Friday, January 23, 2015

Luis Gets a Pacemaker

Luis' heart malfunctioned.  A healthy vital and active man, he suddenly could not walk to his car without fatigue and feeling winded.  A trip to the doctor showed his heart rate was too low and a trip to the cardiologist showed he had good heart muscle but the electrical conduction of his heart was not working. He needed a pacemaker. It would be an overight stay.

He was scheduled for the procedure at MidAmerica Heart Institute, which happens to be a premier cardiovascular facility in the country.

Dr. Sanjaya Gupta is a handsome, young internist/ cardiac eletrophysiologist.  With illustrations on his Ipad, he explains to us what happened.  Your heart, he says, is strong but the electrical circuitry is faulty.  As people age the electrical circuitry degenerates much like the electrical wiring in an old house.  The wires degrade, has erratic conduction causing the lights to flicker and eventually not turn on at all.

He explains that in the heart are specialized heart muscles which function solely to conduct electricity to trigger heart contraction.  It starts at the sinus node to pace the atria that pump blood to the ventricles then to the atrio-ventricular node to pump blood out.  Luis' sinus node was fine but the AV node had failed completely.  The resulting heart action could sustain the resting body but not body in action.  He needed a pacemaker.

Dr. Gupta explains the procedure.  He makes a 3 inch incision by the collarbone where he can access the vena cava, a huge vein that receives blood from the rest of the body.  He threads titanium wires encased in silicone, the size of a spaghetti noodle inside the heart and positions it somewhere in the lower part of the ventricles where he screws it.  Once in place, the pacemaker, the weight of 2 silver dollars, is inserted under the skin.  The pacemaker is programmable for the individual's needs.  Since his sinus node is healthy, the impulses are routed from there to the pacemaker which then paces the ventricles.  It is usually set to a heart rate of 60 to 130 beats per minute.  If needed, down the line, the pacing can be programmed to start at the sinus node.

Luis agreed to the procedure but he did not want to be awake during the surgery.  The doctor and the nurse anesthetist assured him he would be in dreamland.

The procedure took 90 minutes.  Dr. Gupta explained how the procedure went.  He said he is always thrilled when the heart accepts the pacemaker and readily gives up the function to the device.  The only restriction post-op is that for 6 weeks, he not raise his left arm, (the side of the pacemaker) over his head  and not lift any weight with that arm so as not to dislodge the electrodes.  Luis has to take it easy for 6 weeks to give the body time to grow tissues around the titanium wires.  Then he can resume normal activities. (He also has to give up using the chain saw,archery, arc welding, rifle shooting, activities I'm sure may have been in his bucket.)  He receives a software app for his phone so that periodic checks of the device is done simply by placing the phone over the pacemaker.  The wire and electrodes will last his lifetime but the battery needs replacement every 10 years.  The new devices withstand being around microwaves and MRI scans but will trigger the TSA scanner at airports. (He says he does not mind the hand pat but only if done by a beautiful woman.) After the initial 2 week and 3 month checks, he only needs appointments yearly and on the 9.5 year, the battery will be replaced.  I have not found any battery for my computer, phone or car that lasts that long.  The doctor sighs.

So, Luis has a new lease on life.  We did not expect such a life threatening condition but the wonders of modern medicine are prolonging our lives.  I went to medical school in the 60's and respirators were just being put to use then.  We were doing dialysis through the peritoneum and gall bladder surgeries took several weeks of recuperation and time off work.

We are very grateful but as I have been taught in medical school, it is not a matter of adding years to life, but of adding life to years.  So, Luis and I are working on how we can make this life useful and meaningful not only for us both but especially for those lives we touch.

Wednesday, January 14, 2015

Growing Older

Most of the time, I do not see myself as being old.  I am reminded of my age only when I go to bed at night and those darn aches and pains just start getting pesky.  However, I have been thinking of age lately, (ordinarily nothing more than a number.)

This month, I accepted a month long assignment to provide psychiatric coverage in a center for cognitive disorders in Osage Beach, Missouri.  I did it mainly so I could spend some time  in my condo in this resort town that I had not visited in years. In the process of honing my geripsych skills, I have to come to terms with the inevitability of growing old and what that means to me.

My love, Luis, had been suffering from that virus, flu or flu-like whatever that a lot of people have been getting this winter.  He is my age and recalls being felled by illness only once in his life when he had acute appendicitis.  He exercises, eats right, is very involved with his children and is active from dawn to midnight.  He is always coming up with strategies for what he calls living well in our 70's. (Sadly, it includes exercise which is not in my vocabulary. I do yoga already. I protest to him. Is that not enough? He urges me to swim and walk and bike.)

That this flu-like illness would render him at 50 per cent activity is truly unacceptable to him.  And now he has a slow heart rate which precludes him from driving until the doctors can make a definitive treatment plan.  These last two weeks of his body saying, "Wait a minute.  I need to slow down for a moment" is just really difficult for him.

I ask myself.  What happens when denial no longer works for the aging body?  It gives Luis and I pause.  Dying is no big deal.  It is continuing to live a full life in the face of the limitations of a body that has lived too long that requires some thought and preparation.  I am thankful that my children , indulge my independence and have not seen fit to take over my life. I plan to live the rest of my life with purpose and meaning even when I must inevitably accept limitations.

In 2007, Atul Gawande, published an article titled , Rethinking Old Age in the New York Times, where he is a regular contributor. Next to my son-in-law, Alex Tizon, Dr. Gawande is my favorite writer and story teller.  I have been rereading this article lately.  It is as timely now as when he wrote it 8 years ago.  I highly recommend it for anyone who hopes to grow old....someday.


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