7. Rehabilitation

My first appointment with the doctor was 1 week after my discharge.

The doctor recommended a few things.
· Use the chest strap, to hold the chest especially when coughing, or laughing
· Use the TDL stockings to prevent water retention on the leg
· Exercise using the Respiflo 2500, to strengthen the lungs
· Take long walks, climb stairs, etc

The TDL stockings, chest strap and the Respiflo are included in the physiotherapy provided by the hospital. I used the chest strap and the TDL stockings only for three weeks. To use the respiflo, you have to exhale, and then suck in through the hose, and see the volume inspired. Just after the operation, I only managed 750 cc. Slowly the figure rose, and now I can reach the maximum 2500 cc easily.

However there were other things suggested by the doctor. So I went to a pharmacy and bought myself three things :
1. An Omron BP meter, and
2. An Omron blood sugar tester, which requires accessories such as lancet, test strips, and alcohol swab.
3. A 200W Philips Infra red, which I used to warm up the affected areas on my leg, to replace the hot compress which was not very effective. This helped dry the wounds faster. Bruise marks on my arm and my legs disappeared by the 6th week, possibly aided by the use of this infrared.

My BP seemed to fluctuate – sometimes more than 140/100 sometimes around 130/90. But my heartbeats are high, most of the time around 90, and once in a while reaching 100, even at rest! However, when I used the treadmill, fast walk at 5 km/hr, doing almost 3 km at a time, my heart beat maxed at 130 only. The treadmill was bought by my son-in-law, to keep him fit for his regular game of futsal.

My blood sugar was okay, less then 5mmo/L. Maybe my regular consumption of diabetic milk from Abbot also helped.

A fellow who also had bypass surgery mentioned difficulty sleeping sideways. So I tried. There was discomfort at first, but now I can sleep sideways but I still have problems sleeping on my tummy, which thankfully is not my regular position.

Went to the optician last week, and my eyesight was back to ‘normal’ – no more fluctuating readings on the computerized eye tester. So I ordered my new pair of glasses.

Finally, the test drive ... You need chest muscles to steer the car, and with some exercises, I have been driving quite regularly now, without any problems. The only discomfort is the seatbelt straddling my chest, so I had to adjust it.

6. Post Operation : It hurts only when I laugh …

I spent 3 nights in ICU, even though there was no ‘complications’. My heart beat was 80+, my blood pressure was yo-yoing up and down, blood sugar was high. I was given extra blood and plasma.
The nurses were OK. They cleaned my wounds once a day, checked BP, oxygen and blood sugar regularly, and did whatever else is standard. My right leg was wrapped with TDL stockings, and my chest had to be strapped with what looks like a bullet-proof vest. The physiotherapist came for breathing exercises, and guided walks around the floor.
What I could not stand was the food – porridge, soups and things that has that hospital taste. No papayas, bananas, or grapes, as I had to control my blood sugar. No salt, as that is not good for hypertension. And a nurse kept asking me almost every day : What did you eat today? Have you gone to the toilet?
What could I say, all you take in is air … and water. I managed to go to the toilet, though after I was returned to the ward on Thursday 23rd October, and that only with the help of laxatives.

Some visitors asked me : does it hurt? I tell them : It hurts only when I laugh … and even more when I cough. So no jokes, please. That’s why I have this vest on all the time.
I was also asked : was I afraid to have this operation? Well to be honest, I was looking forward to it, and to end this chest pain once and for all. I do not have a new engine, just a reconditioned engine with new exhausts. This is a new lease of life. Hopefully this will last 15 to 20 years; that’s all I ask for. I put my trust in the doctor, and God. And I thank God for that. Thank you too to the team that has done an excellent job.

Here I would like to mention some problems related to the operation :

1. The operation has cost me an arm and a leg. My right arm is blue and black from the wrist to the elbow on the underside which took more than three weeks to disappear. The inside of my right foot is black with bluish red bruises going up right until below the knee. This is taking an even longer time to disappear. The pain in my chest is nothing compared to the pain in the leg.
2. Insomnia. I was restless almost every night, and slept at most an hour or two. The doctor prescribed some sleeping pills, but it didn’t make any difference. It was only after 3 weeks that I started having more hours of sleep, but then again only 3 – 4 hours a night. I spent time watching TV, playing SUDOKU, and replying emails. I received a lot of SMSs and emails wishing me Get Well Soon.
3. After 3 weeks, the wound in my chest is showing signs of healing. However, the incisions on my leg where the vein was pulled out is giving me problems. It is itching and sometimes throbbing. At one time, I took off the TDL stockings for about half a day, and then I noticed the leg bulging and hardening – like an over pressurized balloon. Immediately put the stockings on, and kept my leg above body level. It was OK later, but that was a lesson learned. Basically that saphenous vein is used to route back about 10% of body fluids from the leg to the heart. When the vein is taken, the body fluids will have to find new routes … and since the routes have not been properly established yet, it caused fluid retention.
4. Then there was this thing I mentioned earlier. A lot of things that happened throughout the whole operation slipped my mind. I could not remember who came and who didn’t. I couldn’t remember what actually happened and when. It was only after long deliberations with my wife that I managed to piece back all the things that happened, and to write this blog. I do not know whether this is normal or not.
5. Finally another strange event … I went to an eye specialist to make new glasses. The optician took my glasses and noted the power. Then I was given a computerized eye test. Three times the test was taken, and the readings were fluctuating … so much so that the optician refused to give me a prescription. The readings were considerably lower than that from my existing glasses, but the optician has never before encountered fluctuating readings like mine.

When I checked in at the hospital, I asked my secretary to distribute all my existing arrangements, which she did. I was told to forget about work. One of my colleagues reminded me that my program was too hectic, that I must learn to say NO! I was rushing everywhere, day in and day out, until my heart finally screamed : STOP!
Now I have 3 months to hang around … reading emails, searching the net for details on heart bypass operations, playing SUDOKU, and of course, writing this blog.

How does it feel now? I feel 10 years younger. And I hope I can stay that way … 48 forever!

5. The Operation

I was wheeled to the OT waiting room at 8.30 am Saturday 18th October. A young lady anesthetist started inserting plastic needles on both my arms, and how they hurt! While busy at work, she kept receiving calls : Some people just have no patience, she said, but finally she left, and that was the last I saw of her.

My wife who was waiting outside had a rude call to come quickly to the OT reception. Her blood seemed to drain out as she hurried, wondering what could have happened. Well, the surgeon came over and announced : we’ll have to postpone my ops, as there is an urgent case. A 35 year old Chinese is almost dead from a heart attack. You are stable, and I hope you don’t mind waiting.

I was wheeled back to the ward, with tubes around me.

I had lots of visitors, family, friends, and colleagues. After the operation and discharge, I start to write this blog, and somehow or other, I simply could not recall all the people who visited me. Did my boss come? He did? Wooo … for the first time in my life, my short term memory seemed to fail me.

There was a change in anesthetist, this time a young male. He visited me the night before the operation. I could not recall what was discussed, but according to my wife, he explained the operation procedure, roughly as follows :

Procedure (Simplified)

• The patient is brought to the operating room and moved onto the operating table.




• The anesthetist places a variety of intravenous lines and injects an induction agent (usually propofol) to render the person unconscious.




• An endotracheal tube is inserted into the throat and secured by the anesthetist and mechanical ventilation is started.




• The chest is opened via a median sternotomy (bone saw) and the heart is examined by the surgeon.




• The bypass grafts are harvested - saphenous veins (from on the inside of the thigh to the leg,). When harvesting is done, the patient is given heparin to prevent the blood from clotting.




• I cannot remember whether it was an ‘on-pump’ or an ‘off-pump’ surgery, but the Heart Lung Machine was mentioned.




• One end of each graft is sewn onto the coronary arteries beyond the blockages and the other end is attached to the aorta.




• Protamine is given to reverse the effects of heparin.




• The sternum is wired together and the incisions are sutured closed.




• The person is moved to the intensive care unit (ICU) to recover.




• After awakening and stabilizing in the ICU (approximately 1 day), the person is transferred to the cardiac surgery ward until ready to go home (approximately 1 week).

After, giving the details, I remember him giving me a stack of documents to sign. No point reading, as there would be no operation if I do not agree to sign. You leave me no space for litigation, I commented, and his laugh seemed nervous.

A triple bypass operation, showing saphenous veins grafted from the aorta to an area after the blockages, thus supplying more blood and oxygen to the heart muscles.
My operation was scheduled for Monday, 20th October. A Sunday operation would be prohibitive cost-wise. I cannot remember the sequence of events that happened on that day. When I awoke, I was back in ICU with wires and drips around me. There was no case of seeing the light at the end of the tunnel … hehehe. My breathing was fast and shallow and I was not aware of much pain.

4. Angiogram

I was given some razors and asked to shave, from the chin down … exactly when I cannot remember. Was it before the angiogram, or after …I was ordered to stop taking food or water from midnight the night before. Have no problems with that.

At 8.30 in the morning I was wheeled to the catheter lab (cath lab). The doctor explained what angina is all about, and what he is about to do.

What is Angina

Angina (angina pectoris - Latin for squeezing of the chest) is chest discomfort that occurs when there is a decreased blood oxygen supply to an area of the heart muscle. In most cases, the lack of blood supply is due to a narrowing of the coronary arteries as a result of arteriosclerosis.
Angina is usually felt as pressure, heaviness, tightening, squeezing, or aching across the chest, particularly behind the breastbone. This pain often radiates to the neck, jaw, arms, back, or even the teeth.

Angina usually occurs during exertion, severe emotional stress, or after a heavy meal. During these periods, the heart muscle demands more blood oxygen than the narrowed coronary arteries can deliver. Angina typically lasts from 1 to 15 minutes and is relieved by rest or by placing a nitroglycerin tablet under the tongue. Nitroglycerin relaxes the blood vessels and lowers blood pressure. Both rest and nitroglycerin decrease the heart muscles demand for oxygen, thus relieving angina.

Up to 25% of patients with significant coronary artery disease have no symptoms at all, even though they clearly lack adequate blood and oxygen supply to the heart muscle. These patients have "silent" angina. They have the same risk of heart attack as those with symptoms of angina.

How is an angiogram carried out?

An Angiogram usually takes around 40 minutes to an hour.

A catheter (a thin, flexible, hollow plastic tube) is passed into the artery in the groin or occasionally the arm. You will have a local anaesthetic to numb the area where the catheter is inserted. Using X-ray screening the catheter is directed through the blood vessels and into the heart. You can’t feel the catheter going through the heart because there are not enough nerves in the blood vessels.

A special dye is injected into the catheter and a series of X-ray pictures are taken. The dye sometimes causes a hot, flushing sensation. The dye shows up all the coronary arteries on the X-rays, to see if there are any narrowings or blockages there. While you are having the angiogram you will be continually linked to a heart monitor that records your heart rate and rhythm.
The cardiologist explained the pictures on the monitor. You have 100 % blockages in at least three areas, he says. That makes insertion of balloons and stents out of question. So now the heart surgeon will have to take over.

And as if on cue, the surgeon appeared. I think you are very lucky, he said. We found your problem in time. You don’t have to worry, because your heart is still OK. I have done more than a thousand operations already. We can schedule yours tomorrow (Saturday, 18 October). Wowww, I thought. This is going too fast …

What happens after an angiogram?

After the angiogram, you can expect:

• A pressure dressing is placed on the test site for around four hours.
• Your blood pressure, pulse, breathing and wound site are regularly checked and recorded.
• Intravenous fluids may be given for a short time, although you are encouraged to eat and drink as soon as you feel able.
• You will have to lie on your back for three to four hours, keeping your legs as still as possible.
• You may be allowed to sit up after four hours.
• Often, you are not allowed out of bed until the next day.
• If you are not already on a special diet, a cholesterol-lowering diet is usually suggested.

I was wheeled back to the ward, to be prepared for the big day the following day.

On retrospect, I had undergone a stress test and ECG a year earlier at the panel clinic, and the doctor had suggested an angiogram. But the way he proposed made me suspicious of his intentions – was it in his interest or mine. Now that I have undergone the angiogram, I realize that maybe if I had done so earlier, I may have gone away with just angioplasty, and avoided the bypass operation. It would have been cheaper too. Then again, it could also already be out of question.

3. How the heart works

Had to spend some time to undertand how the heart works, before I could comprehend how it can fail.

The heart has two pairs of chambers or "rooms," the right atrium and ventricle, and the left atrium and ventricle. Oxygen-poor blood from the body is drawn through the vena cava into the right atrium. The right ventricle draws in this blood from the right atrium through the tricuspid valve, and then pumps it out through the pulmonary valve to deliver the oxygen-poor blood to the lungs through the pulmonary artery.

Oxygen enriched blood from the lungs return via the pulmonary veins and enters the left atrium. The left ventricle sucks in this blood through the mitral valve and pumps it out through the aortic valve, to the aorta which then supplies the oxygenated blood to various parts of the body, including the heart muscles.
When the heart's valves open and close, they make a "lub-DUB" sound that a doctor can hear using a stethoscope.
The first sound—the “lub”—is made by the mitral and tricuspid valves closing at the beginning of systole. Systole is when the ventricles contract, or squeeze, and pump blood out of the heart.
The second sound—the “DUB”—is made by the aortic and pulmonary valves closing at beginning of diastole. Diastole is when the ventricles relax and fill with blood pumped into them by the atria.

What is coronary artery disease?

Coronary artery disease occurs when fatty deposits called plaque builds up inside the coronary arteries. The coronary arteries wrap around the heart and supply it with blood and oxygen from the aorta. When plaque builds up, it narrows the arteries and reduces the amount of blood that gets to your heart. This can lead to serious problems, including heart attack. Plaque is a fatty material made up of cholesterol, calcium, and other substances in the blood.

The accumulation of cholesterol plaque over time causes narrowing of the coronary arteries, a process called arteriosclerosis. Arteriosclerosis can be accelerated by smoking, high blood pressure, elevated cholesterol, and diabetes. When coronary arteries become narrowed by more than 50% to 70%, they can no longer meet the increased blood oxygen demand by the heart muscle during exercise or stress. Lack of oxygen to the heart muscle causes chest pain (angina).

An angiogram has to be done to identify the location and number of blocked arteries, and to determine the corrective actions required.

2. Background

How did I get into this condition? No idea. I had my share of games, even did exercises sometimes. It could have been the lifestyle, the food, and other factors I’m not aware of. My mother died of leukemia, my younger sister succumbed to a heart valve malfunction – not related to coronary disease.
I was working with the public sector when my previous boss invited me to join this company as a manager and consultant. I had only two more years to go, and there was nothing much to look forward to, to support retirement. Well, retire means changing your tires. So I didn’t require too much persuasion, and immediately tendered for early retirement.
I was placed in Bintulu, and I stayed there for four years. The job was challenging, looking for customers, providing the services, facing outside competition, developing new products. I travelled all over Sarawak and Sabah. It was only on the fourth year that we managed to exceed our target, thanks especially to my right hand man, who happened to be a woman.
And then I was called to back to West Malaysia – Bangi. I have a new boss here, and I accompanied him on 3 of his work travels. We spent 3 weeks in Sri Lanka, 2 weeks in Japan and 4 days in Brunei. Whilst in Sri Lanka, we were up by 6 every morning, and the agenda was the same : half an hour jogging (I was just walking all the time) by the sea, followed by another half hour in the gym. I found myself gasping for breath half the time. On the trip to Brunei, we were invited to Temburung to see the canopy walk high above the jungle floor which involved a climb of over 1,400 steps, according to our guide. I collapsed halfway and missed the experience. I know my limits.
I did not have a chance to go overseas during the tenure of the next boss, but I travelled extensively in the country. I started feeling discomfort around my upper back on flights, and the effort to carry a laptop and luggage to and from the plane became increasingly burdensome – especially when I noticed bigger people with extra luggage walking past me seemingly without any effort.
I used to drive long distance, alone, and I have to stop regularly as I always feel sleepy. People with heart problems are in danger of suffering from nano-blackouts, and I had one while coming back from Segamat. Luckily for me, I woke up in time to avoid a disaster.
In my classes, I used to tell my students that if you have problems climbing a flight of stairs 3 storeys high, chances are you have a heart problem. Don’t force yourself, or it could be the last thing you’ll ever do on earth. That is why when I have a class on the 2nd floor, I always take the lift … I already know that I have a problem, but I have been procrastinating. I keep telling myself : its gonna be okay. But the surgeon had a different opinion. He says I was a walking time bomb : I could collapse any time …

1. The Defining Moment

I went to bed early that Monday night of October 13th, but around 11.30 pm I woke up feeling like a ton of bricks was pressing on my chest. I sat up, took long and deep breaths, but to no avail. And then my wife came up after putting the grandchildren to sleep. I told my wife I can go to the clinic tomorrow, but she said NO! Go NOW! So off I went to our panel clinic, driven by my son-in-law.

There was only one doctor on duty, and the queue was not unexpected. When my turn came, I had to undergo an ECG. I was given some medication, plus a small pill to keep under my tongue. Then the verdict : The pain I felt was called angina, a precursor to a heart attack. The doctor gave me a referral letter to a private hospital in KL, Ampang Putri Specialist Hospital.

On the 14th, I was back at the office to handle certain issues, and to ask for a guarantee letter. On 15th I had a meeting at Sg. Buluh, and later returned to the office to pick up the guarantee letter. The question haunting me was : should I or should I not go to the specialist hospital … but I realized that it’s now or never. I have been postponing this for too long, and it’s time to face it head on.

Again, it was my son-in-law who sent me to Ampang Putri. The attending doctor, a middle aged lady, made a brief examination before saying she’s not the right person to handle my case. Off she sent me to the cardiologist, a stocky built doctor. There was the ECG again, followed by an echograph, and then a stress test which lasted barely a minute. I have to go for an angiogram, scheduled for tomorrow. I was immediately warded, and I didn’t even think of bringing a change of clothes. Nothing oral to be taken after midnight. Doctor’s orders.