Open Heart

cp

Open Heart:

Personal Injury and War Trauma

by

Michael H. Ducey, Ph.D.

On March 19,2003 I had open heart surgery at Montefiore Medical Center in the Bronx, New York. This was my second such surgery, the first having been done at Evanston Hospital in Evanston, Illinois in May 1996. There were certain dramatic differences between these two surgeries, and these differences raise a number of interesting issues. March 19, if you recall, was the first day of the war in Iraq.

The reason for my first surgery had been a series of angina attacks leading up to an angiogram that revealed I had a case of “triple vessel coronary disease” and would need three by-pass grafts to repair my cardiac arteries. At this point in history I was 62 years old and in a period of what I would call “low-grade death wish”: an emotional condition in which I was not actually suicidal, but still in a mind-set to “tempt fate”. The logic of this condition was as follows:

“Look, universe, I have done my best to use my gifts to devise solutions to some basic human problems. I have made what I consider progress in this enterprise, but after 25 years at it, I have been able to communicate my work to no one. It is not that I have too few “followers”, but rather I not only have no followers at all, I do not even have a single correspondent in the conversation that is my life’s work. Believe me, I have communicated with people–and I know some very bright and accomplished people–and they have all returned my overtures to conversation with absolutely blank stares. It is as if I am speaking a language no one else on this planet understands.

So, universe, here’s the deal. I am going to skip around really close to the edge of death, and if you want to take me, I will make it really easy for you.”

My main means of implementing this low-grade death wish was to consume copious amounts of fried eggs, pork sausage, bacon and such for breakfast on a daily basis, and I mean copious. I was a trencherman. I knew my body chemistry well. My father had died of a coronary at age 59. I read the literature. But in order to make this practice not too lethal, I was also a dedicated walker, even in the winter, and logged many laps on the walking track at the Skokie Fitness Center.

I remember lying in my bed in the Evanston Hospital Cardiac Care Unit after the angiogram and scheduled for surgery two days later. I looked at my surroundings, with all the monitors and attendant personnel, felt what was going on in my chest, and said to myself, “Whoa, so the universe has answered. I had no idea what that answer would feel like. Actually, if I had it to do over again, I would skip the sausage.” But of course, it was too late to get a do-over. I would have to ride this out, whatever it produced.

Ariel and Aimee both came back from New York, and on Wednesday I had the surgery. Dr. Votapka did the triple by-pass; the procedure took about five hours; I went through a pretty routine recovery, and was back at work at Abelson-Taylor six weeks later.

We will have occasion to look more closely at some specifics of this surgery a little later on, when we compare it with the second surgery.

We skip ahead five years to July 2001. I am now living in the Bronx. One Wednesday night I woke up with severe abdominal pains, and after a call to my doctor’s answering service and on his advice called 911 and was taken into Montefiore emergency room. They gave me some morphine (wicked stuff on an empty stomach), did an MRI, found a very small kidney stone, and sent me home.

Two days later I woke up again at night, this time with chest pains. I recognized them as angina, called 911 again, and went into Montefiore emergency for the second time in three days. This time they admitted me to the cardiac care unit, did an angiogram, then did an angioplasty, putting a stent in one of my cardiac arteries. This was performed by Dr. Mark Menegus, who became my cardiologist from that point. Menegus told me that 2 out of the three grafts I had received in 1996 were occluded. These grafts had been harvested from the long vein in my right leg. Then he made the comment, “But that venous material is not really designed to perform that function.” The first of the 3 grafts from 1996 was from my left mammary artery and was in excellent condition.

At this time they also detected a pronounced heart murmur–which had actually been present in 1996, but too faint to cause any concern–and informed me that besides the coronary artery disease, I also had aortic stenosis. My aortic valve was becoming calcified and getting smaller, and although I did not need to replace it now, I would probably have to replace it down the line. We agreed to watch it closely with an echocardiogram every six months.

By the way, the kidney stone turned out to be from a build-up of uric acid in my system (gout), passed by itself, and I went to a higher dosage of allopurinol and added daily lemonade to my diet. No further symptoms there.

But Menegus’ comment about the venous material really set me off. I said to myself, “What the FUCK! If it is not really designed to perform that function, why are they always using it?” Menegus and I would eventually resolve this mystery in a chat in the i.c.u. after my second open heart surgery.

So, after the angioplasty I had time to assess my situation. I concluded I was in serious trouble. I have high blood pressure and coronary artery disease which, in spite of the good drugs I am taking, is going right on its merry way. Two of the three grafts I got five years ago promptly died. And now I have this aortic valve disease. It looks like whatever contribution I have to make to understanding the relationship between childhood trauma and human spirituality might have to be posthumous. O.k., I can deal with that.

But I decided not to go quietly. I would try acupuncture. When I lived in Chicago, acupuncture had completely fixed my gall bladder condition. Here in New York, Shane Hoffman of Turning Point Acupuncture in mid-town Manhattan had magically cured a horrendous shoulder muscle inflammation that drove me crazy for weeks with a 24-hour application of a Chinese herb.

So I went to Shane and he started to work on me with a treatment designed to address issues such as atherosclerosis. I had a treatment once a week for a year. Two things happened. My blood pressure went down, and the shortness-of-breath symptom related to the aortic stenosis significantly abated. I was beginning to think I might avoid the valve replacement surgery.

We did the third six-monthly echocardiogram in February 2003. It showed that the stenosis was progressing unabated. So I told Menegus to start the program for replacement. I told Shane Hoffman about the results and he said that there was possibly another treatment we could have followed, but that right now it was best to rely on Western medicine. A positive thing was that even though the acupuncture did not get at the valve, my cardiovascular system in general was in better condition than it had been in a long time.

The replacement program started with an angiogram, “the study” as Menegus called it. We did this on Monday, March 3. This would be my fourth time on the table in a cath lab, and it was a pretty benign procedure. Menegus did it on an outpatient basis at Montefiore, and he and I chatted while I was under the local anesthetic. There is a brief recovery period after an angiogram. They go into that artery in your hip and have to be sure it is securely clotted before they let you go. Menegus stops by to give me the results: besides the valve replacement, they need to bypass the stent, which has become occluded. Then I hear him on the wall phone just out of sight around the corner from my bed. He is talking to some surgeon, and he is saying, “Hello Dr. Merav. I have a very interesting case here that I think you will like to look at. . . . .”

I have my pre-op meeting with Avraham Merav the following Monday, March 10. He is a sixtyish man, bald on top, wearing a really nice blue suit, possibly Armani or Hugo Boss, and a classic dark red power tie. When he takes my history he writes with two pens. For the pre-op history itself he uses an actual fountain pen; for documents of less significance, he uses a good ballpoint. He has a rapid, firm, decisive stroke with the fountain pen.

He makes eye contact easily. He goes through the usual elements of the consent: diagnosis, risks, etc. He informs me that whereas the success rate for first-time by-pass surgery is 97%, the success rate for what we are doing here is more along the line of 85% to 90%, “about five times more risky” as he puts it. He shows me the pictures from the angiogram. I can see the occluded stent and two more narrow places in that artery, and the outline of the aortic valve. He takes me to the examining room where he looks at the scars from my previous surgeries. He notes that I have “a conduit issue”, but says he is sure they can handle it. I already know about the conduit issue. Besides the previous by-pass surgery, I have had the long vein in my left leg stripped back in the eighties because it was varicose. And then there is that big scar on my left wrist from the motor scooter accident in Delhi, that compromises that radial artery. But apparently the body has a lot of arteries and veins to be harvested.

I have some questions. One is, “Do you have any thoughts on why those two grafts from the first operation quit so soon?” He said, “Well it depends on how you handle them. If you bang them around, they are damaged when they go in.” The other is, “What kinds of things make this five times riskier than first time by-pass?” He says, “Well, going in you don’t really know how the previous surgeon left things. Tissue may actually stick to the inner surface of the sternum when you open it up. You may slice into the previous graft while you are looking for it. There are small chips of calcium from the valve that might get away from you, go to the brain, cause a stroke.”

I sign the consent, and he hands me over to his administrative assistant, Jeanette, and she tells me about dollar cost (I have Medicare only), and we set a date. I say, “The sooner the better” and she calls the OR and finds out that March 19 is available.

Because of the conduit issue, they have me go in for a “vascular survey” on the 15th. The tech uses an ultrasound to measure the productivity of certain blood vessels. In my case they are interested in the right carotid artery, the radial arteries in each arm, and some superficial veins that run across the calf of each leg. The tech is training someone while doing my survey, and I hear him say that my right radial is ok, but my left radial is not so good.

The morning of the 19th, the girls escort me into the OR suite at 6:15 am. There are a few preliminaries, I change into a gown, they take my belongings and head off to the surgery waiting room. A tech comes in to my cubicle and shaves me from adam’s apple to ankle. Then the anesthesiologist comes by and introduces himself, and they wheel me into surgical prep. As we are pulling away I look back and see the considerable tumbleweeds of hair on the floor of my cubicle.

Surgical prep is always a busy place. At least a dozen people in masks and scrubs milling about. At this point in time I have had no mood altering drugs, as far as I can tell (unless they quietly slipped something into me when I wasn’t paying attention). I am very clear, very aware of my surroundings.

They adjust my gurney and have me move my butt over onto a narrow table-like device. They take each of my hands and slide it firmly under my butt so my arms won’t be flapping. Dr. Merav comes by. They pull out each arm and look at the forearm. The original surgery order had said, “possible radial artery”, as I recall. They are talking about where to put the anesthetic i.v., left arm or right. They will of course avoid the arm they want to take an artery from. They seem headed for the right arm and I pipe up, “I heard the vascular survey tech say that my left radial was no good.” Merav is standing right there. “Hold on,” he says, and disappears. A second later he comes back with the written vascular survey report. He reads from it, “Both left and right radial arteries suitable for harvesting. . . ” I say, “Well, you’re the doctor, but I know what I heard.” Merav takes my left hand and looks at the wrist. “Is this some sort of superficial wound?” he asks. I tell him, “No way. I haven’t had any sensation in the heel of that hand for 35 years.” He sounds a bit disgusted as he says, “Well, that rules out the radials.”

Then they come with the cross sticks to support my arms. The anesthesiologist says something cheery, and darkness descends. . . . . The next thing I know, my eyes pop open like two searchlights. I am vividly awake. I can see the ceiling and some fluorescent lights. Can’t move my head. Can only move my eyeballs. I hear a man’s voice, “Oh, oh. He’s awake. He’s really awake.” (I subsequently learn that this was ten hours later),

I also remember coming out of the anesthetic in 1996. It was so different. That time, when I woke up, my eyes were still fully closed. The first sensation I feel is of ice chips being inserted into my mouth. They taste so good. Then my eyes open, but very very slowly, very very gradually. I become aware that my chest feels like they have dropped a house on it. There is no overwhelming pain. They have me pretty doped up. But my chest is as heavy as lead and the weight is completely and totally invasive. I make some murmuring noises. A young women’s voice tells me she is my nurse and her name is Maureen.

Back to 2003. I am vividly awake, and there is no weight on my chest. I have no pain. I blink. Whoa! Have I woken up before the surgery? Is there some sort of break in the anesthetic before it takes full hold? Then I hear the guy say, “Oh, he’s awake.”

I become really agitated. I want to ask someone, “What is going on here? Why don’t I have any pain?” I open my mouth and try to speak. The only sound that comes out is like the sound of air escaping from an empty pipe. I still have the airway tube in me. I learn later that they place it right between the folds of the vocal cords. You cannot make a sound.

I try to gesture with my hands. I am still pretty wrapped up. But I get one hand free and make a writing motion. I am very vigorous about it. This disembodied voice says, “He wants to write something.” They give me a pencil and paper. I try to write. It comes out incoherent hieroglyphics. Another doc tries. Same result. I must have looked really distraught, because they call in my primary care physician, Dr. David Levey. David leans over me, puts his face right in front of mine, grabs me by both upper arms and says, “Mr. Ducey, Mr. Ducey. It’s just 20 minutes till they take the tube out. Just take it easy, and then we’ll talk about it.” This satisfies me, and I relax.

Shortly later, I feel the tube slide out. “I have no pain.” I say.

I must have kept on bugging my attendants in the i.c.u. for 24 hours with this burbling about not having any pain. I think I used the word “miracle” a few times. Merav comes by my bed. I ask him about the pain. He says, “In my experience, there are two factors that contribute to this. One is the skill and meticulousness of the surgeon, and the other is the capacity of the patient for healing.” I say, “And is that capacity for healing the luck of the genetic draw?” He says, “I don’t think so.” This is obviously something he has thought about, something for me to think about. I tell him thanks, and he departs.

Menegus came by for a quick visit not long after I came out of the anesthetic. He was beaming. He took a quick listen with the stethoscope and nodded. “You look great,” he said. The next day he came by again for a longer visit. I asked him the question about venous material. His eyes got big for a second, as he backpedaled. His answer was, “Well I did not mean that in any absolute sense. It really depends on how you handle them. And, all other things being equal, venous material fails more often than arterial material. So, it’s a statistical fact, not a clinical fact.”

Ah, so. That made sense. But both Merav and Menegus used the same phrase, “It depends on how you handle them.” In my thinking about medical science, I form the opinion that there should not be any variation in how surgeons handle graft material. “Handling” the material should be a central component of training. My procedure with Merav had lasted 8 hours. My procedure with Votapka had lasted five. Hmmm.

I have a son-in-law who knows a lot about books. In the several years he has been with my daughter, he has on a number of occasions given me an obscure, little-known book that has an uncanny relationship to things I am working on. On this occasion he outdid himself. The surgery was on a Wednesday. When he and Ariel came by on Thursday evening he handed me a copy of On the Natural History of Destruction by the recently deceased author, W.G. Sebald. Sebald’s work has very recently come under intense scrutiny. He was born in southern Germany a year before the end of World War II, and the subject of all his writings — both fiction and non-fiction — is the question of how do you heal the trauma of war, or as one reviewer put it, “How do you speak about the unspeakable?”

Actually, research being conducted right now at places such as Harvard Medical School and the Hakomi Somatics Institute in Boulder, Colorado is beginning to provide a direct and detailed clinical answer to that question. [See www.trauma-pages.com for an extensive survey of resources.] My main subject of research for the past ten years has been this kind of trauma treatment. For the previous fifteen years I had been studying religion. I had come to the conclusion that religion is behaviorally about pain even though conceptually it is about “God”. My study of trauma treatment made it clear to me that traditional religion is “stage-specific” trauma treatment, i.e., it is trauma treatment for a stage of history when the ego is weak and battered. Thus, religion uses a lot of sedative. And this works, because it moves society and the personality to a later stage of development, when trauma treatment must use techniques of staying awake, and encounter pain more directly.

I only managed to read a few pages of Sebald when I was in the hospital, but they were enough to tell me that my trauma study was right on the mark, and that in undergoing open heart surgery I had experienced the same kind of “destruction” as what went on in World War II and was going on right now in the war in Iraq.

World War II was the first war of “healing” in human history. Mistakes had been made, Germany had been allowed to slide into total social collapse. This produced a great social evil: Hitler and Nazi-ism. There was no way to heal this disease except by allowing massive “collateral damage.” In World War II consciousness was not yet even at the point where it had the concept of collateral damage. So we did Cologne, Hamburg, Dresden, etc. Crude, crude surgery.

So, during my convalescence in the i.c.u. I had plenty of time to meditate on the nature of collateral damage. Because, that is exactly what a cardiothoracic surgeon does. In order to heal the disease, he drops bombs on your thorax. And there appear to be degrees of sensitivity in doing this. Merav is a dedicated collateral damage minimizer. That’s why I woke up without any pain. Dr. Votapka, who I really liked, seemed less concerned about it. Votapka, I should note, was only 38 years old when he operated on me. He clearly had a mind like a steel trap and the hands of a safe-cracker. And his bedside manner was wonderful. But maybe in sensitivity he was more like the bombers of World War II than the bombers of the present war in Iraq.

So, now I have a heart that is good for another 20 years, and a new set of lessons in trauma treatment. I am anxious to get back to work.