Backscatter Scanners and Pacemakers

As you may remember, I almost flew to Atlanta for the recent Heart Walk, but changed my mind when my parents decided to attend, too. While getting my gear organized for the trip I thought about the new “Backscatter” full body X-ray scanners being installed in airports: how do those things interact with pacemakers? The Transportation Security Administration (TSA) recommends that those of us with Pacer Power avoid the metal detectors, and since I got my pacer I’m not cool around large magnets. After all, the doctors use a magnet to set my pacemaker; it stands to reason that another magnet could scramble it! So I pull out my plastic card and tell the TSA agents that I have a pacemaker and request a hand patdown, and just avoid all that.

But what about the new scanners? Friend or foe? Not knowing, I called my pacer lab. The short answer: We don’t know.

The longer answer: There hasn’t been any testing done on pacemakers yet. It’s not really safe to get a human volunteer to test the scanner (“We don’t think anything well happen, Fred, but just in case… sign this release form.”) so the next best plan is a series of tests, usually involving calibrating a pacemaker, taping it to a mannequin, and sending him through a scanner – simulating what would happen to a traveler who happens to have a pacemaker.

If the pacer checks out, you run the test again, and again, and again, to see if going through the scanner multiple times will affect the pacer. Then you run the test yet again – with longer scans and higher radiation levels, to see if that affects the pacemaker. And you keep repeating these tests to eliminate the possibility of a fluke reading.

Wow, that’s pretty involved. It would probably be better if we could borrow a scanner for a few weeks, but I doubt that is going to happen. TSA like to keep things close to the vest, and I bet that goes double for their newest secuity tool. So I figure that the best thing to do if you have a pacemaker is not to risk it – just keep asking for a hand search.

Thankfully, my home airport is so small that they only have three gates. It will be quite a while before they get a Backscatter scanner!

‘These wounds I had on Crispin’s day.’

Monday, October 25:  Saint Crispin’s Day

This day is called the feast of Crispian:
He that outlives this day, and comes safe home,
Will stand a tip-toe when the day is named,
And rouse him at the name of Crispian.
He that shall live this day, and see old age,
Will yearly on the vigil feast his neighbours,
And say ‘To-morrow is Saint Crispian:’
Then will he strip his sleeve and show his scars.
And say ‘These wounds I had on Crispin’s day.’
Old men forget: yet all shall be forgot,
But he’ll remember with advantages
What feats he did that day.

– from Henry V by William Shakespeare, 1599

Open Heart Surgery

OVER IN THE LOST AND FOUND DEPARTMENT:

I had to go to the doctor’s office for a blood test this morning. Later, my mother asked how it went.

“No problem,” I said. “The only thing unusual that happened was that I found an iPhone in the waiting room.”

“What’s the difference between your phone and an iPhone?” Mom asked.

“About $600!”

I turned it in at the Reception Desk, so if you have misplaced your very cool mobile phone – and it has an 803 area code – call your doctor’s office!

*******

Have you had Open Heart Surgery? Are you sure? Because sometimes, Open Heart Surgery isn’t open heart surgery.

Say what?

It may seem like a little bit of a pet peeve, but seriously, if you are going to speak intelligently about a medical issue, you need to learn the terminology. I am certainly not perfect – it is an Emergency Department, but I am one of the worst about calling it the Emergency Room. I usually manage to type Department, but say Room. (No male wants to go to the ED.) I worked at a museum for ten years but still spell it musuem… thank goodness for Spellcheck!

Open Heart Surgery is one of those phrases that is specific, but has come into common use almost as a verb or descriptive term. Ever ask someone to Xerox something for you? You can’t do that – you can photocopy something, but Xerox had rather you not use their company name as a verb. (Page down to “The Xerox Trademark”.)

Actual, true “Open Heart Surgery” means that an incision was made in the heart – but the term has come to mean all surgical procedures involving the heart. The Blalock-Taussig shunt, for example, was not an open heart surgery. This was the first planned Congenital surgery, and no one knew what would happen if an incision was made in the heart. No one wanted to even get near the heart, just clamp and cut that Subclavian blood vessel we talked about, Dr. Blalock. Clamp the Pulmonary Artery and sew the two together, and get out. So my 2nd operation was not an open heart procedure.

My first one wasn’t supposed to be either the Glenn shunt of that time required sewing the Superior Vena Cava closed, cutting the right branch of the Pulmonary Artery and then sewing that into the Superior Vena Cava. That would deliver blood going through the Vena Cava not to the heart, but shunt it over to the right lung. For a person to live with Tricuspid Atresia, they must have an Atrial Septal Defect (ASD) and a Ventricular Septal Defect (VSD). There are no exceptions – if you don’t have those two holes the blood can’t find a route through the heart and lungs. My ASD was smaller than it should have been, so Dr. Gott performed the Blalock-Hanlon procedure on me. In the Blalock-Hanlon, you cut into the Right Atrium and use a probe or a scalpel to enlarge (or create) an ASD. So even though it wasn’t part of the original plan, I did have Open Heart Surgery.

Dr. Clarence Dennis was the first person to try to use a Heart-Lung machine and perform Open Heart Surgery in April of 1951. Dennis and his team thought they were going to be fixing a simple ASD, but almost as soon as the heart was open they found themselves face-to-face with a severe Heart Defect. Dennis later admitted, “I wasn’t even certain what I was looking at.” They got out quickly and the patient died in Recovery a few hours later.

Dr. John Gibbon was the next person to try Open Heart Surgery, using a Heart-Lung machine of his own design. In the early and mid 1950s all heart lung machines were built as needed and each one of them was different, reflecting the perceived needs of the designer. Pretty much the only thing consistent between all of the machines was the tubing, as a certain beer distributor sold tubing that had a very smooth interior. At one time that company sold to just as many hospitals and individual doctors as they sold to drinking establishments.

Gibbon’s Heart-Lung machine worked and the operation was a success! Positive that he was onto something, Gibbon used the Heart-Lung machine three more times – and failed badly each time, resulting in three deaths. Gibbon was shaken so badly he destroyed his machine, burned the plans, and never operated again.

Dr. Robert Gross, who was operating on children to fix their patent ductus arteriosus (PDA) in 1938, also tried Open Heart Surgery in the 1950’s. His idea didn’t require a Heart-Lung machine at all. Gross’ idea was called the “Arterial Well”, a rubber cone open at both ends. This cone was sewn onto the heart in the area of the needed repair. (The original plan was to use it to repair ASDs, and after that, Gross and his team would have to think about further uses.)

Reaching down into the well, the surgeon made his incision in the heart. The rubber cone would immediately fill with blood, but since it was both wide and tall, it shouldn’t overflow. The surgeon was then supposed to reach down into the blood, find the ASD (by feel!) and sew it up. The incision would then be closed (again, only by touch) and the blood drained off with a small pump. Once the surgeon was satisfied that there were no leaks, the Arterial Well could be removed and the blood replaced by IV.

As you might imagine, that idea didn’t work out very well!

Dr. John Lewis fixed an ASD in 1952. Lewis used Hypothermia  – once sedated, the patient was placed in a large tub of ice. The hypothermia worked, but not for long; the heartbeat was slow enough for surgery for only about 10 minutes. In the room with Dr, Lewis was C. Walton Lillehei, who had some ideas of his own. Lillehei used a cross circulation technique – someone of the same blood type (preferably a close relative) lay on a table next to the patient. Lilllehei would stop the patient’s heart, using the second person as a living Heart-Lung machine! Blood would flow through connections and tubes from the patient to the 2nd person, then back to the patient’s body. Although there was always the possibility that something could go wrong and kill the patient and the volunteer, this setup worked. It wasn’t perfect (most of the patients who passed away died from pneumonia, an all too  common occurance in the early days of heart surgery) but the success rate was more than 50%. Lillehei also had a discussion with Earl Bakken about some kind of electronic device that could regulate a heartbeat. Bakken went home and designed the first pacemaker in his garage – and eventually formed Medtronic! Working with Dr. Richard DeWall, the two developed yet another Heart-Lung machine in 1955. This one worked – and it worked so well that from 1955 until the 1970’s, the Lillehei-DeWall Oxygenator was the top of the line model.

So if you’ve had Open Heart Surgery, take a moment to reflect on all the effort – and lives – it took to get it right.

Pacemakers without batteries

My pacemaker battery wears down pretty quick. Not because I am that active (What do you mean, you don’t chop down a dozen trees with a steak knife every morning?!?) but because of a combination of things. I am “100% paced” – meaning my pacemaker is on the job all of the time.

Also, my pacemaker is not in my shoulder. Usually the controller unit is in your shoulder with the leads traveling down the Superior Vena Cava into the heart. (CLICK HERE for a diagram of the standard pacemaker placement.) So my pacemaker is in my abdomen with the leads leading up through the Inferior Vena Cava.

As you look at that pacemaker diagram, you see that the pacemaker leads extend down into the Right Ventricle. That’s not happening in my heart – remember, with Tricuspid Atresia you don’t have an opening where the Tricuspid Valve normally is. So my pacemaker leads end in the Right Atrium, and the pacer needs a bit more of a “Jolt” to push my heart along. So I usually have to get my battery replaced every three to four years.

The initial surgery is hard, they do have to cut you open. The replacement is easier – they make a two-inch incision above your control unit, disconnect the leads, and remove it. Then they attach the new unit, test it, and if all is well they sew you up. Long time readers will remember that my doctors are worried about what might happen if I am put to sleep, so they give me a sedative. I call the sedative Happy Juice for a reason: I’m awake and can talk (and make pretty good sense!) but I am flyin’. Let me tell ya, Happy Juice is some good stuff, and next time I’m going to ask for the recipe!

Of course, the Happy Juice will wear off in a few hours, and then I won’t be quite as happy. So before I was discharged the Outpatient OR gave me a prescription for some painkillers, and that is when the trouble started.

Sometimes ordinary things cause the strangest reactions in people. I have a friend who will not drink Orange Juice – it makes him hyper! A small glass of OJ hits him like a sugar rush, and you almost have to sit on him to get him to be still! Now usually, meds work the way they are supposed to when I take them, but this painkiller never killed any pain… all it did was make me sleepy.

Ugh. Sleepiness wasn’t helping, because I was hurting so bad that I couldn’t lie down or sit up without help. And because the incision was in my abdomen, I couldn’t even roll over. I was trying to sleep sitting up in a straight-backed wooden chair, and a local ER doctor wouldn’t help me. Apparently he thought I was trying to work the system, since his advice was to “grow up.” I had to go back to my Cardiologist in Atlanta to solve this problem.

Thankfully he’s seem me enough over the years to realize that I wasn’t kidding around or trying to scoop some free drugs. He changed the prescription and for the first time in a week, I could lie in bed and sleep.

At one of my worse moments I declared (loudly) that if getting the pacemaker changed was going to hurt like this, then the next time I would just let the battery go dead and take my chances. Thankfully that was just the pain talking, I haven’t lost my sanity. But maybe I can get lucky and get one of those new pacemakers that generates its own power!

Researchers at Princeton University are working on a flexible rubber sheet that can power a small electronic device. The rubber sheet is coated with ceramic nanoribbons and generate energy by movement. In theory, a pacemaker control unit could be placed near a lung (the two current pacemaker placement locations – shoulder or abdomen – should do the trick) and as you breathe, the motion of your lungs would generate the power needed to operate the device.

Meanwhile, they are taking a slightly different approach at the University of Michigan. Tiny generators can “capture” motion and use them to generate power – more than enough to power a pacemaker. This really isn’t new: There are already “Self-winding” watches that create their own power from the back and forth motion of our arms as we walk. This generator can use vibrations from smaller, less rhythmic motions to create their power. The problem right now is energy storage – the research team needs to find a way to store the power generated for the times when motion is low. I know that I would hate for my pacemaker to run dry just because I was sleeping!

All joking aside, I would love to have one of these pacemakers. Even though it is a simple operation and (usually) there isn’t much pain involved, a pacemaker replacement is still a surgical procedure. And as a wise man once said, “Minor surgery is any surgery that they do to someone else!”

Let’s do it again!

“All this has happened before; and it will happen again.” – Battlestar Galactica

I’ll give you three guesses to figure out what I have been doing today.

Today, I went to the doctor’s office to have blood drawn; I bought medication;  and I bought groceries. The groceries I don’t mind – we all have to eat, of course. But since I am on a blood thinning medication (Warfarin) I have to go in every so often and have my INR number checked. Warfarin is a delicate drug – it’s really rat poison – and it seems to be able to go up and down on its own. Tie your shoes, the number goes up. Cross your legs, it goes back down. It seems like anything can affect it.

So you must have your Prothrombin Time (PT) checked. The results are given as the INR Number (which stands for International Normalized Ratio.) If the INR falls within you Therapeutic Range, everything is good. If it doesn’t… your doctor is going to adjust your medication and you’ll have to have a retest, usually in two weeks. My INR number has been riding a rollercoaster lately, and I’m feeling like a pin cushion.

If you are lucky, you can do the test at home. You test your blood much as a diabetic would, only you are looking for the INR number, not a Blood Sugar level.  I haven’t been lucky – My hemoglobin is too high, and it makes the testing machine go crazy. So I have to drive 20 miles for the privilege of having a needle stuck in my arm.

My medications tend to make my head spin, too. I take 14 different medications a day, and if I could figure a way to get the same amount of pills for each prescription, I think I could figure a way to refill them all at once. But no – some of them are 30 day prescriptions; a couple are 60 day; and a few are 90 day prescriptions. I think I go to the Drug Store every two weeks! It’s not difficult (if you keep close track of when you need refill and prescription renewals) but is sure is inconvenient!

This probably sounds like a whine, and it very well could be – it seems that as soon as I get through one “cycle” of refills or blood draws, it’s time for another. And my heart problems aren’t going away, so I’ll be doing this forever. But doing these things are extremely important, and they allow me to live my life. I enjoy life – I just get frustrated at the repetition.

But it is an important part of not giving up. These drugs and the blood tests allow me to do things like go to Houston for Hearts Re-United 2010. I recently got a new laptop bag, and one of the things that was important to me was to get one that had plenty of room for medication. The old one didn’t, and trips longer than 4 days required some creative packing on my part. (NEVER pack your medication in your checked baggage if you are flying. If you go to Detroit and your bag goes to Dallas, you’re in trouble!)

So yes, I’ll whine a little about blood tests and prescription refills – but I’ll still do it. I’m having too much fun to let my bum heart win!

Are you Iron Man? Nope! Just a Funky Heart!

This originally came from Salon.com, but I found it on Dr. Wes’ blog:

Iron Man’s powers are generated from an implant designed to keep his weakened heart from failing. Of course, there are differences in our individual circumstances. Tony Stark, the man beneath the Iron Man armor, designed his own implant in an effort to save himself from a piece of shrapnel traveling to his heart. Not only that, he created the device using material provided by his unwitting captors (Asian Reds in the original “Tales of Suspense” comic; Middle Eastern terrorists in the movie). I am not nearly that clever; my device was built by Medtronic, a Minneapolis company that was started in a garage and is now the largest medical device company in the world. We have so much in common, and yet I have so many things to learn from him. Sure he’s a little smoother in social situations, and better connected, yet at our core we share something rare. We are both cyborgs.

What’s your guess?

From Dr. Wes:

“We’ve got a 40-year-old male with a pacemaker and a strange X-Ray down in Radiology. One of the interns said`Whoa!’ when he saw this but I don’t think that’s his official diagnosis. What do you make of it?”

(Hold your arrow pointer over the X-Ray for the answer.)