Wednesday, September 27, 2006

Little Secrets

He was a huge man, the football-player type, proud, athletic, slightly overweight. Everyone knew him as “Coach.” He stood by the sidelines of all his boys’ games, cheering them on. He had taught legions of young men the game, strategy, and work-ethic of football. But when he could no longer walk the thirty feet to the sideline from his car, he asked his cardiologist and neighbor his options.

After much reluctance, he presented to my office. Suddenly the large-framed man was meek and reserved. “Do I really need this thing?” he asked.

“Here are your options, Coach,” I said. I went on to describe that he had run his course on medications, his heart was getting too weak without some help, and that more conservative measures hadn’t worked. Basically, it was a biventricular defibrillator or heart transplant. He chose the defibrillator.

So when the time came to have his procedure, he was terrified, but stoic. You could see it in his eyes. I asked if he had any last-minute questions. He said “No.” So I turned to prepare my pre-op assessment note and prepare for surgery. But he did have one last request.

“Can I leave my underwear on?” he asked the nurse. “Sure, Coach, it'll be our little secret,” she said in a wonderful gesture to maintain some element of dignity for him.

Off to the operating room he went. Things proceeded smoothly at first. But the first clue to impending problems occurred as we laid him on the table. “Can I sit up?”

We placed a wedge beneath his back to assist his breathing. He was sick as sick could be. Everyone knew it. Everyone knew he had few options left. At 44, he just seemed too young. So we proceeded.

Venous access was easy, and one lead of the three leads was placed without difficulty, but then trouble arose.

“I, I can’t, I can’t breathe! I have to sit up! PLEASE Doc, let me sit up!” And the wrestling match began. “I’ve done this a thousand times, just let me sit up and I’ll be better, PLEASE!” We held him down. With an open wound and no other option for long term therapy, we couldn’t let him rise.

“Call anesthesia, stat. 100% oxygen by facemask, 2 mg morphine, start dobutmaine at 10,” etc., etc., I barked.

Within a minute or two (was it that short?) anesthesia arrived, and the patient was now in dire straights, oxygen level plummeting, heart racing, my sphincter tightening. But with all the skill he could muster, the anesthesiologist placed the endotracheal tube right where it needed to be, and sedated the patient. His blood pressure and oxygenation remained tenuous.

“Call one of the interventional guys and place an arterial line and balloon pump.” Clothes were cut off, the groin area prepped. And once again, the gods answered. The balloon pump added tremendous additional cardiac flow to his weak heart. A foley catheter and new IV’s were placed and he stabilized just long enough to place the biventricular defibrillator, close the wound, and get him out up to the intensive care unit.

Overnight he did better, as his kidneys removed liters and liters of excess fluid from his lungs. The next morning, the breathing tube was removed. We were all eager to see him. But was most impressive to me, was the nurses and techs who wanted to see him, too. After all, they had braved the tense moments, the anxiety, the fear. “Can we follow you up there?” they asked.

“Sure. You guys can cover my back in case he gets mad at me for what we did,” I joked. So up to the ICU we went, our little electrophysiologic entourage.

And there was Coach. Looking exhausted but breathing better than ever. “I don’t rattle anymore,” he said. Everyone was grateful.

Then, time stood still for a moment. The nurse that had been there just before his procedure leaned over to him and whispered shyly and apologetically:

“I know you wanted your underwear on, but I had to cut them off.”

He smiled and said,

“Sweetheart, you're the best. Thank you.”


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