Pre-Op & Post-Op

They began wheeling me to the OR right around 2am. My mom and my cousin were walking down with us. My dad was on a flight back to Philadelphia. Everybody had been notified of the news. I was ready. I think.

My mom kissed my forehead. We all hugged. And then I blurted out the million dollar question, “Mom, what if I die?” 

And then she replied with the same thing that she had been saying for weeks. 

“If you had to die, you would have died already. You tried dying so many times already and you didn’t. You have a lot of things left to do in this world. You aren’t going to die.”

I’m not particularly spiritual, but in that moment, it was such a perfect thing to hear. Moms really are the best. 

The OR was so bright. I hadn’t been in one of these rooms since my General Surgery rotation in medical school. And this one was top-notch. Huge. Probably the size of my whole apartment. There were at least two large HD screens staring at me. Everything was white, blue, sterile. Cold. Fascinating. I saw a generic OR checklist up on a screen, and my name was written somewhere already.

The technicians were getting some things together. The nurses began asking me some basic questions about my birth date, my allergies, etc. I don’t know if it was because my voice cracked, or because I was unusually quiet, but I think everyone around me knew how nervous I really was.

They tried to make me laugh by saying things like, “You’re gonna be famous after this, girl.”

I reacted with sarcasm, of course. I think I asked them to try not to kill me. 

“We know what we’re doing. This isn’t our first rodeo,” they replied. We laughed some more. 

The attending Anesthesiologist came in to help with the placement of my (millionth) arterial line. 

“You know, these don’t hurt as much as I thought they would. I don’t feel a thing. I actually feel great,” I told him.

“That’s because of the Versed we just gave you.”

I chuckled.

“You ready? We gotta get you back to saving lives,” someone else said. I smiled. Yeah, I guess I did have to go back to saving lives. That made me feel better. Just a little tiny hurdle, a speedbump if anything. You’re going back to work in a few months. This is nothing.

There were a few people coming in and out of the room— making me smile, shaking my hand, giving me high fives. The CT Surgery fellow came in and asked if I had any last minute questions.

“Can you get rid of my uterus while you’re in there? Just take that thing OUT!” I asked him.

“We really only deal with the chest … but we’ll see what we can do,” he replied, with a smile.

Someone asked me what kind of music I wanted to listen to.

There was no question about it. The man who had gotten me through all of my life’s struggles. Always do your best, don't let the pressure make you panic and when you get straaaanded and things don't go the way you plaaaanned it…

“Tupac.”

And then they actually put on Tupac radio! I felt at ease. I felt good (again, might have been the Versed…). 

I heard one of the nurses say that the “heart was good to go” (I didn’t know this, but apparently the surgeons have to do one last visual check on the donated organ after it has been procured and tested extensively). They had just finished examining it, and the attending was preparing to start the surgery. “They'll all be in here soon, okay? We’re gonna finish getting you ready.”

The attending and the fellow are probably changing into their scrubs, tying their caps. They're in the locker room, probably talking about how the Sixers have been doing. There’s a medical student reviewing the nerves and vessels around the heart; she knows that she'll be pimped on them. She’s nervous because this is her first open-heart case. There’s a resident running towards the OR while inhaling a protein shake because he hasn’t eaten anything in several hours. My case woke him up from sleep. I’m sorry about that; I know how much you hate cases in the middle of the night.

Alin, this is nothing for them. It’s second nature. One beautiful incision after the other. Their well-trained, delicate hands know the ins and outs of open-heart surgery. They check off each action, one by one, in their brilliant minds. Cut here. Snip there. Be careful of the recurrent laryngeal. Remove heart.

Take my heart out. 

…

No. You know what? Violently rip my heart out of its cage! Get rid of it. This stupid heart that put me here in the first place. I was proud of you at first for living so long, but now I’m angry with you for dying so early. My life had been going so well. So well. I had worked so hard. I rarely complained. I was a good person for the most part. I did nothing to deserve this. Here I am now, all alone on this cold metal slab, just patiently waiting for the most frightening moment of my life. You’re barely working. You’ve decided to be difficult. You’ve made everybody put their lives aside to worry about me. I hope you’re happy.

I had a love-hate relationship with my old heart, but I spoke to it often. I was very open with it. (And, in case you’re wondering, I can say the same thing about most of my human relationships. Sigh.)

I felt it, though-- I was getting more anxious. Angry. Sad. Self-pity at its finest.

“Can I just talk to my mom one more time?"

“Absolutely. Here, call her,” said my nurse. She handed me a phone.

I called my mom and I told her that they were about to start. People were setting up around me. There was music playing. Things were getting blurry. I think the medications were kicking in because I started tearing up. I felt really warm.

“Mom, I’m not going to die during surgery, right?”

“You’re not. What do I keep telling you!"

“But remember, this is risky open-heart surgery.”

“But remember, you have so much left to do in this world."

I remember nothing else, other than a very distinct and overwhelming feeling of peacefulness (but again, that might have been the Versed…).

I understand the basics of Critical Care Medicine. I read the literature when I can. I know that less sedation and early mobility have the best outcomes for our intubated patients. Blah blah blah. 

“Can we just decrease their sedation? See how they do? Let’s get them off the vent by tomorrow?” I recalled asking an ICU nurse many-a-times in my career. 

Oh but I am so sorry for all of the times that I’ve done that. So, so sorry. I want my patients to do well, but I never knew how uncomfortable that breathing tube was. I would be called to go back into their hospital rooms because they were becoming agitated. “SIR, I KNOW ITS UNCOMFORTABLE! BUT JUST WAIT A FEW MINUTES! PLEASE!”

But no. No no. I didn’t know how uncomfortable it was. Now I do.

Here we were again. Me vs. The Vent. I gagged on my own secretions, and tried to grab the Yankauer suction handle. F&#%! I’m in restraints again!!! I think I was trying to scream. There were a few people around me. My nurse walked in, surprised. “It’s okay! We’ll see if we can get that out soon? I’ll be back.”

A respiratory technician came in and I kept pointing to the tube in my mouth. I started crying. Pure agony, I promise. Please someone help me, I just want this thing out.

My nurse came back in with some paper and a pen. 

Any complications?

Increase fentanyl or propofol?

Increase propofol?

EXTUBATE?

I felt like nobody was listening to me. Or reading me, or whatever. And then the attending walked in. “Hey Alin, I’ll be the attending doc for the night, okay? So we were going to extubate you in the morning, but if you're comfortable with it, we will do an SBT, get another gas, and go from there.” 

Oh, cool. He knew that I was a doctor. I liked that doctor talk. I gave him my restrained thumbs up, miserably losing my battle with The Vent in tears, while coughing up all sorts of secretions. My lips were dry and bleeding. There was sputum just slowly dripping down my chin and onto my gown. It was probably the most pathetic moment of my life. Those poor restrained thumbs up…..

(I laugh about it when I look back. Why? I came to find out later that the intensivist on call during those nights was someone who I had looked up to for years— one of the reasons why I was even going to do an ICU fellowship. I knew about his work since medical school, and wanted to be just like him “when I grew up.” Funny, right? So imagine drooling in front of your role model— just a humble, world-renowned ED/Critical Care physician, no big deal— who you’ve been excited to meet for years. Yep.)

He said that he’d be back in a few minutes, and the respiratory technician came back in. 

“We are just waiting on the blood gas results, okay, dear? I know it’s uncomfortable. I’m so sorry. Just a few more minutes.” 

I tried to glance at my ventilator settings. I passed the SBT. Please. WHAT DO YOU NEED AN ABG FOR!

Honestly, I don’t even think that I realized that I had just had heart transplant surgery. I couldn’t think of anything except getting that tube out.

The respiratory tech started setting up another oxygen machine (something we do when we extubate people instead of letting them breathe on room air right afterwards). And then, she pulled out the tube. And I took my first breath as Post-Transplant Alin. 

I felt wonderful.

I was so excited. My family was standing around me. They were clapping. I tried to feel for my own radial pulse. Top-notch! Bounding. Surreal. Beautiful.

I took a look at all of the new fun medications that I was on. 

Insulin drip? What the hell? Why do I have these wires coming out? What even is THAT wire? Do I have TWO central lines? What does that machine do? Is this a pacemaker? Why do I have a pacemaker? 

I lifted up my gown (I had no shame, ever). Woah, look at all of these surgical chest tubes! I looked at Matt and pointed to the chamber. I wanted to see how much I was draining. 

I was The Quintessential ICU Patient. Post-Op. In the CTICU. Lines, tubes, and wires everywhere. Dressings on top of dressings covering I-don’t-even-know-whats. My hair was a complete mess. My whole body was orange (from prepping me for surgery). I looked like a puffy, orange (but smiling) blowfish with wires coming out of every orifice. A child’s 5th grade science project.

Or, as my best friend (who is not in medicine), put so eloquently: “You look like an outlet.”

I guess most people wouldn’t be that excited, but when you’re almost an intensivist-in-training and also critically ill in the ICU, you may just look at these things in a different light.

And I guess that was the lesson of the day, confirmed over and over again throughout my struggles earlier this year. Your psyche, your perspective really do go far when it comes to life’s hardships. 

What do I mean?

Thanks to my mom, I calmed down about the surgery. She helped me realize that I was strong. It became nothing that I couldn’t handle. 

While I was in the OR, I was surrounded by lovely people who reminded me that they do this all of the time. I talked myself into the fact that it wasn’t a big deal— I literally knew what they were going to be doing. It became no big deal. 

After the surgery, I didn’t see my lines and tubes as painful torture devices that were there to just irritate me or perhaps leave awful scars. Instead, I saw them as incredible pieces of medical technology, each playing a major role in my healing (and some even keeping me alive). They reminded me of the reason why I had gone into medicine in the first place— why I was especially fascinated with Emergency Medicine & Critical Care: to help the sickest patients who needed the most support. I wanted to make sure that our fierce, determined attitudes and excellent resuscitation skills helped save not only their lives, but their souls. I wanted to remind them that there is so much hope and potential left, even after dancing with death and slowly sinking into the worst moments of their lives.

Sure, I was in pain, but I was lucky. It was such a humbling moment. The most humbling moment of my life.

And here is where I’ll say it: It was an honor to be in my patients’ shoes.

I’d be able to laugh and cry with them. I’d be able to physically feel their pain, their anxieties. I’d be able to read their minds— all of their thoughts about death and if their lives had any meaning at all, if they had truly lived it well. I’d know that their dignity meant everything to them. I’d know that their insomnia only came from every single one of their life’s regrets just being replayed over and over again in their heads during those nights. Every single one.

I would say things like, “MRS. SMITH, I KNOW ITS TOUGH!”...

... and I would really know how tough it was. 

How phenomenal was that? 

What an honor it truly was...

How interesting life is... 

But hey, that’s just how I saw it. 

Sorry I yelled at you earlier, Old Heart. I guess that you taught me a lot over the last few weeks.

To end this post, just remember …

…. keep ya head up.

The Call

Going back to my hospitalization…

I always had many people around me, especially in the evenings. On this particular day, I had two of my friends visiting me. My family had decided to go out for the night after I pushed them into doing so. “Please go. Have fun. FOR me,” I told them. 

Where did they decide to go? A nearby casino. My family really is amazing. 

My friends were sitting next to me— I was particularly close with them and was very excited to have them there that evening. We chatted for a while. I told them the story about how I accidentally snapped at the CT surgeon earlier in the day, because I mistook him for Matt. We talked about the overly zealous guy from dietary services, who was so keen on always getting my order right. I told them that I had argued with the Cardiology fellow and Anesthesiologist about keeping me NPO for a procedure—“It’s not like I ask my dying patients what time they’ve eaten before I emergently intubate them!” Right? (I mean, I’m right.)

After a while, they let me unleash my anger.

Every day, I would have to explain to people that I didn’t care if the food wasn’t the best. I didn’t care if the sun wasn’t shining into my room that day. I didn’t even care about my gown being too big on me. Thank you for reminding me how shitty my situation was (even shittier than I thought) by bringing up all of those shitty little things that I wasn’t even worried about in the first place.

I barely had an appetite, so when I did, I was happy to eat. And you know what else? My hospital wasn’t a restaurant. My hospital was a world-renowned academic institution with some of the most brilliant doctors and nurses that I had ever met. I actually didn’t want my hospital to be a restaurant.

Honestly, though, I was lucky to even be alive to have the option of eating. Even syrup-less pancakes with apple juice were delicious when you were constantly being reminded that you might die that day.

Sure, the sun wasn’t shining into my room and my view wasn’t the best, but when was a hospital room supposed to be a hotel room? Plus, I preferred this sub-par hospital room over a shelf in the morgue. I assure you.

And ah, my favorite complaint: my gown didn’t fit me. What did people want me to do about that? Every time my visitors were dramatically worrying about my gown size, I remembered that old Brian Regan bit. Brian's optometrist once confronted him about his lazy eye, and followed it with, “It’s no big deal. It doesn’t affect your vision or anything. I just thought you’d like to be self conscious for the rest of your life.” Ha.

So others complained for me most of the time, while I just laid there and wondered when they were going to stop being so pretentious and ignorant. When were they going to start worrying about the things that they really needed to worry about? Sometimes, I wondered how they would feel if they were in my place. There is no way that they’d be complaining about the cafeteria food if they were on their deathbed.

Maybe.

I don’t know.

People are strange.

I had always hated perpetual complainers, but throughout this hospitalization, I came to the conclusion that I never wanted a toxic complainer in my life ever again. I remember reading something like, “You have to die once to really learn how to live.” Take that piece of truth to your heart. Swallow it whole. Remember that constantly complaining isn’t going to change anything. Life is so incredible and has the potential to be lived so well. Some definitely need to realize this more than others.

Anyways, back to my story.

It was a good visit with my friends. After the visit, I was basically alone in my hospital room— a rare occasion for me in the evenings. I was feeling very tired that day. I didn’t really know what I wanted to do before going to bed, so I was just staring at the walls. I looked over at my monitor. I glanced at the medications I was on. For once, I decided to turn the TV off (if you know me, you know that I cannot live without background noise— the noisier the better).

And I just sat there. 

I then remember my nurse coming in with a phone and telling me that I had a call. He handed me a phone and left the room. 

“Hello?”

The only thing I remember from the phone call was:

“Blah blah blah blah MATCH blah blah blah HEART blah blah ACCEPT?”

“Yes. I have to go call my mom now.”

And that was the best I could do. I have to go call my mommy now. No “thank you,” no “OH MY GOSHHH!” There were no balloons. There was no party. There was no clown, no party favors, no crowd. My residents and nurses weren’t throwing confetti into my room, either.

I was just comfortably alone. During the happiest moment of my life. I felt pure bliss.

And then, I felt nauseated.

And then, I vomited.

(Just like I always did, since I was a child, when I was nervous about something. Physical manifestations of how I was feeling psychologically, I think.)

I called my nurse and asked for some Zofran and mouthwash. 

“There’s a heart!” I told him. He was very excited too, and he told me that he’d come back in a few minutes with a plan. 

I had promised my family and closest friends that I would call them the moment I knew that I had a match. But (please don’t hate me), in that moment, I just wanted to sit with myself. It was a quiet 10 minutes. I did some reflecting.

I thought about who my donor could be. Maybe a 20-year-old female involved in an MVC. Perhaps a 26-year-old male who was braindead after a sudden illness. Maybe my donor was that other 30-year-old female who deteriorated after losing a battle with some random genetic condition that she didn’t know she had. 

Did my colleagues try to resuscitate this person? Could I have ever potentially resuscitated this person?

Moment of silence. I thanked my donor and their family.

I wrote in my journal, “Thanks for 30 years of service, Heart.” Super cheesy, I know, but I didn’t want to forget how I was feeling in that moment. Grateful that my poor heart had come such a long way with me. Thirty years of craziness.

I found myself smiling. I was going to live. The rest of this was going to be easy. They were going to crack my chest open, take my heart out, put a new one in, put a few vessels together. It wasn’t an extremely complicated surgery (from what I remembered during medical school). I would wake up afterwards. Probably with some pain. I would get discharged in a few days. I would go back to my normal life. Kind of.

I guess one of the hardest thoughts that I ever had (and continue to have) was this: things were never going to be normal normal.

But I would get as close to that as possible. 

This was nothing that I couldn’t handle. I had gotten through Organic Chemistry at UCLA. I used to work full-time night shifts while attending an accelerated Master’s degree program in the mornings. I had moved from Los Angeles, CA (population: 10 million) to Cumberland Gap, TN (population: 500) all on my own, without knowing one person, and had beautifully made it through medical school there.

I had once battled a complicated case of appendicitis (not surprisingly, I had been very stubborn about going to the ER then, too) and I had been able to make it out alive. I had actually showed up to Anatomy Lab just three days post-op (I was kicked out by my professor, though … “You need to go home and rest!”)

This was just a minor little speed bump in my life.

My friends would repeatedly remind me that I hated anything that came too easy— we’d joke about how this would happen to me just because I loved challenges. 

Everything was going to be okay.

In that moment, I also decided that after I woke up from the procedure, I was going to do *something* with my life. Something special to honor my donor for the rest of my life. It would be something to make that family proud. I didn’t know what, but I knew that I would. 

With this inconvenient life event, I would grow. I would learn from it and I would use it, ultimately, to change the lives of a few other people (or perhaps the world, ha).

“Your character is built on how you handle moments of adversity,” I read somewhere. 

I think I was handling it well.

After my contemplations, I called my mom and asked her to kindly step away from the slot machines and return to the hospital (that part of my story always makes me laugh). I then proceeded to call the rest of my family and closest friends. I sent a message to my residency Groupchat. I texted some of my attendings. 

My nurse brought in some Zofran, some mouthwash, and chlorhexidine for my final ICU basin bath. OR Start Time was scheduled for 2am. Eventually, my family and friends came running into my room. The night float residents and interns barged in to give me hugs. Even the Pulm/Crit fellow (who had been consulted a week ago) came by before leaving the hospital. “I just wanted to say congrats. We were all rooting for you in the MICU. Thank you for being you.”

The Anesthesia resident came in with some paperwork and a hug. A few of my former nurses surprised me with “Congratulations!” and tears of joy. The CT Surgery fellow walked in, excitedly. “I’m so happy for you! Let’s do this!” he said.

“Yeah, okay! But who’s gonna be cracking my chest open in 6 hours?” I asked him.

“I probably will,” he said.

“That’s f&*%ing awesome. And don’t worry about the scars. I’m not one of ‘those’ patients.” I told him.

“You’re not like most patients, Alin.”

We all laughed.

“Oh yeah, speaking of, I’m apparently really difficult to sedate.” I told the Anesthesiologist.

“Yeah, that’s not surprising, but we’ll take care of that.” We all laughed some more.

I was so happy. I’m telling you— pure bliss.

I knew that everything was going to be okay. Life was going to be different, but everything was going to be okay.

To end this post, here are some memories from the day that I got The Call:

Ventricular Tachycardia

(Disclaimer: I was transferred to different hospitals a few times during my month-long battle with heart failure — hospitals will remain unnamed. Some of these stories are not in chronological order.)

In order to see how my heart was doing, the team decided to slowly wean me off of milrinone, which was the medicine that was helping my heart pump. Unfortunately, with every slight wean, I would get sicker than before. My cardiac index would go all the way back down to “Almost Death” level, and I would have trouble breathing. 

When they increased my milrinone back up, I started having bouts of “ventricular tachycardia.” We tried to explain to my parents that this was an abnormal (and dangerous) heart rhythm.

“Is this like when they shock patients in movies?” Dad asked.

Without having to go into the whole “pulse vs. no pulse,” “stable vs. unstable” explanation, I just said, “Yes.”

“No. You don’t have that.”

So, there was that. 

Sometimes, throughout my hospitalization, I would get pacer pads placed on my chest before sleeping (the ones that they use in movies to shock patients). I didn’t want my parents seeing this, so I figured out a way to use two gowns to cover up the stickers on my chest. There’s a lot you start doing in these situations so that those around you don’t feel bad for you (you’ll see what I mean).

One night, I was started on intravenous amiodarone, a medication that would help temporarily suppress these abnormal rhythms, which were becoming more and more regular.

I woke up at 2am and began vomiting profusely— on my bed, on the floor, all over my beautiful hospital gown. I couldn’t find the call bell to call for help, and so I just started screaming for something to help with my vomiting. “Zofrannnnnnn!! Please!!!!” Luckily, someone heard my calls for Zofran. My wonderful nurse came in with a basin, and told me that she had to call the resident to put the order in. 

“Can you please make sure that she also orders an EKG! I don’t want to be on two QT prolonging meds at once! Tell her I have no pain! No chest pain either!” 

And then I went back to vomiting my chicken soup and chocolate pudding. The resident came to see me, listened to my lungs, sat with me for awhile until the Zofran was given. I asked her if she would call her parents in this situation and we talked about how difficult this all was for me— trying to balance being a doctor with being a patient, trying to balance how much I was hurting with how much I wanted to show that I was hurting. I also jokingly asked her if they needed help with saving any lives out there, and she jokingly replied, “We’ll come get you if anybody needs to be intubated.”

If you’re reading this some day, I appreciated that a lot. You were probably on hour 22 of 28 with no sleep, and this patient just kept throwing up and you had so many charts to sign. But you made me feel normal, and that order of Zofran was one of the best things that ever happened to me that week.

The vomiting subsided after the medicine was given. I asked my nurse if I could try to wash my hair in the shower. She said that I couldn’t because I had a Swan-Ganz catheter in my neck. It couldn’t get wet. 

After an aid helped me clean up with a new gown and fresh bed sheets, I decided that I was still going to wash my hair. First of all, it had been over 10 days since it had been washed. Second of all, there were chunks of dried vomit creeping out of the ends. I walked over to the bathroom with my portable monitor and IV pole in place, and told my heart to please not go into V-tach while I did the almost impossible. I took a comb, wet it, and ran it through my hair for a few minutes. I used hand soap to wash out anything I could. Better than nothing. My nurse walked in and asked if everything was okay by the sink. 

“Yeah just … washing my face!” Washing the hair on my head connected to my face. 

I went back to sleep for a few hours, and woke up to my family at my bedside. They said that I looked pale and asked if everything was okay. 

“I had that weird heart rhythm again so they started me on some other medicine. Made me throw up.” 

“WHY DIDN'T YOU CALL US!!” 

My mom grabbed her purse and took out a salt shaker. She proceeded to pour salt around my bed, right onto the hospital floor. “This is to ward off evil so that doesn’t happen again. You should’ve called us."

Mom, this is for vampires I think… what are you doing…

But I let her pour a little bit of salt on the floor. She then went on to tell me that I shouldn’t have washed my hair because I was going to catch a cold (don’t even ask about this myth I’ve been dealing with for 31 years). I nodded my head, and then noticed that my dad was quiet, almost in tears.

I told him not to worry about the rhythm, that it was all under control now. My aunt called my cell phone, and then she started crying because she had heard about what had happened that night. “I’m okay! Look! I’m talking! Really! Just a side effect of the drug,” I told her.

I found myself consoling those around me way more than the other way around. I was never looking for pity, but I had to tell quite a few loved ones to stop crying and that, although I wasn’t in the best shape health-wise, I was in good spirits and wouldn’t lose my positive attitude. I had to listen to people tell me things like, “Oh, you poor thing. You had your whole life ahead of you!” and “You’re such a good person and you always have the worst luck!” and “I am SO SORRY that YOU have to go through this!”

I had to take it all in. Some days were harder than others. Just a couple of those closest to me were the only ones who would hear me vent once in awhile, after my parents had left for the day. We’d laugh and cry and be angry and laugh again about the awkward things that were constantly being said to me. My dry humor would come out with comments like, “Sustained V-tach with an index of 1.3 and all the inotropes are maxed out, dudes. They may as well get Palliative WITH Transplant consulted at this point.”

Those same close friends, all with backgrounds in medicine, would sometimes get quiet after my snarky comments. Then I would tell them that I was okay, and that I would stop joking around so much.

So that’s the thing about life. These crazy things happen. You can only control your reactions and your actions around these experiences, be as strong as possible to keep fighting (but give into your weak moments too— it’s a part of the process), and accept the fact that you need to take these damn experiences and make something of them. In my opinion, there is no point in laying around and sulking all day. There is no point in letting others’ words get to you. It won’t change the situation.

Besides, I’ve always been good at consoling others.

To end this post, here’s a quote that goes with this theme— I've always been a fan of some principles of Stoicism. I don’t think Marcus Aurelius actually said this directly because he didn’t speak English, but it sums up Stoicism pretty well: