Tuesday, 1 June 2021

The Holy Land. Pt.1.

 Wanderings in the Negev Desert.

It was in 1996 when I took a year of sabbatical after having been the chair of the Department of Family Medicine at the University of Saskatchewan for ten years. I spent half my sabbatical at Duke University in Durham, North Carolina, working with their renowned stroke prevention unit, with Dr. David Macher and his colleagues at Duke University. I had been involved with a similar unit at the University of Saskatchewan that was focused on stroke prevention as applied to primary care.
The second half of my sabbatical, starting in January, 1996, was spent in Israel as a visiting professor at Ben Gurion University in Beer Sheva, the gateway to the Negev Desert. Historically an intriguing area, the odds are that when you stub your toe, the object you hit dates from long before the Christian Era (you can read your bible if you want to know more!). It was regarded as a bit of a backwoods then, apart from its outstanding Ben Gurion University. Extensive building was going on everywhere and still is and friends who have visited since tell me I wouldn't recognize it. I was working as a visiting professor in the Department of Family Medicine and since the provision of health care in remote northern areas of Saskatchewan was provided under the aegis of my department, one of my interests was in outreach medical care in remote areas. Because of my experience in this area, the Dean of. Medicine at BGU requested that I review and comment upon outreach medical services in the Negev Desert and make any recommendations that I thought appropriate.
It was after a presentation to faculty when we were discussing issues of providing medical care in remote areas, that I was approached by Dr. Mahmoud Maroud , a senior resident in the department of family medicine at BGU. His resident project was a study of medical care to patients living in remote places in the Negev. He had heard my presentation regarding the role the department of family medicine played in developing medical care to people in Northern Saskatchewan.
Saskatchewan's 651,036 square kilometres of land area, (population about a million) is larger than all but two states Alaska, which is almost three times the size, and Texas, with a population of less than 20,000,000 at that time. The Negev, on the other hand, is an area of 13,000 km squared, with about half a million population, about 25% of which are Bedouin. Dr. Maroud, a Bedouin, observed that many of the issues in delivering health care to the native population in remote parts of Saskatchewan were similar to the issues of delivering health care to the remote desert Bedouin, despite the great difference in area served, and of course the climate. Half of the Negev Bedouin lived in unrecognized villages in traditional Bedouin nomadic tent communities and half of them lived in towns built for them by the Israeli government between 1960 and 1980. Dr. Maroud, invited me to accompany him on his tour to visit and comment on Bedouin communities and their health care issues. I enthusiastically accepted his offer, ecstatic at the prospect of having a guide who spoke Arabic, Hebrew and English fluently and who, as an insider, would provide access to people and places I would otherwise have little chance of meeting. He informed me that he would contact me for his next foray into the desert. I informed him that my wife and companion was interested in coming along and he responded by pointing out that this would be fine in most but not all of the places that we were to visit, emphasizing the dress code and a number of other issues with which my wife and I were well familiar, that would make an accompanying woman's presence tolerable in the Bedouin culture. Several days later, he phoned.
Here my journal notes start and I share them with only small corrections:
On January 16th 1996, at 3.10pm the phone rang at the apt. It was Dr. Maroud, and he arranged to pick us up later that same afternoon to visit a fairly near-by Bedouin settlement and introduce us to the Bedouin way of life. He was a tall, dark, man with a strong face who looked to be in his mid thirties, dressed in modern style and spoke accentless English. I introduced him to Irene, and we both climbed into his small car to begin what was to be an eventful and unusual day. We drove out onto the road from the small modern town of Omer on the periphery of Beer Sheva where we had rented an apartment. The setting was more reminiscent of California than Israel and we drove towards Shoket Junction while Dr.Maroud gave us a short history of the Bedouin and of himself.
He told us his uncle was a member of the communist party and he himself had gone to medical school in Czechoslovakia and then came back to Israel for his postgraduate training.
His off the top of his head population figures, and remember this was 1996 were as follows. There were approximately one hundred and ten thousand Bedouin in the Negev, and another hundred and ten thousand in the north of Israel. There were approximately two and a half million in total, mostly in the surrounding Arab countries, but extending as far as Cuba. We could not imagine how they came to migrate there, but as the story unfolded we were later able to gain some insight as to why that happened.
When we reached S.Junction we turned left and headed to Leguia, and pulled off the highway onto a dirt road. The dirt road appeared to have no distinguishing features. We seemed to be driving across oceans of sand with no identifying landmarks and the idea did cross my mind that we could perish in the desert if the car broke down or worse. (No mobile phones in those days!)
"How do you know you turned off the highway in the right place?" I asked. This was in the days before GPS. "It all looks the same to me."
"We should see a water pump in about another five minutes and then turn right," he said.
"And what if we don't?" I asked.
He laughed."then we'll just have to stop and ask someone!. You think that there's no one to ask, don't you?"
He was quite right, we hadn't seen anything or anyone since we had left the road.
"Now, I'll just point out some things as we drive along. Oh, and there's the pump just popping its head over the sand dune almost straight ahead."
M. pointed out to us the galvanized iron huts and tents on the one side of the road, so well blended in with their background we would never have noticed them if they were not pointed out to us by someone who knew where to look. On the other side of the road were some new houses built by the Israeli government. He commented that though the new houses looked lovely from the outside that the inside was not correspondingly furnished, and usually contained the furnishings typical of the interior of the tent. The new houses, known as planned settlements, had electricity and running water, while the old shanties had no such provisions, although many of them had small generators.
The car climbed up a small hill. We got out to look around.From the top of a hill we were standing on, Mahmoud pointed out a fine, affluent home that would have looked quite in place in California and informed us that it was being built by one of the wealthy members of the tribe and it needed to be large because he had three wives. He commented that many of the young men were reverting to having two or three wives if they could afford it. I asked him jokingly if that was what he had in mind. He laughed back,
"I don't think my wife would let me -she's a Czech!"
I asked why some of the Bedouin have new homes in settlements (the so-called planned settlements), while others stay on in tents - the old settlements. Apparently, the issue is one of giving up land in exchange for resettlement homes, and according to M. there is some pressure on the Bedouin to resettle. The reason for this is ascribed to 'security reasons'. We then headed east toward Ksifr and turned south across land where no life could be seen, unless trained eyes were there to point them out. M. pointed out more Bedouin tents that were almost invisible against the background of the rolling hills of sand and some green. The green, I was later to find out is wheat, somehow shlept out of this sandy, stony terrain and looking pathetic when compared to the lush prairie wheat fields where some of the farms were nearly as big as Israel. We continued up a meandering stony path, which I wondered if the car could negotiate, Finally we arrived at the high point, overlooking several Bedouin tents. Out of nowhere a white car appeared, a menacing man behind the wheel. M indicated to me that I should lower my window, and started talking to the driver of the other car in Arabic. Once he identified himself as a fellow Bedu, the animosity vanished instantly, and the man came around and shook his hand, ignoring me. M. showed us some olive trees, explaining to us that the Bedouin don't usually grow trees but the land ownership act stipulates that if there are trees growing on the land it implies ownership. He also explained to us that the Bedouin build permanent structures inside the tents, another sign of land ownership.
We continued driving over this harsh, pitted, rutted, uneven terrain, over mounds of rocky sandy earth that I was sure the car could not negotiate. I could picture the undercarriage hung up on some huge sandy knoll. M. however seemed to have no such worries, seemed to know every inch of the terrain and traversed it with complete confidence, everywhere pointing out with pleasure Bedouin tents invisible to the casual eye. Back onto a road where we drove to another resettlement road, beyond the new dwellings, some of which looked very nice, There was a magnificent timpressive looking mosque. We stopped to look at it, and I asked M. if I could take a photograph.
"Of course!" he answered. I pulled out my camera and took a photograph. I was just getting back into the car when a rather aggressive young Arab man came over to ask what we wanted. Again M. responded in the Bedouin dialect, introducing himself. The man asked in Arabic some questions.. (I confirmed this with M. later). "Are you Bedouin?"
M answered in the affirmative, entering into a short discussion. The young man was obviously dealing with a person of some status. After which much shaking of hands (including mine!) and friendly farewells. I don't think I would have felt very comfortable stumbling into this by myself. I asked M. what would have happened if he wasn't there, he answered that we would have just been told to move on.
He looked at the magnificent mosque I had been photographing.
" Where do you think the money came from for this mosque," he asked me.
"Where?" I asked, not wanting to offend him with my opinion.
"From fundamentalist countries like Iran and Iraq. They are trying to foster fundamentalism among young Bedouin. The Bedouin are traditionally non political, but there is some fundamentalism arising among the young people, who feel their needs are not being met and they are in danger of losing their land."
We pulled out towards the road again.
"See how far the school is from the village?" he asked, "why do you think that is?"
"I don't know," I answered.
"It's because the teachers don't feel safe with the school being right in the village," he said, "in the case of any trouble the school could become a fortress. "There is the Kupat Cholim clinic, also quite far from the village, for the same reasons." He pointed out the medical clinic to me. It looked nice and modern and clean, but there was nothing going on in it. Certainly no doctors or patients visible. How was that?
He explained to me that women could not come to the clinic unaccompanied by a relative - usually male. He pointed out that many preferred ritual healers and avoided modern medicine if they thought they could.
More next week.

Like
Comm
    • Like
    • Repl

Monday, 24 May 2021

My Left Foot.

 Christy Brown  and Others.

My Left Foot.
Christy Brown.
I stood there, a lone medical student, at the bottom of bed number thirty-six. I had been dispatched to do my first solo history and physical examination. Of course I had done many before, but always as part of a team or with at least one other student or intern.
Lying on the bed was a young man, about my age writhing in spastic, athethoid movement, neck extended and rigid contractures of the arms and legs and a more shocking example of the physical misfortunes than I had ever seen. He seemed to totally lack any sort of control over his body, until my shocked eyes fell on his left lower extremity. Between the big toe and the second toe of his left foot he was holding a pen, and despite the spastic movements of the rest of his body, he was writing in a small , precise cursive hand (foot!) on a stabilized notebook. It was amazing to watch.
After I got over the shock of seeing a human being who seemed to be dealing in some way with the unimaginable devastation, I managed to pull myself together and said apprehensively, " I'm Stan Smith, a medical student, and they sent me down to take a history and do a physical examination. Is that alright?" He nodded affirmatively.
The patient, Christy Brown, later internationally known as the author of the book and subject of the movie "My Left Foot," and "Down all the Days" and a number of other books and paintings was kind to an apprehensive new clinical student.
His speech was dysarthric and difficult to understand, his manner kindly. He was obviously used to this teaching hospital routine. I won't attempt to replicate his spastic speech - that would just make him - and me sound stupid!!
"Yes, I know you students have to learn from someone," he replied in the dysarthric staccato drawl.
I was grateful I could understand him and he me.
I took a history of sorts, more social than medical. He told me he nearly died during delivery and that he had suffered serious brain damage. We got on to his life.
Christy was born at the Rotunda Hospital in 1932, - three years before I was born. He had twenty-two siblings, (Yes, 22 !) out of which thirteen lived. His parents were urged to commit him to hospital as he was so spastic, but deferred. He was thought to be mentally impaired and received most of his education from his mother.
"So what do you do most of the time?" I asked him.
" I write," he said. "I've started doing a bit of painting too," he said.
He had a certain leprechaun- ish look about him that precluded an overly sympathetic attitude and made me feel that somehow he was managing to get some fun out of life, as indeed he was. If you want to know how, read "Down all the Days". He was addicted to alcohol, which I am sure brought more to his life than ever took from it. His brothers pulled him around in a cart, mainly to the local pub and fed him Guiness.
Daniel Day Lewis played the role of Christy Brown with great insight and the movie itself kept reasonably close to the facts.
The only other famous 'medical case' I (almost) met in my student days, was Douglas Bader, the legless RAF Air ace, who was a double lower limb amputee as a result of an air crash and talked his way back into combat missions sans legs, until he was shot down and became a prisoner of war. He came to the Meath Hospital to encourage and reassure pediatric amputees regarding their future life, though I don't think he was recommending that they become fighter-pilots!
An even more remote potential patient was Her Majesty, Queen Elizabeth, who visited Saskatoon many years ago when I was Chair of the Department of Family Medicine and the Emergency Department. Her Majesty, of course, traveled with her own team of Physicians but as their access to all of the facilities of University Hospital had to be through a duly qualified physician with full privileges I was selected and thus I can claim to have been duly appointed Physician to the Queen for two days! Unfortunately, I wasn't smart enough to request a written testimony at the time. Fortunately, Her Majesty and her physicians didn't require my services!!

Thursday, 6 May 2021

Cabbage Pt. 3

 Cabbage Pt 3. The Nortel Pillow.


Cabbage 3 -Post Surgery.

   Much of my discomfort came later and was due to a hyperesthesia (super-sensitivity) of the scar. So much so that even touching the area was painful.. The touch of clothes brushing over the hypersensitive scar tissue was more painful that some of the really big stuff that seemed relatively painless. How is it no one has ever thought of a little plastic cradle one could tape over the scar to prevent clothes from brushing against the hypersensitive skin? Maybe I need to invent such a gizmo? It would be relatively easy. I thought maybe I'd do it when I was better! Needless to say, I never did. Somehow, that night crept by, a nanosecond at a time, it is true, but a least I could see that the morning would come eventually.

          Morning at last! Moved out of the ICU and to the step-down unit. I had been in the ICU for two days instead of one, not because I needed to be there, but because they had nowhere else to put me. Another day there and I’d really have been crazy, but now I had windows and daylight and could see the sky. Oh happy day!

   My surgeon, the guy who was holding my heart in his hands just hours ago, was standing at the bottom of the bed, relaxed and easy.

   “Everything went well; you’re good for another thirty years!”

   I was glad to hear that.

   Soon my family were sitting by the bed and had obviously seen a good deal more of me in the past 48 hours, than I had of them. They reassured me of how good I looked, and in fact I wasn’t feeling too bad as long as I was lying fairly still in the bed. But I knew that the therapists wouldn't let me lie in bed for too long and, after adequate numbing with narcotics, they had me walking a few steps later the same day.

  The following day my surgeon came around to see how I was doing.

   “You are good for another twenty years,” he smiled.

   “Not so fast,” I threw at him, “yesterday you said thirty, so that’s thirty percent deterioration in one day.”

   He laughed indulgently..

   My main complaint, until now, had been nausea, and had been controlled mainly by living on juices and apple sauce and processed fruit, and sending my set meals back without even looking at them. Now I was ready to tackle something a little heartier. Normally, I am not a fussy eater. The meals came, as I found out later, from some central depot. Before taking the lid off, they looked like Air Canada meals (economy), which when I used to fly a lot were not too bad. I remember the choices – “fillet, chicken or fish?” Any resemblance finished on lifting the outer plastic cover. What took place under the cover defied description. Once the lids were whipped off these dishes any inclination to eat was gone. Irene took one look and vowed that my food would be coming from home! Subsequently it did.

   

The Nortel Pillow.

   Nortel was a Canadian communications company in the days when Canada was a successful country. After an outstanding performance it went into a nosedive and a lot of people lost a lot of money. China (Huawei) denied that it had reverse engineered the product and destroyed Nortel. Most of us knew better. On post op day two I was moved to the step-down unit. Because post op breathing and coughing is important the physiotherapist gave us a pillow to clutch to take the tension off the scar when we coughed. Having taken a beating on my Nortel stock when that company went bankrupt I was more than a little surprised to see beautifully embroidered on the pillow 'with the compliments of Nortel Networks'. Nortel had cost me a lot of money and the irony of the situation left me uncertain of whether to laugh or to cry. I decided to laugh even though it hurt! (After all, I had my pillow to hug!) The guy in the bed next to me heard me laughing. We chatted a little. A healthy looking fifty -five year old, he had found his way into the cardiac unit as a result of forcefully pulling open his car door and hitting his subcutaneously implanted cardiac pacemaker so hard with the edge of the door that it was totally wrecked and needed immediate replacement.

   "What's the joke?" he asked. I told him.

   He examined his pillow. He laughed. "I guess I have the same twenty grand pillow!"

  We laughed so much that the nurse came over to see what was wrong.

  Thereafter we referred to the pillows as our twenty thousand dollar pillows, because that's about what they cost us. There are no free lunches!

  On day three my surgeon popped in to make sure I was doing okay and my scar was okay.

     "I have two important questions to ask you today. "

     "Okay, fire away."

     "One, when can I get out of here?" I asked.

     "A couple of days."

     "Maybe tomorrow?" I bargained. "If you look out of the window you can see my condo. I could be in emergency quicker from there than you can get me down from here." I was on a higher floor in the hospital so that statement was probably true.

     "We'll see how you are tomorrow. The other question?"

     "When can I have a martini?"

     "As soon as you can get some to bring you one." he intoned, his Scottish accept a little more prominent than usual.

     I love the Scots!

   The next day he arrived after his operating list and I was ready for him.

   "I think I'm ready to go home today," I said cheerily. I could see I was starting to wear him down.

   He countered with, "You can go as soon as you have had a bowel movement." Sometimes the bowels are a little slow to start functioning after major surgery,

   " I've just been," said I triumphantly.

   And that's how I managed to go home on the fourth day after my quintuple bypass!


Some post surgery thoughts:

  A bath! Oh, what a pleasure, oh what a joy! And, oh, how much muscle power it takes to get in, wash yourself and to get out! Amazing how much leverage, torsion and other forces involved in just sitting up, pushing yourself on to your feet, while praying that your feet don't slip away from under you, cracking your cracked thorax on the side of the tub, and ending back at the hospital. And where does all that disgusting dirt in the water come from anyway, when you haven't been out of your house and barely out of your bed since the last bath? Anyway, it confirms that the simple joys are great!


Note to Friend on Dec 2. (while still under the influence of medication!)

   Apropos of nothing, but in the light of some of our recent discussions, I thought you might be interested in this paragraph I just read in the NY Times Review of Books, from the review of the book by Harold Bloom entitled " Where Shall Wisdom be Found?"

"It reminds me of the experience of a friend years ago,” he wrote, “when, awakening from major surgery, she heard in the recovery room a faint voice reciting the Easter soliloquy in which Goethe's Faust comes back from the brink of suicide to the joy of life. Through her anesthetic haze, she wondered to whom the voice belonged until she recognized it as her own; speaking a poem she had known by heart since childhood and somehow retrieved from deep memory during induced sleep."

   Oh, what strange  things we store in that three pounds of jelly in our skull!

   

   Finally, A colleague phoned and was pressing me for information about the pain and pinning me down for some descriptors. My bottom line and I knew him well enough to know he would understand the simile, “ - like coming home hungover, getting into a fight and having your chest and ribs kicked in!”  Not very eloquent, but I think more accurate than described in any medical text!

 





     


Tuesday, 27 April 2021

Cabbage Pt 2.

Cabbage.  Pt 2.

'Cabbage' medical jargon for Coronary Artery Bypass Surgery

When I sprung it on relatives, colleagues and friends that I was planning to have bypass surgery, the first response tended to be reassurances as to how healthy I looked, and questions as to how long I was ill. Funny, because I never considered myself ill at all. After all, all I had experienced was a bit of breathlessness and a little tightness in my chest when I exerted myself. I could swim laps indefinitely, as long as I used commonsense and didn’t try to break records. And after all, I was sixty-nine, no spring chicken in anyone’s language. How was that to be equated with illness? I was never ill a day in my life. Never missed a day of school or university or work. Ill indeed, I thought indignantly! In fact, quite honestly, I was really only proceeding with surgery prophylactically, because the genetic scales were so heavily weighted against me. Was I just going to sit around and wait for those obstructed coronaries that I had looked at on the angiogram to totally plug and kill a huge chunk of my myocardium, or even me. I was determined to get those obstructed coronaries before they got me. So I carried on going to work every day, waiting to hear from my surgeon’s office as to when I would be having my surgery. Meanwhile, I was daily fielding a litany of phone calls from relatives and other well wishers, including dutiful nephews and nieces who no doubt were responding to their parents exhortations gracefully and did their duty. I could tell they were impressed when in response to their questions I told them I was having a quintuple bypass. That was rare at the time - the only other case of a 'quintuple' that I knew of was Bill Clinton!
Thursday - the day before Surgery. After a fairly normal day at work during which the objective was to keep as busy as possible, and to keep my mind off the following days ordeal, I headed home. At least, I consoled myself, as I manipulated my Honda along the dark, wet slippery country road, against a continuous steam of giant SUVS, nothing I was going to encounter in the next few days was going to be more dangerous than this. A serious martini and a light supper followed by a sleepless night, rounded off the day.
The nineteenth of Nov 2004 - day Zero! Up at 5 am and son David picked us up at 5.30 for our morning appointment. I remember, in a gentler more civilized era when patients were admitted the night before surgery, rested, worked up, sedated and assured of a good night's sleep . In the olden days, we used to think that getting the patient as relaxed and stress free as possible had some bearing on the patient’s subsequent progress. But that was before we had a Health Care Industry. Getting the patient up at 5 am is hardly conducive to survival, let alone surgery.
At 6 am I was through the admitting area, hardly noting all those other poor souls with their problems small and great, but none I was sure, as great as mine.
A kiss goodbye; a word of encouragement from Irene and David; clothes deposited in a plastic bag and on to the OR . Although over the years, I had spent many hours in operating theatres, this one seemed so small and so crowded with people and equipment that I wondered if there was enough room for me.
The Anesthesiologist greeted me as I was wheeled in the door.
"So you're Dr. Smith?'' He smiled, effortlessly sliding the IV needle into a vein.
"Yes, that's me,” I tried to smile back and think up a clever witticism I could throw out.
The lights went out.

I opened my eyes. The anesthesiologist was gone; it was all over, and I was surprised at how little pain I had. Just like my niece had said of her anesthetic - 'light off, light on. Like flicking a switch!” She had also added that it had made her a little less fearful of dying, and as I reflected on that particular piece of philosophy, I found I was in agreement with it.
Now I had to get the damn tube out of my throat. My God, I couldn't talk! I made as much noise as I could to attract attention and look as though I was really suffering - maybe that way I could get rid of it! The Nurse leaned over me.
“Are you having a lot of pain?” she asked sympathetically.
I shook my head - no, but harrumphed and coughed as much as I could to make it quite clear I wanted this damn tube out of my throat. Maybe if I coughed enough I'd manage to propel the thing across the room.
I could hear the machine behind me, but couldn't see anything. Where was I anyway? Alive, at least, and no sign of any stroke or paralysis or anything else horrible as far as I could determine. I seemed as sharp as ever! I tried to cough up the tube. The nurse injected something into the IV tubing in my arm and I drifted into some pleasant place.

I woke up with vague pain everywhere, and a horrible nauseated feeling. The lCU nurse slouched by. “Something for the pain?” she said, pulling her drooping sweater up around her shoulders. She deftly deposited a little cardboard container with two pills in it, in my hand, and propelled them into my mouth. I swallowed them and soon dozed off again.

“Are you on these pills too?” I politely asked the woman just to the right of my shoulder. I couldn't figure out why she was wearing a pretty bonnet right there, in the ICU. I managed to twist my neck around, to get a better look at her and saw this was an electric fan somehow managing to look like a woman's face, framed in a bonnet. I gave a little chuckle to myself, as I realized what I had done- no wonder the poor old geriatrics got wingy after a few days on narcotics. I had at least one other similar encounter and resolved I’d have to cut back on the pain pills. I looked at the clock, 11.10, but was it night or morning?. I drifted off to sleep again, and had a long deep sleep. I woke up again, thought I had slept for hours, and looked at the clock. 11.20! I couldn't decide if I had slept right around the clock and it was 11.20 twelve hours later, or just ten minutes had gone by. Then I noticed people all hustling around and going somewhere! Something was wrong, I was going to watch what was going on very, very carefully It looked like some sort of a set from the movies, something funny was going on here. Everyone seemed to be leaving. My last thought before drifting off to sleep again was that they really needed to have windows in these places, or everyone would end up disoriented and crazy.

Someone woke me up and was offering me pills again.
“I think I'm going to throw up,” I said.
“Hold on a minute,” the nurse said, a large basin appearing from nowhere.
I felt horrible, retched and threw up a large amount. The relief was immediate and wonderful. I closed my eyes and drifted into a deep sleep. When I looked at the clock a long time later, it was only 11.30 pm.

I was watching the Iraqi war on the television. A bullet in the chest. Must feel something like having your chest cracked open, I thought.

“Rate the pain with a number" a nurse asked. "if 1 is very mild pain and 10 is the worst pain you’ve ever had."
What does that mean? Depends on who you are and how much pain you have experienced. Where is 10 if you’re lucky enough to never to have had much pain? I rated my current pain at 5 - a nice median number!
"There's a button attached to your IV that will give you a pre-set dose of morphine whenever you press it to relieve the pain if you need it."
"Thanks," I said. I used it about twice and it made me feel worse than the pain! At least I don't have to worry about becoming a morphine addict!

Monday, 19 April 2021

Have a Heart! -Cabbageg Pt 1.

Cabbage. Pt 1.

 Have a Heart!!

Its seventeen years now since I had my coronary artery bypass surgery. Just a short time ago, a friend of mine who was booked for an angiogram and may be having a bypass procedure asked me about it and I responded as accurately as I could. I mentioned to him I had taken notes at the time and that I had later published an article about it in a medical newspaper, The Medical Post, describing the procedure. Although I have yet to locate the article, I still have my post surgical notes that I offered to share with him.
Here they are starting with the angiogra a procedure that involves passing a catheter into a groin artery and threading it right up into the coronary arteries, injecting dye and estimating the amount of blockage.

Bypass. Pt 1. The Angiogram.
I stared straight upward at the big overhead scanner, that would be photographing my coronary arteries soon. I was rationalizing the risks of the procedure and knew I took a bigger risk every time I took the freeway. Cardiac arrest, well that was easy enough to deal with, a couple of good electrical shocks and it either started up or it didn't. And if it didn't, nothing too serious, you didn't even know about it. No, I wasn't worried about that, or about a hemorrhage from the thigh artery; they can always fix that. The only thing I was really worried about, was stroking out, ending up like a close friend, a helpless prisoner in his own body. Death was a lot easier to handle. Not that I wanted to die; I still had plans and ambitions. Far more pressing than any of the above thoughts, was the itching and burning in my groins, despite the copious shaving cream and the fresh new razor I had used when following the shaving instructions. My sympathy for the poor metrosexuals, who shaved this area on a regular basis as a part of their daily ablutions had increased.
I had kissed my wife goodbye and walked toward the Cath Lab, double gowned. Modern sensibilities and sensitivities ensured that patients no longer wandered hospital corridors with 'back to front gowns', their tails hanging out for general condemnation or admiration. I'd been issued with two gowns, one opening at the front and one at the back, providing total coverage. No locker, I held my clothes in a white plastic bag, in my right hand.
The Nurse introduced herself. "I'm sorry we're running a bit late," she said. "What do you want us to call you? Dr. Smith or Stan?"
"Stan will do," I said. "And the wait is okay, I haven't anything else to do today,"
All of a sudden, a masked pirate, swung into the cath lab. At least that's what he looked like! He wore a red floral bandanna, with the collar of a bright red shirt peeping above the drab green of operating room attire. Was this really the balding middle-aged doctor, with a rather peculiar sense of humour, that I had spent a half an hour with last week? I guessed it was.
"He's got a rather peculiar sense of humour" warned the nurse whispering into my ear.
I smiled back weakly and nodded.
Don't worry," the pirate said to me, "this won't be too bad."
"Very few things in this life are as bad -or as good as they are reputed to be", I replied, the homespun philosopher as usual.
The pirate pondered for a moment, and then said, "I think that sums up life pretty accurately."
He had told me last week that the rare complications of the procedure included hemorrhage, stroke and cardiac arrest, to name the most severe. "If you hemorrhage we might have to do some surgery to stop it, if you stroke out, there's not much we can do, but if you arrest we can defibrillate you on the table," he said benignly,.
Then, he went on to tell me that I would feel a strange warm feeling, when the dye was injected into the intravenous which had been set up right at the beginning of the procedure.
"You'll feel hot and wet all over, and might even feel as though you had lost control of your bladder, but don't worry, you won't and I'll be standing right there," he said with a strange sensitivity, I didn't expect.
He injected the local anesthetic into my groin, and after a few moments I felt nothing, but the miraculous relief of the itching and burning of the razor burn.
He brandished the sleek cardiac catheter like a rapier.
"Now I just take a run at you with this!" He laughed., holding up the catheter.
The nurse bent over and she whispered reassuringly into my ear, "he's just kidding", and even though I knew it was joking, I wondered how many times I myself might have caused a frisson of anxiety in a patient, with a light word, meant to be humorous and to reassure. It surprised me that I felt nothing at all, as the catheter ran up through my femoral artery, up my aorta and into my heart.
"You can see it all there on the monitor," the male nurse said, "if you don't mind seeing that sort of thing."
I looked at the x ray of my heart beating. I saw the thin line of the catheter thread its way into my coronary artery, like a wire coat hanger being threaded into a key hole. I hoped it would leave enough room for the blood to get through.
"Take a deep breath and hold it," commanded the Pirate.
I did as I was told, until it started to hurt, I waited a few moments.
"It's starting to hurt," I said, knowing that was because he was depriving my poor myocardium of much needed blood.
"That's okay, it's supposed to. You can let it out now."he said.
The pain resolved quickly.
Okay, now I'm learning how to play this game, I thought.
As soon as I started to feel some discomfort as the next coronary artery was being threaded, I didn't wait. "It's starting to hurt". Save my myocardium.
"Okay, you can breathe out."
Ah, now I've got it mastered, I thought.
The procedure was repeated a few more times, with little discomfort and the monitor show continued. After a few more thrusts, peppered with light commentary, the show was coming to an end.
"We are just about coming to the end of this, and I'm going to be thrusting my fist into your groin, to maintain pressure to prevent bleeding." he said. "You just lie perfectly still and we will get these three big strong nurses to lift you over to the stretcher."
Two of the nurses were fairly slight young women and the other was a slight young man. They picked up the stretcher sheet corners and whooshed from the gurney on to the stretcher.
No wonder they all have back pain, I thought, knowing that many of the patients they lifted were twice or three times my weight. A fist was thrust into my groin, applying firm pressure. The impatient Pirate took control of the gurney with his other hand and wheeled it quickly out into the corridor.
A couple of words in my ear, "your right coronary is a hundred percent blocked, your left anterior descending about fifty percent blocked, and the obtuse marginal and posterolateral branch of the circumflex eighty to ninety percent. I think you are a bypass candidate." This guy didn't waste any time.
Too impatient to wait for orderlies or porter, one fist applying pressure to the puncture wound, he wheeled me straight down to the ICU. Irene was waiting outside the Cath Lab.
"Are you alright?" she asked me, we pushed on. "Are you……?" she directed her question to the pirate.
"I'm the orderly," interrupted the man with the strange sense of humour.
"He’s the doctor - with a strange sense of humour," said I, "This is Irene, my wife."
"Hello," said the Pirate, pushing right on for the ICU, where Irene wasn't allowed to follow.
"I'll see you as soon as they move you," she called out.
And there he stood with his fist pushing into my groin for the next ten minutes.
"Drink lots and wash out all that dye," he said, "and keep lying absolutely flat for the next hour or so to try not to start up any bleeding from the puncture wound. I don't even want you to raise your head, then we'll move you to the observation ward."
Every few minutes the nurse solicitously bent over me, with a glass of water and a flexible straw. I gulped greedily at first, but then started to think of the consequences of pushing the fluids too enthusiastically. I didn't want to have to empty my bladder while I was lying flat on my back, and that was going to be at least the next hour. Better to wash the dye out a little more slowly, and a little later when I could at least sit up, it might be easier.
A nurse I hadn't seen before breezed into the room.
"I'm taking you down to the recovery unit," she said, wheeling the gurney out of the cubicle it had been occupying for the last hour. She got almost out of the unit, when the Pirate swung in.
"Where are you taking him?" he barked rudely.
I wondered if I had just been saved from a hijacking.
The unfortunate nurse flushed and said, "just to the recovery room."
"No one leaves here until they have been checked by me," he commanded gruffly. "I have to make sure they are not bleeding."
He rolled the gurney back behind the curtain, pulled back the gown and looked into my groin, was satisfied and said quietly, "okay, you can go."
She rolled me to the West Wing, where I was deposited in a two bed ward, the other bed was empty. Irene awaited anxiously.
“Are you okay?”
“Yes, everything feels numb right now,” I said.
The ward nurse was cheerful and pleasant.
“You’ve got to drink lots of water," she said cheerily, "wash all that poison out of you. And I bet you're starving. What would you like to eat?"
"What's on the menu?" I hadn’t eaten since the day before.
"Sandwiches, cookies, whatever you'd like. But you have to drink lots, juices, ginger ale, cranberry juice, whatever you fancy. If you do real well, I'll let you stand out of the bed to pee." She smiled.
This was the best offer I'd had all day. I gulped down a glass of cranberry juice through the flexible straw and ate a tuna sandwich. It was a little easier to drink now that I had been promoted to sitting up a few degrees. What was it that they'd said a few degrees every hour? I was starting to want to pee. The nice nurse whisked by with the water.
"Have a nice big drink now and I'll let you stand out at the side of the bed," she said.
I thought that one over and decided it was a deal. I sucked down a big gulp of water and looked over at the side of the bed to the bedside table, where amidst the debris of sandwiches and small juice containers, I saw the new, pristine, disposable urinal. A far cry from the old stainless steel ones, which were handed out when I was a student. I flipped off the lid and tried it on for size. It seemed fine. I swung my legs over the side of the bed, barely sitting on the edge of the bed. I was lucky my weight was propped on the bed for as soon as I put some weight on the right leg, it collapsed under me. I tried to feel it; it was completely numb. Totally anesthetized! I carefully propped myself against the edge of the bed, put the urinal in place, and was all ready to pee, when the commotion behind the drape that surrounded my bed distracted and inhibited me. The nurse stuck her head through the drapes,
"You've got a new neighbor," she said,
Irene, who had stepped outside for a moment popped back in.
"Everything okay?" she asked.
"Yes," I sighed, giving up on the bottle, and swinging back into the bed.
Irene sat on a chair near the end of the bed. The New Man's wife sat on a chair at the end of his bed. They were nice friendly people; I had seen the New Man come into the intensive unit soon after me. They started talking to Irene immediately. I felt overwhelmed with a desire to sleep, so I kept eyes closed and didn't pull back the drape.
I heard them talking and Irene replying, and then I drifted to another place where I was lying on a chaise, on a beautiful sunny day dozing, before diving into David's pool to swim another twenty laps, just to show myself I could do it without any chest pain.
I woke up about half an hour later, and thought I ought to be more sociable. Just as long as the New Man or Mrs. New Man didn't discover my occupation!
"Hi," I said to Mr. and Mrs. New Man.
"Hi," said Mr. New Man, "have a nice sleep?"
"Yes, thanks," I answered. Now I really wanted to go to the bathroom.
"What do you do, Stan?" asked Mr. New Man.
No, I thought, I'm the patient, today, I can’t tell him I’m a physician.
"I work in Mount Brydges," I answered, leaving it there.
Mr. New Man left it at that.
"Is your leg numb?" I asked.
"No, never was."
"Been to the bathroom yet?"
"Yes, the nurse let me go just before you woke up."
I had a bit of feeling in my right leg now. How come Mr. New Man had already been allowed the luxury of actually navigating to the lavatory on his own two feet? Well, I was going to make my own way there. I slid out of the bed, could feel my right leg ready to buckle when I tested it for weight, found I could stabilize it with my hand, and hobbled the few paces to the bathroom. There was a convenient bar to hold on to, which made it easy. Ahhhhh, heaven!
It was easy after that. I joined in the conversation, checking for sensation in my leg at frequent intervals. After all, I didn’t want to be in here a moment longer than necessary and the nurse said I would be able to go as soon as my leg would support me sufficiently to independently walk down the corridor and back.
And Sure enough another hour made all the difference and I could indeed walk down the corridor under the watchful eye of the nurse. She whisked me into a wheelchair and out to the waiting car
"Good luck for your surgery " she called after me as I got into the car.

Part 2, the Bypass Surgery- to follow.