Saturday, 30 August 2014

Straight from the Heart (VI: CABG): The Story of My Tryst With My Heart Ailment, Part-VI of VII

Straight from the Heart :
The Story of My Tryst With My Heart Ailment

Straight from the Heart (1) : The Story of My Tryst With My Heart Ailment
Straight from the Heart (2) : “Rational” Thinking, Irrational Acts
Straight from the Heart (3) : When the Unthinkable Happened : Angioplasty, 1999
Straight from the Heart (4) : Back to Life as Usual, with a Minor Throwback
Straight from the Heart (5) : Déjà vu
Straight from the Heart (6) : Opening Up to Open-Heart Surgery (CABG)
Straight from the Heart (7) : Post-Operational Recovery
Straight from the Heart (8) : One Year After

Part-VI of VIII


Opening Up to Open-Heart Surgery (CABG)

Not Angioplasty; Open-Heart Surgery
Dr Wani advised me around 12.30 pm on Thursday, 3 July 2014 after Angiography that in view of my 5 blockages between 85% to 100%, including the one in the Left Anterior Descending coronary artery (LAD: 100% blockage) where during the Angioplasty in 1999 a stent was put, Angioplasty on me was not possible.

I felt disheartened that the only heartening remedy for me was Open-Heart Surgery (CABG)—and sooner the better.

Like Edward de Bono explains in Lateral Thinking, we tend to put boundaries on possibilities. My outer-most boundary was Angioplasty.  Open-Heart Surgery was something I had never even once considered as a possibility. But, now it brutally stared me in the face. How what you never expect happens?

I not only had to come to terms with the looming possibility of soon being at the receiving end of CABG, I had to take a decision fast; for Dr Wani had stressed “sooner the better”, and that was backed up through an SMS to my wife from Dr Sejao, who had been apprised of the Angiography results by Dr Wani.

Which Surgeon? When?
If CABG had to be done, then in which hospital, and by whom? That was the next logical question.

“Who does open-heart surgery here [in that hospital—KDAH: Kokilaben Dhirubhai Ambani Hospital]?” I asked Dr Wani on 3 July 2014, when he recommended CABG.

“Dr Lad,” he informed, “Dr Vidyadhar Lad.”

“How’s he?” I instinctively let out an unnecessary query.

“Good!” responded Dr Wani.

“Can I meet him?” I asked, sitting in hospital-bed in a reclining position with my right thigh heavily and tightly bandaged and not allowed to move, and still some hours away from being discharged.

“Yes, sure. The sister here would see to it. I would instruct her,” said Dr Wani.

Shortly afterwards my wife and the two daughters were permitted to meet me, and came over to my bed. I told them to do a fast research on the web on their tablets on Dr Lad and on the other renowned heart surgeons in Mumbai in other hospitals; and further check-up information on Dr Lad in KDAH itself. Their short visit-duration over, they were requested to wait outside.

After over an hour I saw one young, smiling gentleman walking towards me along with my wife and my elder daughter, Manasi. He extended his right hand towards me for handshake and just said, “Dr Lad.”

“Oh, Dr Lad. Glad to see you. But, I thought you were a friend of my daughter, and had come along after knowing I was in the hospital. You look so young!” I said.

“No, no. I am not that young. I am 44. I have just studied your angiography and other test reports, and was coming to meet you,” he responded laughing.

“Can you please explain briefly all the relevant stuff about this open-heart surgery, including the cost,” I queried.

Dr Lad gave an overview. The cost seemed reasonable, considering the quality of services and the facilities available.

“Dr Wani has advised that CABG be done as soon as possible. So, what is the earliest it can be done here?" I queried.

“We can schedule it next week. But, before that you have to be off blood-thinners—those medicines that you have been taking have to be stopped," Dr Lad informed.

We told him we would take a final decision in a day or two and would inform him accordingly—we thought we would check up with other renowned doctors too in other Mumbai hospitals.

Dr Lad went over to a table across and began looking at my file and the medicines I had been taking.

“Dr Lad,” I interrupted his study of the file, “what is the risk percentage of CABG?”

“About or rather less than one percent,” he informed. “However,” he continued, “looking to your state of health, that risk is zero percent for you!”

“Zero percent!” I repeated after him.

“Yes,” he confirmed with quiet assurance.

That swung the scales. Later, after Dr Lad had left, and my wife and daughters filled me in with their local enquiries and their research on the web on Dr Lad and others, our views converged—Dr Lad was the right person; we need not go anywhere else; and we must finalise date of CABG that day itself before leaving the hospital.

As I was still in bed, and not allowed to walk, I asked my wife and daughters to seek an appointment with Dr Lad, meet him, and settle the earliest possible date for CABG. They sent an SMS to Dr Lad, and as is Dr Lad’s excellent habit, they received his prompt reply: appointment was scheduled after about an hour. They met him. He explained to them the details on “Beating-Heart CABG” (technical details covered in Part-I of this blog-post) that would be performed on me. The date of the operation was fixed for the earliest possible date—Wednesday, 9 July 2014. For the purpose, I was to get admitted at the hospital late evening by 8pm on Monday, 7 July 2014; and was to remain off blood-thinners starting that day itself—Thursday, 3 July 2014.

After discharge, we all left the hospital by about 5.30 pm on Thursday, 3 July 2014.

My younger daughter, Manini, who divides her time between Germany and India, being director in two companies, one in Germany and the other in Pune, left for official work in Pune on the morning of Friday, 4 July 2014. However, the elder one, Manasi, who works in Oracle-Hyderabad stayed back. It was after a long long time she was spending so many days with us. We watched Football World Cup 2014 quarter-finals between France and Germany on Friday, 4 July 2014. Germany, of course, won, but by only 1 goal. On the 5th and 6th too we watched the quarter-finals.

Back to KDAH for CABG

Then came the D-day. On Monday, 7 July 2014, I packed up. My wife Debu, Manasi and I left for the hospital in the evening at about 6.30pm. We were now familiar with the registration process. We filled-in the forms, paid and registered at the ground floor.

The Ward
A twin-sharing room was allocated on the 13th floor: room number 13033. We moved to the room by about 8pm. The room was neat, clean, spacious and well-lighted, and was centrally air-conditioned. It had an attached toilet. My bed overlooked the metro-line, and one could watch through the large, wide windows beautiful multi-coloured metro-trains going to-and-fro. Early next morning I noticed the sea visible through the window in far off distance. My area was separated from the area of the other patient by curtains.

There was a side-sofa along the window for visitors, and for the person accompanying the patient (guest) to sleep in the night. They provided bed-sheets and blanket for the guest too.

The first thing I was required to do was to change into the hospital-provided patient’s clothes. I did so, and although I was then quite normal, I started feeling depressingly like a patient.

Soon after hot soup brought in thermos was served, followed by dinner. The fare was healthy and good.

Manasi and Debu went down to the ground-floor restaurant for dinner. They were back by 9.30 pm, accompanied by Manini, who had come over straight from Pune. Later Debu and Manini left for home, leaving Manasi to give me company.

The room was equipped with a cable-connected 32” LED-TV facing each bed. That is, there were two TVs, one for each bed. I just checked the TV functioned well, and listened to the news. There was no World Cup match either on the 7th or on the 8th July.

Good mood turns sour
On the first day, or rather night, there was none in the other bed, and hence no TV noise.

However, as they say, ‘good times don’t last’! And, next day early morning saw the entry of a patient who was to occupy the other bed in the twin-sharing room. No sooner was he in, his TV started blaring out. He switched among various Hindi movie channels and seemed happy watching atrocious movies at high volume. I requested for ‘some mercy’, to which he readily responded by decreasing the volume temporarily, and then reverting to his ways after some time.

I started cursing the facility of providing TV. If it had to be provided, then head-phones too should be made available, so that others are not forced to listen. Besides, there should be an instruction/request displayed prominently beside each TV: “Please don’t disturb your neighbour. Play at low volume: use head-phone if your neighbour feels disturbed.” I found it difficult either to focus on my iPad or to sleep.

I had to be operated the next day, and my hitherto good mood—thanks to the cleanliness and excellent ambience of KDAH, fine view from my wide window, and admirable, empathetic behaviour of hospital staff, besides palatable healthy food—began to turn sour.

Helpless with regard to the neighbour’s TV, I, contrary to my nature, went silent, and began to brood—something which I had not indulged in at all. “If only I had never smoked—giving it up 14 years back was not enough—I would not have been in this health/heart-mess. Had I not been in this mess, I would not need to be operated upon. Had the operation been not necessary, I would not be in KDAH. Had I not been in KDAH, I would not have been in this bed 13033. And, had I not been in this bed, I would not have had this neighbour! So, the fault is mine and mine alone!!” 

My younger daughter, Manini, later remarked I had gone rather silent a day before the operation. Well, the reasons were what I just described. Once I had decided to go in for the operation knowing that the alternatives to it were much worse, where was the question of shying away from the requirements or being scared of what lay ahead. In fact, rather than being apprehensive, I was hopefully looking forward to my forthcoming birthday on the 29th July by when I expected to be in a much better shape—like it is said by/of Narendra Modi and his government: “Achchhe din aane wale hai [Good days are about to come)!!”

Pre-Operative Tests

Blood/Urine Tests, Chest X-Ray, ECG & 2D-Echo
They took blood and urine samples for various tests.

Then a member of the hospital staff came over with a wheel-chair to take me to the X-ray room on the first-floor for my chest x-ray. I asked him if I could walk with him, rather than going in a wheel-chair—it felt so embarrassing. He didn’t mind, so I walked with him.

Later, a wheel-chair came to carry me for ECG and 2D-Echo test. I again walked with the hospital-staff, ignoring the chair.

Tests Relating to Radial Artery
For the next test, in the late afternoon, the hospital-staff did not agree to my walking along (what if someone complained?), and I allowed myself to be wheeled, avoiding eye-contact with all. I found the test rather queer. The concerned doctor was running a probe on my left-hand forearm and wrist, and watching a monitor. Unable to understand the purpose, I queried him. The following is the gist of what he informed and what I gathered from other sources:

Arteries harvested for CABG
For the purpose of Coronary Artery Bypass Graft (CABG), that is, Open-Heart Surgery (OHS), arteries from the body of the patient are used for bypass graft. Which arteries are used?

Usage of great saphenous vein (GSV) of the leg used to be common, but is no longer so.

The arteries often used/harvested are the radial artery and that from the chest.

Radial Artery (RA)

The usage of radial artery for coronary artery bypass grafting has gained growing popularity among cardiac surgeons on account of its superior pre-operative and post-operative course compared to saphenous vein grafts from the leg. It is much preferred over femoral approach due to better accessibility, hemostasis (surgical procedure of stopping the flow of blood) and shorter hospital stay. Radial arteries are the conduit graft of choice after internal thoracic arteries because they are relatively easy to harvest and have a larger diameter than other arterial grafts.

Further, the forearm is less prone to infection compared to the leg because of better vascular supply. Local neurological complications are infrequent and can be minimized if anatomic relations with the artery are respected and cauterization near nerves is avoided. Harvesting usually involves an incision extending longitudinally throughout the forearm that is not cosmetically appealing. In my case, as it turned out later, they did something better: rather than incision extending longitudinally throughout the forearm, they made only three cuts of about an inch each, which they then used to harvest the artery.

When harvesting the radial artery, typically the non-dominant arm is used: in my case, the left-hand.

The test was done on my left-hand radial artery to evaluate if it could be harvested. The test results, as the concerned doctor told me, were negative. However, prior to operation, the test was re-conducted—as Dr Lad obviously preferred the better option of harvesting radial artery—and the re-test showed that my left-hand’s radial artery could be safely used. The same was done.

Left Internal Thoracic/Mammary Artery (LITA/LIMA)
Harvesting of LITA/LIMA has gained popularity for CABG, and has advantages over other methods.

In my case, both RA (Radial Artery of the left-hand) and LITA/LIMA were harvested for grafting.

LITA is the cardiac surgeon's blood vessel of choice for CABG as it has superior long-term patency to saphenous vein grafts from the leg and other arterial grafts like RA, when grafted to the LAD (Left Anterior Descending coronary artery) which clinically is generally the most important vessel to revascularize.

I don’t recall any pre-operative test done for LITA.

Pre-Operative Preparations

In the evening of Tuesday, 8 July 2014, a hospital staff came over to remove my body hair from neck down. He didn’t have to do much, as the same had been done about 6 days back, prior to Angiography.

I was asked to take dinner early, and to have a bath after a gap of two hours, thoroughly and liberally applying Bactoscrub (an antiseptic, anti-bacterial medicated liquid soap) from head to foot. Around 9pm on 8 July 2014 I had a bath with hot-water and applied Bactoscrub. After I had dried myself, a hospital staff came over and applied Betadine neck-down all over my body, turning its colour to yellow. After it dried up, I wore fresh hospital-clothes.

“You would need to wake up at 4am tomorrow morning,” I was told. Thankfully, the nurse woke me up only at 4.30am. After a cup of hot-tea and two biscuits, I went through my morning ablutions.

A hot-water bath, using Bactoscrub from head to foot, followed. That had a collateral advantage. I had been feeling slightly scratchy on my head, although I had no dandruff. All that disappeared with Bactoscrub. Later, upon discharge, I bought two bottles of Bactoscrub, and have been regularly using it.

After the bath, a hospital-staff again came over to paint my whole body neck-down with Betadine, turning it yellow. After Betadine dried up, I wore fresh hospital-clothes.

Funnily, my neighbour in my twin-sharing ward had also woken up by 5am, and had started his racket of watching aloud a Hindi movie. I was to anyway move out for operation after some time, clearing out the ward; with a hope to return to some other ward, after operation and a stint at ICU. Operation began to seem a desirable option to run away from the TV and the ward.

After the operation, and before being shifted from the ICU to ward, I actually requested Dr Lad if I could be shifted to a general ward, rather than a twin-sharing room, thinking the general ward would not have TVs. "Why?" he asked perplexed. "I can't stand TV," I told him and narrated my experience. "But, the general ward has five beds and five TVs, one for each bed," he responded laughing. "Even we sometimes find it difficult while we go for visits, with all those five TVs blaring!"

To Operation Theatre

My wife, Debu, and my younger daughter, Manini, had slept in the ward itself overnight. My elder daughter, Manasi, my son-in-law, Arun, also working in Oracle, who had since arrived from Hyderabad, and my younger sister, Poornima, who had come over from Nagpur, landed at the ward at about 7am in the morning.

At about 7.30am I was wheeled out on a bed to be taken down to the CABG Operation Theatre on the third-floor. The group—Debu, Manasi, Manini, Arun, Poornima—followed me. We went down the lift to the third-floor. As I was moved towards the operation theatre, we parted company. They all wished me, and I put my thumbs up as we parted.

God, Religion & Minimising Anxiety
I didn’t feel nervous or anxious or anything. Like I had done while undergoing Angiography (which I have described in Part-V of this blog-post) on 3 July 2014, I began repeating a long string of names of gods and goddesses, and lost myself in it. That’s the advantage of belonging to a polytheist religion like Hinduism. You may take names of a dozen or a score or several score gods and goddesses—even over a million, if you know the names and have the time! Fortunately, polytheist religions like Hinduism are genuinely the religions of peace, as they are tolerant, respect all faiths, and believe there are many ways to God, and all paths deserve to be respected. Not having the arrogance to declare itself as the only true religion, or its gods as the only gods worth worshipping, and believing in the principle of "live, and let live”, Hinduism respected and absorbed different groups worshipping different gods and goddesses, leading to multiple gods and goddesses and multiple prayer practices and rituals. 

However, what is truly unique about Hinduism is its large-heartedness and democratic spirit. You may adopt different methods of prayer, different rituals, and pray to different gods—yet, you remain a Hindu. You may not even pray or ever go to temples, yet you are a Hindu. You may not even believe in God, may be an atheist, and yet you are a Hindu. In Sanskrit, atheism is called nirisvaravada—doctrine of godlessness—and an atheist is called a nastik. Hindu atheists live by Hindu values and traditions, and for them Hinduism is a "way of life", not a religion, and they do not accept the existence of God. Among the six schools of Astika—theist—Hindu philosophy themselves, two do not accept God: the Samkhya and the early Mimamsa school. Both reject creator-God. Apart from this, there is an explicit atheist school of Hindu philosophy—that of Charvak, established around 300 BC. It neither believes in the creationist-God, nor in after-life. Charvak rejected both the Vedas and the caste-system.

In Jainism, propagated by Lord Mahavira, there is no place for personal or impersonal God as the creator or sustainer of the universe, and there is no notion of outside force regulating reward and punishment.

Buddhism is more a spiritual philosophy and a "way of life" than a religion. It rejects the notion of creator-God. Here is what Buddha said:
  Believe nothing. 
  No matter where you read it,

  Or who said it, 

  Even if I have said it, 

  Unless it agrees with your own reason 

  And your own common sense.

Another good thing about Hinduism is that you can flip between being a believer, an agnostic and an atheist as often as you wish and any number of times—neither Hinduism nor the Hindu gods nor the Hindu goddesses mind!

Yet another notable thing about Hinduism is that a Hindu need give NO weightage to any Hindu Dharm Guru (equivalent of a Pastor, Mullah or Pope) or to his or her diktat. That is, a Hindu is directed by NO religious head. A Hindu need not care what a Hindu religious head says or directs, nor need he care about what the scriptures/religious books say or direct. A Hindu knows that things change with time, what was said or written centuries ago may be wrong, and he or she must go by his or her own choice and reason, in keeping with the changing times.

One thing worth-noting about all those who founded new religions is that they were actually irreligious! Irreligious in the sense that they rebelled against the religion they were born into, and founded new religion. What one must learn from them is the rebellious spirit, the guts to question one's belief and that of the religion one is born into, and go in for change and fresh thinking. All religions are old and outdated and out of sync with the reality. True religion is to be a good person (tolerant of others, behaving well with all, to be good to all, to change rationally with the requirements of changing times, and so on); and NOT to stick to outdated, age-old practices or to observe some set rituals or to wear certain kind of dress or to pray in a given way. A good person who is irreligious or atheist is far superior to a devout, religious person who is otherwise. 

In the Operation Theatre

As a first-step, the anaesthetists introduced themselves to me, told they would give injection on my thigh, and did so as gently as possible. I only recalled Dr Lad telling me the day before that when I begin to regain my consciousness in the ICU after the operation I would find tubes in my mouth and would be unable to speak, but that I should not worry—the tubes would be withdrawn after about two hours, and I would find my voice to be hoarse initially. Even as I considered all this, I imperceptibly lost my consciousness.

Certain technical details of the Beating Open-Heart Surgery I have already covered in part-I of this blog-post.

Briefly, the other particulars, to the extent I could gather, are as under (As I was unconscious during the operation, I can’t vouch for anything. I would be happy to stand corrected on any point):

After anaesthesia, a breathing (endotracheal) tube is inserted and secured by the anaesthetist.

A tracheal tube is a catheter that is inserted into the trachea for the primary purpose of establishing and maintaining a patent airway and to ensure adequate exchange of oxygen and carbon dioxide.

The chest is opened via a median sternotomy. This procedure provides access to the heart and lungs for surgical procedures.

In median sternotomy a vertical inline incision is made along the sternum (breast-bone) from the suprasternal notch (top of the sternum, after the large, visible dip below the neck) to below the xiphoid process (the cartilaginous section at the lower end of the sternum). The sternum is then cut with a sternal-saw (bone-cutter). The cut halves of the sternum are then slowly spread apart with a retractor, something similar to a brace. This allows physical access to heart. Closure requires reunion of the sternum with stainless steel sutures (thread).

Sternum saw that cuts open the sternum (breast-bone)

The bypass grafts are harvested. A CABG involves taking a blood vessel from another part of the body – usually the chest, leg or arm – and attaching one end to the aorta and the other end is sewn on to the coronary arteries beyond the blockages (please see diagrams in Part-I of this series of blog-post). This new blood vessel is known as a graft. In my case the internal thoracic artery and the radial artery of the left-hand were harvested and used as five grafts for my five blockages.

As mine was a beating-heart, off-pump CABG, devices must have been placed to stabilize the heart.

Once the grafting is over, chest tubes are placed in the mediastinal (space between right and left lung) and pleural space to drain blood from around the heart and lungs. In my case, there were three tubes—two inserted in the two sides of the chest, and one at the top of the stomach, below the sternum. The chest tube is inserted through a 1-inch cut in the skin between your ribs. The tube is connected to a special canister kept on the ground. Gravity allows draining out the blood. A stitch (suture) and tape keep the tube in place.

Chest tubes are used to treat conditions that can cause lung to collapse: after surgery/trauma in the chest; air leaks from inside the lung into the chest; fluid build-up in the chest (pleural effusion) due to bleeding into the chest.

My left-hand forearm from which radial artery was harvested was also bandaged, and a tube was placed in the forearm under the bandage to drain blood.

Thus, there were 4 tubes—three into the chest and stomach, and one in the forearm—inserted in my body to drain blood. The other end of the tubes went into a receptacle into which blood was collected.

The sternum (breast-bone) that had been cut to gain physical access to heart was wired together with steel wires, and the incision, which was about nine inches long, was closed with suture (thread of catgut, silk or wire used by surgeons to stitch a wound).

Out of the Operation Theatre

I could hear some sounds, some commotion, but unable to open my eyes, I could not make out much.

After a while I heard someone say aloud the operation was successfully over and I was in ICU, and I could open my eyes. I believe I heard some clapping too. I desperately attempted opening my eyes, but all I could make out through the microscopically-opened slit of my eyes were splashes of yellow. Had I gone blind?—I wondered. I again tried, but failed. About to give up, I made out splashes of red too. Am I going to see paintings of yellow and red for the rest of my life?—I thought, horrified. No, I must not lose heart, I must try, I told myself. Then my eye-slit became a little larger, and I could notice some shapes. That gave me hope. I put all my effort on both my eyes to open to the full. Gradually, it happened. I saw hospital-staff around. Someone said everything had gone fine. Perhaps it was Dr Lad (I don’t fully recall). I made a gesture to thank him. I could not speak, as I noticed tubes jutting out of my mouth.

After a while, one by one, my wife, daughters, sister and son-in-law came over to see me from a distance (lest any infection be transmitted) and wished me quick recovery.

I later learnt the following from my wife and daughters:
Tense and anxious, they were all—Debu, Manasi, Manini, Poornima, Arun—waiting outside the operation theatre in the waiting area. The operation was to last several hours, and as none of them had eaten since the morning, they took turns going to the ground-floor restaurant both to eat and to relieve tension.

Apparently, around an hour and a half went by in initial preparations. I was re-painted with Betadine. Radial artery test was redone. Other things were set.

I understand that the actual operation commenced at about 9.30am. The operation lasted about 4 hours and finished around 1.30pm. After post-operation observation, I was reportedly brought to the ICU at about 2.15pm. I regained consciousness in the ICU at about 3.30pm.

In between, when one of the doctors from the team doing the operation came out for a while, my wife, tense with what might have been happening, rushed to him to enquire. "Things are going fine. He is stable. Three grafts have already been done. Two more to follow," he informed. That brought some cheer to my wife and others.

In the ICU

My body and the attachments
Till then, I had not really attempted to take stock of my own body. Like I had mentioned in an earlier post in the context of the Angiography, I felt as if my body stood leased out to the hospital for a temporary period, and I had lost my rights over it. I was rather reluctant to do a self-check afraid I would be violating some unwritten terms of lease.

Leaving apart the mental block, even otherwise, the physical position that I was in made it difficult to take stock of self.

I was lying on my back, covered with pieces of blue-coloured thick cotton sheets. The purpose of pieces was to expose specific portions of my body when warranted, without disturbing the other parts.

There was an IV-fixture jutting out of my neck, making head movement difficult. Another IV- fixture was on the wrist of my right hand.

My left hand was in bandage, with a tube coming out, and going into a receptacle—to drain blood. That was thanks to the radial artery harvested from my forearm. A finger of my left hand was caught in a probe measuring my pulse on an ongoing basis, and displaying it on a monitor kept on a rack to the left of my bed, behind my head. These two almost immobilised my left hand.

A wire inserted into my femoral artery of the leg through a hole in the groin, through which the Angiography catheter had been inserted, measured my femoral blood pressure on a continual basis, and displayed it on an monitor kept on the rack behind. This partially immobilised my right leg.

A single ventricular pacing wire was placed inside my chest, going into the heart.

The nine-inches vertical wound on my chest, where the sternum (breastbone) was cut, was bandaged.

Three tubes, meant to drain blood out, jutted out from my chest and stomach. Their other end went into a bottle kept on the ground for collecting blood.

Thanks to urine catheter, yet another tube carried urine into a bottle kept on the ground below, because there was no question of my sitting up, walking and using toilet.

There were thus a total of 5 tubes coming out of my body.

I mostly lay flat on my back. Nurses did recline it to  allow me a semi-sitting position when I had to consume juice or tea through a straw, or had to meet visitors. It was not possible to turn on my side to the right because of the IV-fixture jutting out of my neck. However, the nurses helped me turn marginally to my left, when tired lying in the same position, by pushing some sheets under me from the right-side.    

The routine
Despite the above, I must admit I was not in much pain—at worst I was uncomfortable. However, I slept well. In fact, when the nurses used to wake me up between 5.30 to 6.00 am in the morning, I used to get irritated for being woken up at that unearthly (as per my habit/definition) hour. They helped me brush my teeth. However, they didn’t have much to clean or bathe me except dab me with a wet cloth (sponge bath) a little on the legs and on the exposed portions of my hands and neck. But, I liked the wet-tissues (wet with eau-de-cologne) on the face—that dramatically freshened me up.

After that little wet-wipe, I eagerly looked forward to the morning tea, taken through straw for the first two days. It was liquid diet for the first two days. Soft, solid food was served from the third day, and regular food from the day I was shifted to the ward.

Nurses had 8-hour shifts, and hence 3 nurses in turn helped you out during the 24-hour period.  All nurses took good care, were invariably well-behaved and very helpful.

I came to ICU in the afternoon of Wednesday, 9 July 2014, after operation, and remained there for three days till the afternoon of Saturday, 12 July 2014.

After a day in the ICU I desperately looked forward to using my iPAD and/or reading newspapers, periodicals and books. But, those were barred in my own interest—lest I get infected. That made passing time a little difficult. What do you do? Either just sleep or look around. Fortunately, my bed was near a large window through which I could watch the rains—it had been raining heavily.

Another noticeable things was the frequent thorough cleaning/disinfecting of the ICU. The concerned staff would wipe with disinfectant-soaked cloth practically everything in the ICU: bed-frame, bed from below, chairs from top to legs, cupboards, racks, windows, window-sill, and even walls and ceiling! And, not just once in a day. About every three hours they would repeat the process. An inspector would come checking each thing with a fresh paper-tissue in hand for any evidence of dirt.

Gradual detachment of attachments
My position in the ICU remained normal, and fortunately there were no anxious moments. All instruments generally showed normal readings.

On the afternoon of Friday, 11 July 2014, a day before discharge from the ICU, the process of detaching the attachments commenced.

The first was removal of the wire through a hole in my groin into the femoral artery meant to measure femoral arterial blood pressure. Such blood pressure measurement is more accurate than that through the normal non-invasive method. A lady doctor came and told me it would be painful and she would therefore inject local anaesthesia in my thigh. She did that quite gently. She then removed the wire and the attachment and told me she would have to keep the perforation pressed with her hands—and it would pain—for at least 15 to 20 minutes lest the blood should spurt out. She did that skilfully. She then tightly bandaged the perforation and the thigh, and kept a heavy slab on it. Lest the blood should ooze out, don’t move your leg for 4 hours and let it remain under this heavy slab—she told me. I thanked her and complied.

In lieu of the wire in the groin, a wire was placed inside my right-hand forearm artery (to measure radial blood pressure) through the hole that had been earlier made for Angiography.

Next day morning, that is, on Saturday, 12 July 2014, the tube from the left forearm was removed. Then the urine catheter was removed.

Meanwhile, I heard cries from a bed in the ICU some distance away. I asked the doctor, who then was near my bed, what it was. “That’s on account of removal of chest tubes. It pains. Patients cry out and shout at us,” he informed. “Oh!” I said thoughtfully as I looked down anxiously upon my own chest tubes. “We would shortly take out your tubes too,” said the doctor. “But, don’t worry, we would do it as gently as possible.” I got busy internally reciting my long string of names of gods and goddesses. Presently, the three tubes were pulled out one by one. It was exceedingly painful, but I only contorted my face without crying out even as I continued reciting names of gods. The three wounds/holes where the tubes had been inserted were bandaged.

The IV-fixture of my neck was removed.

After an hour, another doctor came and removed the single ventricular pacing wire embedded in my chest. It gave a stinging burning sensation upon removal, but thankfully only for a few seconds. The doctor told me to not move for two hours.

Lastly, the wire inserted in my right-hand wrist and the IV-fixture of my right-hand were removed.

Once free of all attachments, I was wheeled out of the ICU.

In the Ward

I was shifted out of the ICU on the third-floor to a twin-sharing, centrally-airconditioned ward on the thirteenth-floor on Saturday, 12 July 2014, at about 1pm. The new bed-number was 13069. My bed was near a huge window that provided an excellent view.

Free of attachments, I could then move around. Of course, bandages on the chest and left-hand remained, preventing me from having a bath. Among the first things I did was to shave, and then to ask my daughter, Manasi, to shampoo my hair even as I bent down my head into the wash-basin. I then washed myself stomach-down, and dabbed the non-bandaged portions of the rest of my body with eau-de-cologne soaked towel. That made me feel better. Used to at least two baths a day—morning and evening—I had been feeling terribly unclean.

Later on the day of my arrival in the ward, an occupant for the other bed in my twin-sharing room (with area of each partitioned by curtains) arrived. He was a Bengali gentleman from Tezpur, Assam who had undergone Angiography that day, and was scheduled for Angioplasty after two days. His was a very gentle, non-intrusive family who watched TV only at very low volumes. Having undergone Angiography (which is done without anaesthesia), he was genuinely mortally scared of Angioplasty, which too is done without anaesthesia. I gave him courage saying I had undergone the same in 1999, and that it was not really a big deal at all. But, he remained un-reassured. “Why can’t they make you unconscious and then do what they like? Why torture you when you are wide awake? Such primitive methods!”—said he, wondering at the lack of empathy in such operative procedures. After Angioplasty he was shifted to another ward, but his relative met my daughter and informed that all went well. Thanks to him, and with his permission, my daughter, Manasi, and I watched on TV in our area at low volume both the 12th July world cup football match for the third place between Brazil and Netherlands, and the final between Germany and Argentina on the 13th July.

I was allowed to use mobile and iPad in the ward. That helped me pass time. There have been arrogant, incompetent critics, but I have always admired the unmatched ease of writing of RK Narayan. I consider him as a natural writer close to ground and without pretence, who can make even humdrum interesting and engrossing. Reading his novels or short-stories submerges you. I re-read, after a very long gap, his “Guide” and “Painter of Signs” on the iPAD and felt as engrossed reading them as I had felt when I first read them.

The fare of early morning hot-tea and biscuits, breakfast, pre-lunch soup, lunch, evening tea with snacks, pre-dinner soup followed by dinner, and bed-time hot-milk was healthy and palatable. I found my hunger had grown, and unlike the pre-operation days, I eagerly looked forward to each meal, cleaning up all offered.

My chest x-ray was taken to check if things were normal.

Looking to my faster than normal recovery, Dr Lad allowed my discharge by Tuesday, 15 July 2014.

In preparation of the discharge, physiotherapists visited me and advised me of the exercises to be done, especially breathing and chest-expansion exercises. I was provided with an Incentive Spirometer and taught its usage to help improve functioning of the lungs.

Diabetes specialist came over to advise me on the dosages of insulin to be injected prior to each meal. I was required to be on insulin for a month. As I didn’t know how to inject myself, I was asked to acquire insulin pen (please see picture below), which makes it a child’s play to inject oneself.

I was also provided with a chest ster-grip ( a broad belt) that was to be tightly worn around the chest for about 2 months.

Completion of all formalities for discharge was over by about 2 pm on Tuesday, 15 July 2014, and readily surrendering my hospital outfit and donning my shirt and trousers, I happily moved out.
Onward to Post Surgery Recovery at home in the next (last) part (VII) of this blog-post...

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Rajnikant Puranik
August 29, 2014
91-22-2854 2170, 91-98205 35232

Thursday, 21 August 2014

Straight from the Heart (V) : (Déjà vu) The Story of My Tryst With My Heart Ailment - Part V of VII

Straight from the Heart :
The Story of My Tryst With My Heart Ailment

Straight from the Heart (1) : The Story of My Tryst With My Heart Ailment
Straight from the Heart (2) : “Rational” Thinking, Irrational Acts
Straight from the Heart (3) : When the Unthinkable Happened : Angioplasty, 1999
Straight from the Heart (4) : Back to Life as Usual, with a Minor Throwback
Straight from the Heart (5) : Déjà vu
Straight from the Heart (6) : Opening Up to Open-Heart Surgery (CABG)
Straight from the Heart (7) : Post-Operational Recovery
Straight from the Heart (8) : One Year After

Part-V of VIII

Déjà vu


Since College, my last 47 years (1967 to 2014) of good health were punctuated by about 3 months of ill-health (December 1999 to February 2000) that included heart-problem and Angioplasty. A minor heart-related health-event occurred in January 2007, but it lasted barely 3 days. Otherwise, it had been life as usual with fairly active (though not intensive) physical life that included daily walks, swimming about twice a week, and occasional gym for short periods. Smoking I had left in December 1999, and my food-habits have been fairly healthy, involving NO junk food or soft-drinks.

For many months leading up to June 2014, I had been going daily for an evening walk in a BMC ground, with a good walking track, not too far from my residence in Borivali-East in Mumbai. I normally took five rounds of the ground. However, when absorbed deep in some topic or immersed in music with ear-plugs on, the rounds would climb up to 10 or even 12. At times I felt a little exhausted after 2 or 3 rounds, but discovered that if I persisted without halt, the comfort-level would return and I could easily take more rounds.

On 21 June 2014, as I was walking towards the BMC ground, I suddenly felt breathless. I halted; stood resting for some time; then resumed. After another 5 minutes of walk, I felt the same, halted, stood resting for a while, then resumed. Finally, I reached the ground. However, I had to stop for breath after each half-round. Disappointed, I terminated the walk session after two rounds and returned home, halting periodically to gain breath. I wondered what had gone wrong. I had been taking medicines regularly, still...

Next day, on 22 June 2014 evening, I again went for a walk, and I again encountered similar problem.

Thinking it was a transitory phenomenon, I persisted the next day on 23 June 2014. But, it became worse. I had to return home without even reaching the ground.


I visited Sanchaiti Hospital, Kandivali-E on 24 June 2014 along with my wife and consulted my doctor, Dr Sejao Vidyasindhu, MD. The doctor was of the opinion that what I was experiencing was “Angina-equivalent”. He advised we must lose no time in getting ECG, 2D-Echo and Angiography (CAG) done; and till that is done I must forget about walks, do no exertions and take complete rest.

His cryptic declaration of the state of my heart and the immediate-next-steps-advice left me no room to fool myself that “things might not be all that bad” and provided me no scope to “to further kick the angiography-tin down the road” buying more time, hoping, God willing, things might turn out okay even otherwise.

Dr Sejao Vidyasindhu had been treating my wife, and had ably handled my father’s case too in the past, and I knew him as a no nonsense thorough professional who always offered the right advice.

Dr Sejao advised I get Coronary AngioGraphy (CAG) done at the earliest at some really well-equipped centre through a cardiologist of proven competence, honesty and integrity. He suggested, as top option, Dr Sunil Wani at Kokilaben Dhirubhai Ambani Hospital (KDAH), Mumbai, and gave me his mobile number.

Initial Diagnostics : ECG & 2D-Echo

Knowing Dr Sejao as a thoroughly competent professional of high integrity, I did as he advised on Tuesday, 24 June 2014.

Not being able to get through to Dr Wani on the phone (most doctors remain busy with patients and can’t pick up phones like you and me), I sent an SMS. The response was prompt, and an appointment with the cardiologist Dr Sunil Wani at Kokilaben Dhirubhai Ambani Hospital (KDAH) & Medical Research Centre, Four Bungalows, Andheri-West, Mumbai was fixed up for 4pm on Thursday, 26 June 2014.

I went alone for the appointment, not wanting my wife to confuse the doctor with her inputs, although my wife wanted to accompany me.

I met Dr Wani at his cabin in the Cardiology OPD on the first-floor of KDAH. After discussions with me and check-up, Dr Wani sent me for ECG and 2D-Echo-Doppler, facilities for which were on the same floor. Dr Wani asked me if I had come unaccompanied, and appeared a little surprised when I responded in the affirmative. Similar was the reaction of the technicians who did ECG and 2D-Echo-Doppler, and of staff who wanted the person accompanying me to go make the payments for the tests. An unaccompanied heart-patient appeared to them to be an abnormality. They didn’t realise I wasn’t regarding myself as one till the tests proved otherwise; and after the breathlessness of 21-23 June, I was no longer in a similar state and was feeling normal.

The ECGs had been done before, so there was nothing new in it for me. However, 2D-Echo-Doppler was new.

Two-Dimensional Echocardiogram (2D-Echo)
2D-Echo uses ultrasound to picture out the heart. It displays a cross sectional “slice” of the beating heart, including the chambers, valves and the major blood vessels that exit from the left and right part of the heart. Doppler is a special part of the 2D-Echo that assesses blood flow (direction and velocity) as it makes its way through and out of the heart. One hears “swishing” or “whooshing” sounds during this part of the procedure.

Apart from information on the size of the chambers, dimensions, volume and the thickness of the walls, and details on valves, 2D-Echo determines if the pumping power of the heart is normal or otherwise, and if reduced, to what degree.

You are asked to take off your shirt and vest to bare your chest, and to lie on your left side as the technician moves the transducer head (microphone-like gadget that takes a “picture” or video image of the heart) across different parts of your chest to get different views of the heart.  A gel is applied to the chest or on the transducer. You may be asked to breathe slowly or to hold your breath.  A connected monitor shows the images, which are preserved. A cardiologist reviews and interprets the recordings. It is a painless non-invasive procedure that takes less than 30 minutes.

Our heart is a pump. At rest, our heart causes about 5 litres of blood to circulate to our body per minute, by some 70 rhythmic contractions. Our heart pumps blood twice. First, it pushes the blood returning from the body through vena cava into our lungs for oxygen. Returning from the lungs, oxygenated blood flows into the heart, which routes it into the aorta and onwards to our body.

Often, a term pumping rate as a percentage is used for the heart, although it is actually the Ejection Fraction(EF). EF determines how well your heart pumps with each beat, and is usually expressed as a percentage. A normal Left Ventricular EF (LVEF) ranges from 50% to 70%. LVEF of 65 means 65% of the total amount of blood in the left ventricle is pumped out with each heart-beat. LVEF may be lower when the heart muscle has become damaged due to a heart attack, heart muscle disease (cardiomyopathy), or other causes. An EF of less than 35% increases the risk of life-threatening irregular heartbeats that can cause sudden cardiac arrest (loss of heart function) and sudden cardiac death.

After my 2D-Echo was done by the technician by about 5.30 pm  on 26 June 2014, I showed my curiosity to know the result. She told me the doctor would come, study the images and let me know. Upon my persistence, she only asked if I had experienced an even in the past (heart attack) that might have damaged the heart’s pumping capacity.

She phoned Dr Wani, who instructed her to ask me to wait there only at the 2D-Echo location. Dr Wani came by about 6pm, had a close look at the images, and asked me to come over to his cabin.

In his cabin, Dr Wani asked me the same question that the technician had asked. He then informed me that there was a definite deterioration in my pump rate. He put the figure of LVEF at 40%. Other than that, my 2D-Echo indicated near normal status.

That figure of 40% disheartened me. So, there was indeed something wrong with me!

Déjà vu : Angiography Again

Looking to the ECG and the 2D-Echo results, Dr Wani advised the necessity of Angiography (CAG).

Knowing I couldn’t any more claim otherwise on the state of my heart, after the 2D-Echo results, I realised I had no further leverage and that I could not kick the angiography-tin further down the road and buy time.

I enquired from Dr Wani all the relevant particulars about the proposed CAG. He gave me a printed sheet of options (type of stent and ward) and corresponding costs.

He told me that if CAG is done in the afternoon, I would have to stay overnight and could go home only the next day. However, if CAG is done early morning, I could go home by the evening. I promptly chose the early morning option, never wanting to stay at any hospital more than the minimum necessary. Morning slot was not immediately available—the earliest slot was on Thursday, 3 July 2014, which I unhesitatingly grabbed.

Reluctance to Inform Others
I was not in favour of informing others—even my two daughters, Manasi and Manini, at Hyderabad and Germany respectively—for I considered Angiography to be too minor a thing, and a possible Angioplasty after that (if at all warranted) to be not a big deal.

However, my wife confided in the daughters. Upon learning of the same, I dissuaded them over phone from taking the unnecessary trouble to come over. Yet, both landed at Mumbai on Wednesday, 2 July 2014.

To KDAH on Thursday, 3 July 2014
Dr Wani had advised me I should take just a cup of tea in the morning with two biscuits, and should be at the hospital (KDAH) by 7.30 am to 8.00 am in the morning of Thursday, 3 July 2014.

We all got up early by 5.30 am, got ready, and proceeded for KDAH by 6.30 am. First was the payment and registration on the ground floor, which we completed by 8.15 am.

Thereafter, we proceeded to the third-floor where the “Cath. Lab.” and the facility for CAG (Angiography) were located. We waited for a while. I was called in by 8.30 am, while my wife and the two daughters waited outside in the “waiting area”—a clean, well-furnished place.

I was shown my bed. Then, a hospital staff took me to a room. He asked me to take off all my clothes to facilitate shaving of all my body-hair, except, of course, the head. I was given hospital-clothes to wear. So dressed, and looking like a patient, I very self-consciously walked back to my bed.

To Cath. Lab.
At about 9.15am I was wheeled into the Cath. Lab. for Angiography. The staff got busy in necessary preparations and adjustments of instruments.

I didn’t feel abnormal or anxious or nervous. I complied with whatever were the demands of the staff—which were not much. I had to only lie on my back—comfortably. I didn’t have to stretch my arms above sandwiching my head and ears, like I had to do in my previous CAG in December 1999—which was uncomfortable and painful.

Dr Wani arrived around 9.45am after preliminary preparations were over. He wished me and reassured me everything would be fine.

A small hole was made in the artery of my right wrist. It was slightly painful. No anaesthesia is given for Angiography. Dr Wani then pushed a catheter up my artery through the hole. I have already covered the technical details of Angiography in my previous blog (Part-III), hence I won’t repeat them here. I could see a wire dangling and struggling up on the screen, but it couldn’t make much headway. After repeated tries, Dr Wani informed there appeared to be a cramp up inhibiting the further movement of the catheter. He, therefore, withdrew the catheter from the wrist.

We would have to do it from the groin, said Dr Wani; and the staff got busy blocking the wrist hole and making preparation for CAG through the groin. Finally, a small hole was made in the groin into the femoral artery up which the catheter was inserted. It was painful.

CAG through the groin was successful. It took a total (including the first CAG attempt through the wrist) of about 90 minutes, including preparations.

I have a funda or a technique or what may be called a formula to beat the pain or to divert attention from the violation of my body: I repeat to myself internally a long string of names of Hindu gods and goddesses, and the process of doing so helps me forget the immediate material environment even as I try to rise above the mundane. This technique helped me comfortably sail through the Angiography.

At the end of it all, while still lying in the Cath. Lab., Dr Wani came up to me and said briefly in subdued voice: “There is blockage. I would appraise you of the details later.”

Blockage? Angioplasty?
That put me down, but I tried to console myself with: ‘Ok, some blockage. Won’t go away with medicines? At the most Angioplasty then! And, maybe, not one, but two stents. Still, perhaps a week or less in hospital. That’s fine, I can handle that.’

I was wheeled out and taken to a ward just outside the Cath. Lab. I was told to remain in reclining position, and not to move my right leg or bring any pressure on it. Groin-hole and the surrounding area on my right thigh were firmly bandaged, so also the hole in my right wrist.

After a while I was given some refreshment. Meanwhile, Dr Wani had met my wife and daughters waiting outside and had appraised them of the status with the illustrated map of the coronary arteries of my heart.

Not Angioplasty; Open-Heart Surgery
Dr Wani later came to my bed, smiled, showed me the Angiogram, and indicated to me on the same I had 5 blockages between 85% to 100%. He then said Angioplasty was not possible, the only remedy being Open-Heart Surgery, and sooner the better.

Open-Heart Surgery was something I had never even once considered as a possibility (earlier, I had taken details and rates for only Angiography and Angioplasty from Dr Wani, never having queried him on open-heart surgery); and now it stared me brutally in the face. How what you never expect happens?

Onward to Open-Heart Surgery in the next blog...

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Rajnikant Puranik
August 21, 2014
91-22-2854 2170, 91-98205 35232