It's Party Time!

Twas the night before…

Well, I don't think it is hard to imagine how difficult it is to sleep the night before open heart surgery. And, I am proud to report that after conducting extensive research in the area (one night) the hypothesis is confirmed. Before they crack your chest open with a overpriced skill saw it is damn near impossible to sleep. But, beyond the "normal" amount of worry I was also dealing with some pain from the installation of the catheters for the block from the day before.

In the last post I mentioned that they had been bugging me all day; and, that pretty much was the way it was until I got prepped the morning of surgery. Best I can figure is that inserting the two catheters (plus the saline and x-Ray contrast injections to confirm placement) through the muscle into a tiny space where the nerves from the chest connect to the spine irritates those nerves. And, since these are the nerves that communicate pain from the front of the chest, it felt just like my chest hurt. (for comparison: it is not as intense as the actual pain from the procedure – maybe 30%)

To be clear, despite hurting for over 12 hours and really not being able to sleep / be comfortable, I am a huge fan of paravertebral blocks. I can personally attest that when they work (and are managed effectively) I was significantly more comfortable than with the oral meds or IV narcotics. All without any of the downsides of the narcotics to 'boot' (and the 1980s definition of 'boot' is the most appropriate here.)

So, I would take the night of discomfort I had in an instant vs. not having the blocks and their relief post-op. (The real upside is that the discomfort made me very glad to get to the hospital at 5:15am because it meant that I finally could get something to stop it.)

So when it was time to get up and "wash" I hit the surgical pre-wipes quickly and was ready to go well before we needed to leave. 

Pre-Op:

The pre-operative experience went totally as expected. I showed up at 5:10am registered with the desk (same great crew as the day before for catheters insertion) and was shortly camped out on butcher paper. Everything was the same as before except I did notice one difference: my prep-bay had a little blue "surgical shave" handwritten sign. (As soon as I saw it I immediately started itching for some reason.)

Turns out a "surgical shave" is as aggressive as it sounds. Below my neck I have one tuft of hair left on my kneecaps plus some mottled patches on the arms. But, that is about it. (Respect level for my female friends has been appropriately increased.) 

After the shave came the relief from the catheter placement I was hoping for. The pain team arrived and graciously gave me a full bolus dose of Bupivacaine. Within 15 mins all of the discomfort was gone. Along with it went much of the sensitivity in the center of my chest. Huzzah! This gave me real hope for pain management after surgery which was great to have going in. 

I was one of the first patients lead back into pre-op and by 6:15am the whole bay was really jumping. There were patients getting prepped, patients waiting with their families, and the hustle and bustle of the surgical teams collecting their charges to wheel back to an OR.

By 7:00 the pace really had slowed down and the room was nearly empty: but, I will still there. Turns out that my procedure had been pushed back behind an emergency case that came in the night before which was just finishing up in the main OR. So I had to wait until around 9:15 or so before they were ready for me. Of course it increased anxiety having to wait longer but, honestly, I was okay with it. I was comfortable and was enjoying passing the time with girlfriend and catching up with my dad.

So when the anesthesiologist showed up to give me something to "get ready" to go back I did not think about it much at the time. I asked what I should expect to feel and he mentioned it would feel like a few drinks. Sounded interesting to me....He injected my IV line and I remember feeling a slight rush followed shortly by a much bigger fuzzy wave. 

I distinctly remember saying as the wave arrived something like: "Yeah, that really does feel like a few beers!" after which point I have got nothing…

Surgery:

I have been told that after the drugs kicked in I got really smiley, happy, and clearly "out-to-lunch" while we said goodbyes. All I can say is that either:

1. My dad and girlfriend are the best kind of people in the world because they did not video this …or…
2. They are really good liars and I just have not seen said video yet.

(I am really hoping for option 1. Although, dad is an attorney…)

After getting wheeled back there was around another hour of preparation. Where I had a bunch more lines inserted. Lines that I am actually very glad not to be able to remember getting.  I gained an arterial line in my left wrist and an IV in the back of my left hand. I also an got IV inserted in my neck. All, told I had 3 IVs (both hands and neck) and one arterial line.

The surgeons got to work around 10:00 that morning. And, first up was the unroofing of the LAD. This apparently went very well and they were unable to uncover much of the artery. As expected, not the whole 8cm, but enough that hopefully it won't be causing more issues. The LAD bridge really was very deep and at one point while unroofing a section of it that section expanded significantly
– having been freed from 46 years of encasement. (Given the way it was explained to me the best analogy I have is: think about a sleeping bag rolled up in it's sack. Then cut the sack the long way along one side. It does not unroll but it does expand without the sack to hold it tighter. I think it was sorta like that but more uniform of course.) 

Next was to apply the graft from my leg (that was the final choice: preserving the radial and LIMA for use later if necessary) to the Ramus. The goal was to do that after unroofing the Ramus but apparently after actually seeing my heart the Ramus bridge was determined to be just too physically hard (plus risky) to attempt to unroof. So because that bridge was very short anyway, and very close to the plaque it was influencing, they just bypassed them both.

All of these procedures required me to be on the table for about three and a half hours. But, what is even better than the shorter surgical time is that it was all accomplished without heart / lung bypass or even any extra blood! (A major heart surgery without a single drop of extra blood performed on a 100% beating the whole time heart certainly was not the expectation – and I am very grateful that it was not required.) 

So around 2:30pm or so in the afternoon I was wheeled into the ICU.

Waking in the ICU:

I remember "dreaming" a little before "waking up". Apparently, before I think I was awake,  I asked the same set of questions over and over for a little while. Things like: "what are my O2 sats?" or "how did it go?" (Honestly, I think girlfriend and dad are just making this up. **I** remember everything from the ICU clearly – and I don't remember asking those questions at all.) 

As the haze of the anesthesia wore off, and after family had to leave, I do remember thinking: "Hey, I made it…I wonder if everything works?" So I conducted some experiments: I remember moving my arms a little with no issues. I moved my left leg with no pain. But, moving my right leg really did not feel quite right. Did not hurt, but did not feel great either. Okay. No serious problems there.

Then I went for broke and focused on my breathing. First off, just breathing did not hurt. I felt like I was breathing fine and since I was not intubated was able to control the pace a bit. I did notice I was taking multiple, and rapid, shallow breaths. So I tried to slow down the pace and breath deeper. I succeed in slowing the pace but not in breathing deeper. The reward for this combination of success & failure was a rather serious alarm from my O2 monitor. Okay, got it: I was balanced right on the edge of normal / caution oxygen saturation. 

Last, it was time to try and take a deep breath. Now, I have to assume that a "deep breath" to me back then is not even close to a "deep breath" even now (1.5 wks post op). But, regardless I did accomplish what I felt was a reasonably deep breath. The reward this time was predictable – OW!  Okay, so they really did do the surgery.

But, that pain was not as severe or as "Oh CRAP" as I had expected, or prepared, myself for.  And, that was the first moment I started to believe that it was really going to all be okay. I could do this. Everything serious seemed to be working and, at the very least, the pain could be managed – I just had to avoid doing stupid things (more examples of stupid things in later posts).

I think all of this would have taken place around 6:00 pm or so. 

As the evening went on the pain started to grow. The bolus of Bupivacaine I had earlier was wearing off. I mentioned to my nurse that I was starting to hurt and she told me that the pain team delt with the blocks so she could not help there. But, there also were orders for IV pain medications too. So we decided on paging the pain team and trying the narcotics as a bridge until they could arrive. 

I will spare everyone the specific details of the next sequence of events and rather just summarize them here:

1. After surgery I was still "nothing by mouth" so no water or food.
2. Pain medication, especially strong narcotics, can make you vomit.
1. This is worse if your stomach is empty.
3. Anti-nausea drugs work really well but there is a delay between giving them and when they start working. Plus variability in how long they last and their overall effectiveness.
4. Hospitals have you rate pain on a 1 - 10 scale. With 1 being very mild and 10 being the worst pain of your life. During my previous 46 yrs on this planet I never really had a solid clear winner for a level 10 pain experience: I do now.

By 1:30 in the morning everything settled down. The block had been re-bolused and was working well enough that previous few hours' "narcotic --> vomit  --> anti-nausea --> repeat" dance party was done. I was finally feeling pretty good…

…and that is when the nurse came in and told me that I would be moving soon. With a value of soon measured in hours not days. Wait…what…moving soon! I was just admitted to the ICU sometime around 13 hours ago. I was supposed to be in here for one or two days not 13 hours.

Turns out there was another emergency surgery underway and that patient was going to need to an  ICU bed. And, since the ICU was full that meant the healthiest patient in there had to go; and, that patient was me. 

I was not thrilled since after my "dance party" I just now felt the ICU staff / pain team had just figured out how to make me comfortable. But, I trusted the IICU (cardiac care wing) would be able to do the same thing. The only other added wrinkle was that the ICU did not want to give up it's bed (other patient arriving too soon I think) to transport me so they were going to put me into a wheelchair to move me.

So approximately 13hrs after surgery I was sitting up, getting out of bed, standing, turning, and sitting down again in a wheel chair. It does not seem like much…but, I have raced crew at the university level before so I know a little about exertion. Crew taught me what it was like to go 120% all out in every race, pass out crossing the finish line, loose 3 lbs in just sweat during a race, and work out 5 hours a day. Crew takes real effort but...

…I think that was easier than just getting up and moving myself to the chair was that night. I was exhausted, sweating profusely, dizzy, hot, and nauseous after just that simple activity. But, I did it!

This was only the first of many "accelerations" my post-surgical hospital course was going to take. More on those in the next posts.