Emergency
It was Tuesday, August 2, 2016. I was 55 at the time and in fair to good health. Or, at least like most people, I thought I was. I mean, I have Chronic Kidney Disease (IgA Nephropathy), Barrett's Esophagus due to a hiatal hernia, and borderline hypertension. But, all of that has been under control.
I had gotten up for work just like most days, at 5:15 am. Nothing out of the ordinary. Nothing to worry about. Everything seemed fine. Again, just another typical work day. It gets to be about 7:00 am, and I’m five minutes away from leaving the house. I’m in the bathroom brushing my teeth, the last thing in my ritual of getting ready for the day. Then, it's off to work.
Lucky for me, I am not yet on my way, a half hour commute, driving alone in my car. If I had, I don’t think I would be here telling this story.
I just put my toothbrush away, and that’s when it happens. Without any prior warning or symptom, I'm struck with a sudden, intense pain in my chest. I reel a bit from the shock of it. Besides a feeling of extreme tightness, as if I’m having a Charlie Horse in my chest muscles, there's also a burning, tearing sensation, like something being ripped apart inside my chest. I’m in a lot of pain and panic immediately sets in. There is no mistaking that something terrible has just happened. This isn’t heartburn. This isn’t indigestion. My first thought is that I’m having a heart attack. Frightened, but still able to walk, I make my way into the living room to find my wife, Carole.
I don’t want to scare Carole, but I know I need help – immediately! I blankly tell her that I have this terrible pain across my chest. She can tell from my expression that there is something serious going on. She asks me to describe the pain. I don’t know what to say except that my chest really hurts and that it feels wrong, that it is something I never felt before. I sit down in our armchair and hold my chest.
Carole asks if I need an ambulance or if it is ok for her to drive me to the emergency room. I feel that it should be OK to drive there ourselves. So, Carole tells me that she needs to go and get dressed. She rushes back into our bedroom. Feeling a bit uneasy, I lie down upon our living room floor. I’m still thinking that I’m having a heart attack. So does my wife, for she comes back and has me swallow an aspirin. I can see the panic in her face, and I can hear it in her voice. As Carole leaves to get dressed, she keeps talking with me. I later find out that she was making sure that I was still OK. It turns out to be a good thing she does, because I eventually pass out. I soon awaken to my wife frantically calling my name, urging me to regain consciousness, yelling for me to not die on her. She tells me that I had passed out. I deny it, though I cannot remember the last minute or so. Now beyond worried, she forgoes driving me to the hospital and calls 911. This is where my memory of the day becomes unclear. I remember the EMTs coming into our house, bending over me on the floor, and asking me what happened and how am I feeling. They are very calm and talk to me nonchalantly, trying to ease both Carole's and my fear.
Once the situation was explained, the EMTs take my blood pressure and check other vital signs. I hear my wife telling them that I had passed out, which I still don’t fully realize because my mind is now a bit fuzzy. I do understand that things are not good, but I feel better knowing that at least professional help is there. After getting me onto a gurney, the EMTs wheel me out of the house and into the ambulance. Realizing how serious this is, I think I start going into shock. What the hell is going on? Just how serious is this? I finally begin to think, am I going to die?
I notice that my right hip begins to hurt. The pain isn’t too bad, at least not yet, and I don't think much about it. After a minute or so, the ambulance finally begins moving and soon I am on my way to St. John’s Methodist Hospital. The hospital is probably about twenty minutes away with normal traffic and lights. Once outside my neighborhood, I hear the sirens turn on. It reinforces to me about how critical things are. I still can’t believe this is real.
On route to the hospital, my chest pain gives way to an excruciating pain in my right hip and leg. The pain is not sharp, but it is strong and uncomfortable, as if someone jammed a large metal ball underneath my upper leg muscle and then pressed down hard on it. It is the type of pain that grows over time, becoming more unbearable with each minute. I begin crying out from the pain. I would find out later that the hip and leg pain was due to a lack of blood flow to my leg muscle. From here on, my memory is sketchy at best. It's now sometime between 8:00 and 9:00 in the morning. I don’t remember getting to the hospital or talking with any of the doctors or nurses or even having an examination done. I do have a vague recollection of begging incessantly for pain medication for my leg and hip, the pain has become intolerable. But, apparently, the doctor cannot give me pain medications yet until they figure out what is going on. This will be my last memory of the day even though my wife later tells me I was awake throughout the time until my surgery, which will be hours later.
What I will eventually learn about what happened to me at St. John's Methodist Hospital ER is that the ER doctor, Dr. Denise Ryan, had the insight to suspect my condition – an aortic dissection due to aneurysm. This is a rare and often fatal condition, and not many doctors encounter it. Therefore, some don’t consider it. Since my event, I have heard a few horror stories about how some doctors misdiagnose the symptoms of an aortic dissection. Apparently, once a heart attack is ruled out and not having any other indicative lab results, some doctors chalk up the chest pain to indigestion or some other minor condition. The patient may even be sent home, which is dire considering how time sensitive an aortic dissection and aneurysm can be. This time, however, I am one of the lucky ones. I am so grateful that the staff at St. Johns was aware of the possibility. Having checked my blood pressure, the ER nurse saw that the pressure in my one arm was significantly different than my other arm – an indicator of an aortic dissection. Without delay, Dr. Ryan orders a CT scan to confirm. Once my condition is confirmed by the scan, Carole is told that I need cardiac surgery – immediately. In fact, I am to be life-flighted to Houston Methodist Hospital in the Texas Medical Center since I need a specialist for this type of surgery. Carole is in disbelief. I have gone from a possible heart attack to a life-threatening situation where each second counts.
Later, at Houston Methodist Hospital, Carole is directed to where I am being prepped for surgery, which is a good thing since she is able to answer any questions that the hospital has for me. When I am finally ready, she wishes me well. However, I am apparently still out of it, either from the pain or from the dissection itself, and I'm not very responsive to Carole. This will be the last time Carole sees me before surgery, and she is worried beyond belief. Unfortunately, I don’t remember any of that. I wish I could. However, as I already said, I don’t recall anything else beyond those few fuzzy moments at St. John’s Hospital. Which isn’t all bad because I also don’t remember anything about being transported by helicopter, which is a good thing due to my fear of heights.
Surgery and Cardiac Arrest #1
As it turns out, my luck is still with me. One of the best cardiac surgeons in the world, Dr. Michael Reardon, is there to operate on me. Before performing my surgery, Dr. Reardon explains to Carole about what my surgery will entail. One of the things that he informs her about is that because of the trauma due to my dissection, I will need to have my aortic valve replaced. He tells her there are two options when replacing an aortic valve – a mechanical valve or a biological valve. A mechanical valve lasts longer, but the patient needs to be on blood thinners for the rest of their lives. A biological valve lasts ten to fifteen years, but it does not need blood thinners. Dr. Reardon also discusses that when the time comes to replace my biological valve, it can most likely be done by using a catheter going through an artery (not another invasive surgery). After discussing all of this over with my wife, he asks which one does she wish to use. She has no idea which is better, and asks Dr. Reardon what he would do. With his easy-going demeanor, Dr. Reardon says, “Well, if it was my little brother, I’d go with the biological valve.” That satisfies Carole.
Dr. Reardon assures Carole that I will be fine, that I will survive. I commend Dr. Reardon for being so compassionate with my wife and easing her worry. Carole later tells me that after seeing Dr. Reardon’s calm and confident attitude, she had no idea just how risky my condition really was. That’s because Dr. Reardon made it sound like this is just another routine surgery for him. And, for him, it is probably true. However, I have been told since that my chance of survival that day may have been less than five percent. Not just because of the complexity of the surgery, but because many people don’t even make it to surgery. I’m so glad that Carole did not know this before my surgery.
Well, it seems that my luck will push that five percent survival chance to the limit. When it comes time for my surgery to begin (now about 12:00 or 12:30 PM), I barely manage to make it into the operating room before my blood pressure crashes to zero. In other words, I have a cardiac arrest. This occurs just after being given general anesthesia. Dr. Reardon is forced to start emergency surgery and he begins cutting me open right away.
My surgery will be open heart surgery, which means a sternotomy – my chest cracked open. Once my insides are exposed, Dr. Reardon discovers that the reason my heart has stopped was due to blood pooling around it. Apparently the aneurysm at my aortic root finally ruptured causing it to bleed, and the blood got trapped inside the sac surrounding my heart, the pericardium. The trapped blood exerted too much pressure, or tamponade, on my heart for it to be able to beat. Once Dr. Reardon cuts into the pericardium to relieve the pressure, my blood pressure returns. With the immediate crisis over, Dr. Reardon can continue on to repairing my aorta. For the repair of the aorta, I will first need to be put on a heart-lung bypass machine. An incision is made to my front right shoulder area near the top of my pectoral muscle. A cannula, or tube, is sutured into my right subclavian artery. This tube will supply blood flow coming from the bypass machine. To return blood back to the bypass machine, a sump catheter is placed into my right superior pulmonary vein. Finally, a cardioplegic cannula is placed into my coronary sinus. This last tube is used to supply medication directly to my heart in order to stop it.
Once the bypass machine is hooked up, they begin cooling my body. This is something that I never heard of before. I'll find out later that a lower body temperature during cardiac surgery helps protect my heart, brain and other organs by slowing down my metabolism and reducing the amount of oxygen needed to my organs. The next step is to clamp off my aorta. At this point, Dr. Reardon can deliver the cardioplegia medicine to my heart. He can also open up my aneurysm. When he does this, he discovers that my dissection extends into my left coronary artery. Before repairing my aorta, he cuts free both of my coronary arteries, which branch off of the damaged aortic root. Now severed, my left coronary artery can be repaired by placing rows of sutures in it. And, as planned, my aortic valve leaflets are removed for later replacement. After about thirty minutes of cooling and after the cardioplegia medicine fully kicks in, my heart stops. Dr. Reardon can now begin repair on my aorta. Because of the aneurysm rupture, there is more damage than he expected. He is forced to replace the entire ascending portion of my aorta from the root to the arch. He uses a dacron graft, a synthetic material, for its replacement. I am still in awe that a tube made of synthetic material can replace someone's main blood vessel. Once the graft is sutured in place, blood flow is resumed and my body can start to be warmed again. Next, my new biological aortic valve is put in, but it must be self-constructed by Dr. Reardon to be seated properly. Finally, my coronary arteries are reattached. Holes are cut into the dacron graft and then the arteries are sutured on. All that is left is to wean me off of the bypass machine, unhook everything, insert a chest tube, and close me up.
All in all, my surgery takes about six to seven hours, and I will have been given many units of blood. It is unbelievable how much blood is lost and used for this surgery. But, because I am still "oozing" blood, Dr. Reardon decides to stuff my chest cavity with surgical packing. The consequence of this is that my chest will have to remain open. When I think about that now, I still find it hard to imagine being left with an open chest. It's still a bit unnerving. Anyway, Dr. Reardon plans to close my chest tomorrow once he confirms all my bleeding has stopped. Once bandaged up, I can be taken to the critical care ICU.
Cardiac Arrest #2
Not long after being put in ICU, I will arrest once more. This time for about fifteen minutes.
Dr. Reardon has to reopen my chest. He doesn't find anything significantlly wrong - no ischemia, no bleeding. He deduces that the surgical packing placed against my heart was causing tamponade, and the constriction became too great for my heart to pump (just like what happened to me when the blood from my aneurysm pooled around my heart). Once Dr. Reardon relieves the pressure, I become stable. After forty-five minutes to ensure that all is really good, Dr. Reardon is satisfied that I am out of the woods. I am taken back to the ICU. It is now somewhere between 10:00 pm and 11:00 pm, and there is nothing more that can be done besides wait and pray.
Early the next morning, Dr. Reardon can finally take me back to surgery. When he does, he sees that I am doing fine. I can now be closed up. And, I must say that Dr. Reardon does a remarkable job. Much later, when I finally take a look at my incision wound, my scar is hardly noticeable. In fact, with my chest hair, one might even miss it.
Aftermath
I will remain unconscious for three days, and I will stay in the hospital for three weeks. I will have suffered two minor strokes, either from the surgery or the dissection itself, and I will endure a few complications, such as throat muscle atrophy requiring a feeding tube to be surgically implanted. All of this will be followed by weeks of rehab, months of recovery, and a lot of pain, frustration and depression.
To this day, almost four years later, I must live with my "new normal” due to the physical restrictions necessitated by my dissection. I am happy to be alive, but saddened to have lost some of my future dreams.
Aorta Damage
I had never heard about an aortic dissection before, and I had no idea what it was. What I’ve learned since is that the aorta wall is made up of three layers – the intima, the media and the externa. My aorta aneurysm had stretched my aorta until a tear in the inner aorta wall (the intima) began. From there, blood pushed in-between the layers of the aorta wall, separating the layers. This is a dissection.
My dissection started near the aorta root, close to the heart and continued up the ascending aorta. A dissection in this part of the aorta is called Type A and it is the most dangerous. My dissection continued through the aortic arch, down the descending thoracic aorta, down the abdominal aorta and into my right iliac artery. A dissection in the descending part of the aorta is called Type B.
I also have something called a false lumen in my descending aorta that goes to my right iliac artery. A true lumen is the normal tubular conduit for blood to flow through the aorta. A false lumen is the dissected pathway between the aorta wall layers, resulting from the tear in the wall. My false lumen is patent, or open, meaning that blood is still flowing through it. In fact, my false lumen is supplying blood to my right iliac artery. The disadvantage with this is that the blood pressure in the false lumen can sometimes push down onto the true lumen
restricting its blood flow. Luckily, I am not affected by this.
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As far as what caused this, there is no clear answer for me. Something had to have weakened my aortic wall. For some people, it is due to a connective tissue disorder. Some may have a congenital defect, or have had an injury. Some get this due to uncontrolled or chronic high blood pressure (even from high intensity workouts like heavy weight lifting). Still others get this from other means.
One of those other means is the usage of a class of antibiotics called Fluoroquinolones, like Levaquin. These antibiotics are extremely strong and have been found to weaken the aortic wall. I have taken this type of antibiotics at least a half dozen times. Ruling out the usual causes, my personal feeling is that this is how I contracted this condition. My cardiologist was not aware that Fluoroquinolones could cause a dissection, so he attributed it to high blood pressure and my exercise routine using weights (even though I am no body builder). I also contacted the John Ritter team in Houston and gave them my DNA, but based on my profile, they did not think I have a genetic disposition for dissections. So, it looks like I will never know why.