Chapter Two "The Sequel"

"The pain did not go away. "

The pain did not go away.

It began just after midnight on Saturday evening and was clearly the result of the excellent dinner, a dozen snails, a nice German white wine, gammon and pineapple and a good burgundy followed by stilton.

But the pain did not go away.

It was lying underneath the sternum it was heavy and it would not go away. Strange thing that - the antacid hasn't helped either!

The pain stayed all night and nothing helped, - not milk, - not burping, - not standing, - not sitting , not moving around nor sitting still.

Sunday morning was a day on call. By half past eight the calls were coming in and by nine I was away to get some visits done. The pain still hadn't gone away!

It was a brisk frosty November morning and none of the patients were too dreadfully ill until the man with the chest pain.

He had had his chest pain since the middle of Saturday night it was lying underneath the sternum and it was heavy, and it would not go away. Strange thing that - the antacid hadn't helped either!

The pain had stayed all night and nothing helped, - not milk, - not burping, - not standing, - not sitting , not moving around nor sitting still. Within minutes the front line ambulance and paramedic were round - the leads on, the rhythm strip in my hand the defibrillator by his side and the patient away to the local CCU. ( That pain in my chest really isn't any better at all)

By eleven o'clock I arrived at the house of a patient with abdominal pain. He had phoned early because he had been seen by the duty doctor the day before and been told he had gall stones. When he woke this morning he still had abdominal pain. My suggestion that he might like to take his prescribed analgesic before phoning for a further visit had not gone down well!

There was no reply - I banged - I knocked - I shouted ( and the pain still didn't go away!) No reply.

The neighbour said "He goes bird watching on a Sunday - His mate was round an hour ago - he's gone bird watching"

I thought perhaps his mate took him to A&E

The accident department was busy - but my patient was lying on a trolley, waiting for an ambulance to take him back to the DGH at the bottom of his road - that's the one without an Accident department but on call for surgery today - and the one I would have sent him into quicker if he'd waited - without disturbing A&E - but what the hell. (That pain's not gone)

On the way out of the department the Consultant in A&E came over "Don't fancy a locum tonight do you?" He said.

"Not really" I said " I'm on call, and I've got a bit of chest pain" ( Don't mention chest pain in A& E Departments)

Well, these trolleys are a bit hard but it's quite nice to be lying down - they are fussing a lot. Could some-one phone my partner and tell him where I am, - Oh and by the way there's a pregnant lady still waiting for a visit for vomiting.

That ECG doesn't look too bad does it - mind you the pain still hasn't gone

Oh - OK I'll wait for the Medical SR on call but I still think that ECGs OK.

The SR thinks it would be wise to pop me into CCU and do some enzymes - I think perhaps someone should tell my wife - and could you ask her to come in by taxi - my car's parked in the consultant car park and she'll need to rescue it before someone clamps it.

I know that that Isosorbide is going to give me a stinking headache!!.

Well, I knew the isosorbide would upset me. The head ache is awful, pounding and persistent - ( but I think the chest pain has gone!)

It's quiet and peaceful - the ECG is OK there's no tachycardia, no dysrythmia.

Bp's ok pulse is fine (the chest pains gone) I could be out of here by tomorrow!

Good Morning - no I feel fine - oh I see the enzymes are up a bit - you want to wait for todays results.

Pulse OK BP OK No dysrythmia, no tachycardia just wait for the enzymes ( I think that ST segments moved a bit - shall I tell them or wait?)

OH!! You want another ECG!!!

"I see - you think streptokinase would be a good idea - Yes I understand, no driving for at least a month, probably off work till February, no nights no weekends till March"

Did I know on Saturday night? Can you really rationalise substernal chest pain that lasts 12 hours as "indigestion"

The answer is as clear as can be. Substernal chest pain in a patient that lasts more than thirty minutes is cardiac until proved otherwise. Chest pain in a GP is always indigestion - !!!!!! until he sees a sensible doctor

Sequel - "A Sharp Intake of Breath"

Three hundred and forty days later the pain came back!

Much wiser now, I stayed at home - and called out my GP. Well the pain wasn’t too bad - though it was familiar, and it didn’t go away. The Consultant followed the GP, a reassuring ECG and advice to rest. I think I was reassured. Eight days later the pain was still there - not severe and another visit by my GP’s partner. Still no diagnosis and the pain still there.

In the wee small hours my nerve broke - and the pain was a little worse. I elbowed the wife and said "Call an ambulance it’s time to get this sorted out."

A&E Departments seem very sparse and unwelcoming at 4.30 in the morning and the pain is definitely getting worse - morphine seems like a very good idea. The next 48hrs are a bit of a blur but I do recall someone saying "Don’t give him streptokinase, he had it last year"

Quite right. So in with the TPA.

I hate to say it but " The pain hasn’t gone away"

Back into the ambulance and a blue light ride down the M1 to our nearest Cardiac Surgery Unit - this is all getting a bit out of hand!

Time for a coronary angiogram! Quite interesting really and all that fiddling around in the right groin has quite taken my mind off the chest pain. Now for the pictures.

I had never realised how expressive a sharp intake of breath can be - not mine but the operators, and even I can see on the screen that dye is not flowing where dye ought to go!

"I see, the left anterior descending is totally blocked right at the origin - that’s a turn up for the book!

"Much too close to the junction of the left coronary trunk, we really can’t dilate that. It’s surgery for you I’m afraid"

Saturday morning and here I am in Theatre, not that I recall a thing. Sunday was a bit of a blur as well but I remember Monday! Pipes everywhere, a pain in my chest that felt as if someone had attacked me with a circular saw and coughing? - don’t ask. The mere remembrance makes my eyes water. I will say one thing though, that pain I had before appears to have gone!

Modern surgery is amazing, here we are Tuesday morning, 4 days post op and already they are talking about sending me home on Saturday, and me still looking like a left over prop from Dr Who and the Cybermen with cables here and tubes there, they must be joking.

No joke - Saturday and back at home

He went like one that hath been stunned, And is of sense forlorn: A sadder and a wiser man, He rose the morrow morn. ( The Rime of the Ancient Mariner (1798) pt. 7 Samuel Taylor Coleridge 1772·1834 English poet, critic, and philosopher)

I am now much more careful of myself, my weight is coming down and I now take regular daily exercise. The pain has only come back once since the bypass, I know why, - too much exercise too soon after a heavy lunch on the hottest day of the year so far, but :-

The pain went away!!

Much Later - "A Long and Lonely Road"

18 June 2001

Its been quite a long time since the bypass.  I keep meaning to write a follow-up, but time keeps passing!

There have been good times and bad times – but at least I am still here.

The bypass was seven and a half years ago.  On 28^th of December 1994,  six weeks or so after the original operation,  I suffered  an acute infectious episode affecting my left foot.  Quite bizarre really and I came to know them very well because they recurred every six weeks almost like clockwork for nearly two years and then less frequently through 1997  with only one attack in 1998.

I thought it was all over – but it wasn’t.  I had a further attack in August of 1999

It has now been nearly two years since that last attack but who knows?

The attacks were really quite strange, and to this day we have no diagnosis, no explanation, and no idea what they were.

All the attacks were identical.  They began quite suddenly with pain in the left groin,  persistent, uncomfortable and quite unique.  I came to recognise the signs.  Once the pain had become noticeable I had exactly 40 minutes before the next stage

Invariable, always exactly on time and always exactly the same.  40 minutes after the  pain came the shakes and the rigors with the sweating.  Nothing could stop it, nothing made the slightest difference.  Uncontrollable shaking, fever and sweat like you’ve never seen sweat.

We learnt very early that only one course of action would work.  Into bed, sponged down by my wife and left completely alone.  Fluids in large quantities whenever possible.  And I lost 48hrs every time.  12 hours of misery followed by a slow but progressive improvement over the next thirty-six

But during those 36 hrs a rash would always appear affecting the front two thirds of my left foot.  Over the next three or four days as I improved the foot would blister and by the end of seven days all the skin peeled off.

And six weeks later it happened again – and again – and again.

No diagnosis, no ideas and no significant treatment.  X-rays of the foot were not helpful, an abdominal scan revealed no pathology and blood tests showed nothing.  But it kept coming back.

The first attack was very, very frightening- indeed that is probably true for the first three or four – there were times at that stage when I doubted if I would survive, but after the forth or fifth I began to realise that no matter how bad I felt I had always survived in the past and it became an accepted fact that I would continue to survive – no matter how bad I felt at the time!

After about two years I enlisted the aid of my neighbour – a bacteriologist at the local hospital.  Despite the lack of diagnosis or signs he advised high dose, high potency, long term combined antibiotic therapy and I started a very long course.

Things have got better – but I still worry that it could all return.

Whilst all this was going on I was trying to put my life back together.  The operation and the early infection had left me quite run down both physically and mentally, something I really only recognise with long hindsight.

I did not return to work.  In the immediate post operative period the recurrent rigors were enough to prevent work and I was still suffering some chest pains and shortness of breath.  I attended a weekly cardiac rehabilitation programme at my local hospital but in May 1995 I was fortunate that I was able to attend a four week residential rehabilitation programme.

That marked a turning point.  In addition to a structured rehabilitation programme I was introduced to a course of acupuncture which did seem to ease pain which I was experiencing form the chest scar.  By the end of the course I could see the beginning of an improvement.

But it has been a long and sometimes lonely road.   I have continued to follow an exercise programme.  Based on the American Heart Association guide lines, it is a regular,  low impact,  low intensity,  moderate duration,  cross platform,  pulse rate controlled cardiac rehabilitation programme  

American Heart Association - Exercise Recommendations

In practical terms that means I go to our local sports centre every weekday morning and exercise for about two and a half hours.  This includes cycling, using the stepper and the treadmill followed by a session in the swimming pool.  It doesn’t get any easier.

My diet has changed significantly.   Low fat, lower calories, a more Mediterranean diet.  Regular attendance at Weight Watchers.

I have also been able to experience treatment by a practitioner in Traditional Chinese Medicine  - including acupuncture, physical treatments and massage – and I continue to see him from time to time

And of course regular medication following the changes and fashions of the medical profession. 

Aspirin, of course – a beta-blocker,  then added later an ACE inhibitor and then at the end of 2000 a statin.  
Scottish Intercollegiate Guidelines Network - Management of Stable Angina

I still get occasional chest pain, sometimes enough to worry me – but usually only if I do something stupid – carrying heavy loads – trying to rush – or if I get worked up or flustered – but I cope.

Perhaps the most significant problem on a personal level has been unusual.  Since my operation my personal thermostat seems to be disturbed.   I tend not to feel the cold – a bit of a problem really since because I do not feel cold, if I go out when the weather is bad I do get cold even when I do not feel cold – and then I get chest pain and short of breath.

Conversely, I do not cope well with hot weather.  As soon as the temperature rises I sweat continuously. Even a slight rise in temperature  brings it on, a matter which I find acutely personally embarrassing.

None of the problems really matter though.  Despite the sweats and rigor, despite the chest pains and shortness of breath, I never loose sight of one over-riding fact – it is now 2,500 days since my bypass  - 2,500 days I might never have had.  Thank you  

24 June 2001

I have dated these last two entries because I do not believe what has happened!

After over 5 years I decided to update this history and included the most troubling aspect – the rigors and fever and swelling of my foot because it had been 22 months since I had had an attack – I published the account on 18 June 2001 – and on 21 June 2001 I had another attack exactly like the previous attacks

I need hardly say that I am very disturbed, upset and depressed

13 March 2002

Got into bath at about midnight feeling on top of the world.  Got out ten minutes later and started shaking.  Classical pattern emerged. 

Violent rigors for twenty four hours followed by sweating for twenty four hours.  At that stage things appeared to be as usual but as the swelling of the left forefoot started it was clear that the swelling was worse and by Saturday morning I was very unwell with what was with hindsight severe dehydration as well as severe cellulites. 

Seen by both on call GP and consultant Bacteriologist who recommended very high dose Amoxycillin ( 1G tds ) and Clindamycin  (600mg qds ) initially.

Reduced to 500mg tds and 300mgs qds after 48 hours.  Elevation +++++   Fluids +++++

Well – it went away and stayed away for 6 years but on 23 November 2008 it came back – exactly the same and responded as usual to high dose antibiotics!  

It is still with me in 2009 - one attack in New Zealand in April and a second in France in July but both happily very short lived because of early high dose antibiotics.

June 29th  2011

Well it came back again!!

On the evening of July 29, 2011 it came back again.  Exactly the same as before.   Pain in my left foot and left thigh followed by the rigors, sweating, hallucinations, pain and swelling of the left foot.

I took the antibiotics immediately and it settled down very swiftly.

The whole episode only lasted about 36 hours, but unfortunately it did interfere with my plans.

I had been due to fly from the South of France up to London on July 1 to attend a presentation at the RAF Club in London.  I was unable to flyand  I therefore had to cancel flights and my hotel and was unable to attend the presentation which was being made by my former Squadron and was being attended by many of my old colleagues.

I was naturally very disappointed.

I have kept good medical records and this was the 33rd episode in the last 16 years.  

No diagnosis -- No reason or cause has been  found

It really is very depressing!!. 

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