Monday, August 27, 2007
Don't Try This At Home
In retrospect, I suppose it was stupid.
Deep vein thrombosis (DVT), meaning developing clots in the large veins of the legs which can break off and travel through the heart and into the lungs (pulmonary embolism -- PE --) is a risk of most major surgery. The general risk comes from the immobility of lying motionless on an operating table for a period of time (venous circulation in the legs depends much on muscular action, which milks blood north with the assist of one-way valves in the veins.) There was a time when such clots were an unrare complication of surgery; in fact, years ago I lost a couple of patients to it, despite doing everything we knew to do in those times. Now, because of several measures, the complication -- at least at a level where it's noticeable -- is quite rare. Those measures include much better peri-operative hydration, early ambulation after surgery, and the very common use of low-dose blood thinners before surgery along with pump devices on the legs during (and sometimes after) the operation. For certain orthopedic or pelvic operations, and with laparoscopy (which adds to risk by blowing up the belly and often tilting the patient head up, both of which tend to add to blood congestion in the legs), the risk is increased and these steps are virtually always taken nowadays. Which is a good thing. The last time I saw DVT with or without PE in a patient of mine was many years ago. I have, however, seen it quite close recently. Coulda killed me.
After I sort of retired, I did some things I'd been meaning to do for a long time. Took an acting class. (Well, that ended quickly enough: in high school and college I had some leading roles in musicals, and had delusions...) Went on a trip up the Amazon River. Got back into shape and resumed bicycling, including a couple of several hundred mile rides. All of which, you'd think....
So anyway, at the height of my healthfulness, not long after finishing a long bike ride (and many months after flying to Peru and back), one day I began to notice I was shorter of breath on biking exertion than I'd been. Figured I must have a little respiratory infection, backed off a little but kept riding. A few days later I took my son to a basketball game, seated in a place with criminally minimal foot and leg-room (anyone been to Key Arena?) Shifting uncomfortably throughout the game, I complained of my left calf in particular. But I didn't think it related to anything but the cramped quarters. Until a day or so later when I noticed the calf was pretty big. Us biker guys gots big calves and nice quads. But they're supposed to be sort of equal, side to side. This wasn't.
Reluctantly, I saw my doc. (He's "mine" in the sense that I list him as such when asked to. I don't do the, y'know, regular checkup thing.) I have to say even he figured, "Naw, couldn't be... but let's get a doppler anyway..." Having driven to his office, I also drove to the lab, where the study showed a clot flapping its way right up to my groin, big as life. (The clot, not my groin. Sadly.) I drove back to his office.
"No way," I said when he ordered me to the hospital. "It's been going on for several days, I've been biking. If it was going to kill me, it already would have, wouldn't it?" I'm bigger than he is (bigger, not smarter), and somehow he agreed to outpatient treatment. So I got daily injections of fragmin while I waited for the coumadin to take effect, and spent most of my time on my recliner. Also, I figured if a big clot broke off at home, my chances of survival were approximately the same as if it happened in front of the cardiac team; but with less fuss. The outcome is pretty much binary: fatal clots are fatal, and survivable ones would generally allow time for a ride.
Faced with a similar patient with similar demands, I'd have insisted with everything I had that he go to the hospital for a few days and stay on complete bed rest until fully anticoagulated. Or had him sign something if he refused. I still haven't decided what I'll do if I really get sick sometime. As comfortable as I've been caring for the ill, as glad to help and gratified by it, the idea of being that dependent on other people -- the idea of one person (not one person: this person) taking up that much space in the order of things seems disproportionate and uncomfortable. Don't get me wrong: it's quite OK for you. I'm just not so sure about me. And what the heck. My recliner is pretty comfortable.
[Clarification: This incident occurred a couple of years ago. Other than mild post-phlebitic syndrome, I'm fine. Maybe it was the recliner reference in the last sentence that was confusing: I was just thinking ahead...]