Tuesday, October 28, 2014

The Wonders of Role Reversal

Another day, another pacemaker, at least so it seemed at first.

The usual greeting the patient, answering the last questions, consent signing, placement of the IV, EKG leads, prepping of the surgical site and initiation of the pre-operative antibiotics were all recent memories.  He laid there, smiling, knowing he'd made the right decision after years of struggling with his arrhythmia in other ways.  His heart was showing signs of slight weakening and his arrhythmias remained too fast despite a multitude of therapies, so he had agreed to proceed with placement of a biventricular pacemaker with later ablation of his AV node some weeks later after his surgical wound was well-healed.

The nurses and technicians in the room were wonderful, reassuring the patient as they moved him to the narrow procedural table.  More wires were connected to monitors and a blood pressure cuff placed. The instrument table laid ready, and the patient's choice of soft rock could be heard faintly in the background.  The pre-sedation note was completed and checklists reviewed.

Meanwhile, I donned by lead, bouffant hair net, headlamp, and face mask, then scrubbed for the procedure.  Shortly thereafter I turned to open the procedure room door with my backside and was quickly greeted to a hearty "Time Out!"  The patient's identity and procedure confirmed, I could see the patient smiling:

"We lawyers like to hear those things," he said.  (Yes, he was a lawyer.*)

"Nurse, make sure you give him a ton of sedation - he'll need it, okay?" I joked.  We laughed together at the thought.

"1 of Versed and 25 mcg of Fentanyl," the nurse shouted to the control room.

"1 and 25," the control room answered.

He and I had struggled together with his arrhythmia for years, finally agreeing that this option at this stage in his arrhythmia's progression would be best. 

I made my way to his side and once again prepped his chest with chlorhexidine prep sticks, letting each dry before the next was applied.   The surgical sight was then drapped to provide an island of an orange plastic film surrounded by a sea of blue paper covering.  Other drapes were secured and a pocket for instruments was made.  "Everybody have lead?" I asked.  The x-ray system was enabled, then the pacemaker system analyzer cable, a SiteRite ultrasound probe and Bovie pen made ready.   All was set to begin.

"Mr. Jones (not his real name), I'm going to start to numb your skin with the local anesthestic.  This will sting," I said.

"Okay..." as he braced himself for inpact.  Then:

"Come-on, doc, you can do better than that!..." as if to mock me, jokingly.

"Yes, I can, " I countered, then proceeded to administer more anesthetic to the area.  As the area became more anesthetized, his shoulder seemed to relax.  No doubt the Versed helped a bit, too.

I continued, locating the appropriate spot, then performing the incision.  He was unaware.  The pocket was created first, then I found the vein and placed the first lead without a problem.  Badda bing, badda boom.  Now for the next…

Then, out of the blue:

"Doc, I heard you're having a knee replacement ... "

"Just a partial, I hope ..."

"Hey, I just want to tell you.  It's the best thing I ever did. Listen, it's not as bad as you think, but there's quite a bit you have to be ready for…  Don't forget to preload the Miralax - that iron supplement before the procedure to slow you down and then the narcotics afterward to stop you up: it's a Machiavellian ploy by those orthopedic surgeons to assure your discomfort."

I chuckled as I thought about this.

"And whatever you do, take the pain medication before physical therapy.  I had a physical therapist threaten to fire me when I failed to take the pain medication 45 minutes before therapy.  And get rid of all those rugs.  It really helps to plan your trips when you get up.  Think about what you need and what you might need to limit your trips.  I'm telling you, this saved my life.  You know I'm writing a book about stuff like this... I'm waiting on the proof. Don't come back too soon.  Have you completed your FMLA forms yet?"


"FMLA.  Look it up.  Loads of fun.  Anyhow, be nice to your wife - you're gonna need her.  Trust me on this..."

And on and on it went: patient treating doctor, until his pacemaker was done.  Then, finally, I had a chance to reciprocate:

"I'm closing."

"Thanks, doc, and good luck.  You're going to do fine."


* ... yes, he gave me permission to tell this story.

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