse to exclusively care for him or her. I had written articles about this ICCU before. I was told it was world-class, and nothing but only the highest standard of nursing care will do at this unit.

Seeing me shivering, the nurse adjusted my blanket so it covered my chest, hands and legs adequately. Patient monitoring machines beeped all around me.

Although I was given more than excellent care here, I must admit this is the most difficult part of bypass surgery. About six tubes were projecting out of my body. And the most difficult one to bear was the endotracheal tube (ETT) in my throat. The ETT is placed in the throat to establish and maintain airway support. It was choking. It made my throat dry and sore and I was thirsty, craving for 100 Plus.

I could not talk with the ETT in my throat and so I communicated with my nurse by writing.

“I want water,” I wrote. She wrote back: “No liquids yet, you might throw up and that is risky.”

Although she was an expert in coronary care nursing, she also had that humane aspect called TLC (tender loving care). I must have looked so pitiable to her that she left my bedside and returned with a bowl of crushed ice with some gauze in it. She dabbed the wet gauze on my lips and it felt good.

After a while, she let me help myself to the wet gauze and I was glad she did. When she was not looking, I picked up a piece of the crushed ice and greedily sucked it. It felt a lot better.  This “cat and mouse game” went on through the night and the good part of the following morning with fresh supplies of crushed ice. Blissfully by forenoon, the ETT was removed and I was told I will be transferred to the high dependency unit (HDU).

Hallucinations

Over at the HDU, Nurse Shazlinah was put in charge of me. Tubes and catheters were still sticking out of my body but I felt a lot comfortable as the ETT ordeal was over and I was already eating porridge and drinking 100 Plus. However, there was another problem confronting me. I could not sleep in the day time and at night as well.

After Shazlinah gave me my medication at 9pm, she expected me to sleep. But she found me wide awake at 12 midnight.

“Why are you not asleep,” she asked.

“I can’t sleep” I said.

“Did you sleep in the afternoon,” she asked, and I replied “no.”

“Try to sleep,” she coaxed and I tried.

At 2am, she still saw me wide awake.

“Still can’t sleep,” she asked and I nodded.

“Are the surgical wounds hurting, do you want morphine” she asked again, and I said: “No, I am seeing things”.

“What are you seeing,” she asked me.

I told her: “I am seeing colourful procession of bottled medicine, pills, tablets and capsules. They come before my eyes, one after another, and when this procession is over, another one comes. The second one is a procession of many people in a colourful parade. I see Mardi Gras procession, Merdeka Day parade and people in a Hindu religious procession like Thaipusam.”

Amused, Shazlinah giggled but she knew I was not talking nonsense.

“You are indeed seeing things. You are hallucinating,” she told me, adding that hallucinations are common among certain patients who have undergone a long period of sedation under anaesthesia. Shazlinah then paged for the doctor-on-call.

The doctor who came to attend to my hallucinatory symptoms studied the notes and, then escorted by Shazlinah, asked me a few questions at my bedside.

“When do these hallucinations come on,” he asked.

“The moment I close my eyes, the show starts. It is like a movie in fast cuts, and it keeps on repeating like reruns,” I replied.

“Are you a compulsive movie person,” he asked, and I said: “I hate watching movies or television. I only watch news and documentaries.”

“Do you usually consume alcohol before bed time,” he asked, and I shook my head.

“What about sleeping pills and other narcotics,” he asked again, and I replied “no.”

He told me anaesthesia can cause patients to hallucinate. He also said he will prescribe a “mild sedation” through the intravenous line and assured me I will have a good night’s sleep.

Shazlinah injected the medication through the intravenous line in my carotid artery. After that I slept like a baby.

The next day, when I was told by the morning nurse I will be transferred to the normal ward, I could not believe my ears. This time, I was not hearing things. Nor hallucinating.