Wednesday, November 09, 2005

New Plumbing

In the blink of an eye (seriously! that's about how much sleep I've been getting!), my first month of Internal Medicine clerkship is behind me, and I am already up to my elbows in Med 2. From the intellectual masturbation and pristine ivory tower-ness of Yale, to the...well, I don't really want to know what goes on behind closed doors among the scores and scores of men hospitalized at the VA. The one thing that hasn't changed is the age of my patients--almost all are still clocking in at over 65, if not over 85.

Speaking of age, let me introduce: My patient. He's charming, he's sensitive--he even gives adorable answers to my mundane questions, like "am I in pain? I was until you walked in here..." (how come boys my age never woo me like that??) And so well preserved! He could easily win at one of those amusement park stations where they bet you your money against their stuffed animal that they can guess your age within 3 or 4 years. The guy doesn't look a day over 65, not with his full head of white hair neatly sculpted in Ken-doll waves around the smooth furrows of his face. Mature, maybe, but not old. And it doesn't stop at his neck: inspecting his non-gnarled hands for clubbing or cyanosis, poking his strong sock-suntanned ankles for signs of edema, listening over the broad expanse of his back for any lung crackles or wheezes; not only do I not find any evidence of pathology on physical exam--I don't really find much evidence that this is truly an 85-year-old's body! I'm almost tempted to call in the DNA experts to do whatever their equivalent of counting rings is.

Except...that he brings with him a story. They all do. This one starts at the end of spring--this past spring--the day he turned 85. "It was the beginning of the end," he mourns to me, and as quickly as he cracked a joke 5 minutes ago, I now see the glimmer of pre-tears appear glistening on his lower lashes. First, his eyes went bad. Then, his heart slowed down dangerously, and he had to get a pacemaker installed. And, now that it's beating faster than before, it seems that his heart has caught up with his chronological age and remembered its instructions from the CT surgeon god (or was it the riverdance goddes?): Get Clogged. In just six months, the poor guy has gone from running his own business and being completely independent, to lying in a hospital bed getting told that all 3 of his major coronary arteries have some major clumps of junk blocking them up, and--oh yeah, he's going to need triple-bypass, open heart surgery if he wants any chance of significant improvement.

Yes, owned his own business! And not just any old business; our man with the clogged up drainage system was working until the day he turned 85 as a self-made....plumber! So it wasn't hard to explain what the options were: (1) Drano, aka conservative medical management. Unfortunately, with blockages this big, there probably isn't a type of Drano strong enough to guarantee any longterm improvement, let alone safeguarding against major plumbing disaster. (2) Roto-rooting, aka coronary angioplasty or stent placement. Unfortunately, there are so many different blockages that to carve out and prop up the needed number of vessels/pipes would probably not be worth the investment of time or mone. And the big cahuna (3) Replace the pipes, which in this case means creating a detour of new pipes around the worn out parts of the old ones, aka coronary artery bypass graft surgery, aka CABG, affectionately known as "cabbage" in the medical world. (although, given that the surgery is a kind of makeshift solution, I think they should call the CABG surgery the "cabbage patch"! ha!) Right, so these are the options. Now, choose. By tomorrow. And if you want to go home to think about it for a week or so, we can't guarantee that you won't have a heart attack and die. Yeah, sorry.

What would you do? Or what would you have your father/grandfather do? On the one hand, he's already lived a full life as an airforce pilot, a husband, a father of two children, a self-made plumber--why mess it all up with a major surgery that will set him back at least 6-9 months, if not give him a stroke and set him back forever? What are we hoping to give him, anyhow--10 year survival outcomes for a surgery like this just don't become much of an argument in a patient who's already 85. On the other hand, his worsening chest pain since June has stolen whatever exercise tolerance he used to have--from crouching under strangers' sinks and traipsing into basements and sheds, he has been reduced to "a lump on the couch" who can barely cook his own meals anymore. Most of all, he can no longer do the thing that used to give him more pleasure than almost anything: playing golf.

So, it all comes down to one question (it always does): Is a rib-cracking, 6 hour long, highly risky, surgery in which your body is connected to a pump while your heart is stopped and the new piping is stitched in, a surgery that takes months to recover from and which may or may not ultimately improve your individual quality and quantity of that worth spending 1 day--your next birthday, say--just 1 day swinging your golf clobs out on the course, hearing the satisfying thwak of metal on white dimpled plastic, feeling the grass roll beneath your feet, the sun and trees brushing soft gusts of happiness through your neatly sculpted Ken-doll waves, and being able to walk--slowly, perhaps, but completely pain free-- to the next hole?


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