Bypass: Postscript

When you write about something like bypass surgery most people expect a Readers’ Digest-ish paean to the human spirit.

Friend Vikram Rajaram was one of many readers surprised by the levity of tone and profusion of bawdy and naughty bits in my account. He also had a fair question.

“What gives one the strength?”

As with most questions there is a short answer and a long answer. The short answer involves a cow. But the long answer first.

You get your strength, my friend, from those around you. The family rally around. All families do. To what extent they comprehend what is happening, beyond a universal dread of major surgery, makes a difference. All families deal with adversity. Knowing how well equipped yours is, helps.

Being in a position to pick and choose the people, the place and the timing for the procedure, helps. Having the family participate in this process, helps.

The patient, eventually, has to do nothing. Everyone else deserves a great vote of thanks.

Kusum and Alok, first, for dealing skilfully, lovingly and patiently with a difficult person. An even more difficult patient.

Favourite cardiologist Dr. Sugandhi Gopal who determined that it was time to determine what was going on. Dr. Subhash Chandra who actually did the angiography. Friends in the medical profession who guided the decision process after the angiogram. Dr. M M Chengappa, Dr Anu Chengappa, Dr. Ramana Rao and Dr. Mysore Nagendran. Thank you, all.

Getting a surgical team who are as good as any in the world, and can talk to you all the way to and through the entire process, really helps. Hats off to Dr. Ganesh Iyer, and his colleagues, Dr. Gangadhar and Dr. Bhaskar, at the Manipal hospital. Many thanks for your skills, and more for your empathy.

Getting a service team at the hospital that constantly delivers beyond expectations and beyond the call of duty, is worth far more than one imagines. Most of them come from God’s own country, Kerala. And serve humanity, from Bangalore to Benghazi to Baltimore, like no other people do. One day some future Margaret Mead will research and explain this phenomenon. For now, unlimited and never-ending gratitude to the Florences and Angels, too numerous to list.

A salute to the physiotherapists who led the recovery effort. The comforting Prem, the persuasive Sakshi and the provocative Palak. They also laid down a lifelong exercise regime for me to follow. To be candid, I resent that last bit a bit.

Those who donated blood. Lawrence Tony, Vinoo Krishnan, Indu Das, and Abha Jhol. How do I thank you adequately, for this ultimate gift?

One person who packs a sturdy soul in a compact frame, daughter-in-law Priyanka, does not feature in this account as she was hijacked by an itinerant virus. She was with us all in spirit all through.

Some of those whom I have lost, came to visit me disguised as thoughts. Au revoir.

The most difficult time for the family is when the actual procedure is on. Those unending six hours are pure agony for those outside. Thank you Santosh Jhol, for bringing it home to me in stark terms, when the procedure was still being scheduled.

Those who came in that day and sat by with Kusum and Alok  helped more than anyone else. To bro-in-law Satish Khanna, aunty Gayatri Seth, uncle Rajinder Seth, and honorary family members, Abha Jhol and Vikram Rajaram, a heartfelt thank you. Nowhere near enough I know. Vikram, you’ve stood by us all through the very difficult year and half that we have just gone through.

That is the kind of support that one draws strength from.

And inner strength? 

That is where the cow comes in.

When I was five or so my parents decided that a daughter added to the two sons they had would complete the family. In due course a bonnie lass was born.

While the rest of us were fed regular milk that came from a cow, she, after being weaned, was fed some concoction that came in a “Made In England” tin, which bore the strange name “Cow & Gate”. The label depicted a pastoral landscape featuring a well endowed cow and a gate leading, presumably, to a farm.

At some stage a parent explained that the delicious, creamish and sweetish powder was made from vacuum dried cow’s milk and secret ingredient ‘x’, which made it better than the actual stuff you bought from the local guy with his harem of cows.

It took a while, but I finally understood that there was just no way to establish that the stuff could actually make your child stronger. It was just a matter of perception.

That is what inner strength is. A matter of perception. You are strong if you think you are. Not if not.

PS: There is a question raised by many readers who found my use of the diminutive and inclusive personal pronoun ‘we’ in place of the megalomaniacal and egoistic “I”. All I can say is that that is how it came to me as I sat down to write. No offence meant.

Bypass IV: Going Home

"How long before we can get back to the golf course?" is the question we had posed to all the surgeons and cardiologists we met in our pre-surgery rounds.

"Two months" was the answer. Standard deviation : nil. Considering their diverse backgrounds, it is obviously a figure approved by the IMC, the RCS and the FDA not to mention the International Golfer's union. Or mandated by God. It also turns out to be accurate.

No one told us how hard we would have to work to get there. We thought the two months will be like an extended recovery from a nasty flu. Lie back and get unending TLC. All needs, whims and fancies met. We know how to deal with that.

Reality Bites
Shortly after we are ferried back from the ICU, and before we have settled in, the young physio-therapist turns up with an equally young associate. Manuben One has a piercing gaze and holds our attention effortlessly as she describes in a soft voice the physical routines we have to follow. Manu Two has dancing eyes that dare us to look away as she demos an exercise or corrects what we are doing .

Walking Solves Everything
The first thing they teach is to Suck and Blow. The exercise tool for lungs is a plastic contraption with a teat and balls. Suck ten times. Blow ten times. Repeat till the balls are jumping around happily.

Next come exercises for the chest, arms and legs. Fatigue is not an excuse, it earns a very short respite. In no time they have us standing up and trying to take a step. Alok and Kusum told to encourage us to do the routines as often as possible. They take it very seriously. They hassle, cajole and help us.

In three days the Manus have us walking out of our rooms and around the corridors to cheering from nursing staff much like a one year old gets when he takes his first few steps. On the fourth day they take us up and down a flight of stairs.

Talking Helps
All three surgeons visit us every day at different times. They never miss. One day they come even after a sixteen hour overnight surgery. Hats off.

Surgeons Two and Three are primarily on check up rounds. Removing sundry detritus left behind by the procedure. Questions are asked and are answered. By them and by us. Medication for pain management as also for regulating liquid and solid input-output is constantly fine tuned. The dressings come off. As do the pacemaker wires inserted 'just in case'. Very businesslike.

Surgeon One comes in the evening. His visit is more like a social visit. He sits down with the family and we have a natter running to half an hour or so. This, more than anything else, helps us mentally along the path to recovery and gives everyone the confidence that things are turning out well.

He apologises, almost, for the hospital food. We discover his favourite sin food is Samosa. His wife has learnt not to expect him with certainty for any meal. Somewhere along the line he also takes a quick look at how we are coming along physically.

He takes us through what is happening and will happen inside our body. The refurbished heart he has fashioned for us should serve us well for 12 to 15 years if we take good care of it. The fractured rib cage he has given us will never heal. The veins he harvested will leave our lower legs numb for months to come with shooting pain from time to time.

The first evening he cautions: Be prepared for good days and bad.

A Horrible Day
The third day after surgery is the worst we will go through in this episode of our life. We don't sleep well, waking up again and again to answer the call of the diuretic we have been given. Kusum sits up all night by our side. Alok lies awake on a couch in the living room, jumping up every now and then as we stir noisily. A she-dracula turns up before dawn to draw blood. The bath service arrives at 7 a.m. and is followed shortly thereafter by house keeping and then by breakfast.

By 9 a.m. we are through for the day. Washed out. Manu One and Two arrive at the appointed time. For the first time in our life we turn away attractive young women. They make two more attempts during the day before giving up in pouty good grace.

When Surgeon Three arrives for the first medical call, we lay down the law. Henceforth, no one will disturb us before 8 a.m. He instructs the staff nurse. Thank you. Then onwards everything is tickety-boo.

Chalo Ghar 

On the fifth day out of the operation theatre, Surgeon One tells us that they are done with us. They will carry out a few tests the next day and if all is as expected we can go home the day after. That would be three days short of the plan.

The next day Florence One, after doing whatever tests can be done in the rooms, sends us off in a wheel chair with a pilot to the lab for an echo-cardiogram. Alok is our escort this time.

The Ultimate Test
As we wait, bored to distraction, in the Sunday-quiet corridor for the elevator to the lab floor, we hear a clickety-clack approaching from behind us. As it nears, we look south-south-east to find a pair of red stiletto heels leading to well turned ankles leading on to slim fit denim jeans leading further north to a rare sight, an end that justifies the jeans.

We look north-north-west to see if Alok shares our appreciation of perfection and find a wicked smile.

"Ready to go home, Dad!"
"Absolutely"

And so it comes to pass.

ps: For Alok's take on the ultimate test, click here.

pps: This is the last post on the Bypass per se, but Friend One called after the last post to say, "Levity is all very well but you need to put down stuff describing where you find the strength to go through something like this". Son One says we need to acknowledge everyone who helped us go into it smiling and to come out of it smiling. Fair enough. So here it is:

Bypass: Postscript

Bypass III : D-Day and after

“Surgery is controlled arrogance”, says Dr. Memhet Oz, Heart Surgeon, Author & T.V. personality.

We don't know about arrogance, but someone who takes a band saw to another's sternum, not in anger but in peace, must surely have enormous self confidence. And a team he can totally count on, from able deputies, to highly trained and committed nursing and support staff.

We are scheduled for 7 a.m. if there is no priority emergency case. A couple of kindly looking staff appear on the dot, slide us onto a gurney, strap us down and wheel us away. Wan smiles from Alok and Kusum as they walk along. A few words. A reassuring touch. A small squeeze.

All very much like the pre-op scene from countless movies - thirty seconds in English or three minutes in Hindi. Except no background music. And the scene is badly lit.

We reach the O.T. doors and are handed over rather like a le Carre character at Checkpoint Charlie. Dossier passed on and I.D. band on the wrist cross checked.

Just inside the doors in a holding area are two other patients. A young gentleman on a gurney. A young lady in a wheel chair. The chap is in for a kidney transplant. The lady is his sister, the donor. We send someone out to call Kusum in and introduce her to the real life heroine we have just met. Pleasantries are exchanged. Smiles all round.

Ere long we are taken in to the theatre. We can't see much. From muttered conversation emerges the now familiar 'small prick'. And before we can congratulate ourselves on not getting hassled this time we are hearing a babble of slightly louder voices. Words emerge. It's over. Welcome back. Darling. It's all over. Went well.

We open our eyes and are in the ICU bed surrounded by doctors, a few angels and the wife, dressed like an angel. Half smiles gradually spreading.

A tipping point

The easy part, for us, is over. The most difficult part for the family is over. So far they have been helpless, if somewhat petrified, observers. From now on they are a crucial part of the recovery team. The critical part for the doctors is also over, though they may not know it yet.

Surgeon One’s pre-op chats start playing back:

You will wake up with a tube down your throat.
Check.

Don't panic. Don't try to talk. It will be taken out in a couple of hours. Throat will be sore for a while.
Okay.

You will have multiple connectors into and out of you. Some to provide sustenance. Some to extract fluid from the chest. Some to track vital signs.
Check.

You will have a catheter inserted for urine elimination.
O God. Is this what it feels like. The constant feeling of wanting to but not being able to pee.

You will come out feeling like you have been hit by a locomotive.
Not at all, Sir. Not yet. There is no pain. There is also not much feeling. We are probably still partly under the influence.

We can see that it is latish afternoon. The wife comes in a few times. We drift in and out of slumber under the watchful eyes of angels. Various buzzes and beeps and a screaming baby constitute the background score.

The tube down the throat is taken out. First thing we do is ask about the catheter. No chance till tomorrow, we are told.

Small things will occupy all of your mind. Like a seed stuck between your teeth. It can't do any harm, but your tongue will worry it until you get it out: Sure enough. Our pillow is too fat. At home we use two pillows. Here, three different types are tried. Too fat. Angel One pulls out a roll of surgical cotton wool, peels off a cover from a pillow and fashions, on the spot, a pillow that feels just right.

We drift into a disturbed sleep. Enormously aided by the So Hum mantra dredged up by a drugged brain from a distant past.

Another tipping point

Day Two dawns with a glass of juice and offers of tea, coffee and breakfast. We are only interested in getting the catheter out. In due course it happens. The moment this irritant goes we start feeling the fractured sternum. It is like the rib-cage is in a vice.

Around eleven or so a young physio-therapist turns up accompanied by his deputy, a bespectacled young lady. He checks out the basic motor functions and reflexes and explains the rehab regime that will be put into practice.

We complain about the rib-cage. He sits down and gives us a magical vibratory finger massage. We know that he won't be around all the time and ask him if an electric massager will do. Sure. This will become a useful accessory over the coming weeks.

We will never see Physio One again. We don't know it but two things have just happened. Having examined the damaged goods, he has taken charge. And, once more, a young lady has sneaked in, unheralded, to tell us what we should be doing for the rest of our life.

Throughout the day various angels keep flitting around. Every now and then someone asks if we need the pee bottle. We don't. Restoring Input-Output is a major post-operative concern. Around 6 p.m. Surgeon Two tells Angel Two, "Reinsert the catheter if it does not happen in the next half hour."

Angel Two can see the look of panic on our face. She offers to pull the screens around the bed for privacy and help us pee standing up. We know that won't work in a public place. We ask if we could be taken to a bathroom. Being an angel she doesn't think twice. Commandeers help and organises a wheel chair. Removes whatever connectors are removable.

There is the chest drainage system which can't be disconnected. The tube connects to a cylindrical contraption in which is sloshing some reddish stuff. She helps us onto the chair and picks up the thingamajig and off we go.

Within minutes she has positioned us on the throne, dismissed the help, and started a tap running into a plastic container. This sets up the sound effect women have used for centuries to get recalcitrant infant bladders to let go. It works within minutes on a 63 year old. Angel Two who has been patiently standing by heaves a sigh of relief. As do we, never deeper.

The next morning we are released from the ICU and wheeled back to our room.

Next
Going Home

Bypass II : On to the Theatre

12 August 2010. Looks like payback time for the lifestyle choices made all through one's life. Knowingly. So no regrets.

But, before cutting and chopping, perhaps some more previews of the precious angio-graphic film are in order. We give ourselves two weeks and set out, avec la famille, to present it to half a dozen prominent cardiologists and surgeons.

A surgeon we meet loves the film so much, he sings along to the action on the screen drumming his fingers to the beat. He calls up the referring cardiologist and, without missing a beat, goes

“O.K. I have seen it. There are at least three grafts that I can see. But it’s a mess. I’ll have to take a final call when he is on the table. Probably end up grafting everything in sight.” Then turning to us, drumming incessantly, “You heard that. Any questions?” None now. Perhaps later. Can we call him? “Mr. Manchanda the moment you step out I will not remember your case.”

We love the guy. As we leave him knowing we will never see him again, he fires a parting salvo “Please don’t trust any cost estimates my hospital gives you. Just add 50%."

Next we call on a cardiologist friend who looked after us for many years. Those who know both of us think that we drove the poor soul away from regular practise into the relative sanity of medical research. Not wholly true. He is rabidly anti knife. His reaction: “If you go to a fish monger what do you expect him to sell you but fish? Dr. X is the guy I would trust to find a way around surgery, if there is one. Go see him. If he says you need surgery, you do.” 

So we did as bid. Dr. X said we did indeed need surgery. 

No way to bypass the bypass, we call up the Manipal Hospital, talk again to Surgeon One and fix a date. These are the people we are most comfortable with, and they have been endorsed by our friends in the medical profession.

Surgeon One tells us that all we need to do before going in is organise four units of blood. While it is not really needed during the procedure nowadays, it is collected as a measure of abundant caution. The man offers to be a standby donor, if we run short of donors.

Well wishers chip in

While all this is happening, friends and relatives, as also those in it faar-de-faanner-fit, write, call, visit or all three. Everyone has a story. Their own, or second hand. Almost all positive.

Our sole brother had bypass surgery some ten years ago. Our sole brother-in-law had two angioplasties some twenty years ago. He comes in from Chandigarh to be with the family.

An old college friend’s wife calls from Calcutta. From her personal experience on both sides we learn that it is much easier being inside the OT rather than outside. We are in because we have earned the privilege or been blessed with it. Anyway we are under anaesthesia. Those outside have done nothing to be there, are worried sick and have no idea what is happening inside.

Another lady visits and regales us with stories of failed open heart procedures. This includes the hilarious tale of a bloke declared successful who suddenly decides to give up the ghost after two uneventful days in the ICU. She has us in splits.

We prepare a will and brief the family on what to do if.

Like a vacation

Going in for a medical procedure is like going on a beach vacation. You don’t need any clothes.The latest wife, however, like all good Indian wives on a beach vacation, needs to pack practical but modest garments for the duration.

It’s sold as a package. Ten days. All found. Price depends on type of accommodation. Luxe block has more staff per bed. Attached bath. Fresh linen daily. Dedicated pantry. Room service on demand. Horrible food.

30 August 2010. We check in. Allotted the same suite we had for the angiography earlier. Received by the very same Florence One who had processed us then. In no time there is a parade of people coming in to check blood pressure, draw BUS samples, and carry out ECG etc. For some tests the labs won't come to us. We are wheeled out for a sightseeing tour of labs, escorted by Kusum. One lab is in the basement next to the mortuary. Just a reminder.

A dietician drops in as does the anaesthetist. Everyone is relieved we are not diabetic. Small favours gratefully received.

Somewhere along the line a moustachioed bloke turns up, demanding that we strip. He then unpockets a razor and proceeds to relieve us of body hair from neck to toe. It takes six blades. About three blades through, Surgeon One peers around the curtain between the living room and the bed room with a loud “Hello Anil”. This is followed rapidly by “Sorry, will come back later”. Followed by equally rapid exit stage left.

Through all this, No. 1 Son Alok is donating blood and co-ordinating with some half dozen donors. Mostly his friends. Including one young lad who very nicely comes up and wishes us good luck. And a remarkable, also remarkably attractive, young woman who happens to come in with someone and decides to donate. We do not get to meet or thank her. The only donor we know is young Abha Jhol, daughter of an old college friend. 

Meanwhile, a couple of good friends are nice enough to come by and keep Kusum company. Making sure the two men in her life haven’t driven her completely bonkers. Yet.

The Man Himself

Towards the evening, Surgeon One drops in with his retinue. He spends a few minutes briefing us on what to expect the following day. We are relaxed before he starts. By the time he is done it begins to look like a picnic.

He then dismisses his staff and settles down to general chit chat. We agree that it is not easy to organise a family vacation when the wife loves shopping, the teen daughter is interested in ancient civilisations and you want to chill out in pleasant open spaces and beautiful landscapes. And how wives really do not understand that an emergency surgery is more important than a dinner date.

This diverting interlude is followed by a Gandhian enema. The day ends with a hot purifying bath. We are not sure if we are given a relaxant but we sleep well through the night. Dreamlessly.

P.S. There are many reasons to neither confirm nor deny the existence of a Pre-CAB club.

Next

D-day & After

Bypass Bypass

Our first-born, and so far only son, Alok, has suggested a few times that we write about our recent coronary artery bypass graft surgery. Called CABG. Pronounced 'cabbage'.

We held back for over two months. Partly because everyone who experiences a major medical event talks about it. And partly because we wanted some time lapse to ensure a degree of objectivity. We finally decided to write. Mostly about things we did not hear from others.

Bypassing the Cardiologist

It all started when she looked deep into our eyes and said "I need to see what is cooking in your heart".

In another day and age, some six months earlier, hearing such a thing from someone as comely as she is, our heart would have skipped a beat. But given that we had failed two successive stress treadmill tests and that she is our cardiologist, the heart stood firm and took it on the chin. In the context of recent episodic breathlessness, she was prescribing an angiography.

She was off the next day for a trip abroad and the procedure would be scheduled on her return. However, after further breathing distress, we were referred by a friendly doctor to another highly regarded cardiologist. He agreed that an angiogram was called for.

That is how, a week later after playing 18 holes the previous day, we landed up hale and hearty in the Cath Lab of Manipal Hospital. Within what seemed like minutes we were re-garbed in striped hospital pyjamas, wheeled into the procedure room and a Florence was pulling our pyjama bottoms down while another one was exclaiming "small prick".

Aghast at the insolence, we were about to protest when she injected the anaesthetic and we realised that she had just been reassuring us about the needle. In short order the doctor had inserted the catheter, injected the dye, looked at the result and was telling us "Mr Manchanda, an angioplasty will not do. You need multiple bypass grafts."

With these fine and comforting words he left us in the hands of the Florence duo to brief our anxiously waiting family. We were wheeled into the Cardiac Intensive Care unit and left to stew in peace while a few Florences fussed around.

After a while Alok and our favourite wife Kusum, both looking slightly dazed, were ushered in. Over the preceding twelve months they had dealt with the protracted terminal illness of our mother. We couldn't even begin to imagine what was going through their minds. We dared not think about what they would have to put up with in the coming weeks. All we could say to them was 'Aal eez well'. Apparently a popular catch-phrase, that we didn't even know we knew, from a recent Hindi movie.

A couple of hours later we were wheeled into our suite where we were to spend 24 hours. Under observation and the tender ministrations of Florence One. Talking some with Alok and Kusum. Mostly sleeping or playing with the dual-remote control, motorised, multi-section, all singing, all dancing bed. Plenty of scope for a fit minder and a bored patient to have lots of fun.

Before discharge the next day the family had another session with the doctor. We all saw the fine film starring our 'dil' again. He advised that while no adverse event was imminent, we should start planning for surgery. He suggested a chat with his colleague, the head of cardio-thoracic surgery.

The surgeon saw the film, declared it a hit, and agreed with the cardiologist. No surprises there. He then briefed us on what to expect in surgery including the procedure itself, risk factors, after effects, rehabilitation and recovery. He commented on our general good health and strong heart musculature to indicate that the risk factor would be much lower than the 2% general average. Over the next week or so we would talk to him again and again with questions as they occurred to Alok, or Kusum or to me.

Basically what happens in CABG is that the rib cage is hacked and jacked apart to reach the heart. The affected vessels are isolated and alternative routes provided for blood to flow. Then everything is sewn back together - the bone with steel wire and the skin with dissolving thread. The main graft uses the internal mammary artery (who knew we had one? and to spare!). The other grafts use arteries or veins drawn from arms and legs. We would need at least three grafts.

While the heart gets a new lease of life, everything else gets jiggered up in the process and has to be rehabilitated.

It occurred to us that the doctors we were meeting were far better communicators than most people, including communication professionals, we had come across in decades of corporate fooling around.

Next 

On To The Theatre