Possible (part II)

If you haven't read part I please start there.

It was just before being wheeled toward the ambulance that I heard the name of the surgeon who would soon be operating on me - Dr Eric Kirker of The Oregon Clinic. I quickly brought up his bio on my trusty Samsung Charge. I was surprised by how young Dr Kirker was - not that that's a bad thing. Younger surgeons are often trained in newer techniques so this didn't bother me at all.  If I had searched a bit further I might have seen this story on Eric. But even if I had seen the article, I couldn't have known the significance and the how it would soon directly impact me. Eric is one of the very few cardiac surgeons anywhere capable of repairing, instead of simply replacing, a damaged aortic valve.  That he practices close enough at the Oregon Clinic and was available to operate on me was a very lucky break.  He left for vacation just a few days after my surgery.

On the ride in I was imagining that I had a simple bubble or weakening in a small part of the aorta vessel, which could be fixed with the equivalent of a tire patch.  That didn't seem so bad to me.  I joked with the EMR guys about how much I really wanted that helicopter ride.  The said the slow way was always the best way. I must have been a boring ride for them as I only had a single IV line delivering a blood pressure reducer, and otherwise was pretty good.  I brought up a navigator app on my droid (I'm such a geek) so I could follow our progress into Providence Portland Medical Center where the surgery was to take place. I also tried to read some mindless (Stephanie Plum) ebook using the Kindle reader so I didn't have to think much.  Meanwhile Julia had to run around HRM hospital and grab my abandoned bike and then drive home and pack clothes and everything else for both of us for an unknown length of time in Portland, and then chase the ambulance into the big city.  That she managed all that, and did so extremely well with such emotional pressure is incredible.  I'm sure I would rather be in my shoes facing the surgery then in her's not knowing what was going to happen.  OK I need to take a deep breath now...

We arrived at Providence and I was rolled into the ER reception area.  Everyone looked extremely calm, almost bored.  I joked that this was not at all what I was expecting.  I wanted to see doctors running around screaming "Stat, stat!", IV lines flying, blood dripping, and bodies being shocked back to life.  This was clearly not happening.  Everyone laughed. After a few minutes I saw a group of men approaching and immediately recognized Dr Kirker.  He introduced himself and I told him I had already seen his bio.  He thought that was funny.  The next stop was the cat-scan (CT).  This wasn't so funny.  The CT itself is no big deal.  I already had an IV line into which they could easily inject a solution to make my blood show better on the images.  I noticed this on the final pass when my body felt like it was being heated from the inside.  Kind of like being slowly cooked in a microwave I uncomfortably imagined, but the sensation only lasted a minute or so.  I was wheeled out to meet Dr Kirker and the un-fun part really started.

To be easier I'll go with first names.  Eric had a serious look and his eyes were a touch tired.  Later I found out he had been up most of the previous night performing a similar operation to what I was to undergo.  So this is what Eric told me.  I had a 7.6cm dissecting aortic aneurysm.  Dissecting means the internal layers of the aorta are starting to pull apart - in surfing terms it means my aorta was de-laminating (which is usually when you throw away that old board).  The aorta is typically between 3-4 cm as it leaves the heart.  Anything over 4cm is a concern.  6cm is a medical emergency requiring immediate surgery to repair. Many people suffer a rupture and unfortunate sudden death before they get to that point.  Mine was 7.6cm (during the later surgery they actually measured it at 8cm).

It got worse.

The aneurysm had torn open my aortic valve which was subsequently damaged.  The damage caused 40% of the blood pumped by my heart to escape back through the damaged valve and into the left ventricle. Meaning my heart had to pump 40% harder to deliver the equivalent blood. Well that at least nicely explains being a touch tired on some of those long uphill rides!

And it got worse.

The dissection of the aorta continued through the ascending curve and into the descending aorta.  And all the way past my kidneys and to the leg branch.  The only good news was my kidneys appeared to be somehow undamaged despite all of this.  The aneurysm resulted from a fairly common birth defect:  I was born with a bicuspid valve, which has only two flaps instead of the usual and preferred three.  Two flaps put more pressure on the aorta and subsequently can lead to an aneurysm such as this. (so at least it wasn't my bacchanalian lifestyle that caused all my problems).

Whoa!

Eric was looking me straight in the eye and continued. "This is very serious, as serious as it gets.  The survival rate from an operation like this is typically around 50%, but in your case being so fit and stable, which is a very good sign, I'm thinking only a 5% chance of death.  And a 2% chance of a stroke.  I'm going to try and repair your valve.  You're young and very active so this is important.  But if I can't repair the valve, it has to be replaced it with an artificial valve and you need to make a decision.  I can use a bio-mechanical valve which usually needs to be replaced every ten years or so, and that requires another significant surgery. Or I can use a mechanical valve which should last your lifetime.  However mechanical valves require you to stay on blood thinners for the rest of your life, and this can  impact your active lifestyle.

Whoa again!

It's difficult for me to recall  at this moment exactly what I was thinking just then, or if I was thinking at all. I wanted to ask if I still had a tiny chance of returning to my former active lifestyle but that seemed like far too much to hope for. It seemed increasingly likely that simply being alive might be my most optimistic scenario. Things had happened so fast that reality hadn't fully sunk in.  The idea of having a surgery every ten years did not appeal to me.  I told Eric I would choose the mechanical valve. He agreed with that and told me the surgery would happen tomorrow (Tuesday 9/13) at 1pm. This would give him a chance to get a good rest and have all the necessary materials on hand, such as the mechanical valve and sufficient blood.  Again I seemed stable so he didn't see this as a big risk and it improved my outcome. I was happy to hear that, so we shook hands and Eric left.

In part I, I mentioned that I was lucky the aneurysm wasn't discovered on Maui even though it's typically best to catch any disease as early as possible.  It now seems likely that the typhus infection had put more stress on my heart and hastened the dissection process,  but by itself did not cause the aneurysm.  So when I had the typhus its possible I already had a significant aneurysm.  And the problem with that is you cannot fly with such a condition.  Emergency surgery would typically be performed by a non-specialist who would use only the safest and most expedient techniques.  Meaning I would not have had a surgeon as skilled as Eric  and  replacing my valve would be the only option.  Of course in the meantime I could have easily died so many different times as we surfed and windsurfed all winter and spring on the north shore of Maui. Not too mention the summer of mountain biking and windsurfing the gorge. Somehow it seems that my body compensated for everything and allowed me to continue these intense activities as if little was going on.  Everyone is still scratching their heads over that.

I also mentioned that riding the ambulance was a positive sign.  A life flight would have meant the surgery needed to be performed immediately and with less preparation.  And I'm not sure if Eric was available to perform such an immediate critical operation that day, and so again repairing the valve might not have been possible.  Andy, the echo tech, had directly contacted Aly Rahimtoola, a Cardiologist at Providence, who evaluated the images and then went out of his way to personally contact Eric, knowing he was the only surgeon capable of providing the best outcome for me. Aly had also contacted Karen O'Neil the ER doc at HRM and between them decided I was likely to survive an ambulance ride - being very stable - and therefore the surgery could be performed at a more optimal time. (Later I found out that patients with such an extreme aneurysm are often dead within the hour, but again my vitals were all good). All these decisions turned out to be the best for me, but I understand how often the easiest and safest route is taken.  It's always a tough call whether to choose safety or a more aggressive though risky procedure that might provide a better long term outlook.  I do know that right now as I write this I am forever grateful that the riskier path was taken.

But all that had already occurred in the background, and all I knew at the moment was that I was being taken to CICU to wait for surgery.  Around 4pm Julia got to my room. We hugged and she joined me on my bed. I must have put my mind into some kind of zen state because details are a bit fuzzy.  I recall ordering my "last meal" of turkey with mashed potatoes and gravy (wasn't bad, this became "the usual" for dinner).  We watched some MNFB and I remember thinking how as a boy football was everything to me.  Now not so much (of course windsurfing and surfing had really stepped up). I took one of the first sleeping pills of my life. The nurses changed, I got a little suppository to clean me out before surgery (fun!), and Julia stayed with me until they kicked her out at 2:30am (the nurses let her stay until I fell asleep).

Julia spent the night on the couches of the CICU lounge and was right back with me by 8am.  My nurse (one nurse per patient in CICU) came over and explained to me what was going to happen post surgery.  Right now I had one IV delivering saline and the blood pressure reducer (my goal was under 120 and I was pretty close).  In a nutshell she told me I was going to have a lot more tubes going in and out.  A lot more.  Julia and I stayed together on the bed until the anesthesiologist came into my room at 1:15 and said they were ready to begin.  I turned to Julia and told her to please not worry, that I was going to be fine, and that I loved her.  I did believe that my physical shape was going to help so I had some faith.  I told her I would see her soon and they rolled me toward OR.  I remember seeing the surgeons scrubbing and they gave me the injection to put me to sleep.  I was feeling warm and comfy as everything faded to black...

Go to part III.