Thoughts on Surgery | Andokides' Porch

Thoughts post-surgery

Prep: It’s not yet 6am. I’ve been up since 3:30 or so. I’ve already had my vitals measured and recorded, and I have confirmed my full name and date of birth for maybe the dozenth time. I’m lying on a gurney, naked, while a middle-aged African American woman who probably makes minimum wage and who likely supplements her income with government food assistance, who must have gotten here by car because MARTA, the local transit system, doesn’t start running until 5am--I’m lying on this gurney naked while this woman takes a razor and shaves me bare from neck to knees. I haven’t looked like this since I was eleven or twelve. This woman wielding the razor, denuding my genitals is the only person I’ve met in my visits to the hospital so far who isn’t so cheerful that you might think you were at Disneyland. She doesn’t do the post-shave antibiotic scrub as prescribed in the handouts and prep instructions I’ve been given. I don’t dare call her on it. I’ve already had to do two antibiotic scrubs myself. I live near this woman. Not this woman specifically, but I ride the train with her daily. She gets off at my stop in her scrubs after a long shift and catches a bus home where her children are waiting to be fed and cared for. Right now, as she finishes up with the razor, I’m hoping she has more to be happy about than is immediately apparent to me. I vow, if this surgery is successful, to vote for Bernie Sanders.

Surgery: I remember being wheeled into the OR and being positioned under the huge round operating lights, like flying saucers hovering over me, ready to transport me to Alpha Centauri. Right now, I’d rather risk that trip than undergo this surgery. I’m terrified. A major disadvantage to having time to plan for this surgery rather than having it come upon me unexpectedly: there’s a lot more time for the imagination to run wild. The nightmares can be spectacular. Despite the situation, I make a weak attempt at a joke. “Oh, I must have gotten the part,” I said as I looked at the array of lights. I don’t know that anyone heard. That’s the last thing I remember before waking up in the cardiac ICU.

The technique pioneered by my surgeon bears the acronym LEAR for “lateral endoscopic assisted by robots,” and is considered “minimally invasive.” “Minimally invasive” must be considered relative to other available techniques. This is not Dr. McCoy of the Starship Enterprise waving his magic sensor. Here’s what I glean from the surgery report. They shut down the heart and the lungs and put me on a heart-lung bypass machine through incisions in the neck and groin. This all happened “uneventfully” according to the surgical report. Had the patient’s perspective been included, “uneventfully” might not have been the adverb chosen. They collapsed the right lung in order to reach the heart from the right side of the chest and “docked” the robot through five incisions in between ribs on the right side of the chest. Happily, I have wide spaces between my ribs, so no breaking of bones or even significant stretching was necessary. Somewhere in here, the pericardium was opened, and that’s when we got down to business. “Back at the robot the left atrium was then opened and a sump was placed in the back of the left atrium, and the septum was retracted anteriorly. We got good exposure of the valve. There was rather a broad segment of prolapse of the posterior leaflet including P2 and P3. This was repaired with 3 sets of artificial chords and 1 small plication between P2 and P3. We placed a #23 band from trigone to trigone with running 4-0 Gore-Tex.” In other words, my heart is now held together with a combination of modern miracle fibers—Dacron, Gore-Tex, and a very expensive washer, the only washer I’ve ever known that has a serial number. My heart is now fully outfitted to go camping. “We also closed the orifice of the left atrial appendage. We had a good valve test. Copiously irrigated out the left atrium and left ventricle, and then closed the atriotomy with a vent across the valve. We de-aired the heart and then released the balloon occlusion. The heart spontaneously defibrillated. We then further de-aired, and then removed the vent and tied down the atriotomy. We pulled back the instruments and ventilated both lungs. We rewarmed and we then weaned from bypass with good hemodynamics. … We looked in the right chest, and there was no bleeding seen. We placed a chest tube through the right arm hole. All incisions were then closed in layers. Patient was changed to an oral airway from the endotracheal tube, and was transported to intensive care in stable condition.” If the prose is not breathtaking, the procedure apparently was.

The ICU: The ICU was experienced through a pharmaceutical haze. Imagine being on Quaaludes in a bad Las Vegas casino. There’s a continuous background of chimes and bells, but they’re very slow. There are red and green and blue blinking lights, some of them displaying digits, but not in the profusion found in a casino, and there are no ecstatic celebrations of a jackpot, not even occasionally. In the casino, it’s the booze; in the ICU, it’s the drugs; either one enhances the temporal dislocation that the ICU has in common with a casino. There are no windows; the activity level remains relatively constant 24/7. Is it noon? Is it morning? Is it evening? Except for the delivery of the food trays, who would know?

Hospital Hierarchy: Hospitals, like the Church of Scientology, the Roman Catholic Church, and the military, are strictly hierarchical institutions, and as with the churches in question and the military, they use uniforms to signal rank. According to a handout provided to patients at Emory St. Joseph’s, “Nurses wear navy blue and white. Nurse Techs red and black [as do devotees of Richard Wagner]. Respiratory Therapist[s] wear olive green. Department Secretaries wear khaki. Housekeepers wear brown.” Presumably doctors and physician’s assistants wear whatever they want, but they weren’t on the ward very often, and when they were, the preferred uniform was the white smock or jacket. There is a scholarly treatise to be written (if it hasn’t been already) on the semiotics of the hospital. When I was moved from the ICU to the recovery ward, I was asked to change my hospital-issue socks from the purple pair I’d put on prior to surgery to a light blue pair. Perhaps if I had become disoriented or had tried to escape, they would have known where to return me. I believe the light blue might have been a step up in the order of patients.

“How are you doing?”: “How are you doing?” has been the repeated (and appreciated) query from family and friends since I was sent home. But I don’t really know how to answer. “They say I’m doing extremely well,” has been my response. I’m really not qualified to judge. While in the hospital, I was surrounded with people for whom heart surgery is a part of daily life. They had a raft of data and were intimately familiar with the norms of recovery. The cardiac recovery nurses and staff could, at any given moment, tell me exactly how I was doing. “You’re doing great!” “Oh, yeah, that’s perfectly normal.” And then they cast me out on my own. This is, I ardently hope, the only time I will ever have heart surgery. I have no idea what the norms are or what to expect. Now, almost two months out, I’ve not returned to pre-surgery activity levels. I get winded easily, and I tire relatively quickly. So, how am I doing? By some measures, not as well as before surgery. On the other hand, I’ve now had two follow-ups with my surgeon and one with my new cardiologist. Both seem to feel that my progress has been excellent. My cardiologist had to sign a form permitting me to begin a new fitness regimen with a personal trainer at Georgia State. He chose to explain the decision not to send me to cardiac rehabilitation with a quick “too healthy.” He assures me that returning to pre-surgery levels or even “better than ever” (I’ve never had a fully functioning heart, after all) is not an unreasonable expectation, but that it could take a few months. He sees no need to see me again until December.

And herein lies the paradoxical character of an advanced surgical technique such as LEAR: the outward visible signs are incommensurate with the underlying impacts. Just shy of two weeks after surgery, I, with my surgeon’s blessing, returned to swim practice with my Master’s team. I looked a bit as if I had gotten into a fight with a vampire and a flock of buzzards. One of my teammates ventured to ask what had happened to me. In front of most people, though, I wear more clothes than I do at swim practice, and there’s little evidence that I’ve recently had major surgery. Even at the pool, the evidence is fast diminishing. Casual acquaintances think I must have had something on the order of hernia repair. My surgeon got inside the chest in a neater, cleaner, less obtrusive way than the old sternotomy, but once inside, the same things were done. It has been difficult, even for me, to reconcile the external evidence with the persistence of the internal symptoms.

An experience such as heart surgery, because it is so extraordinary, diminishes one’s own authority regarding one’s own status. When in the course of everyday life we are asked “How are you?” we answer relative to the considerable database we have composed of our own experiences over our lifetime and of what we know about the world and the experiences of others. When we are uprooted from the quotidian realm and placed in what, for us, are singular circumstances—the death of a life partner or a parent, for example, a serious surgery, surviving a terrible accident, witnessing something horrific--we have no normative data except for our own norms, which have been rendered irrelevant. It provides no real illumination, in such a condition, to answer “How are you?” with “I’m not my usual self,” but it’s the only true answer we can provide, and it reveals the alienation from self that such experiences induce.

What the body remembers: There was one small issue following my surgery, a syndrome with the acronym SAM for “systolic anterior motion.” With an extremely low dose of blood pressure medication, it seems to be under control, so much so that the cardiologist who read an echocardiogram done two weeks after surgery missed it completely. My surgeon saw it because he knew exactly what he was looking for. Still, there was a period of about a week while waiting for the results of this post-op echo that a “re-do” was put on the table as a possibility. I got chilled at the very possibility—my entire body reacted to the suggestion--and for a week, my anxiety level was as high or higher than it had been leading up to the surgery. Modern anesthetics are a miracle. My most painful conscious experiences in this whole process were having the urethral catheter and the chest tube removed. There has been nothing horrible in any of this. Yet my reaction to the suggestion that a second surgery might be needed tells me that the body remembers even when the brain has been taken out of circulation. I don’t know my neurophysiology well enough to provide a technical theory, but the body experiences trauma, and even if that experience is prevented from reaching the conscious brain, somewhere in our nervous system, we store that information, and it exerts an influence over the way we see the world from then on.