And the Winner is ….
So, it turns out that my defribrillator is the tortise. The heart I need is the hare. My defibrillator chugged along, slow and steady, for ten years, and finally won the damn race. When I was first admitted, I had a conversation with one of the senior heart failure docs I really like. He said, “Oh, I think you’ll likely get a heart before the defibrillator runs out of juice.” However, the heart I need, to further belabor this already strained metaphor , sprinted, stopped, and screwed around, without crossing the finish line.
Last week, one of the cardiac residents came into my room around 9:15 A.M. and said; “OK, we’re going to replace your defibrillator battery today.” I think I actually said, “what the fuck?” to him. I thought I had more than a month on the battery, but they didn’t want to wait. Apparently, they don’t like to do a transplant while there is a healing wound. That’s understandable, but how about a little warning?
I knew it wasn’t his fault, so I apologetically told the resident I was irritated with the electrophysiology team. “Maybe” I huffed, “they could give a person some advance notice that they are having a major procedure.” If they’re going to make healthcare a commoditized service, you sometimes have to ask to speak with the manager. An hour later, a group of the EP doctors were in my room apologizing. I guess that makes me a “Karen”, and the hospital an Olive Garden.
Ultimately, I was making a lot of noise for nothing. I didn’t mind doing it that day, since I’d have the weekend to recover and would get some Percocet for my trouble. I was wheeled down to the cath lab for the procedure by one of the CCU nurses, and that poor resident I yelled at earlier, a skinny, dark-haired Jewish kid with wire rim glasses. He is probably 25 years old, but looks 16. Doogie Horowitz, M.D., if you will.
I’ve been very lucky to receive excellent care from a majority of the doctors and nurses I’ve encountered in my 25 years of ARVD treatment. This most recent experience at NYP Columbia has been no different. As a patient, you spend much more of your time with nurses than with doctors. The doctors whiz by on their rounds, talk at you quickly and with great confidence, while also somehow hedging. It’s an exaggeration, to be sure, but with a grain of truth. They’re the big brains.
But the nurses, they do the work. They clean and dress the wounds. They take the vitals, draw the blood, empty the bed pans. They listen to the complaints. They comfort. It is a bizarre level of intimacy with a stranger that must be difficult to understand for people who’ve never spent weeks, or even days, in the hospital. I don’t pretend bad nurses don’t exist, they definitely do, but I’ve been lucky to avoid most of them.
Once we are in the cath lab, where they turn over patients the way a restaurant turns over tables on a busy Saturday night, the atmosphere is very different than it is up on the ward. The nurses on the CCU have to be comforting, they are often caring for patients when they are at their most vulnerable. Cath lab nurses are much more jocular. They’re all business; move ’em in, move ’em out.
Before a defibrillator implant procedure in the cath lab, you’re brought to a staging area where nurses take vitals, go through various checklists, get your consent, and explain risks. They also shave your chest, where they’ll be cutting, and your pubic hair. I have had dozens of catheterizations over the years. They always shave my pubic hair “just in case” they end up having to go in through the vein in the groin. They never do, though. It’s become a running joke with my friends.
Two women did my prep. They were very funny, almost like they were doing a Latina Laverne and Shirley bit. We joked around. You can always get a laugh from a nurse if you bust on a doctor, so I told them about my conversation with Doogie Howser. Thankfully, they were old enough for that joke and seem to appreciate it. As they handed me off to the procedure nurses — Kevin and Jimmy — they said “look out for this one, he thinks he’s funny.”
If the staging nurses (I’ve forgotten their names) were Laverne and Shirley, Kevin and Jimmy were Lenny and Squiggy. Both were middle aged and they were hilarious. Kevin was an Irish Catholic type (his entire family graduated from Boston college) and was definitely the Lenny. Like nearly half the nurses I’ve encountered at this hospital, Jimmy was Filipino. He was generally quiet, until he hit the ball-buster Kevin with a lethal joke. “This guy, he rides his bike to work every day. You’d think he would be skinny.” They had fairly constant banter that suggested they’d worked together for years.
The electrophysiologists were about to replace my defibrillator, a single lead device that only paces or shocks the right ventricle. In its place, they would implant a dual lead device that paces both the atrium and the ventricle to synchronize the beats between the two chambers. First, they made a small incision, maybe 3–4 inches long, in my right pectoral muscle, opened the small pocket in the chest that held my old defibrillator, and removed it. Then, they pulled the single chamber lead from the right ventricle and fed the dual chamber lead into the heart. Finally, they put the new generator in where the old one was, and sewed me up. The whole deal, from when I laid down in the lab, until I was back in my room, took a bit over two hours.
For the doctors, this is a routine procedure. They probably do hundreds per year. Kind of a different story for the patient. For starters, you’re conscious when they do it. They use propofol (yes, the Michael Jackson drug) but not quite enough to knock you out (in case you go into a tachycardic rhythm). They also load the device area with a local anesthetic, lidocaine, so it’s not really painful while the device is being removed or implanted. There is no way to describe the sensation of being conscious while they do this, besides “freaky.” I don’t recall much about the beginning of the procedure because the propofol hits fast and is used, at least in part, because it acts as a memory eraser. It usually does the job.
This time, for some reason, I have a very clear memory of the latter part of the procedure. At some point, I started having a conversation with Kevin, but I remember thinking to myself “dude, what you’re saying doesn’t make any sense at all.” I must have gotten pretty annoying because the doctor said, “will you please stop talking?” By that point, they were feeding the dual lead through the vein and into the heart. The lidocaine numbs the area enough that it doesn’t hurt. But it is still so weird. You feel the lead creeping along through the vein. It feels like a moving, squeezing pressure. You’re aware of the lead’s progress, but it doesn't really hurt. It made me think of when you try to feed a busted drawstring through a pair of shorts, only bloodier.
Once the lead is placed, they implant the defibrillator, pushing the whole thing back into the little pocket in the chest that they opened up earlier, and where it is supposed to live for the next 10 years. Not mine, of course; the new defibrillator comes out at the same time the new heart goes in (take that, Aetna). We’re two hours in by now, and I’m almost fully conscious, but also completely high. I can feel them stretching and pulling to force the device into the pocket. It somehow feels awful, but without hurting much at all. At one point, as they got really rough, I aped the Chevy Chase joke from Fletch, “you using the whole fist, doc?” It didn’t land with the doctor, and he asked if I needed more lidocaine. But Kevin caught the reference and burst out laughing.
I don’t want to give the impression the procedure is a picnic. For something more than two hours, I’m flat on my back with my arms lightly restrained. If my nose is itchy, I can’t really scratch it. My face is covered with sterile towels and I’m more than a little claustrophobic. The lidocaine injection is probably the most painful part of the whole thing. “Ok, a little pinch and then a burn,” says the anesthesiologist, as I get stung by a murder hornet. There are long stretches of strangely painless discomfort and deep anxiety, all while I’m floating around in a narcotic swamp.
They sewed me up and sent me back to the CCU, where I spent the next couple of days in the warm, velvety embrace of percocet. And now, I’m back to waiting for that heart, which is out there somewhere on the course, idling in the shade with the hare. They will get to the finish line whenever they feel up to it. I’ve never been much of a tortoise, I’ve always been a hare. But the race is over, and now I’ve got nothing to do but wait for my heart to arrive. I think the best thing I can do, is start acting like the tortoise. I’m finally old enough to know I’ll be better served by a slow and steady approach to all this waiting.