Wednesday, April 22, 2009

4.21.09 the implantation

Today was the D-Day. I showed up at 7am , super-irritable because I had had nothing to eat or drink since 10pm yesterday, and I did not get home with my poor dog Madison until 8:30 pm, racing down from Skippack on the turnpike in the pouring rain. She was supposed to be in an Elizabethan collar for 3 days after emergency surgery for an absessed tooth (that cost her momma $1200) while she wore a Fentanyl patch for pain. I just could not leave her in the collar because not only could she not get out through the dog door with the collar on, but she looked so damn depressed in it; the collar dragging on the floor as she weakly stumbled into the furniture. So off it went, but I was worried she would chew off the patch. If either she or the other dogs ate it they could die. So needless to day there was not much time to calmly reflect on how my life was about to change.

At 6:58 am, Mark and I walked into the EP reception area there was an older couple checking in before me. They both were in their seventies, and the reception lady told them to have a seat. Mark whispered in my ear that he was pretty sure that that old guy was getting a pacemaker today, go figure. After the man was called up we could hear him answering the receptionists' questions.

She asked him his date of birth.

“November 11th, 1930.” Mark and I started hysterically giggling.
Like I needed one more reminder that I was too young for this shit.
There they are behind me: the surgery was supposed to take about an hour, but it takes about an hour just for them to prep you. First they take you to a bed and hook you all up with all the leads for the monitors and the blood pressure cup, and put you in a hospital gown ( I was able to keep on my boyshorts and smartwool socks, because last week I froze my toes off.)

I had done the entire EP test with no sedation at all I had toyed with the idea of doing that again this time. ....but after all they were making an incision in my shoulder. Dr. Mark used his surgical expertise to advise me to take as much sedation as they would legally allow.

A number of people came down and talked to me about the procedure and made me sign a bunch of forms. They told me I would have light sedation, or "twilight" but would be awake the whole time. Then the Head Nurse, an Asian woman whose name I cannot remember, marched in. She stuck my IV in and this time it hurt, even with my large easy-to-navigate veins. I found out later that she stuck me with an 18 guage needle, probably because she was in such a damn hurry she did not want to wait for the IV to drain. I was brought on a stretcher to the OR.

(They take latex allergies seriously here)

Then I climbed off the stretcher and into the bathroom, where I peed into a cup so they could see if I was pregnant. I'm not. They lifted me on the operating table where 5 nurses immediately started to work on me, with the asian Head Nurse cracking the whip. She told them, “we have to move fast today because we have two cases.” I mumbled that they did not need to move toooo fast....

They hooked up the IV, put all of my monitor leads and blood pressure cups on (yes, again) then proceeded to scrub my left breast and shoulder with this green cold liquid that felt great running down my back. The OR is kept very cold and I swear they store those plastic patches they use to hook you to the monitors in the refrigerator. Finally I was hooked up and Monique my nurse adjusted some blankets over me. My wool socks kept my feet nice and warm and this was good.

checking the equipment as I was wheeled in

I squinted to look at the monitor and asked the nurse what my heart rate was since they had taken my glasses. My blood pressure was about 110 over 69 or something. My heart rate was 43. Keep in mind that I had no coffee or food this morning; if I had had a cup of coffee it would be 55 or so. I explained to them that if I fell asleep it might drop into the 30s and they should not worry, that was my normal rate. Then they took my glasses away and covered my upper torso with a surgical drape so I could not see anything anyway. Soon Dr. Callans came in and said hello and they told me they were going to add some sedation to the IV since they were "ready to rock and roll." It felt cold going into my arm. Then it felt really nice.

Then Dr. Scollan, the Fellow who works with Dr. Callans, started injecting the site of the pacemaker insertion with lidocaine, "big stick and some burning." They got it all numbed up, then they opened up the site, which was in my delto-pectoral groove my just above my left breast below my shoulder. I was awake the whole time, and could feel the pressure of the incision but not the cut. Monique, my nurse, asked me if I was OK and did I feel any pain. I said I was fine.

We were going to insert the pacer under the muscle, so this was a little more involved surgery than the typical beneath the skin type, but if I did it that usual way you would be able to see the pacer sticking up right underneath my skin since I have very little subcutaneous fat in this area. So to place it beneath the muscle they make the incision, part the pectoralis major muscles, and slide the pacer in between. Needless to say it was not so easy with my anatomy.

The first thing they do once they have you opened up is to lacerate the cephalic vein and thread the 2 leads down into my heart, one in the atrium and one in the ventricle, as in the pic above. The leads are actually about 15 inches long as it is a circuitous route. As this was happening, Monique would monitor my stats and ask me how much pain I was feeling. I was fine for the most part, I would occasionally twitch when the leads hit a part of the vein which brushed against a nerve. They had some difficulty getting the leads where they needed to go. Then the leads needed to be screwed into the pacemaker, which is pictured here
just about actual size, although mine is slightly larger since they wanted to add an extra couple of years of battery. Then the pacemaker needed to be shoved into that little space that they opened up in my delto-pectoral groove. I think is was during this prcess that they hit the nerve that goes down into the funny bone in my arm and from then on I was uncomfortable.

They had some trouble getting it into place. Perhaps they cut the incision too small in an attempt to keep my scar as unnoticeable as possible. It seemed like they were shoving the pacemaker into that hole, tugging and pushing on my flesh. I imagined them grabbing onto my pec muscle with both arms and tugging, stamping on the pacemaker with their feet in an attempt to fit it in, but then they were flushing narcotics into my veins so I was sometimes in a quasi-dreamlike state. Then Dr. Scollan sewed me up, and Dr. Callans made a joke that even Mark would approve of the beautiful job he did. The surgery had already taken longer than expected. I could feel what seemed like dull needles pierce my skin as the lidocaine was starting to wear off. They tested the pacer, I did briefly lose consciousness at this point, and came around to the sounds of strange numbers being called out by a female voice, an exchange of digits that I did not understand, as they did not correspond to heart rate or blood pressure or oxygen. Valerie, the Medtronic rep, was testing the pacer with Dr. Callans. I guess it was the frequency corresponding to voltage readings or something. A this point I was feeling more discomfort. Monique leaned down and asked me if I needed anything. I was picking up on some negative energy in the room, frustration or irritation or something. I heard the doctors speaking in hushed tones to each other.

Apparently the lead in my atrium was not reading.

This means they had to rip open the sutures and basically start over again. They should have injected more lidocaine at this point, because Mark told me later that it only lasts about an hour. Monique asked me if I needed anything for pain. I am not sure why I kept saying, “I’m OK.” I think part of it was I wanted to see if I could get through this procedure with minimal sedation, I had my camera with me and I whispered to Monique that she should take a picture while I was still all bloody and cut open. She whispered back that she did not think she could legally do that. The other reason was it had been my experience that the medicine they used to block pain receptors always make me nauseous. So I said I was fine.

They pulled out the pacer and threaded a new lead into my atrium. Then they screwed it back on the pacer and there was what seemed like a tremendous amount of pushing and pulling to get the pacer back into the pocket. They apologized to me for all of the manhandling. I mumbled cheerily that it was OK, but the combination of the pain and my squeamousness was starting to get me agitated. I believe that at this point the HN realized that they were going to be very late for the second case. I never saw her again.

Then Dr. Scollans sewed me up again, and this time I felt every needle prick. Ouch. I decided I needed to tell Monique they needed to put something in the IV for pain, although at this point the surgery was essentially over. Monique responded and announced that she was giving me x grams of Fentanyl. (yes, the same med that Madison the dog was on)

Valerie called out her numbers again, as this metal mouse-shaped piece of metal was placed over the incision, I felt an electrical current and my heart responded with a flutter, and the voltage was tested, frequencies were adjusted. I guess this time everything came out ok. I barely remember that part, because all of a sudden I was incredibly nauseous. I told them I was feeling really sick, and they looked up at the monitor and said they were going to give me something for the nausea. I found out later that I had gone vagal and my blood pressure had dropped to 60/40 or something, and my heart rate dove well into the 30s. Dr. Callans said to give me Atropine.

Which they did, and whatever else, and the nausea subsided. I was getting very strong hiccups in my diaphragm from the electrical current of the pacer stiumulating my phrenic nerve. This was really annoying. The doctors had left the OR and many of the nurses as well but Monique had to call Dr. Callans back to make another adjustment. Finally they were able to wheel me out of there….around noon.

As I was wheeled out of the OR onto the stretcher the nausea hit me again like a wave. Steve, my nurse from the EP test last week, came over and asked how I was doing. I was sweating profusely, drenched all of a sudden. I mumbled "OK", staring weakly at him. I was sure I was going to throw up. I had turned a ghostly shade of green, my pressure had dropped again and my heart rate monitor was screeching it's alarm. Someone grabbed a plastic hat-shaped thing that you would use to collect a urine sample from someone who had no aim. Suddenly there were 4 nurses hovering around me, and one of them set one of those portable defibrillator units down on the end of the stretcher. I clutched at the plastic dish, and someone injected something else into my IV to bring my pressure up as they wheeled me into recovery. The nausea subsided, I was put into a bed and hooked to everything again, and my mom was called in.

Finally at 12:30, the procedure was over. I was very sore and stiff, but happy to not be throwing up.

I did doze for few minutes, and when I opened my eyes Mark was at my side. He gave me a hug and I asked him if he was between surgeries. He was. He had talked to Dr. Callans and had gotten the scoop about the dead lead. He stayed for about 20 minutes and then had to go back to save someone’s life.

For the next several hours my mother stayed at my side, and we chatted. People would call and I was able to hand her the phone, I did not feel like talking to anyone. About an hour later a nurse wheeled a portable x-ray machine over to me to check to see if during the surgery they had punctured either my heart or my lungs. They had not. Awesome.

I was still getting strong hiccups in my diaphragm so Valerie came back a few hours later and performed some adjustments to the pacer.

Basically the unit was pacing me when it should not be:

As you could see here was I was lying in bed and being paced artificially. It is important that we adjust the pacer so it does not pace me unnecessarily; since 1. it feels weird and 2. it will prematurely wear out my battery. A battery change means more of this stuff that I went thought today; I am in no rush to repeat this drill again.

the view from Valerie's strange suitcase

So finally at 5pm they discharged me, and I was sent home with a prescription of Darvocet. I thought I would only need a couple of days of pills. ha. that's a whole other story.

Anyway, Mark made me fried skate with capers and leek and shiitake mushroom risotto, and then Colin and Michelle came over and there was more food and many laughs. I convinced Michelle to help me make chocolate chip cookies, which we did. I ate 4.

And so ended a very long and life-changing day for me. I slept well that night. I was still under the effects of the sedation (what little there was) and looking forward to mending up and being able to test this new little device of mine on the bike, cauz God knows I am not going to win any beauty contests now with this thing:

before.......and after......

1 comment:

Sabrina said...

Gees, that is a melancholy ending to that dramatic tale. What will it look like when the swelling goes down?