Tuesday, September 25, 2007

My Achy Breaky Heart

I have adopted this classic old country ditty by Billy Ray Cyrus as the theme song for my latest encounter with the Reaper.

On a recent Sunday I went for a ride in the Tyrol on the Killercycle.


It had been some time since the Killer and I had been out together. Our route began in Ellmau, ran through Going, Oberndorf, St. Johann , Going again and back to Ellmau. A pleasant two hour ride, with a few serious hills. On the last serious hill, coming out of St. Johann, something inside began to flash yellow warning lights. I hate to stop once underway, but this time I did. There was a convenient bench along the route, so I took a minute to sit down. At that moment, my brother Joe happened to call me from somewhere in Utah, so I took the call and we chatted for a few minutes. That was enough to give me a rest. I mounted the Killer and rode easily back home.

I was overdue anyway for my annual cardiology check-up, so the next day I called my cardiologist Dr. Zahi Ibrahim's office and set an appointment for the following Thursday at noon.


(Dr. Zahi Ibrahim)

I arrived on time, atypically, parked illegally across the street and entered. I hardly had time to scan the latest Golf magazine when I was called to the EKG room. A nurse took blood, and I reclined on the exercise table for a resting EKG and then an exercise EKG following. Midway through the resting EKG the door opened and another nurse called out "don't do the stress EKG!" Dr. Ibrahim thereupon appeared and asserted that my blood showed a suspiciously high level of an enzyme called troponin and he was calling time out to check it again.


Computer model of the complex crystal structure
of the human protein c
ardiac troponin.

This beautiful but nasty little glob of protein is emitted from heart muscle cells when they are worried. And when heart muscle cells are worried the owner of the heart has reason himself/herself to worry also. (I did not know this then.)

Dr. Ibrahim, who is a very class act, walked casually back into the EKG room, reported that the second test also showed heightened levels of troponin, sat down at his desk, picked up the phone, asked for the intensive cardiac station at the Klinikum rechts der Isar around the corner, advised them he was sending a patient immediately and ordered an ambulance. After I peeled myself off the wall I told him that under no circumstances was I going to a hospital with a latin name or any other name. I raised many fundamental objections: I felt fine, my car was illegally parked, I had other plans for the day, I had no toothbrush, etc. He smiled sweetly and gazed upon me as a savant looks upon a fool. ("In patients with acute coronary syndromes, cardiac troponin I levels provide useful prognostic information.... If a blood test for cardiac troponins is positive, coronary angiography is typically performed on an urgent basis, as this is highly predictive of a heart attack in the near-future.")

Within minutes, an ambulance and crew and emergency doctor appeared in the doctor's office and gently guided the sputtering, idiotic patient into the van:



There I was, like it or not, back at the damned Klinikum rechts der Isar, where I had already spent one or more visits for similar reasons.



Still protesting, I was wheeled into the cardiac instensive care station, there to be greeted by the redoubtable Prof. Dr.med. Josef Dirschinger:


Der Kathetermeister

After a quick blood test, he confirmed my troponin reading, nodded gravely, and recommended that I give thanks to Dr. Ibrahim for getting me to the clinic in record time. (I took his advice and later sent Dr. Ibrahim a case of 'La Pieve' Chianti Classico from Fabrizio Ferrucci's shop in Radda in Chianti.)

With my troponin running rampant Prof. Dirschinger advised there was no alternative but to do an angiogram and have a look inside. I surrendered. I had been there before and knew the angiogram itself is a non-event from the patient's point of view. Entirely painless -- only 15 - 40 minutes of boredom.

Two hours later I sailed into the heart catheter OR on my gurney, slid into the arms of the snazzy new catheter machine they had installed with the help, in part, of the fees I had paid after my last outing. A two-nurse team, kindly, well-trained and bossy, did the prep, shaving me and swathing me in bilious orange disinfectant. The Kathermeister entered and called for a catheter.


Heart catheter -- an expensive roto-rooter


As the procedure began, so did Beethoven's Seventh Symphony (at the Klinikum rechts der Isar they are civilized enough to provide tasteful background music) on the stereo system in the OR.


The Seventh Symphony

Step 1 brings the slight sting of the injection of a local anesthetic where the femoral artery passes through the groin. Then the catheter slides up the artery (you know it is happening but you cannot feel it) and injects the inky fluid which gives definition to the coronary arteries -- the back of the brain registers a sudden rush of hot fluid, but it quickly passes. On the monitor at the upper left the patient can watch it all as the x-ray scanning arm passes back and forth over his chest, but to the patient's untrained eye it is a meaningless, gray, throbbing video landscape.


In Step 2 the catheter re-enters the femoral arter
y and crawls up and videos the arterial lay of the land on the surface of the heart, looking for problems, i.e., arteries narrowed or closed. The Professor now reports that he has found a badly narrowed artery and proposes first to open it and then to implant a coated stent to keep it open, assuming I consent.


Frame from my angiogram showing narrowing where
middle artery joins saddle

Well, what choice do I have? (Are you sure? How much will it cost? Can I see your license? I want a second opinion. Have you done this before? What happens if you screw up? Is your insurance paid up? .....) Bring it on!

A colleague of Prof. Dirschinger's
holds a stent up for view

So steps 3 and 4 proceed. The balloon opens the artery. The catheter goes back and forth. The 7th symphony plays on. The stent goes in. Shortly, the Professor sings out in a satisfied tone, "fertig, es hat geklappt!"


Subsequent frame showing
artery now expanded as it joins saddle

Having delivered his verdict, he turns and exits the OR. At that moment the 7th Symphony ends and the 8th begins. So we know exactly how long it took -- the precise length of the 7th Symphony -- the "apotheosis of the dance" it is called, but it was no dancing matter in the OR that day.

Thursday, September 06, 2007

Una Furtiva Lagrima per Luciano Pavarotti

The news of the death today of Luciano Pavarotti in Modena of pancreatic cancer moves me to post this video of him singing my favorite aria, "Una Furtiva Lagrima," from Donizetti's L'Elisir d'Amore. He was such a great artist, whose voice we instantly recognize from the first notes we hear him sing, and, though I never met him, was such a huge and human personality. I think back upon the hundreds of hours I have spent listening to Pavarotti and shed una furtiva lacrima of my own for Luciano tonight. CNN says that his greatest achievement was to "bring classical music to the masses," which is of course nonsense. He was an artist and his greatest achievement was his art.

Sunday, September 02, 2007

A Thinking Soldier's Man -- Return of the Video



The video of Col. Nagl's appearance on The Daily Show included in my post "A Thinking Soldier's Man," of August 26 , 2007, below, has apparently been pulled by YouTube and can no longer be accessed from my blog. The community of YouTube users is, however, irrepressible and the video has already re-appeared, so here it is again.