The 2014 Warm Showers hosting season started early, with three brave riders in January, taking advantage of the mild but wet Pacific Northwest winter to head from Seattle to Los Angeles.
Unfortunately, the season was cut short: our own “training” rides and mini-tours, starting in New Mexico and California in late January and early February, continuing in April and May in Washington and Idaho, were truncated because of increasing back and chest pain while riding. We finished a successful 2013 riding and tour season (including a 700km self-supported tour to cap a 2500-km yearly total) after seeking treatment for GERD (gastro-esophageal reflux disease), but the symptoms progressed to a wider spreading chest pain as the 2014 season developed. After returning from a really scary 30-km ride in Idaho at the end of May, and experiencing chest pains even while walking, I pressed for more comprehensive testing to get a better diagnosis: we were a mere six weeks out from a scheduled supported week-long tour and needed to train.
A treadmill test on Friday, June 13 (an auspicious date) made it absolutely clear that the problem was cardiac-related, and severe: the test was aborted after less than three minutes, with blood pressure and pulse over 200 and the EKG trace looking like a major earthquake. After being sent home with nitro tablets and some powerful heart regulators and told to “do nothing” over the weekend, a visit with the cardiologist on Monday got me scheduled for more testing on Tuesday, June 17, a cardiac catheter probe, which showed nearly total blockage of the main cardiac arteries, only days or hours (or one bike ride) from what would have been a fatal heart attack. I was wheeled from the recovery room at the test center directly to surgery, where I had a full six-hour open-heart procedure.
While still in the hospital, I took us off the Warm Showers schedule for the summer, and cancelled our late July tour: I went home at the end of the week a temporary invalid, confined to a (new) recliner in the living room for a few weeks while Judy, a retired nurse, slept on the sofa for a few nights and then in the downstairs guest room. After a few weeks, I could, with help, get in and out of the guest room bed, as lying flat helped the healing some, but continued to spend part of the night in the recliner for the next two months. After a month, I was strong enough to climb stairs to the master bedroom, and able to walk a kilometer or two, slowly.
Now, eight weeks after what can only be called emergency surgery, and six weeks after a repeat hospitalization for severe pulmonary emboli and subsequent warfarin regimen that will last for six months or more, recovery is in sight. I am driving again, and able to walk at least 5 km on outings 4-5 days a week, but not yet cleared for heavier duties like opening the garage door and other pushing and pulling, so our guest room is still closed. We’re off to Portland, Oregon by train and public transit next week for a conference, and on vacation in early September, one we had hoped would be filled with day rides, but we will need to be content with hikes and walks. The bicycle needs to wait until the bones are completely healed and probably until the blood thinner treatments end. We might open our doors to guests for a week or so between the Oregon trips, in late August, but only if I get medically cleared for more activity.
But, by mid-September, we should be on the Warm Showers active roster again for the Fall Pacific Coast touring season, briefly, but at least for a couple of weeks before we head to Montana in early October to re-winterize the cabin we last saw–buried in snow–in March, and to build a ship’s ladder to replace the vertical ladder to the loft, now that I have joined the ranks of the old and feeble, to avoid undue strain on the divided and now “zippered” sternum, which I have been promised will soon be strong enough to withstand hours on the handlebars for many touring seasons yet to come.
Warm Showers (www.warmshowers.org) is an international organization of bicycle tourists who provide lodging—at a minimum, a place to camp and access to shower and toilet facilities—to other cyclists on tour. Many hosts also provide full guest services: bed, meals, laundry, transport to and from public transit facilities and bike shops, sag service, and storage (bike boxes, etc). The web site is run by volunteers and funded by donations, and guests are never charged for services offered. Warmshowers.org is also on Facebook, where members discuss travel and post photos.
It’s been exactly one month since I woke up a little after midnight with a tube down my throat and two more sticking out of my abdomen and a long red seam down my chest, where the good surgeons from Franciscan Cardiothoracic Surgery had pried me open to re-plumb my heart. My last clear memory before they yanked the throat tube out was of looking at an X-ray image of totally blocked main left ventricle cardiac arteries and being told I was headed for surgery instead of home, some 14 hours earlier.
As if recovering from that trauma, which included several hours of having my blood diverted through a fancy aquarium aerator while my heart was taking a nap and my arteries were rearranged and supplemented with veins fished out from behind my left knee was not enough, two weeks later I ended up back in hospital again with severely painful clots (embolisms) in my lungs. Nevertheless, healing proceeds: in the last week or so I’ve been able to spend enough time at the computer to do actual damage.
First, there was the matter of fixing a software package and install script hastily uploaded to the client site the night before surgery. Secondly, a local heat wave was setting off overtemp warnings on my development laptop, when I noticed that the graphics processor wasn’t reporting temperatures. Foolishly, I attempted to upgrade the graphics driver, ending up with a text-only display. Hmm, back out, reinstall the stock drivers, and the graphics desktop returned, albeit with a few quirks. I’m still not up to speed yet–when I think hard, I break into a sweat and have to take a nap, so best not tackle any seriously difficult problems just yet.
Several other projects have simply been put on hold: I have been content with putting in short half-hour spurts of work once or twice a day. As noted elsewhere in earlier posts, my rehabilitation has already started with daily walks to keep the circulation going and build up cardiac strength. Early walks, plodding along in a light-headed daze, have given way to reasonably-paced striding. After having tackled a few wilderness paths that proved to be a bit rugged, we’ve contented ourselves with flat-land walks on the north side of Shelton, close to the medical facilities, or, alternately, on the relatively flat and convoluted running trail through the greenspace near Shelton Creek, a park called, appropriately, “Huff ‘n Puff.” These excursions have extended to 1-3Km, of duration 30-55 minutes. Meanwhile, I’m still under motion restrictions while my sternum knits itself back together under the wire lacing that held it shut after surgery, not to mention recoverying from abused and sore muscles and ribs that were stretched and bent into abnormal shapes.
One of the side effects of such drastic surgery, where life is sustained artificially, is the possibility of cognitive impairment: fortunately, so far only a few well-known facts have had to be re-verified, but we haven’t pushed the envelope too hard or taxed the coding skills excessively. Starting coumadin (warfarin) treatment to avoid repeat emboli has been a bit of an ordeal, with twice-daily injections of blood thinner while adjusting the rat poison dosage to get to the proper levels. The formula also includes careful attention to diet, to reduce the amount of clotting factor, vitamin K, which is present in most green leafy vegetables, a challenge for a dedicated vegetarian. But, finally, after two weeks of injections and frequent blood tests, we are “in range.” This means no more injections and now just a matter of infrequent blood tests to adjust the warfarin dosage from time to time and avoiding cuts and bruises for the next six months while the treatment runs its course.
This interlude of recovery gives us pause to think about the gift of a few more years to enjoy life and family, and to think about when to declare a true state of retirement and what exactly that entails. Unix and Linux will always be a part of our life, but perhaps with a little more focus on enhancing personal goals and less about deadlines and external projects. We have grandsons who are beginning to mess around with computers and need some guidance (i.e., indoctrination in the benefits of “the one true operating system” and maybe some instruction in scripting and programming). The new generations of tiny machines with analog interfaces, like the Arduino and Raspberry Pi beg to be incorporated in other hobbies and home projects. The rehab program requires regular exercise, which means much more time on the bike when we get cleared for that type of activity (probably after the bleeding danger is over: meanwhile, trips to the gym for some stationary workouts are in order). Yoga is another activity on modified hold until the bones and muscles heal. Beginning a new phase as a cardiac patient puts a new perspective on life, truly a reboot and fresh start with new priorities and goals.
The newest Mason County Park is Oakland Bay Park, off Agate Road near the head of Oakland Bay, 15Km from downtown Shelton. The park is down a narrow dirt road to a well-appointed parking area and well-signed trail that winds down through a forest of Western Red Cedar and maple, dropping 40 meters in elevation to a bench above the bay, near Malaney Creek before looping back up a series of switchbacks and stair steps. A single park bench is placed at the only view of the bay, the low point of the trail.
This hike was possibly a bit more ambitious than expected for less than a month from open heart surgery and two days out from my hospital stay for pulmonary embolism, but we had been fairly active before the operation. The main concern was to avoid falling, due to knitting bones and a heavy load of anti-coagulant.
We hiked this on July 9, 2014, and had the entire park to ourselves, the previous user having been in process of leaving as we arrived. I’m not sure of the distance for the loop trail, but it was certainly more than 1Km, plus a number of ups and downs and switchbacks over the 40-meter elevation change from top to bottom.
Because of my recent heart operation, we are off the bike until the bones heal. However, part of the cardiac rehab is regular walking. Not satisfied with marching up and down Railroad Avenue (on good days) or circumambulating the sidewalks and trails around Mason General Hospital (on bad days), we’ve been looking at the many short hiking trails around Mason County. Mason County Washington encompasses the lower arm of Hood Canal and several inlets of South Puget Sound as well as islands and the southern quarter of the Olympic Mountains. Therefore, there are lots of hiking opportunities.
We started with the county parks, but there are also a few city hikes of note in Shelton. One is the short Goldsborough Creek trail, that provides access to the former site of the Goldsborough dam that supplied power to the city of Shelton and later to the Simpson Lumber Company from the late 1890s until the late 1990s. In 2001, the 30-foot-high dam was removed, replaced with 34 concrete weirs spaced down the drop to allow salmon to climb past the former dam site to spawn in the headwaters in the marshes near Little Egypt Road.
The trail starts just past the Ford/Chrysler/Jeep dealer, at the driveway to the Pavilion (now the Shelton Senior Center), and follows the old dam road for about 400 meters before a side trail leads to the creek and then along the creek side back to behind the car dealership. In addition to the weirs, there are a number of trees that create obstacles and pools. In July, the creek levels are down, but the weirs are popular with white-water kayakers during the spring runoff. The forest is mixed lowland trees and shrubs, with abundant sea spray, just starting to bloom.
The lower loop trail is little more than 1Km. A less-distinct trail continues another several hundred meters to the Simpson Railway where it crosses the creek.
We walked this trail on July 4, 2014. A couple of hours later, I had a pulmonary embolism that was totally debilitating and required several days treatment and recuperation in hospital, so we were fortunate that the clot didn’t choose to move during this wilderness hike.
“The time has come,” the Walrus said, “To talk of many things: Of shoes–and ships–and sealing-wax– Of cabbages–and kings– And why the sea is boiling hot– And whether pigs have wings.”
–Lewis Carroll, “The Walrus and the Carpenter”
Cardiac Artery Bypass Graft (CABG, pronounced cabbage) is not a term one thinks about while riding one’s bicycle. Indeed, the association is with elderly, out-of-shape American males who have been indiscriminate in diet and lax in activity. However, all of those things are cumulative over time, leading eventually to atherosclerosis in the elderly of both sexes who haven’t succumbed to some other infirmity. Somehow, though we don’t feel “elderly” at 70, we do fit the demographic age group, are overweight, and exercise in spurts.
So, after a decade of daily bicycle commuting, near the end of which a cardiac stress test was passed with flying colors, I found myself, in semi-retirement, having some pain on casual, but aggressive riding. “Out of tune, out of shape” seemed a reasonable assumption, and, indeed, the pain vanished with longer rides and more regular riding. This went on for the next nearly five years, with occasional attempts to find answers, and several thousand kilometers of training and touring.
However, the persistence of some pain, usually at the start of a ride, led to a medical consult before commencing on our 2013 self-supported bicycle tour. GERD (Gastro-Esophageal-Reflux-Disease) seemed a resonable solution and, indeed, a round of the popular treatment Omeprazole seemed to alleviate the symptoms, and off we went on tour, with no adverse affects during the 700-Km tour, riding up to 70Km per day over several weeks, towing a heavy (45Kg) trailer full of gear.
After the tour, however, the symptoms resumed, and eventually could not be reconciled to either poor choice of food before or during the ride (though cold weather was once thought to be a factor). A second round of Omeprazole was ineffective, though a switch to the more preventive treatment, Ranitidine, seemed to help some. Rides became shorter, as pains returned soon after the start of a ride, and required a stop to subside. And, multiple stops, on a 30-km ride around Payette Lake in Idaho.
Yet another medical consult, this time insisting on a cardiac stress test. We had registered for a week-long inn-to-inn bicycle tour at the end of July and were woefully behind in training for it. After waiting more than a week for a referral, we took matters into our own hands and contacted our HMO’s cardiac unit directly, the closest in-house cardiology department being in Tacoma, rather than Olympia, where we usually go for specialty care. Yes, we could get in Friday afternoon. Meanwhile, the referral through our primary physician came through, too, though we would not have been scheduled until at least the following week.
On Friday, the stress test started normally, though my pulse rate went up quickly and blood pressure had been abnormally high during the last few doctor visits (abnormal for me, but apparently not for the average 70-year-old in poor health). As soon as the test went to the next level at three minutes, classic angina pain set in; every reading spiked as pulse and blood pressure headed for the 200 mark, and the EKG readout looked like the audio track from one of our grandson’s heavy metal rock recordings. The test was immediately terminated. The cardiologists had gone home for the day, so I was prescribed a cocktail of nitro and heart regulators and sent home for the weekend, cautioned to “do nothing.” Of course, I did tidy up, package, and upload my latest code project to the NIH, so as to justify my time and possibly leave behind something useful…
Monday was a consult with the cardiologist, who, with one glance at the EKG result, announced “serious blockage,” and muttered “time bomb” while scheduling a cardiac catheterization for early the next morning to plan the next step.
Cardiac catheterization is a minimally-invasive look at the heart’s arteries with a scope inserted into a groin artery, through which also the blocked artery might be opened without surgery using a balloon and a mesh expander called a stent. The procedure is performed at an ambulatory surgery center, in this case, at the Franciscan Cardiac Unit at St. Joseph’s Hospital in Tacoma, 80Km from home.
On awakening, I was shown the result: two of the three major arteries supplying blood to the left ventricle (the big one) were blocked over 90% and the third one compromised. The blockage, at the junction of the arteries, was not fixable and would have to be bypassed. I had been minutes from a fatal heart attack every time I had felt a twinge in my chest over the past at least 200Km of riding, or even while taking out the garbage. In these cases, the patient is not released, but scheduled for open-heart surgery at the next available opportunity.
Fortunately, there was a procedure in progress and the team agreed to put on a second procedure (an open heart surgery for bypass or valve replacement takes four to six hours or more). I was sedated once more and wheeled off to the surgery suite.
I have been told that the prep is quite involved. First, they paint you orange from head to toe with an antiseptic solution, attach various plumbing to manage bodily fluids, stuff your nose with anti-MRSA goop, then chill you to preserve the meat for what comes next, which is both terrifying and a miracle.
To get at the heart or lungs, sometimes surgeons can work between the ribs, or cut through only a few on one side. But, for most, it is necessary to open the thorax completely, which means cutting the sternum from top to bottom. I will have a scar about 25 cm long from my collar down.
Next, the blood flow is diverted through a pump and diffuser to oxygenate the blood and keep it flowing through the brain for next hour or so. And the heart stops, the old definition of The End.
Working quickly, the surgical team takes sections of veins harvested at some point in the process from the legs and chest and sews them into the main arteries and the blocked arteries to create a new pathway. Fortunately, with bicycling, I had lots of nice leg veins from which to choose, leaving a rather large scar behind my left knee. and an area that will remain numb for at least several months.
With the two bypass channels secured in place, and the seams checked for leaks, the heart is restarted and the massive wounds reclosed, stitching bone back together with heavy-gauge wire, and super-gluing external tissues together.
Finally, at nearly midnight on a day that started before 8:00 with the first injections of sedatives, I become aware of what seems to be a vacuum cleaner hose stuffed down my throat, which is being pulled out with the most unpleasant sensations. Amazingly, the tortured vocal cords still work, but it hurts. I immediately begin coughing up a sticky clear fluid and foam that is trying to fill my lungs, a process that continues, nearly two weeks later. Deep breathing exercises are supposed to help the expectorant process, but the ribs and chest hurt, and the lungs don’t seem to expand all the way, possibly due to two rubber tubes stuffed in the sac with them, that are draining fluid and blood away into a container under the bed.
But, the important part is, I am still alive, and probably wouldn’t have been had I not sought treatment when I did or had persisted in “riding through the pain” the last couple of months when we aborted rides that were especially painful.
Before long, I get bundled out onto a high-rise walker with hooks and racks for oxygen and aero-bars for a cruise around the ICU station, two laps. Before leaving the Intensive Care Unit, the various tubes get yanked out, and off I go down the hall to the Progressive Care Unit, where I have to get up to the bathroom. Often. Meals are delivered, but the food is inedible, some beef-eaters idea of “vegetarian” cuisine as boiled-to-mush starch and green paste. I manage a few pieces of melon and occasional bowl of cream of wheat or oatmeal, and beg a snack pudding from the floor nurses the last day.
After I spend two nights in the PCU, get my cardiac jumper cables snipped (they are supposed to pull out, but hang up somewhere) and demonstrate the ability to climb a long flight of stairs without aid, Judy arrives with my clothes (sans personal cell phone, which disappeared somewhere during the personal effects transfers) and I am out the door, four days nearly to the minute that I was wheeled into the operating room for prep, and climb a bit unsteadily into the car for the 80-Km trip home, via the pharmacy. I am now officially labeled with Cardiac Artery Disease, and must take several medications daily for whatever time remains to me.
Adapting to the residual diuretics, laxatives, and pain killers is part of the post-op/post-hospital period., and brings its own set of horrors. Judy has bought me a La-Z-Boy chair, electrified, in which I will spend the next few weeks until I can lever myself in and out of bed without putting weight on my shoulders/elbows, etc. No pushing, pulling, or lifting more than 4Kg until the cloven sternum is fully knitted under its metal lacing. The lung fluid continues to collect, now without a built-in vacuum, but I learn to spit into a cup without leaving slug trails everywhere, mostly. Sleeping in the chair elevated to aid breathing and coughing leaves me with a painful kink in my neck (hence the title).
Sleep has eluded me since waking festooned with tubes, with the constant need to clear my airway of slime. I am expected to get 8 hours of sleep, but it comes in 10 and 15-minute snippets. The food is better, as Judy learns to cook what I usually prepare. Melon continues to be a favorite, but I am soon eating well, then sleeping longer and longer as the flow of slug slime from my lungs diminishes. It is hard to remember to use the “Incentive Spirometer” gadget they send home to build up your lung capacity and help clear the fluid. The indicator is set at 750ml: I started past 1500ml in the ICU and peak the device at 2500 by the time I am home, leaving me to nearly turn blue waiting for the device to reset itself. I still need to remember to practice deep, cleansing yoga breathing several times a day.
Finally, I manage to get in at least four hours of sleep, in 30-minute chunks as the diuretics work to dump the remaining 5 liters of fluid pumped into my system during the surgery by the heart-lung machine. This works too well, and I am soon 5Kg below my check-in weight by the time the pills run out. I also had dropped the narcotic pain killers, opting for plain acetaminophen instead, so I spend most of the next day fuzzy and depressed, nose dripping, like a street junkie down on his luck.
Six days after returning home, I am ready to venture out: first mission, replace my lost phone. A trip to the mall 30 Km away in the rain is mostly pleasant–I am not allowed to drive for six weeks while the bones heal–but then, done with the diuretics, the accumulated laxatives win the battle for fluid. Dizzy with low fluid levels, I stumble from one restroom to the next as we finish our shopping and head for home. Still, I am alive, and moving under my own power. Life is good.
At last, down to my normal lifetime medication list and the lung output continuing to drop, we can plan the rest of the recovery. The glue lines start to itch, tapes begin to peel, walks around the yard become less tiring. Back and forth up and down the sidewalk; breathe, fall into an even cadence, faster, further. There are trails yet to ride.
Dr. Roger Chamusco and P.A. Bjorn Larsen, Group Health Cooperative, who treated my symptoms as an emergency and acted promptly.
Dr. Susan Hecker and her staff, Franciscan Cardiothoracic Surgery, who stayed overtime after a long procedure to perform mine, tired, but steady.
The ICU and PCU staff at St. Josephs Hospital, who put up with me through my recovery and discharge.
And, of course, Judy, who put on her nurse’s hat once more to see me through transition to convalescence at home and was there for me throughout my ordeal, and who said “Stop!” when I pedaled to the edge.