Straight from the Heart :
The Story of My Tryst With My Heart Ailment
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-III of VIII
When the Unthinkable Happened
Those were the busiest days—rather months and years (1998 onwards)—of my life. I was shouldering multiple high-level responsibilities. As head of Information Technology (IT), I was responsible for smooth IT operations in all branches and offices.
Managerial & Technical
On top of it, I had taken up a mega software project: Comprehensive Banking Software covering Core Banking, Retail Banking, Corporate Banking, Trade Finance, Wholesale Banking including Domestic and Forex Treasury, General Ledger, Client Delivery including ATM, Phone Banking, Internet Banking, and exhaustive Management Information System with graphs and RBI Reporting System. What is more it incorporated in-built Audit-facilitation modules.
Conceptually, it was a comprehensive banking software like none that existed. Normally, banks use separate software packages for each segment from different vendors that run on different hardware, operating systems and environment making their operations and management that much more complex and costly. A typical bank may be running over two score software packages—big and small.
Disparate systems lead to further complexities, rather they make terrible complexities unavoidable. That’s for three major reasons: (1)Interfaces. If a transaction in System-A must get reflected or must have a counter-part in System-B, then a software interface has to be developed to do the job—that’s yet another software package to develop, modify with changing needs, and maintain. For say 10 systems to thus inter-communicate, there would be 10 such software interface packages. (2)G/L. Creating daily General Ledger requires sourcing/piping data from different systems. (3)Data Warehousing, MIS & Reporting. Comprehensive MIS & Reporting requires data to be collated from various sources. That requires ETL tools (Extract, Transform & Load Tools) and developing, modifying as per changing needs and maintaining ETL system/codes between each system and the central database (data warehouse). Such systems can’t be efficient as delay in data from one or more systems would mean overall delay.
The system I had conceptualised envisaged drastically minimising the above complexities. One, because the database software would be same across different modules/packages and uniform bank coding system was to be implemented across, obviating any need for data transformation. Two, many modules/packages would stand integrated, hence no need for interfaces and data-extraction from multiple systems. Three, Central Data Warehouse would get automatically populated with daily data after the EoD (End-of-Day operation), obviating a separate process at the end of each week or month or quarter or half-year or year to populate the Central Data Warehouse for MIS & Reporting.
I not only had to manage the existing operations in branches and offices, I also had to lead a large development team for the project. And, it was not just overall management. I am also a domain expert in many areas of banking and I helped vet the final specs (specifications). I personally wrote specs of certain modules where I wanted to implement novel functionalities and elegant logic. I supervised development of a uniform banking coding framework that applied across modules/packages. Being also a qualified software technical expert, I architected and developed the generic framework for the software product and designed/vetted the database design. I also personally coded a few critical modules. All modules incorporated built-in debugging framework.
I knew from experience that all aspects of life have a political component. Even in the previous relatively less ambitious software projects I had faced and tackled what is called “dirty politics”.
But, this ambitious comprehensive banking software project which touched the life of practically all in the organisation and had the potential to be disruptive, evoked the jealousy of many and provoked still more to engage in rumour-mongering, spreading of negative messages and in dirty machinations—from bottom to top!
Handling politics proved to be as challenging as the managerial and the technical side. Besides, it was avoidable waste of precious time and energy. The worst aspect was that it was a source of unnecessary constant tension.
My personal view is that any organisation wanting to build a quality software product has a responsibility to build a firewall around its managerial-technical team that shields them from destructive politics that saps the energy, drive and motivation of the team.
I recalled what I had read in the book “The Politics of Projects” by Robert Block. However, comparatively my experience was more varied and worse!
The project took off during the latter-half of 1998 and had a three-year time-line, including implementation.
My team and I got fully sucked into the project. Many of us worked for over 12 hours a day. We even worked full-time on many Saturdays, Sundays and holidays. On many occasions I worked through the night at home.
The toil increased, the tension increased, and so also the neglect of health and smoking.
After the project commenced I took no leave. There was just too much to do, and time was too short—leave was out of question. Even Saturdays, Sundays and holidays went into the work.
However, I could not avoid attending the marriage of my favourite niece, Tachu, at Indore at the end of November 1999.
While attending the marriage at Indore, I received a call from my office at Mumbai that my colleague and deputy had unfortunately expired. How?—I asked shocked and taken aback. The details were something like this. He was on his way to Nariman Point in a taxi to attend a meeting. While nearing the destination, the taxi-driver got a little confused and asked my colleague in the back seat if he should continue going straight or turn to his right. Not receiving any reply he looked into the rear-view mirror, and turned it to scan the back-seat. To his amazement, the back-seat was empty. Shocked, he slowed down and took his taxi to left and stopped. He climbed his driver-seat and gazed down at the back. He couldn’t believe. He got out and opened the backdoor. My colleague was lying sprawled on the floor of the taxi. He tried checking his pulse. There was none. He rushed him to a nearest hospital. But, he was already dead. Dead of heart-attack!
Back in Mumbai : Health Check-up
I rushed back to Mumbai, though, by then, the funeral of my colleague was over.
Shocked by the incident, the Chairman had directed comprehensive health check-up of all top-executives at Lilavati Hospital, Bandra.
I landed at Lilavati Hospital on the morning of Wednesday, 15 December 1999 for health check-up. All kinds of check-ups and blood-tests were done. Tests included among many others chest X-ray, sonography, ECG, and stress-test. While undertaking the stress-test on tread-mill, I remember the cardiologist Dr Vidya Suratkal telling me to stop if I felt exhausted or breathless or felt any strain or discomfort. But, as I encountered no such problem, I completed the test without any difficulty.
I was told to come the next day afternoon to collect the health check-up report and meet the doctor who would explain the same to me.
Health Check-up Report
Accordingly, I was at Lilavati at about 1pm on Thursday, 16 December 1999. I met a lady doctor at the ground floor in an over-sized room sitting behind a huge table. She welcomed me, asked me to take my seat and turned behind on her revolving chair to fetch a file from a drawer. It was my health check-up report.
“I have already studied your report,” she said.
But, she again turned the pages for a re-check, and after she was through to the last page, she looked up, smiled and said: “Everything is fine. No issues. Even your sonography, ECG and stress-test reports are fine.”
“But, just one point,” she added, as she handed me the file. “Your glucose level came abnormally high. Why? Are you a diabetic?”
“No,” said I. “I got the glucose blood-test done just about two months back on the advice of my eye-specialist, before having the glasses changed. Fasting was 97 and PP 132.”
“Oh, then the current high might be stress-related. Please get the test re-done,” she advised. “Do you have some facility near your residence?”
“The pathological laboratory is in my building itself. No problem. I would surely get it re-checked,” I assured her.
I got up with the file, shook hands, thanked her, and as I turned to leave, I felt pain in my chest, similar to what I had felt in the morning before leaving for the office.
“Does this shop in your premises also keep soda?” I enquired of her.
“You may try? But, why?” she asked.
“It seems I am having some gas-problem. In the morning too I could feel it rising and pressing my chest, but soda had helped,” I responded.
I hurried to the shop, ordered a soda, and quickly gulped a mouthful. The pain increased. Suddenly, while I sensed shooting pain in the bone of my left arm, I felt as if my chest was being compressed internally. I rushed to the room of the lady doctor I had just bid goodbye to. Fortunately, she was there.
“What happened?” she asked, concerned.
I simply clutched my chest and my left arm.
“Chest pain?” She immediately got up, came to my side, gently held my hand, and took me towards the lift.
As we waited for the lift, my condition worsened. I wondered if I would be alive by the time the lift came down. It seemed like ages. Presently, the lift came, and she took me to the first floor, and then to the room where Dr Vidya Suratkal was sitting.
“What, Mr Puranik?” Dr Vidya asked.
“I am in bad shape. I am having severe chest pain,” I said.
I was quickly seated on a bed. A nurse took out my shoes and socks. Dr Vidya put a tablet (Disprin, as I learnt later) in a bowl of water, allowed it to dissolve, and asked me to drink. She then asked me to open my mouth, lift my tongue, and put a tablet (Sorbitrate, as I learnt later) under my tongue. Then, she helped me take out my shirt and vest, and put probes on me for ECG.
“Strange!” Dr Vidya said. “Only yesterday we did the stress-test and you cleared it with no difficulty.”
She looked at the ECG report and said: “You need to be admitted to ICCU. But, I don’t know if they have a bed free. Let me check.”
By then, I began to feel better.
“Fortunately, they just discharged a patient from the ICU,” she said. I was soon wheeled out and taken to ICCU. Within minutes my clothes were changed to that of the hospital’s, I was put on drips, and various probes monitored my state.
Dr Vidya then took the phone number of my driver, and called him up. My driver Ravi was totally baffled when he looked at me. We had stopped by at the hospital only for me to collect the report, as I had informed him; not to get admitted! Dr Vidya took my office and residence telephone numbers from him and was kind enough to contact and inform all concerned. She just told me to lie down and rest and not worry, and that everything would be taken care of. And, it indeed happened like that.
In ICCU : Waiting for the Next
I didn’t recall having been admitted to any hospital for a long long time. Of course, while in primary school I had undergone tonsils operation, and at the end of my first year in college (1967) while I had gone for a Science-Talent Summer School in Bangalore I had caught jaundice and was admitted to St Martha’s Hospital.
Other than those I have had little to do with doctors, injections and hospitals. In fact, for the last 32 years—right since 1967 till December 1999—mine was a singularly unmedicated body: no health problems, no medicines, no injections. I never had headaches, and rarely had fever. Stomach upset, sometimes. That was about all. I rode motorcycles like Royal Enfield Bullet, Yezdi and Rajdoot even on dirt and kacha (unmetaled) roads of villages, and scooters for over three decades, but never met with an accident or even had a scratch thanks to these vehicles. In my previous job, which I did for 19 years, and where the medical reimbursement for self was unlimited, I had claimed less than rupees 2000 as medical reimbursement during 19 long years!
Host of injections and drips and tablets at the ICCU therefore unsettled me initially. I was not used to them. But, I told myself I had only invited these by persisting with smoking, so why complain now—I had not reckoned that the cigarettes that I had loved for 32 long years would betray me so!
But, I soon became impervious to medication. Let them put as many injections as they like. Live with it. Just ignore it. It was as if I had surrendered the ownership of my body or had temporarily leased it out to nurses and doctors. They were free to perforate me with injections or drill small holes into the arteries of my wrist or groin whenever they wished. Initially I tried to humbly enquire the purpose of each such violation, but was either politely but cryptically told the purpose that I didn’t quite grasp; or was told to just not bother as everything would be alright; or sometimes the doctor or nurse pretended they had not quite heard me; or they let me know through their gestures that I need not be too curious, and in any case I won’t understand even if they were to take the trouble. It was like I had even surrendered the RTI (Right To Information) on my body. I remembered in college that when someone got too nosy with questions, we would comment: “Curiosity killed the cat.” However, the curiosity here was my own body, and not some external third-party thing, and I resented this economy on information, though I did appreciate that their time-constraint did not allow them the luxury of expounding on each procedure. But, some indulgence would have been appreciated.
But for the discomfort of drips and other attachments, I soon had no complaints in the ICCU. The doctors, particularly Dr Vidya, were very good and kind, the nurses were helpful and empathetic. Even the food, though expectedly not scrumptious, was healthy, and nothing to crib about. They were planning for angiography, but wanted me to be stable first. However, after a day at ICCU, I felt healthy enough to wonder if I really had a problem.
Fortunately, I had a book with me on which I had just started in the car the day I was admitted. It was a thick bound book of over 600 pages: “A Life of Our Times” by Rajeshwar Dayal, a member of ICS with a distinguished diplomatic career, and a Padma Vibhushan awardee of 1969.
With the book keeping me engrossed, forget about the pain, I could not even complain of boredom.
Finally, the D-day came.
Angina, Angiography & Angioplasty
What is Angina?
Angina is the pain consequent to an area of heart muscle not getting enough oxygen-rich blood. It is also called Angina Pectoris.
The angina pain could occur in multiple ways. It could be a feeling of pressure on your chest, or it could be as if something is being squeezed inside your chest, or it could be as if the pain is being caused by indigestion or gas. In addition to or in lieu of chest-pain, it could be a shooting pain in your shoulders, arms, neck, jaw, or back.
Angina can be classified into four types: stable, unstable, variant (Prinzmetal's), and microvascular.
Stable Angina, the most common type, occurs when the heart is working harder than usual, and it has a regular pattern. This pain subsides once you take rest or take your angina medicine. Apart from physical exertion, stable angina may also be caused by emotional stress, exposure to very hot or cold temperatures, heavy meals, and smoking.
Unstable Angina can occur with or without physical exertion, and rest or medicine may not relieve the pain. It could be a sign of imminent heart attack (myocardial infarction). It doesn't follow a pattern, and may be more severe than stable angina, even dangerous, requiring emergency treatment. Rupture of plaque results in blood-clots that may partially or totally block an artery causing unstable angina. If a clot is large enough to completely block the artery, heart attack may result.
Variant (Prinzmetal's) Angina, rather rare, is caused by a spasm in a coronary artery. It generally strikes between midnight and early morning, and may be relieved by medicine. The spasm can be caused by exposure to cold, emotional stress, medicines that tighten or narrow blood vessels, smoking and cocaine use.
Microvascular Angina is relatively more severe, and lasts longer. This may be a symptom of Coronary Microvascular Disease (MVD) that affects the small coronary arteries.
Angina is a symptom of an underlying heart problem, generally of coronary heart disease (CHD).
What is Coronary Heart Disease (CHD)?
It is also known as Coronary Artery Disease (CAD).
First, what is Coronary Artery?
Coronary arteries supply blood to the heart.
(Courtesy: Texas Heart Institute)
The aorta (the main artery—originating in left ventricle of the heart and extending down to the abdomen, where it splits into two smaller arteries—that distributes oxygenated blood to all parts of the body) branches off into two main coronary arteries (in the heart), which in turn branch off into smaller arteries, for supplying oxygen-rich blood to the entire heart muscle. The Right Coronary Artery supplies blood mainly to the right side of the heart, which is smaller, as it pumps blood only to the lungs. The Left Coronary Artery branches into Left Anterior Descending (LAD) Artery and Circumflex Artery, and supplies blood to the left side of the heart, which is larger and more muscular because it pumps blood to the rest of the body.
What is Coronary Artery Disease (CAD)?
CHD or CAD is thanks to build up of a waxy substance called plaque (plak) on the inner walls of coronary arteries.
Plaque narrows and stiffens the coronary arteries causing reduced blood-flow to the heart muscle—resulting in angina (chest pain). Plaque build-up also increases the probability of formation of blood clots that may partially or fully block blood-flow—leading to a heart attack.
CAD also called Ischemic Heart Disease (IHD)
CAD/CHD are also called Ischemic Heart Disease (IHD). Ischemic refers to inadequate blood-supply to organs, especially heart muscle.
What causes CAD (or CHD or IHD) ?
CHD is caused when the inner layers of the coronary arteries are damaged. They may get damaged on account of a variety of factors, such as (1)smoking; (2)high percentage of certain fats and cholesterol in the blood; (3)high blood pressure; (4)high sugar in the blood due to insulin resistance; (5)overweight or obesity; (6)lack of physical activity; and (7)unhealthy diet. Other causes of CHD can be (a)old age (over 45 in men and over 55 in women) and (b)family history of early heart CHD.
Electrocardiogram (ECG), Stress Test and Chest X-ray help in diagnosing CAD. ECG records heart’s electrical activity: how fast it is beating; its rhythm (steady or irregular); strength and timing of electrical signals as they pass through the heart. ECG can show signs of heart damage due to CHD and signs of a previous or current heart attack. However, in some angina-affected persons, ECG comes out normal (like it had in my case when I had gone for health check-up on 15 December 1999)! Even Stress Test may come out normal, like it had in my case!!
Two-Dimensional Echocardiogram (2D Echo)
This was not done for me in 1999, but was done in 2014. I would therefore postpone its details to the next part (IV) of this blog-post.
What is Angiography (CAG)?
In Coronary Angiography (CAG) an iodine dye (a radio-opaque contrast agent) is injected into the blood-vessel and images (called angiographs or angiograms) are taken using X-ray based techniques such as fluoroscopy. A thin, flexible tube called a catheter is inserted into either the femoral artery in the groin in the thigh, or in the artery in the wrist. The catheter is threaded into coronary arteries, and the dye is released into bloodstream. Special X-ray photographs are taken while the dye is flowing through coronary arteries. The dye lets doctor study the flow of blood through the heart.
Anaesthesia is not given for angiography, and the patient can watch the screen showing the progress, though he or she can’t make much out of it.
It is painful when a hole is done in the artery for the catheter. However, the CAG itself is not generally painful, and lasts about 40 to 60 minutes—may take longer too.
What is Angioplasty?
Angiography is for diagnosis, to find blockages, if any, in the coronary arteries; while angioplasty is the cure to tackle those blockages.
Angioplasty is also called Percutaneous Transluminal Coronary Angioplasty (PTCA).
In angioplasty, an empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed location of the artery and then inflated to a high pressure. The balloon forces expansion of the inner plaque deposits and the surrounding muscular wall, opening up the blood vessel for improved flow.
A small mesh tube called a stent is usually placed in the artery as a scaffold to ensure it remains open. When a stent is used, it is ready-prepared around a balloon before it's inserted, and expands when the balloon is inflated, and remains in place when the balloon is deflated and removed.
There are two main types of stents: (1)Bare metal (uncoated) stent; and (2)Drug-eluting stent, which is coated with medication that reduces the risk of the artery becoming blocked again. Drug-eluting stent can’t be used in certain cases.
The procedure takes about two hours. Recovery from angioplasty takes only a few days.
My Angiography & Angioplasty
But for my head, they shaved me from top to bottom. The guy who did it was an expert and carried out the operations skilfully, without any discomfort to me. But, it was in that process that the realisation dawned upon me that something much more serious was about to happen.
Operation Groin Hole
Then I was told that for angiography they would need to keep me ready with a small hole made into my groin to facilitate catheter go up the artery. As I lay still, the hole was made, but the blood forcefully spurted out. I could feel severe pain, but all I could see lying down were tears streaming down the eyes of the two nurses holding me. Somehow, the blood-flow was managed, and “operation groin hole” was declared successful.
Angiography, as I experienced it
Angiography is (was) done without anaesthesia. I was asked to lie down flat on my back with my arms up horizontally, almost touching my ears and head on each side. It was this constant position of arms that was more painful and uncomfortable compared to the angiography itself. It pained a little when they inserted the catheter up my groin (through the hole previously made) through the artery. They gradually moved the catheter up. I could see a wire struggling to move up on the screen. There were moments when you felt a burning sensation and pain. Based on the process the cardiologists could tell where the blockage, if any, lay. However, to me nothing of the sort was visible, except a dangling wire and some splashes. Watching the screen, I didn’t even feel it was my inside on display. It was as if some external body was being explored—at the expense of some occasional pain/burning sensation to me.
It was all over fairly quickly. Not more than 40 minutes.
Angioplasty, as I experienced it
I was told later the result of the angiography: one over 90% blockage in a vital artery—LAD. Angioplasty was scheduled two days after the angiography.
Angioplasty is (was) also done without anaesthesia. Again, a catheter was inserted up the ready-made hole in the groin, but this time with a balloon and a stent. I, from the patient’s angle, didn’t find any significant difference between angiography and angioplasty. Angioplasty took over an hour.
After angioplasty I remained in the ICCU for about two days and was then shifted to ward.
Convalescence or recuperation didn’t seem to be much of an issue, for I had been feeling normal. The only issue was insulin which had to be administered to me before break-fast, lunch and dinner. It was only that which made me feel I was unwell.
Back at Home & Office
After a few days I was back at home.
A nurse (there was a mini-hospital in our building) used to come to administer insulin, thanks to the newly picked up diabetes along with CHD. This diabetes business upset me because I didn’t have it before.
After a gap, mainly on account of the temporary insulin phase, I was back at the office, as busy as ever on the project.
Thankfully, angiography and angioplasty do not put you out of action as recovery from them is fast.
I had given up smoking on 16 December 1999. My food and other habits have any way been always healthy.
Forward to 2014: Next two parts of this blog-post.
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Monday, August 11, 2014
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