On Cabbages and the Fragility of Life

A jarring, life-altering, encounter with emergency Coronary Artery Bypass Graft (CABG – pronounced, “cabbage”) surgery

The Gathering Storm

It all started on November 19, 2020, when I went for my annual physical exam with my primary care physician (PCP). In that visit, he expressed the concern that my blood pressure was elevated, and my heart rate was on the high side. He gave me a new prescription. I have never been under the care of a cardiologist in my entire life. After retiring from full time ministry 2 years ago, I have wanted to go under the care of the cardiologist who takes care of my wife. I’ve always been impressed with his intelligence, his diagnostic instincts, his timely and wise interventional skills, and the top-notch circle of heart specialists in the NJ/Philadelphia region in which he belongs. Additionally, he and I have developed a good rapport throughout the time he was caring for my wife. But up until that point, I did not have a legitimate complaint to go under his care and be covered by my health insurance. This was the opportunity I was waiting for. I took the initiative of asking my PCP that I now wanted to go under the care of a cardiologist. He gave me his encouragement to do so.

By December 4, 2020 I was able to get my first appointment with my wife’s cardiologist, Dr. Casey Wong. In that visit, he scheduled me right away the following week for an echocardiogram on December 9, and a complete stress test on December 11. During the stress test, when he was monitoring the dye tracer that was was just injected into me during exertion, he mentioned aloud, “Elmo, I have concerns.” He probably was setting the stage to prepare me for some unpleasant news. But a sense of foreboding came over me instead for the first time – the kind that draws you inwardly to yourself, without words. The day after the test, his office called me to set an appointment for a telemedicine consult on December 17 to discuss the results of my tests. He started our telemedicine meeting by saying, “I have good news and I have not so good news.” I found myself remaining quiet. He continued without any interruption on my part, “Your echocardiogram was normal. Your heart valves and heart muscles are healthy. But your stress test showed a slowing down of the tracer dye on the left side of your heart, which suggests blockage in your cardiac arteries. You will need to undergo cardiac catheterization right away to visualize with specificity where the blockage is occurring. You might need angioplasty or stents. But there is also a 20% chance that you will need an outright open-heart bypass surgery.” Stunned, I struggled to remain calm. I asked how soon he wanted me to have the procedure. He said, “If I had my way, I want to see you do it next week.” There was a tone of urgency in his voice.

I felt myself resisting the news at first. Denial and reality became, for a moment, fused into an altogether undefined feeling. The brief hesitancy to accept the unpleasant news expressed itself very quickly through me bargaining for more time. I said it is Christmas week next week, and there are already a few family activities lined up through the remainder of the holidays. And so I asked, taking into consideration my entire clinical picture, how long could he really allow me to safely wait. He said, “OK, you can get through the holidays. But you need to have it no later than January 6, 2021.” He then asked me to choose between two hospitals – The Hospital of University of Pennsylvania across the bridge in Philadelphia (where my wife was treated), or the Robert Wood Johnson University Hospital in New Brunswick, NJ – both top tier research and teaching hospitals in the region. Mindful that I wouldn’t be able to do some driving, I chose the RWJH in New Brunswick, NJ for better accessibility for my family. And so it was set. Dr. Wong referred me to Dr. Andrew Shanahan, an interventional cardiologist (a specialist in cardiology who is trained in cardiac catheterization and associated cardiac interventional procedures). Dr. Wong assured me that he will only refer me to the best. The following day, I got a call from Dr. Shanahan’s office to confirm my appointment for the January 6, 2021 procedure, and to begin the patient registration process with me. The swiftness with which this was moving reminded me again of the urgency in the initial tone of voice of Dr. Wong. The full reality of the seriousness of the Dr. Wong’s findings began to dawn on me.

I asked the nurse of Dr. Shanahan if I could have a personal meeting with him before my procedure (I wanted to first meet and hear from any doctor who was going to conduct a procedure on me). She accommodated my request right away and said that the earliest availability of Dr. Shanahan is December 24, 2020, Christmas Eve. In that telemedicine consultation, Dr. Shanahan explained to me in detail the importance of the cardiac catheterization procedure. He said that the stress test only gives a general picture. The cardiac catheterization will definitively map the exact location and accurately assess the nature of the obstruction. I asked him to give me his assessment of the data from my stress test that Dr. Wong sent to him. He said I have lateral ischemia (a restriction of blood supply to tissues, causing a shortage of oxygen necessary for cellular health) on the left side of my heart. He confirmed Dr. Wong’s impression that it is suggestive of blockage(s) in the blood vessel(s) on the left side of my heart. He added that a cardiac catheterization will go in there with a camera and visualize exactly where the blockage is located and in which blood vessels. January 6, 2021 came. I was asked to report to the hospital at 5:00 AM for a 7:00 AM procedure. Because of COVID19, I was to come alone because the hospital is not allowing any visitors. My sister and my wife drove to drop me off at the hospital. It was a day procedure, so it was in the plans for them to just come back to pick me up later in the day.

After arriving at the hospital, I was directed to a dressing room where I was asked to change my clothing into hospital attire. Shortly after that, I was wheeled to the cardiac day-procedure area where the staff admitted me, and started an IV line. Dr. Shanahan and his nursing team came to meet me and gave some final instructions – I will just be given a mild sedative to relax me, but I will be conscious throughout the procedure. Then I was wheeled into the procedure theater. The aseptic, clinical smell of the room was distinct. It looked like a high tech theater full of electronic equipment, and large digital monitors. I was moved to the procedure table, and the final prep for the procedure began. I heard the nurses go through a checklist, reciting aloud each step while another nurse echoed redundantly the previous call to confirm, like pilots in a cockpit. This was all happening while another technician was immobilizing my right arm. Dr. Shanahan had indicated that he decided to use the radial artery on my right wrist to introduce the catheter. I thought to myself, this is reassuring. They have done this so many times before. The nurse tells me that she just gave me a sedative through my IV, that it should calm me down. Then I heard Dr. Shanahan announce, “I will begin.” I felt a slight pinch on my right wrist, as the catheter was introduced. I didn’t feel any more pain or anything unusual after that, only that the room grew quieter. I knew that Dr. Shanahan was doing his thing. I was feeling no pain or discomfort. A surreal thought came over me during that quiet moment – the thought that a catheter was snaking its way through my arm arteries, then through its larger branches in my chest, and then on to my heart. I marveled at the wonder of science.

Caught in the Whirlwind

After what seemed to be about 30 minutes, I heard Dr. Shanahan announce that he was done. I could hear and feel the team going through concluding procedures, removing the sterile coverings on my body and releasing the restraints on my arms. Shortly after that, Dr. Shanahan came up to my left side as I was still lying down, and then he pulled and tilted a large digital monitor to face me. He said, “I now need to show you what I found. The videos you will see next are real time live feeds of the nuclear tracer that was injected through your cardiac arteries as the X-Ray was recording its flow.” What he showed to me next, and what he said, came like a stunning bombshell to me. He pointed out on the video that the three branches of the Circumflex Artery (which supplies the left and back side of the heart) were all blocked. One was 90% blocked, and the two others were 80% blocked. He said that they were calcified plaques and were impervious to angioplasty (stents). He said that he sees this a lot in people with diabetes, which I have. Without any equivocation, he said that I need to have heart bypass surgery as soon as possible, or risk a heart attack in not too long. I was speechless. I suddenly felt I was being caught in a whirlwind. My mind was suddenly flooded with plaintive questions: How did this happen? I’ve been a fairly active person, and my diet is not composed mainly of high saturated fat food. So, why do I have coronary artery disease? Of all the diseases I have contemplated that might afflict me in life, coronary artery disease was not one of them. How did I so thoroughly overlook this malady that has crept up on me?

I was wheeled back into the same-day cardiac procedure area. Dr. Shanahan came to tell me that he had spoken with my wife, and with Dr. Wong. He and Dr. Wong both agreed to refer me to Dr. Leonard Y. Lee to handle my heart bypass surgery. He said that Dr. Lee is the best cardiothoracic surgeon at RWJH, and renowned in the region. It turns out that he is no less than the chairman of the department of surgery, and the distinguished professor of surgery of the James W. Mackenzie endowed chair in surgery of the RWJH Medical School. My mind was thrown for another spin when Dr. Shanahan mentioned to me that he scheduled me for discharge at 6 PM, so that I could have time to meet Dr. Lee in person to discuss my situation, and the possibility that Dr. Lee could go ahead and do my surgery since I was already in the hospital! He told me that Dr. Lee was in surgery at that given moment, but that he will be seeing me immediately as soon as he was done in surgery. I have always relied on an instinctive analytical approach when confronted with crisis. I have always been able to methodically think through a conundrum. This was different. The avalanche of information I was receiving that day was mind-numbing. I don’t recall that I ever have been, but in that moment I knew I was in shock. I contacted my wife via phone video. Our daughter who is a nurse was with her. Having spoken with Dr. Shanahan, they both encouraged me to just stay in the hospital and have the surgery. My daughter repeated the most urgent finding of the cardiac catheterization: “Dad, one of your coronary arteries is 90% blocked, and the two others are 80% blocked. If Dr. Lee can do the surgery while you are there, get it done.”

A sense of inevitability came over me. I felt helpless. As a former nurse myself before entering theological studies and a life of ministerial leadership, I knew the basic nature of open-heart, coronary bypass surgery. While the procedure has been done and perfected by surgeons for over 50 years now, it still is a major surgical procedure. And then suddenly in that moment doubt, fear, anxiety came together like a thick rue that flooded my mind and spirit. I thought to myself: What if I don’t survive the procedure? If I die, I haven’t even talked to my wife and children to bequeath my deepest wishes for them. I haven’t even given my wife the passwords to all my online accounts, which are all stored in an encrypted app using only one master password! I am so not prepared for this, I thought to myself. And then the office of Dr. Wong, my cardiologist, called. The nurse said Dr. Wong wanted to speak with me. I thought it was a good gesture reinforcing Dr. Wong’s personal touch, and an indication that he has been in close and constant communication with the team in RWJH all this time. When Dr. Wong came on the phone, the first words that came out of my mouth were: “Well, Dr. Wong, I guess I fall in that 20% that you mentioned!” And then he gave me the most assuring words that I needed at that moment: “Elmo, I want you to know that I have told my circle of colleagues that if I or any of my family will ever need heart surgery, only Dr. Lee can touch me or them, no one else. He is the best. I am referring you to no one but the best. In a few months you will be good as new.”

Dr. Shanahan came by again to report that Dr. Lee was finishing up, and that he was coming to see me sooner than expected. In the meanwhile, I was overhearing pieces of conversation among the busy staff who were coming to my earshot about “awful”, “unbelievable”, and “terrible” things happening. My nurse came, and I asked what was happening. He said, the US Capitol was being attacked, overrun, and being ransacked by a rioting mob of Trump supporters. “Do you want the TV turned on for you?” It was, indeed, a portentous day for me in more ways than one.

Shortly after that, Dr. Lee came to my bedside. He introduced himself and his nurse practitioner who was with him. He was not a big man, not even average height, he was medium built. I stand 5’10”, and it was clear by the scale of the objects and furniture around the room that I was taller than him. But his persona was compelling. His calm words had a measured cadence to them, almost professorial, and exuded confidence and competence. It was reassuring to me. He said that after taking a quick look at the films of my cardiac catheterization, it is abundantly clear that I needed immediate bypass surgery. He said that the procedure is 98% successful, and that the remaining 2% of known complications are well recognized, and that the surgical team is well prepared for them. He added that in cases like these, waiting never has an upside, only a downside. I mentioned to him that it was discussed that I should get it done while I am in the hospital. It was a Wednesday, and he said he couldn’t do it that day, and that the earliest he could do it is Friday. And so I asked him: if I was to wait anyway until Friday, could I go home for a few days to better prepare myself and the family? He said yes, we will do it first thing on Monday, January 11, 2021. Once that was settled, and obviously taking advantage of the fact that I was still admitted in the hospital, I was suddenly bombarded with numerous new tests, clearly in preparation for the surgery. Blood was drawn from me from all sides for different purposes, I was taken for chest X-Rays, and for vein mapping ultrasounds. I was finally discharged close to 6 PM, and my wife and daughter came to pick me up. I was sent home with a scheduled set of medications and procedures to take at home for the weekend, leading up to the day of surgery. I felt that the extra few days of waiting gave me some psychological and emotional space to prepare, and to speak further with my wife and family, to say to them what I want to say if I didn’t have another chance to say it to them. I was told to report to the hospital at 5 AM on the day of surgery, Monday, January 11, 2021.

An Extraordinary and Phenomenal Experience with Existence

The night before surgery, I found it difficult to sleep. I was full of anxiety. I began to question myself: Will I have the courage to go through this? Will I survive? What if I die? Am I prepared? Is my faith going to carry me through? The questions were deeply personal. It was an eventful night, no doubt. I was instructed to report to the hospital at 5 AM for a 7 AM surgery. I was to be Dr. Lee’s first patient of the day. The hospital is about a 45-minute drive from our house. We had to be on the road by 4 AM to make it on time. So my wife and I were up at 3 AM . With broken sleep, I felt I was up all night. Again, because of strict COVID19 precautions, the hospital did not allow any visitors. My wife does not drive far and wide. And so, my sister kindly volunteered to drive us to the hospital to simply drop me off. When we got there, I said goodbye to my sister. My wife stepped out of the car to give me a tight hug. I told her again that I loved her. I walked into the hospital by myself. I have never felt so alone. After checking in, I was directed to the dressing room and was instructed to change into hospital robes. I was tagged with 3 bracelets – green for allergy to Aspirin and latex; yellow for fall risk; and white with my identification. A nurse practitioner from Dr. Lee’s team came in to meet me and verify my identity. Perhaps sensing my anxiety, she said, unsolicitedly, that I am in good hands, and that Dr. Lee is the best. It was comforting to hear that again.

In not too long I was wheeled into a multi-unit pre-op room. It was already buzzing with activity that very early morning hour. Someone came to my bedside, and introduced herself as the anesthesiologist who will “take care” of me that day. She had a soothing voice. Going through once again with established protocol, she asked me to self-identify with my name, birthdate, and the reason why I was in the hospital. She then inserted a multi-port IV line on my left arm. I prayed once again, entrusting myself to the Lord, and this time asking him to walk me through the valley. Then I had the faces of my wife, my children, and my granddaughters run through my mind, and clinging to the thought that I still have to meet our very first grandson in March. With a slight defiance, I declared to myself that I still had so much to live for! And then the anesthesiologist said in that soothing voice of hers that she was now going to give me something to make me relax. Her voice was the last voice I heard. My first conscious recollection upon waking up was that there were 3-4 nurses hovering over me, busily doing many but coordinated tasks. I immediately realized that I was still alive! They said I was in the Cardiovascular Intensive Care Unit (CVICU), and that surgery was over and I did very well. I asked if Dr. Lee had called may wife, and they said that Dr. Lee has already spoken with her. Someone asked me if I was in pain, and I said no. They then alerted me that there are several tubes, catheters, and IV lines, including blood transfusion, attached to me right now and to minimize my movements, that if I needed anything to simply call them instead. More importantly, I was so happy that I woke up without the ventilator still in my throat. I must have come up from anesthesia quite well, that they extubated me while I was still in the recovery room not yet fully awake. Thankfully, I have no memory at all of being intubated.

Later that day my telephone was handed back to me, and I was able to make a brief video call to my wife for the first time. Seeing her face, and overcome with gratitude, tears welled up in my eyes as I said my first words to her, “I’m still alive!” The nurses and staff in the CVICU were outstanding in every way. By the second day post-op, when most of my tubes have been taken out, they already had me sitting up in a chair. Dr. Lee came for a second visit, and said that I was doing so well that he is discharging and sending me home on Friday of that week. I was in the CVICU a total of only 4 days. Just amazing! My daughter drove with my wife to come pick me up from the hospital. In the car my daughter said that she was surprised to see me walking out of the hospital unassisted. She was expecting me to still be too weak and at least to be equipped with a walker. I told her that my surgeon was even impressed how quickly I have bounced back. I was released without any mandated cardiac rehab regimen. Instead, I had only two sessions with visiting nurses for my wound care, and 4 sessions with a physical therapist – all at home.

As of this writing, I am almost 5 weeks past my surgery and continue to heal and recover at home. I have been given permission to resume driving. During these days of forced recuperation at home, I have been doing much reflection on this extraordinarily unique encounter with life and its fragility. It has given me a singularly phenomenal experience with my existence. Soren Kierkegaard famously said once that, “Life can only be understood backwards, but it must be lived forwards.” As a person of faith, I could now see the presence of God all throughout that experience. The progression of events leading up to my diagnosis, as unsettling as they were to me, the orderly and timely emergence of skilled doctors along the way, were all God’s way of leading me away from mortal danger. Now I also understood the reason why within the past year I had experienced easy fatigue when gardening around the house, or walking along the walking trail of our development. I dismissed those feelings as just being out of shape, not being in the gym during the COVID19 lockdown. Indeed, as I look back to the confluence of events that led to my emergency surgery, I cannot help but also see the important role that my personal agency played in the timely diagnosis of my illness. Had I not insisted on going under the care of a cardiologist, my routine visit with my PCP last November for my annual check up could have simply ended with me just being content with the new medication he prescribed for my elevated blood pressure. I could still be going about my usual activities right now, unaware that my heart was a ticking time bomb inside me. The invaluable lesson for me is that we must be active participants in our own health care. We are the best advocates for our own health. We need to be curious and honest conversation partners with our doctors. They are vital to our health care, but we just cannot passively submit our lives 100% to them.

The experience also radically reminded me that our body is just a structure that houses our mind and spirit. Many times we go about our daily lives conflating our spirit with our body. We unmindfully assume that they are one and the same, that our body is as indefatigable as our spirit. The net effect is that we often end up pushing our body way past its equilibrium, subjecting it to continuous stress which in turn raises our blood pressure that ultimately damages our arteries. Our body is just a wondrous machine that yet requires vigilant maintenance if we are to enjoy its miraculous and salutary benefits. This distinction between body, mind, and spirit was made jarringly clear to me when I reflect on the reality that the surgeons literally separated my breast bone to expose my heart and lungs. Then they literally paused and stopped my heart and lungs, bypassing my blood to be oxygenated outside my body in a heart-lung machine, so that the surgeon can work on my heart uninterrupted while my blood, rich with life-giving oxygen, continued to supply my other organs to keep me alive. It is a stunning display of the preeminence of medical science and the skill of surgeons. But existentially, it became for me a radical differentiation like I never experienced before, of the body from my mind and spirit. My heart was stopped. But I was not dead.

In our final telemedicine conference, I profusely thanked Dr. Lee for giving me a second lease on life. And then I asked him how I could honor the invaluable gift he has given to me moving forward in my life. With the precise prose characteristic of a seasoned cardiothoracic surgeon, he said: “I did not give you a cure. I only gave you a fix. Live a heart healthy life moving forward.” Soren Keirkegaard was right. We can only connect the dots of our lived experience by looking backwards, by reflecting on the past. Doing so helps us to understand life – both its preciousness and its fragility. And having learned from that, the wise person lives life forward mindful of how to make the body – the temple of the mind and the spirit – better and healthier.

(Featured photo by Piron Guillaume on Unsplash)