Conundrum

Facing belly surgery to repair an incisional hernia on 7 Jan.  Last week had a PM check & battery life now projected at less than a month to 20 months.  RN from pacer clinic says  "No Sweat, you still have 20 months."  Interesting note is that it went from 1 month to less than 1 month in a month.  Hmmmm!  That sounds like a 60 day drop in 30 days.  Today went to Coumadin clinic.  RN takes my pulse on an automatic device & it says HR = 55 BPM./  To which I reply "Impossible, I'm paced at 75 BPM.  Either I've entered EOL or I just had a buch of PVC's.    How qabout taking pulse manually?"   So she does it manualy.  HR = 70 BPM.  "Did I have a bunch of PVC's?"  Yes was her answer.  Mon I'll have a discussion w/ my Cardio's old head nurse & we wil sort out where to go.  Her first response to me was to broach it to the surgeon doing the  job.  (Mine, too!)   Her rationale was tyhe same as mine - entering a major surgery w/ a PM rapidly approaching EOL is a bit risky, considering that I had major complications following last two belly surgeries.

Give me some opinions on the subject.

Donr


22 Comments

Conundrum

by AgentX86 - 2019-12-28 00:24:21

I'm certainly not a doctor but I don't think it's a good idea to be in the middle of surgery when your pacemaker goes tits up.  I don't remember how much you pace, which would be another factor.  You can't rely on the battery lifetime estimates, as you well know. It may be even less than you think. It doesn't sound like a good idea.

Maybe you can get a break on a twofer?  Only one anesthesiologist needed.  ;-)

A difficult decision but .....

by Gemita - 2019-12-28 05:03:41

for me the pacing needs to be "secure" before you can safely move towards dealing with what could be difficult surgery.  

I feel too that the trauma of surgery could make the risk of developing heart rhythm disturbances during, or immediately after surgery, even greater, requiring more power from your pacemaker and increasing the likelihood of an early need to replace the unit.

I do not know how urgently your incisional hernia needs repair but my gut feeling is to sort the pacemaker first to give yourself the best chance of having a successful surgical outcome. Afterall, recovery may be difficult and prolonged after hernia surgery and you don't want to have to be facing further intervention with your PM.  Hopefully you can manage your hernia with other measures in the meantime. Hubby has a parastomal hernia/inguinal hernias so we know the difficulties that can arise but his treatment has been put on hold because of the higher risks of surgery at this time with his multiple health conditions.  He also has a PM that may require an upgrade.

First and foremost, elective surgery has to be as safe as it can possibly be.   Do you feel that surgery at this time is right for you Donr ??  I am not so sure that you do.  Maybe go with your gut feeling and push first for the PM change if your hernia can be stabilised in the meantime and surgery postponed ?  I wish you a good outcome

the choice is yours

by ROBO Pop - 2019-12-28 10:25:40

I see 3 choices.

1. Have the hernia surgery after you get the PM replaced

2. Have the hernia surgery while they replace the PM

3. Have the hernia surgery after you add me to your will

You're welcome for the safe advice

Depending on the hernia you may need both quite urgently

by crustyg - 2019-12-28 10:55:39

Athletic chum of mine developed an inguinal hernia around August time and he's pushed the button to have it treated last week - it's now nearly incarcerated (won't go back inside) so it was only a short step away from strangulated - new hernia to serious in about 5-6months.  You may only be a coughing fit or a couple of sneezes away from your incisional hernia becoming a real problem.

I entirely agree with the above comments - no gas-passer is going to rate you as fit for surgery with a dodgy ticker, so you're going to need the PM box change first.  I rather doubt that anyone will be keen on a single procedure - single visit to the OR perhaps, if you're really lucky - as the PM implant will be done under maximal sterile conditions in an OR equipped for it (PM interrogation kit, no dirty procedures (car crashes, bowel contents etc.)) allowed in it.  My local places won't even let patients into the cardiac suite without a MRSA check and insist on MSSA clear for implants.

Incisional hernia surgery shouldn't open the bowel, but I'd be surprised if any cardiac suite manager allowed it in their clean room, and there's no knowing how many adhesions they will have to fight through to reduce the hernia and close the defect.

Push for PM box replacement at your earliest convenience.  Then, if the hernia rapidly worsens you're good to go.  And there's the small matter of getting you off the rat-poison before either procedure - I suspect a period of time on a 'xaban NOAC is in your near future.

You aren't having great luck!  Sorry I can't be as witty as RoboPop, or manage Gemita's clever pun (gut feeling).

Best wishes.

Good points, Crusty

by AgentX86 - 2019-12-28 12:13:58

It would seem to be obvious but...

"PM implant will be done under maximal sterile conditions in an OR equipped for it"

Mine was implanted in the same cath lab they used for my ablations. They didn't seem to take any extreme measures any of the times I've been in there.  Clean, sure, but I can't imagine it's cleaner than an OR suite used for chest cracking, or whatever.

The Hole Truth

by donr - 2019-12-28 17:32:40

I left out a few things (intentionally).

1)  The hernia was incisional.

2)  It was repaired in May 2014 w/ a complete sheet of mesh that extended from side to siede & belly button to Pubic bone.

3)  The repair failed - the entire left side failed - top to bottom. at an unknown time.  Most likely, it was on Day 7 when I had a severe hurling episode that led to aspirational Pneumonia.  It was decoided that I was probably circling the drain, but, being a D$%#$% stubborn cuss, I beat it in about 36 hours in the ICU.  

4)   I developed a huge bulge (Like an 8 month pregnancy) in my belly & could only go a short time in AM before I became SOB. 

5)  My surgeon told me I was one of the last people to get the offending mesh before it was taken off the market.  

6)  He will fix it for me using a triple layer Gore-Tex & artificial pig skin material.  He says it has an outstanding record of success & anticipates a good outcome for me.

7)  Because the mesh failed the full length of the side, there is no danger of strangulation.    I have already lived with it for several - like 5+ yrs, so there is no problem w/ that.

8)  When he did tyhe original repair in 2014 (ONE yr after the original surgery for a near -malignant flat polyp)  he did it with a 'scope.  He was the oly surgeon in Atlanta who would do a scope repair.  He was considererd the best scope operator in the city.  He found that my entire guts were stuck to the inside wall of my abdomen with adhesions & had to be separetet surgically from that wall.  Took him over an hour to do that.  He did an US & determined that I have no adhesions this time.

9) We have already reviewed the condition of my PM - had a download last month  &  again last week.  I see him on Monday to disccuss the situation.  He has also seen a recent CT w/ contrast  scan Nd done his own US of the region. I also have a session w/ a long-time Cardio nurse who worked in the  practice that has tended my PM issues from day one.  All the people concerned know one another quite well, so there will be a good flow of info betgween/among them.  Unfortunately, the belly surgeon works at a different hosp than the Cardio team, so it will be difficult coordinating this mess.  There is one ray of light - one of the top cardios at the belly surgeon's hosp once worked w/ my Cardio before he sold his soul to corporate medicine, so we will probably get decent cardio follow up & coordination on that critical front.    I have no intentions of going through w/ this belly surgery PRIOR to the PM replacement.    I suspect that my surgeon will support me in this decision.   My Cardio does not yet know about this worm turning, since it is so recent.  He will find out about it Mon or Tues.

10)  Youse guys (A little of my native New Jersey lingo there)  said exacxtly what I expected you to say - and whaat I was saying myself.

Thanks for the support.  I plan to show them what you say - They have yet to disagree w/ anything that has come out of here.

Donr

 

so...

by ROBO Pop - 2019-12-28 18:23:50

Does this mean I'm outta da will?

The Triumph of the Will

by donr - 2019-12-28 23:31:24

Pop:  Of course not.  I'll remember you. 

Donr

MESH

by Gemita - 2019-12-29 04:08:05

What a catalogue of events Donr. You are definitely a fighter and there is absolutely no chance of losing you just yet !  Robo Pop will have to wait for his inheritance or find another donor. 

I have to say using mesh to fix my pelvic organ prolapse is looking less likely now because of the bad press mesh is getting. In fact they have  told me our national health system can’t support it. I hope your offending mesh can be safely dealt with and that the new material will give you a successful repair.

I just love the expression “youse/yous guys”. Actually I first heard it used by my then 6 yr  Australian niece when she tried to wake us up after a long flight (London to Brisbane).  We heard her calling outside our room “are yous guys awake yet”.  She was such a sweetheart and still is.

Sincerely hope all goes well for you Donr and I am glad that in some small way we have all been able to help you. Yous guys are not only a source of experience and vast knowledge but you also bring humour to the table too so keep it up guys

The real question

by Gotrhythm - 2019-12-29 14:52:17

Which surgery to have first? That's not a connumdrum. That's a no-brainer.

What we're really trying to figure out is in which order will insurance pay? And...what's the way to massage the system so that the check marks will line up on the side of doing the pacemaker first?

 

I hope somebody besides me can see how crazy-screwed-up our medical system is that there could be any question of which one is needed first.

I wish I was smart enough to know how to fix it. Everybody here could find him/herself in Donr's position.

Sorry you're facing abdominal surgery Donr. That's no fun. I'll be thinking of you.

It fixed oitself!

by donr - 2019-12-29 19:22:36

Rhythm:   Jujst when us boys were having a little fun, You GOT SERIOUS!  That's OK, I think the PM answered the question  for us.  Went & visited Martha, my good friend Cardio nurse,  She grabbed a watch & my arm & started counting.  She got to 58 when the watch got to 60.  Thinks there were two PVC's in the crowd.  I'm paced at 75.  She proclaiomed me to be EOL, based on that.  Besides, I keep fallng asleep in the car.  I also look like I'm the color of a bedsheet.You guess the color.  Like the Grinch, she says that our surgeon, Jeff, won't touch me w/ a 39 1/2 foot pole.  Tomorrow, first thing, my mission is to call our PM clinic & say the magic words "EOL."  they will immediately call me in for a checkup.   Sorry, POP, you don't get my gol;f clubs yet.

Donr

D%$^

by donr - 2019-12-30 20:11:36

Well, went to the PM clinic , nearly 50 miles from home, leaving a string of State Troopers behind me in various states of upside down w/ their tyres slowly turning.   (Interpretation:  For the BRits, State Troopers = Police; Fopr the Yanks, Tyrers = Tires - or is it  Tyres?)   When I mention ed EOL, it got their attention.  Got there in exactly 1:30 for an appt.  A nice young lady named Sam hung a Hockey Puck around my neck & started fiddling with the screen, using a short pointer.   Her first comment was "Well, you'er NOT in EOL.  You have 8 months left."  To which I responded "Noty too shabby - that means I've lost another month since last Thursday!"  (At that rate, in 24 days I'll be flat on the floor with little "X's" over the spots where my eyes were.  (POP, you will get my golf clubs!).   She told me that all I was having were who;e batches of PVC's interspersed w/ a few PAT's.  The whole discussion devolved into whether to trust a stinking digital computer or Nurse Martha's eyes and fingers.   I was voting for Martha.  Sam was a Millenial, so she went for the coputer.  Being an EXTREMELY OLD Fart, I was with people all the way.   "You wanna talk to a DR?" she  asked with an evil sneer?  (She didn't really sneer, but it makes for a much etter story - Ishoulda named her "Snively,"  but that would have been too much.)  I told her "Yes," as I dug out my cell & dialed my Cardio.  Such bitter, unmitigated gall.   Got an appt w/ him on 6 Jan - but thought it was Tues, next wee.  We will sort that out tomorrow AM.  Snivly (Sam) agrees w/ me that no surgeon in his right mind will touch me & my Cardio will not let him do it anyway.   Anyway, still feel like crap, but am still alive & plugging along.  Mafrtha still swears she only found 58 beats in thet minute, and zero odd ducks - like nearly 20  PVC's.  A classic man vs machine battle.

Donr

EOL

by AgentX86 - 2019-12-30 21:53:53

Donr, I thought you lived in Atlanta.  50 miles from your PM clinic?  Really?  How far do you have to go for a new PM?  China?  The hospital that did my implant (Emory) is about 35mi from home (six hours in Atlanta traffic, for you ferigners) my PM clinic is less than ten miles, very close to where I work (I live out in the sticks).

So Nurse Ratched was you PM tech?  I think I've had her too.

Do they really make you wait until the "TILT" sign shows in your eyes before changing the PM?  It doesn't seem like it would matter much, now or in six months (or days) from now.

Burbs

by donr - 2019-12-30 23:59:03

86:  When we moved into Etlaner, we were up Nawth in Alpharetta.  We boutght 24 acres of good ole Nawth Jawja pine trees and moved into the woods.  It was over 20 miles to Cummimg on rather narow roads.  It was 35 iles to the Perimeter highway and Pill Hill at that time.  There were o major hospitals up there in the woods.  GA Baptist built the first major, modern facility there & opened it just before the turn of theCentury in 2000.  At that time, they still could not do a PM Implant, nor could Wellstar over in Marietta.  Baptist did an expansion  almost immediately agter getting the first section built, but still were not equipped or recognized to perform many more complicated procedures.  In 2003 I had to be taken to St. Joe's for a heart Cath & for a PM implant.  THose are the disadvantages of living out in the woods.  It was just a short time ago that The Northside Hosp in Cumming completed a radiation Oncology clinic. 

I go to my Cardio because I started w/ him in 2002 - and he is great.  No, everyone doesn't like him, but wife & I do.  He sold his soul to Emory about 10 yrs agom so now we are stuck w/ Emory policies & procedures.  Used to be we could get a PM download whenever Cardio thought it necessary.  Now it's once a mnth unless you drive to Midtown or Clifton Road.   Still better than what my B-i-L gets in Titusville, FL - Telemedicine for anything worse than a cut finger.  (Perhaps I exaggerate a bit.)

I go to the same place you do - Midtown.  50 miles, Yup!  18 miles to my clinic for routine appts.  We just live in the Nawthen sticks - the home of "Awesome Bill from Dawsonville," the NASCAR father figure.  We used to vote in his shop.

Ys, we had Nurse Ratched in our clinic.  She lasted but a few weeks till us ferneigners rebelled & sent her packing.

Today's nurse was actually quite noce. Justmade a better story.  She did, however, have absolute faith in computers.  To me they are just a helper for my mind.  They had better match my thinking about how things should look or give me a darned good reason why they are right & I am wrong. 

Don'tr get me started on MEDICARE & PM's (Or any other subject for that matter) .

Donr

Double D%$^

by Gotrhythm - 2019-12-31 16:06:44

Good grief!

I wish I didn't know what you're talking about.

But I do.

 

Straight to the triople dog dare

by donr - 2019-12-31 22:32:06

Rhythm:  It's that season for Ralphie, Schwartz & all the kids from Cleveland!    Scares the crap out of you, doessn't it?  Just to understand the pure terror of the whole mess. I made a decision today:  Called the whole thing off till PM is replaced, which I think is going to happen sooner, rather than later.  In about two weeks I lost two moths of battery time.  I'd hate to be lying on the OR table when it threw up its leads & yelled "I QUIT!"  I don't think either my surgeon or the anesthesiologist would be too pleased either.Just goes to show you - "Never get sick on a Friday or just before a long holiday weekend!"

Donr

Keep up the pressure

by Gemita - 2020-01-01 02:57:30

Hello Donr,

Thanks for the updates.  You did well to postpone your hernia op but I would keep up the pressure on your clinic for an early PM change.  Hospitals in winter are always teaming with extra patients, especially those with heart related conditions and you need to keep ahead of the queue.  I agree never get sick at the weekends or during a holiday period because its official, the chances of a good outcome are reduced - at least here in the UK !

I loved reading about where you live.  Although remote, it sounds absolutely idyllic and transported me back to my early childhood !!  I was brought up in the beautiful countryside of Kent, in a small village called Charing.  Woodlands, high on Charing Hill surrounded our 5 acre small holding where Dad reared 100 pigs and grew tomatoes.  We also had one Jersey milking cow and a handful of other beautiful animals.  Often a pig would be sitting at the kitchen door waiting to be fed in the morning and Mum used to let it in!

Well I hope for the very best outcome for you Donr 

Don

by Grateful Heart - 2020-01-01 19:47:21

I'm away from this site a few months and look what you've got yourself into!!

Seriously, looking at 2 surgeries, I think you made the best decision.  If you recall, my AICD did crazy things at the 10 year mark.  It went into EOL suddenly then bounced back up to ERI after a while but still showed less than 3 months with the alarm going off.  The device company said they never saw this before and needed a full download sent to them.  After the replacement, they wanted the device back to investigate it.  

So the point is.....sometimes, as you know, unexplainable things happen, even if they are rare!!

Now.... about your will.  Can I have your wit?

Grateful Heart 

LKast Will & TEstament

by donr - 2020-01-01 23:39:07

GH:  OK, you can have whatever is left of it -   Probably be worn down to HALF!    POp gets my golf clubs. 

The last few months have been the worst of days.  DEDtails at 11 in a pvt Msg.

Donr

jUST SAWE SURGEON:

by donr - 2020-01-02 15:55:47

He said he cannit do surgery in current state of heart health..  Problem is that I am in constant state of Tri-Geminy.  Too much risk while on the table.

Appt w/ Cardioo Mon AM to see what he can do - if anythying.  Surgeon came off w/ thids statement - "Perhaps you can do what I do - 500Mg of Magnesium daily.  Cures my PVC problems."

I have been fighting PVC's all my PM life of 16 years.  This is not a death seentence, just a life sentence of misery.  Guess it's time to open up a lemonade stand!

Donr

Electrolytes ??

by Gemita - 2020-01-02 18:33:36

Have your electrolytes been checked recently ??  I have tried Magnesium in the form of magnesium taurate which is helpful for rhythm disturbances. Maybe you need IV magnesium in some form. I also take Vit C powder (as Magnesium Ascorbate) which is a good stress supplement.  My EP also has my heart rate set at 70 bpm to outpace (if correct expression) my ectopics esp. PACs which often lead to AF.  I used to get awful PVC attacks (bigeminy, trigeminy, couplets, triplets).  My EP now believes a lot of my PVCs were wrongly interpreted and should have been recorded as PACs with a RBBB pattern. All a bit above me but I realise machines do get it wrong and needs a trained eye to decipher sometimes. Your heart is obviously very irritated from a variety of causes.  You sound as though you have a good cardiologist so I hope he can stabilise your rhythms and give you some much needed respite.  Maybe ask for a med review and new upgraded PM ??  I stopped Flecainide and Digoxin and now only on PM pacing and low dose Bisoprolol !!  Both anti arrhythmic meds proved pro arrhythmic for me and EP agreed.  Nice calm NSR most of the time.

Magnesium

by donr - 2020-01-02 22:34:38

I have a plan all worked out gpr tomorrow.   Gonna sit down w/ Cardio nurse friend to discuss strategy.  See Cardio on Monday.  Will discuss Mg and its uses.  Never been tried on me before.  Got the suggestion rom Surgeon, who runs low on it & takes a 500 MG dose every day.  Said he gets good PVC control from that.

Apparently I am running at 1/3 PVC's now.  Surg says that in his book I am too fragile in cardiac end of surgery.  Probably would not make iot off table alive, let alone through recovery  period.

 

 I saw him today & told him I was going to cancel surgery fir that reason - before he had a chance to give me his opinion.  Probably a good decision on my part.

Donr.

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