Wednesday, August 31, 2011

After Surgery: All the machines!

So I know that this surgery stuff doesn't really seem relevant for MUSICIAN'S health,but since heart disease is one of the major issues for everybody, maybe it can help a musician or two. Just so many things I learned through this process, such as a DNR does not "expire", you need to ask your surgeon what size valve they are putting in, little things that wouldn't have occurred to me prior to this experience. And of course, one thinks that if the surgery is a success, then all is well. Not always the case. A successful surgery can actually cause other things to happen which can lead to unanticipated problems.

So here we are and the doctors have decided that Mom needs to be reintubated. At that point, she just needed help with breathing. But then a number of things happened. First, the heart muscle went into shock. The part of the heart that had been deprived of blood when the valve was so small, was now receiving the appropriate blood flow. It was not used to this and this sent the "healthy" side of her heart into shock. So a balloon pump went in to support that side (the left) of the heart. Next the kidneys started to fail. By this time she was unconscious and showing signs of edema or fluid retention. Her body was swelling, and she wasn't processing liquids. It was at this point that I actually arrived in the States, having been out of the country teaching prior. The doctors used the term "multi organ failure" when I was speaking to them, and I got the next available plane back to Miami. When I saw her in the Surgical ICU unit, she was unrecognizable. Her body was swollen, she was unconscious, and every machine available was plugged in to her, except dialysis. That was added the next day. She was unresponsive and it really did not look good. To add to that, I couldn't enter the room, having come down with a cold on the plane. I could wear a mask and sit outside the door and call to her. So that is what we did. My sister and I were at the hospital almost 24 hours a day, talking, singing, reading and connecting with her. We were also very present with the doctors and the nurses. Everything that was done, we discussed with each other and with them. The only problem was when we were discussing her DNR, signed in 1995. We were told by one doctor that it had "expired". This doesn't happen. For the record, unless it is rescinded by the person who originally filed it, a DNR stays in effect. Fortunately we did not need to implement it. After the dialysis started, her situation began to improve. One by one, the machines were removed, beginning with the dialysis machine. Then the aortic pump was removed, then other apparatus, until we were left with the ventilator. I informed the doctors and nurses, that they had better make sure it was the correct time to take her off the ventilator, because it wasn't going back, so they were aware of necessity of making sure that they didn't do it too early. And when it finally came out, we were on the way. But there were still a number of hurdles to overcome. Next: ICU psychosis (who knew?)

Wednesday, August 3, 2011

The Surgery and Beyond

So the surgery to replace Mom’s heart valve was supposed to be a minimally invasive procedure where they would make an incision between the ribs and replace the valve without having to crack the breastbone etc. Needless to say, this is NOT what happened. It turned out that the blood vessels surrounding the valve had grown too calcified to allow for this type of procedure. Additionally, because the original valve was too small, the space into which the valve needed to be inserted was not sufficient. This was not determined until after they had opened up the chest. At this point another series of bypasses were required in order to create room for the new mechanical valve that they wanted to put in. So all of a sudden we went from a minimally invasive 1 procedure surgery to an open chest with multiple procedures required. The surgery also took considerably longer than originally anticipated. All of this made the outlook for recovery less than optimal.

While in surgery, of course she was intubated, a machine was substituting for her heart and her body temperature was lowered to minimize the risk of damage to the brain. In the recovery room, she remained intubated as they slowly warmed the body and began to try to bring her back to consciousness. The goal is to remove the breathing tube and other machines as soon as possible and get the patient up and running fairly quickly. This actually increases the chances of a full recovery. It also is the only way to assess whether there has been any loss of brain function. Only when the patient is conscious and can respond to stimuli and questions can their mental status be evaluated. By the second day, they had removed the ventilator. Unfortunately she wasn’t responding as they had hoped. She seemed disoriented, in a lot of pain, and really not recognizing her surroundings. Now here’s the thing. Mom has a DNR. The hospital was fully aware of the DNR, it was in her file etc. However, one thing to remember, is that when a procedure is performed in support of another surgical procedure, it may not be subject to(nor should it be subject to) the restrictions that come with the DNR. If she had had a heart attack and entered the hospital with a DNR, they would not have intubated her nor performed any extraordinary life saving procedures, including ventilators etc. But this is a different set of circumstances. She agreed to the surgery, so she agreed to the supportive care following the surgery. Therefore, if reintubation is needed that can and possibly should be done. This is exactly what happened. The plan was to reintubate and then support her through the next couple of days until she was stronger and began breathing on her own. Unfortunately things went from bad to worse at this point.

Next: All the machines!