Wednesday, April 26, 2006
another article
Researchers develop a new way to assess heartbeats
Apr 21 A new light-emitting dye may reveal the inner workings of the heart's electrical system. Scientists hope this approach may shed light on the precise causes of irregular heartbeats and sudden cardiac death.
A heartbeat begins when electrical impulses are fired from the upper chambers of the heart (the atria), which contract in response to push blood into the lower chambers (the ventricles). The electrical impulses continue to the ventricles, causing them to contract and push blood to the rest of the body.
While previous research has explained much about how the heart's electrical impulses work under normal circumstances, it is still unclear what happens deep within the heart during abnormal events such as irregular heart rhythms (arrhythmias) and sudden cardiac death. Sudden cardiac death is death due to the abrupt loss of heart function, often as a result of electrical problems in the heart.
Researchers from the University of Pittsburgh hope to shed some light on the mechanics of irregular heartbeats with several newly developed types of chemical dye. These dyes make it possible to follow the electrical activity taking place several layers below the surface of the heart where cardiac contractions originate.
Visualizing the internal activity of the heart could allow researchers to better understand and protect against what happens during abnormal cardiac events.
The dyes work because of their sensitivity to changes in voltage. When the dyes are injected into the bloodstream and travel through the heart, they encounter voltage changes occurring in the membranes of heart cells. The dyes respond to the change in voltage by emitting different types of fluorescent light, depending on the level of change detected.
The fluorescent light emitted by the dye can be detected and displayed using specialized lab equipment. This allows researchers to actually see the detailed electrical changes taking place within the heart during each beat.
"What exactly causes arrhythmias and sudden cardiac death remains an important question we hope to answer through our studies that make use of a combination of novel imaging approaches. Toward this end, these dyes have proved to be particularly important for recording membrane potential changes and capturing in detail, and in real time, the synchronicity or asynchronicity of the heart," explained the study's lead author Guy Salama, Ph.D., University of Pittsburgh School of Medicine, in a recent press release.
The results of the study were published in a recent issue of the Journal of Membrane Biology.
Tuesday, April 18, 2006
This week's interesting article:
Publish Date: April 14, 2006
Girl's heart restarted after donor organ removed
Apr 14 (Reuters) - A British girl is thought to have become the first heart transplant patient in the UK and possibly the world to have had her donor organ removed and her own heart re-started, a London hospital said on Thursday.
Hannah Clark from south Wales had a heterotopic transplant operation -- known as a "piggyback" because the donor heart is placed next to the original organ -- 10 years ago.
However, complications arose after her body recently started reacting badly to the drugs she had to take to stop her body rejecting the new heart and surgeons took the decision to remove the donor organ.
"We discovered that actually her old heart was now working quite well," said a spokesman from London's Great Ormond Street Hospital for Children.
"So we removed the transplant heart, we were able to take her off the anti-rejection drugs and reconnected her old heart back up again and it worked. She's doing very well."
He added: "We would be surprised if anybody came up with another case. Maybe it's a world first."
Sir Magdi Yacoub, the Egyptian-born surgeon who performed Clark's original transplant, advised surgeons during the February 20 operation. He said he was delighted that the girl's heart had recovered so well.
"Her (original) heart recovered almost completely," he told BBC Radio. "It is now a normal heart. This is a very happy ending."
Medical experts said the operation was an important development in treating people suffering from cardiomyopathy, whereby the heart becomes inflamed and functions poorly.
"Surgeons like Magdi Yacoub have thought for some time that if a heart is failing because of acute inflammation, it might be able to recover if rested," said Professor Peter Weissberg, Medical Director of the British Heart Foundation.
"This seems to be exactly what has happened in this case. The piggyback heart allowed the patient's own heart to take a rest."
He said the modern approach to Clark's problem would be to install a temporary mechanical device, which could be removed after a few months, but that such a method had not been available 10 years ago.
"This is a great example of how a pioneering and novel approach to a medical problem can lead to surprising results that tell us a lot about how some heart diseases progress," he said.
Publish Date: April 14, 2006
Wednesday, April 12, 2006
So anyway, I've been going overboard in describing my hospital stay; let me digress here to some actual content. I may have mentioned that, since I want to remain ICD-less for a while, my regular cardiologist told me to avoid drugs that are known to cause arrhythmia.
Brief summary: avoid decongestants, non-sedating antihistamines, macrolide antibiotics ("mycins"), anything ending in "zole," and large doses of local anesthetics.
Of course we all know to avoid pseudoephedrine (Sudafed) and ephedrine (OTC asthma inhalers) and other drugs in that class. Were you aware that many herbal teas contain related compounds which can also cause arrhythmia? Avoid teas that contain "ma huang" or "Mormon tea" or "desert tea." Also, watch out for any other drug that is labelled as a decongestant - although pseudoephedrine is the most common, there are others. Several other asthma drugs are also stimulants that should be avoided by people at risk of arrhythmia: theophylline and albuterol, for example.
But then, there are more drugs that are arrhythmogenic, that fewer lay people know about. For example, most of the newer "non-sedating anti-histamines" have some possibility of causing arrhythmia. Terfenadine and astemizole are noted in particular.
But the ones you should be MOST aware of are very common, and at the same time very few family doctors/non-cardiologists realize that they are arrhythmogenic: the "macrolide antibiotics." These are the ones that end in "mycin" - such as erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax).
One study notes that erythromycin is especially likely to cause arrhythmia in patients who are taking calcium channel blockers. (diltiazem and verapamil are two such antihypertensive calcium antagonists). Diltiazem and verapamil themselves are potential causes of arrhythmia and death.
Several studies I read also mentioned that the "flouroquinolone" antibiotics (a/k/a "quinolones") could have this effect. The best-known quinolone is ciprofloxacin, a/k/a Cipro. Others include levofloxacin and gatifloxacin.
One drug that can have both anti-arrhythmia properties and arrhythmogenic ones is lidocaine. If you have already had sub-cutaneous (injected or IV) lidocaine and not had any negative effects, then you probably can continue to use it. In fact, "Local anesthetics, such as lidocaine and procainamide, are administered in advanced cardiac life support as antiarrhythmics." Local anesthetics are "cardiodepressive." But, there are two things to watch out for: (1) at high doses, these anesthetics can lead to severe vasodilatation and bradycardia leading to ventricular fibrillation and (2) for people who are on certain blockers - beta-blockers, calcium channel blockers, or H1-blockers - the effect of adding one of these anesthetics can overload the metabolism so it can't process the anesthetics properly. Always let your doctor - and your dentist!! - know that you are taking any of these drugs before they give you lidocaine, which is very common for dental work.
Several articles that discussed the macrolide antibiotics also mentioned that the "azole" anti-fungal drugs could cause certain types of arrhythmia.
There have also been a few reports of cisapride (Propulsid) causing arrhythmia.
Examples of macrolides:
Generic name/Trade name
Azithromycin/Zithromax
Clarithromycin/Biaxin, Biaxin XL
Dirithromycin/Dynabac
Erythromycin/Ery-Tab, Eryc, Ilosone, EryPed, various
Troleandomycin/Tao
Some reference articles, if you want lots more technical detail:
http://jpet.aspetjournals.org/cgi/content/full/303/1/218
http://www.ionchannels.org/showabstract.php?pmid=10444234
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10444234&dopt=Abstract
Note: the following site is not a medical site, and it's from a group that often has a political agenda; I don't endorse this site, and I suggest you take it waith a grain of salt and check everything in it with sites sponsored by reputable medical sources. Nonetheless, you may find it interesting:
http://www.worstpills.org/results.cfm?druginduced_id=7
Brief summary: avoid decongestants, non-sedating antihistamines, macrolide antibiotics ("mycins"), anything ending in "zole," and large doses of local anesthetics.
Of course we all know to avoid pseudoephedrine (Sudafed) and ephedrine (OTC asthma inhalers) and other drugs in that class. Were you aware that many herbal teas contain related compounds which can also cause arrhythmia? Avoid teas that contain "ma huang" or "Mormon tea" or "desert tea." Also, watch out for any other drug that is labelled as a decongestant - although pseudoephedrine is the most common, there are others. Several other asthma drugs are also stimulants that should be avoided by people at risk of arrhythmia: theophylline and albuterol, for example.
But then, there are more drugs that are arrhythmogenic, that fewer lay people know about. For example, most of the newer "non-sedating anti-histamines" have some possibility of causing arrhythmia. Terfenadine and astemizole are noted in particular.
But the ones you should be MOST aware of are very common, and at the same time very few family doctors/non-cardiologists realize that they are arrhythmogenic: the "macrolide antibiotics." These are the ones that end in "mycin" - such as erythromycin, clarithromycin (Biaxin), and azithromycin (Zithromax).
One study notes that erythromycin is especially likely to cause arrhythmia in patients who are taking calcium channel blockers. (diltiazem and verapamil are two such antihypertensive calcium antagonists). Diltiazem and verapamil themselves are potential causes of arrhythmia and death.
Several studies I read also mentioned that the "flouroquinolone" antibiotics (a/k/a "quinolones") could have this effect. The best-known quinolone is ciprofloxacin, a/k/a Cipro. Others include levofloxacin and gatifloxacin.
One drug that can have both anti-arrhythmia properties and arrhythmogenic ones is lidocaine. If you have already had sub-cutaneous (injected or IV) lidocaine and not had any negative effects, then you probably can continue to use it. In fact, "Local anesthetics, such as lidocaine and procainamide, are administered in advanced cardiac life support as antiarrhythmics." Local anesthetics are "cardiodepressive." But, there are two things to watch out for: (1) at high doses, these anesthetics can lead to severe vasodilatation and bradycardia leading to ventricular fibrillation and (2) for people who are on certain blockers - beta-blockers, calcium channel blockers, or H1-blockers - the effect of adding one of these anesthetics can overload the metabolism so it can't process the anesthetics properly. Always let your doctor - and your dentist!! - know that you are taking any of these drugs before they give you lidocaine, which is very common for dental work.
Several articles that discussed the macrolide antibiotics also mentioned that the "azole" anti-fungal drugs could cause certain types of arrhythmia.
There have also been a few reports of cisapride (Propulsid) causing arrhythmia.
Examples of macrolides:
Generic name/Trade name
Azithromycin/Zithromax
Clarithromycin/Biaxin, Biaxin XL
Dirithromycin/Dynabac
Erythromycin/Ery-Tab, Eryc, Ilosone, EryPed, various
Troleandomycin/Tao
Some reference articles, if you want lots more technical detail:
http://jpet.aspetjournals.org/cgi/content/full/303/1/218
http://www.ionchannels.org/showabstract.php?pmid=10444234
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10444234&dopt=Abstract
Note: the following site is not a medical site, and it's from a group that often has a political agenda; I don't endorse this site, and I suggest you take it waith a grain of salt and check everything in it with sites sponsored by reputable medical sources. Nonetheless, you may find it interesting:
http://www.worstpills.org/results.cfm?druginduced_id=7
Friday, April 07, 2006
Essay: What I did this March, Part 2.
So, at 6:00 a.m., once he had noted my room number and phone number and all that, spouse went home to get a few hours sleep. Right after that, more pus decided to gush out of the incision, and my nurse called over a bunch of the other nurses to see it, as none of them had ever seen anything quite like it before. They wound up using an abdominal pad rather than just gauze pads, to cover it; I got a clean hospital gown, and managed to get about half an hour of rest before other things started going on.
Here's what Sunday looked like:
8 a.m. breakfast and fresh bag of IV antibiotic.
8:40 a.m. IV finished, monitor beeps loudly till nurse comes in to re-set things.
9:00 Someone comes to take breakfast trays away.
10:00 morning medications - all my usual daily pills.
Noon - lunch brought in. (Default low-sodium tray, since I hadn't had a chance to pre-select a menu, and it included coffee, which I don't drink.) Also, another bag of IV
12:40 p.m. IV finished, nurse must attend beeping monitor
1:00 one of the miscellaneous cardiologists comes in to get my signed consent for surgery, which involves going over all the risks again. Since I am able to tell him everything that I was told on Friday, plus discuss a little about statistics and probability, and the risks of NOT getting the surgery, which they hadn't even mentioned, he agreed that yes, I probably was giving far more informed consent than most people.
2:00 Spouse returns to visit, having slept a bit, called all the necessary relatives and friends, etc.
Midafternoon sometime - the regular ward doctor drops by to see the new case and ask every single one of the same questions over again.
4:00 Another IV bag. Also, roomie's relatives and friends start showing up. She is a sweet little (4'1", she tells someone at one point) old lady, very popular. Her family and friends are nice - they all say hello to me as well, and make sure to ask if it's OK to move chairs around, etc.
4:40 IV finishes, the usual nurse needed. Also, afternoon "vital signs" - take everybody in the joint's blood pressure, pulse, and temperature.
5:00 dinner, again with coffee I don't want. But also, a menu for requesting particular food the following day!
6:00 take the dinner trays away.
8:00 visitors mostly leave, including spouse; it takes about half an hour for all of roomie's family to clear out. Also, another IV bag, and the usual follow-up 40 minutes later.
10:00 evening medications - doses of stuff that I take twice daily.
Manage to doze for over an hour!
Midnight - IV bag, of course, and
12:40 a.m. IV finished, monitor beeps, etc.
Then I manage to get almost three hours sleep!
4 a.m. another IV bag.
4:40 you guessed it
5:00 morning "vital signs" which include not only temp, BP and pulse, but also making the sleep-deprived get up and get weighed on a scale.
7:00 Dr Brinker stops by to wave hi and get me psyched up for surgery at 8:30. Spouse shows up, too, for waiting purposes.
That's not counting assorted doctors dropping in on my roomie, nor her monitor beeping for one reason or another, nor the ridiculous routine we have to go through in order to pee. So if you notice, I got maybe 4 hours sleep total in there.
At 8:30, I get wheeled off to the surgical suite!!
To be continued!
So, at 6:00 a.m., once he had noted my room number and phone number and all that, spouse went home to get a few hours sleep. Right after that, more pus decided to gush out of the incision, and my nurse called over a bunch of the other nurses to see it, as none of them had ever seen anything quite like it before. They wound up using an abdominal pad rather than just gauze pads, to cover it; I got a clean hospital gown, and managed to get about half an hour of rest before other things started going on.
Here's what Sunday looked like:
8 a.m. breakfast and fresh bag of IV antibiotic.
8:40 a.m. IV finished, monitor beeps loudly till nurse comes in to re-set things.
9:00 Someone comes to take breakfast trays away.
10:00 morning medications - all my usual daily pills.
Noon - lunch brought in. (Default low-sodium tray, since I hadn't had a chance to pre-select a menu, and it included coffee, which I don't drink.) Also, another bag of IV
12:40 p.m. IV finished, nurse must attend beeping monitor
1:00 one of the miscellaneous cardiologists comes in to get my signed consent for surgery, which involves going over all the risks again. Since I am able to tell him everything that I was told on Friday, plus discuss a little about statistics and probability, and the risks of NOT getting the surgery, which they hadn't even mentioned, he agreed that yes, I probably was giving far more informed consent than most people.
2:00 Spouse returns to visit, having slept a bit, called all the necessary relatives and friends, etc.
Midafternoon sometime - the regular ward doctor drops by to see the new case and ask every single one of the same questions over again.
4:00 Another IV bag. Also, roomie's relatives and friends start showing up. She is a sweet little (4'1", she tells someone at one point) old lady, very popular. Her family and friends are nice - they all say hello to me as well, and make sure to ask if it's OK to move chairs around, etc.
4:40 IV finishes, the usual nurse needed. Also, afternoon "vital signs" - take everybody in the joint's blood pressure, pulse, and temperature.
5:00 dinner, again with coffee I don't want. But also, a menu for requesting particular food the following day!
6:00 take the dinner trays away.
8:00 visitors mostly leave, including spouse; it takes about half an hour for all of roomie's family to clear out. Also, another IV bag, and the usual follow-up 40 minutes later.
10:00 evening medications - doses of stuff that I take twice daily.
Manage to doze for over an hour!
Midnight - IV bag, of course, and
12:40 a.m. IV finished, monitor beeps, etc.
Then I manage to get almost three hours sleep!
4 a.m. another IV bag.
4:40 you guessed it
5:00 morning "vital signs" which include not only temp, BP and pulse, but also making the sleep-deprived get up and get weighed on a scale.
7:00 Dr Brinker stops by to wave hi and get me psyched up for surgery at 8:30. Spouse shows up, too, for waiting purposes.
That's not counting assorted doctors dropping in on my roomie, nor her monitor beeping for one reason or another, nor the ridiculous routine we have to go through in order to pee. So if you notice, I got maybe 4 hours sleep total in there.
At 8:30, I get wheeled off to the surgical suite!!
To be continued!
Tuesday, April 04, 2006
Essay: What I did this March, Part 1.
Today, I got the PICC line removed from my arm, which makes typing MUCH easier. So this seems like as good a time as any to fill in the details. As you'll recall from earlier entries, on March 2, I had surgery to try and implant the third lead from my device. When I originally got the device in 2003 (right when I started this blog!) the doctors in Austin had not been able to implant the third lead, the one that goes in the coronary sinus area to stimulate the other ventricle. As it turned out, several years of advances in technology and surgical procedures, and the reputation of Johns Hopkins here in Baltimore, still wasn't enough. After working on it for several hours, the doctors had to declare themselves defeated by a rather peculiar membrane which wasn't supposed to be there.
The longer a surgical site is open, the greater a chance for infection. When I went home on the 2nd, all seemed fine, and everything seemed to be healing up. But alas, that was deceptive. On March 11, we drove to Pittsburgh to visit some friends, and returned on Monday, March 13. That night I actually took a painkiller, which I hadn't done since the night right after the surgery, because my shoulder ached so much. I attributed this ache to overdoing it in Pittsburgh - which we certainly had done - Pittsburgh is a hilly city, and has nowhere near enough parking spaces, and I did more walking there than I usually do. Tuesday I awoke with a head full of cotton balls in place of a brain. Remind me NEVER to take oxycodone again - that sensation of brain numbness was far more distasteful than mere pain would have been. But anyway, somewhere in there, I began to have a fever and chills. By Wednesday, it was a full-blown flu-like illness; in fact, I assumed it was the flu. After a couple of days of sweating alternating with shivering fits, though, I noticed that the pacemaker area was inflamed and tender, and it also suddenly occured to me that no one had ever called me from the surgeon's office for the normal post-op follow-up appointment, which by then should have already occurred. So on Friday morning, I called the hospital. I talked to the surgeon's office, describing the problem and mentioning that I hadn't had a follow-up appointment yet. She said gee, you're right, wonder why that is? We've got a spot next Wednesday morning. So I wrote that in my pocket calendar, and went back to feeling miserable. An hour later, she called back, and said "I've talked to the EPs on call, and they think maybe someone should see you before next Wednesday; can you come in this afternoon and they will see you as soon as you get here?" Indeed. After managing to wash up (remember, I'm still feeling like I have a major case of the flu) and put on outdoor clothes, we drove over - a 20-minute drive turned into 30 minutes by the assorted lane closings and other hazards of urban streets.
As promised, within a minute of checking in at the desk, the EP on call saw me. He looked at the site, felt how it felt as though there was liquid in it, opined that it was almost surely infected and would definitely need exploratory surgery to find out for sure, and that if it was infected, the entire pacemaker would need to be removed. He then grabbed a senior guy who was in the area, to further take a look, which turned out to be Dr. Brinker. The two of them scheduled me for surgery first thing Monday morning, and discussed all the risks of removing the pacemaker with me. This is where this rambling personal essay gets interesting, because you all should know about this too.
→ Removing a pacemaker is harder than putting one in. Scar tissue has grown up around the device and the leads. Around the device, it's not too bad, especially in one that's only been in a few years, as mine was. Around the leads, however, since they are so thin, scar tissue is far more of an issue, usually thicker than the leads. The first thing doctors do to try and remove the leads is to fasten a teeny hook to the end and pull gently, hoping it will slide right out. This doesn't work often - I forget the exact percentage of the time, but I think they said around 10%. The rest of the time, the scar tissue is thick enough to block the lead from sliding. ● In those cases, what they have to do is use a "laser sheath" - a thin tube with a circular laser knife in it, which they then use to tunned through the scar tissue, around the lead, effectively creating a tunnel that the lead can slide through. This is where the risks come in. ● If the laser sheath cuts through anything besides scar tissue, the patient can be in serious trouble. ● The risk of death, although small, is still considerably larger than the risks of installing a pacemaker, or of any other surgery I've ever had done: 0.5%, or 5 in 1000. ● This is high enough that doctors are required to discuss it pretty seriously with the patient. ● Then there's another 1% chance of something getting nicked short of death but serious enough to require immediate heart surgery. ● The remaining 98.5% of the time, everything goes fine.
After being warned of this, and agreeing to the surgery nonetheless, we all shook hands and said our "See ya Monday morning!" farewells.
Warning: gross details ahead. Squeamish persons may want to skip this next few sentences. Friday night, pus began oozing out of the incision, which they had warned me might happen. Saturday, it got worse, and then, Saturday night, the incision
actually opened up a bit - visible holes a centimeter long - and pus began GUSHING out of it. At that point, I didn't think I could just sit around waiting for Monday morning. Once there are visible holes into the inside of my body, even I begin to worry. So, off to Hopkins' emergency room, arriving there around 1:00 Sunday morning.
Emergency rooms are no-one's favorite place. I didn't have to wait too long, though - only about an hour - in the waiting room, before someone could see me. There weren't even many people in worse shape ahead of me. Although Hopkins is in downtown Baltimore, it's not the emergency room that all the shootings and drug overdoses are generally brought to - there are other hospitals around the city that tend to get the majority of that sort of emergency trauma. So the waiting room was pretty quiet, and then the emergency "pod" I went to was quiet. The guy on duty for that pod was a very funny guy. As he was expressing all the rest of the liquid, and making notes, and ordering IV antibiotics and stuff like that, we were carrying on a fairly clear conversation. Of course, as an emergency room doctor, he sees plenty of stuff, including way more pus than I had, but he had to admit that it was certainly the most pus he had seen recently coming out of someone who was sitting upright and cheerfully talking to him. Later, when he was entering notes on the computer, we had a little word game going - was "copious" really adequate to describe that amount of liquid, or was it more than that? We came up with "voluminous" and even "oceanic."
While I was sitting there, with nurses doing blood draws in one arm, and setting up IV antibiotics into the other arm, and people trying to find an appropriate bed on an appropriate ward and a doctor on that ward who would officially admit me, other patients did come through. Someone with a migraine. A woman who had pulled a muscle in her groin, and was clearly angling for a doctor's note that said she couldn't work for the following week - which they refused to give her. And most interesting, a guy who had deliberately drunk a cup of ammonia cleaning fluid, for reasons only he knew. He was in handcuffs and accompanied by several of Baltimore City's finest. Turned out he had been living in a Federal halfway house, pre-release, and that's where he drank the fluid. The curtains between areas muffled most of the rest, but I did hear him say something about how they wouldn't give him any "medication" at the halfway house. When, at about 5 a.m., a doctor finally came to take me up to a bed in the cardiology ward, he was still in there, and cops were hanging around drinking ice water in the hallway.
To be continued!
Today, I got the PICC line removed from my arm, which makes typing MUCH easier. So this seems like as good a time as any to fill in the details. As you'll recall from earlier entries, on March 2, I had surgery to try and implant the third lead from my device. When I originally got the device in 2003 (right when I started this blog!) the doctors in Austin had not been able to implant the third lead, the one that goes in the coronary sinus area to stimulate the other ventricle. As it turned out, several years of advances in technology and surgical procedures, and the reputation of Johns Hopkins here in Baltimore, still wasn't enough. After working on it for several hours, the doctors had to declare themselves defeated by a rather peculiar membrane which wasn't supposed to be there.
The longer a surgical site is open, the greater a chance for infection. When I went home on the 2nd, all seemed fine, and everything seemed to be healing up. But alas, that was deceptive. On March 11, we drove to Pittsburgh to visit some friends, and returned on Monday, March 13. That night I actually took a painkiller, which I hadn't done since the night right after the surgery, because my shoulder ached so much. I attributed this ache to overdoing it in Pittsburgh - which we certainly had done - Pittsburgh is a hilly city, and has nowhere near enough parking spaces, and I did more walking there than I usually do. Tuesday I awoke with a head full of cotton balls in place of a brain. Remind me NEVER to take oxycodone again - that sensation of brain numbness was far more distasteful than mere pain would have been. But anyway, somewhere in there, I began to have a fever and chills. By Wednesday, it was a full-blown flu-like illness; in fact, I assumed it was the flu. After a couple of days of sweating alternating with shivering fits, though, I noticed that the pacemaker area was inflamed and tender, and it also suddenly occured to me that no one had ever called me from the surgeon's office for the normal post-op follow-up appointment, which by then should have already occurred. So on Friday morning, I called the hospital. I talked to the surgeon's office, describing the problem and mentioning that I hadn't had a follow-up appointment yet. She said gee, you're right, wonder why that is? We've got a spot next Wednesday morning. So I wrote that in my pocket calendar, and went back to feeling miserable. An hour later, she called back, and said "I've talked to the EPs on call, and they think maybe someone should see you before next Wednesday; can you come in this afternoon and they will see you as soon as you get here?" Indeed. After managing to wash up (remember, I'm still feeling like I have a major case of the flu) and put on outdoor clothes, we drove over - a 20-minute drive turned into 30 minutes by the assorted lane closings and other hazards of urban streets.
As promised, within a minute of checking in at the desk, the EP on call saw me. He looked at the site, felt how it felt as though there was liquid in it, opined that it was almost surely infected and would definitely need exploratory surgery to find out for sure, and that if it was infected, the entire pacemaker would need to be removed. He then grabbed a senior guy who was in the area, to further take a look, which turned out to be Dr. Brinker. The two of them scheduled me for surgery first thing Monday morning, and discussed all the risks of removing the pacemaker with me. This is where this rambling personal essay gets interesting, because you all should know about this too.
→ Removing a pacemaker is harder than putting one in. Scar tissue has grown up around the device and the leads. Around the device, it's not too bad, especially in one that's only been in a few years, as mine was. Around the leads, however, since they are so thin, scar tissue is far more of an issue, usually thicker than the leads. The first thing doctors do to try and remove the leads is to fasten a teeny hook to the end and pull gently, hoping it will slide right out. This doesn't work often - I forget the exact percentage of the time, but I think they said around 10%. The rest of the time, the scar tissue is thick enough to block the lead from sliding. ● In those cases, what they have to do is use a "laser sheath" - a thin tube with a circular laser knife in it, which they then use to tunned through the scar tissue, around the lead, effectively creating a tunnel that the lead can slide through. This is where the risks come in. ● If the laser sheath cuts through anything besides scar tissue, the patient can be in serious trouble. ● The risk of death, although small, is still considerably larger than the risks of installing a pacemaker, or of any other surgery I've ever had done: 0.5%, or 5 in 1000. ● This is high enough that doctors are required to discuss it pretty seriously with the patient. ● Then there's another 1% chance of something getting nicked short of death but serious enough to require immediate heart surgery. ● The remaining 98.5% of the time, everything goes fine.
After being warned of this, and agreeing to the surgery nonetheless, we all shook hands and said our "See ya Monday morning!" farewells.
Warning: gross details ahead. Squeamish persons may want to skip this next few sentences. Friday night, pus began oozing out of the incision, which they had warned me might happen. Saturday, it got worse, and then, Saturday night, the incision
actually opened up a bit - visible holes a centimeter long - and pus began GUSHING out of it. At that point, I didn't think I could just sit around waiting for Monday morning. Once there are visible holes into the inside of my body, even I begin to worry. So, off to Hopkins' emergency room, arriving there around 1:00 Sunday morning.
Emergency rooms are no-one's favorite place. I didn't have to wait too long, though - only about an hour - in the waiting room, before someone could see me. There weren't even many people in worse shape ahead of me. Although Hopkins is in downtown Baltimore, it's not the emergency room that all the shootings and drug overdoses are generally brought to - there are other hospitals around the city that tend to get the majority of that sort of emergency trauma. So the waiting room was pretty quiet, and then the emergency "pod" I went to was quiet. The guy on duty for that pod was a very funny guy. As he was expressing all the rest of the liquid, and making notes, and ordering IV antibiotics and stuff like that, we were carrying on a fairly clear conversation. Of course, as an emergency room doctor, he sees plenty of stuff, including way more pus than I had, but he had to admit that it was certainly the most pus he had seen recently coming out of someone who was sitting upright and cheerfully talking to him. Later, when he was entering notes on the computer, we had a little word game going - was "copious" really adequate to describe that amount of liquid, or was it more than that? We came up with "voluminous" and even "oceanic."
While I was sitting there, with nurses doing blood draws in one arm, and setting up IV antibiotics into the other arm, and people trying to find an appropriate bed on an appropriate ward and a doctor on that ward who would officially admit me, other patients did come through. Someone with a migraine. A woman who had pulled a muscle in her groin, and was clearly angling for a doctor's note that said she couldn't work for the following week - which they refused to give her. And most interesting, a guy who had deliberately drunk a cup of ammonia cleaning fluid, for reasons only he knew. He was in handcuffs and accompanied by several of Baltimore City's finest. Turned out he had been living in a Federal halfway house, pre-release, and that's where he drank the fluid. The curtains between areas muffled most of the rest, but I did hear him say something about how they wouldn't give him any "medication" at the halfway house. When, at about 5 a.m., a doctor finally came to take me up to a bed in the cardiology ward, he was still in there, and cops were hanging around drinking ice water in the hallway.
To be continued!
