The Etape de Tour Saved My Life - part 4

Open Heart Surgery - what's that ticking noise?

The continuing story of how a perfectly innocent doctor's signoff for an Etape de Tour bike race entry form revealed a collapsing aortic heart valve, resulting in 44 year old cyclist Nigel Dalton having open heart surgery in early 2008.

Part 3 was here if you missed it. It'll make much more sense if you read the earlier ones first!

For a cyclist, one of the most annoying noises on their bike is an unexplained ticking. Seat post? Seat? Bottom bracket? Chain? Cluster? Tooth on one sprocket? Spoke? Freewheel? Dry inner cable? Head bearing? Tick Tick Tick - you sit, you stand, you ride with one leg, it's annoying enough to have you issued a severe ticket for poor bike maintenance and be banished to the back of the bunch.

The worst bikes are Cannondales (which I have) - with large diameter aluminium tubing, the slightest noise is amplified to rifle shot intensity. It's a certain ride home on your own.

When I woke from open heart surgery, there was so much noise around me that the proximity of a loud, regular ticking did not completely register at first. Intensive Care (ICU) is an amazing place - a pressure cooker of medicine, groans, coughs, the occasional shriek, sounds of life, death and dozens of machines that go 'ping'.

You've just emerged from a 6-8 hour period of lying inert on an operating table, worked on by some of the smartest people on the planet - which by the way, if your interest overcomes your squeamishness, then I recommend a BBC documentary called Blood and Guts, where the episode called 'Bleeding Hearts' starts and ends with a woman undergoing an aortic valve transplant like mine.

Patient focus is complete - 2 people at your bedside, no more than a dozen patients in the ward. The ritual of emerging from open heart surgery is well practised - as the BBC web page notes - you have just been is cooled until your brain stopped, and then had all of your blood sucked out, major heart parts replaced, then stitched up and revived.

Which is not a great scene for your loved ones to walk in on (by the way). Naturally keen to see me after 8 hours of zombified 'shopping', Lesley received the shock of her life to find me cold and lifeless in ICU. She returned for a second attempt later on, when I started to show signs of consciousness. Even then she was forced to leave, seeing me emerge from the anaesthetic and struggling to communicate that I thought I was ready to have the breathing tube out.

I'd been suitably warned about this process - I'd wake up with an uncomfortable, fixed breathing tube down my throat and into my lungs. Strict instructions were to not panic, be zen about it (rather than trying to rip out this murderous tube that was choking you, because after a moment's reflection, it obviously isn't!). The moment it starts to frustrate the patient is correlated strongly with the moment they are ready to breath on their own - it's just tricky spotting the right moment.

With tube removed, it was bizarrely comforting to be in a safe place again. It was done. The next voice I recall hearing was the utterly business-like and pragmatic surgeon saying "Nigel, the human donor valve didn't work, the aorta was too damaged, so we've fitted a mechanical valve instead."

"Oh", I thought. Not "oh shit", just "oh'. Nothing I can do about it now ... guess I'm going to find out all about life on the dreaded Warfarin.

That would also explain the incredibly loud ticking in my ears.

The other thing Swee Seow and the team had briefed me well on was that life would get better every day after surgery - with the bar starting pretty low in Intensive Care. The full horror of ICU swam into view as my consciousness steadily returned over the next day.

I was connected to a dozen machines, one via a spider-like robotic device on my neck that had several tubes descending into parts of my heart and chest cavity. I had drains from my chest cavity exiting below my rib cage, wires in a similar position ready to jump-start the heart at a moment's notice, the inevitable catheter, drips and monitoring equipment. My bed-head looked like the Lonely Planet server room and it greatly reminded me of the Monty Python 'miracle of birth' sketch from the The Meaning of Life.

Fact #1: sleep in ICU is near impossible. I passed the first night listening to the ever increasing anger and frustration of the night nurse with an elderly gentlemen recovering from an emergency bypass he'd been admitted for that day. He was trying to tear out his breathing tube before he'd fully gained use of his lungs, and even the threat of being returned to full sedation didn't help. That was solved about 2am when another nurse twigged that he spoke no English, and her Italian language skills came to the fore to calm him down.

Fact #2: it's crazy in there. My immediate neighbour up and died, signaled by the wailing of relatives and rapid closing of curtains. At the end of the room, another woman was yelling out she needed more pain killers - the morphine talking as it happened. All the time, machines, machines, machines - alarms going off, pinging, dinging, a cacophony that chased away any attempt at rest.

Being judged ready to leave ICU and then being wheeled to Ward 6 was the best day of my life. The removal of the really complicated tubes took hours, with the nurse constantly called away, and in no apparent hurry to get it wrong when she came back.

Back on Ward 6 the relative improvement from machine purgatory was immense. The first night I managed to sleep - almost right through. It was less than a month since my failed ECG and Stress Test. I had moved to a beautiful room (seen here with family trying everything out) with all the mod cons.

The pain was also less than I'd expected. Being younger than my average ward colleague by about 30 years, I was warned to expect more chest pain (traded off with a faster recovery). Thankfully, sternums have few nerve endings around them, so sawing them down the middle is manageable on the milder stuff (God bless Panadol). I had one night on Morphine, with dreams so bizarre and frightening you'd have to be a registered clinical psychologist before I shared them.

Both my father and Uncle Lawrence had heart bypasses, and advised that the back pain where the ribs are leveraged open at the 'hinges' had troubled them. I'd got ahead of that one with 2 weeks of massage and stretching to that area before the operation.

The most painful moment was to be revealed much later, on the morning of leaving.

By the 12th I was primed for the big hurdles to leave the hospital.

• Getting my Warfarin dose under control and a stable INR that showed my blood was now thinned down enough to run through the plastic and metal enhancements to my aorta.
• Attending the rehab program, including wincing our way through "resuming sexual activity" and 'heart-smart shopping' with a group of 70-something year olds who have just had triple bypasses.
  
• Climbing the 22 steps to the next floor of the hospital
  

Because we hadn't talked much about the mechanical valve option, I was totally shocked at the noise in my head from the ticking. Dr Seow could read my eyes when I brought it up - "it's a really good one, I can't even hear it from here" he said as he stood 2 metres away with his usual wry sense of humour. "Tell you what, you ring me when it stops ticking ok?"

The aorta splits the high pressure blood across several delivery routes - one of which is the Carotid artery to the brain, via the ear. That's the pulse you can hear at night sometimes, so you shift your head and it goes away. With me, not only can I hear it all the time, you can hear the metallic click of the valve closing as well. It's a great party trick.

By Day 3 I was well enough to starting to think that cycling with a mechanical heart valve was out of the question.

The effect of Warfarin is to thin your blood, which has a corollary of making you bleed more easily. A bike crash at 30 km/h might see you lose some skin, ripping your lycra outfit and getting some bruising. For me, it's a debacle. Once the bleeding has stopped, I have to wonder where internally I'm also leaking blood. And the bruises can be monumental. A decent whack on the head and I'm done for, whereas you're probably just seeing a few stars.

It was clearly visibly upsetting me - would this whole journey that started with the the greatest of good fortune delivered by my bike, end with me never riding again?

When I received a seemingly random,unplanned visit from one of the technical heads of the Cardiac Ward, I'd hidden all the bike magazines and resigned myself to losing my most favoured pastime. I would never see the Pyrenees on a bike. Turned out he was a cyclist too, and we talked about our riding and how great it was to be on the roads around Victoria. To be really alive. Half an hour later he waved goodbye, magazines in hand, and I resolved never to give up riding - to find a way to reduce the risk, and manage if a crash occurred. Not long after, Swee poked his head around the door, waved and winked. Cardiologist and Psychologist it would seem.

In a 'patients behaving badly' reality TV moment that only cyclists would appreciate, I realised that night that SBS were playing the Paris-Roubaix race live, finishing about 2am. With a room to myself, I hatched a plot to fight off the effects of the nightly sleeping pill and celebrate my love of cycling by watching right through. It was an awesome race, but in hindsight must have set my healing process back a bit!

This only left 2 mountains to crest - the first climbing to level 7 of the hospital building, a mere 22 steps away but the hurdle put in front of all patients before they can leave. I trained whenever possible, shuffling laps of the floor, confident at the start and always stunned at my exhaustion, flopping back into bed to recover. When the hour came, I thought of the 18km of climbing on the Tourmalet in the Etape de Tour that I had signed up for so long ago, and fairly flew up the stairs.

Second mountain went unanticipated until the morning of the 15th of April when my INR levels finally became stable. Provided I removed the incredible bandage that sealed up the 25cm chest wound (now healed - blood supply to this area being pretty immense) before I left, I was free to go home. Having had a complete body shave, how hard could that be?

The nurse started to peel up one corner and the problem became immediately obvious. The hair had grown back over the week, and embedded itself in the bandage material (semi transparent in the picture, just showing some of the original iodine yellow tinges). She quickly found herself called away, suggesting I get started on it in the shower perhaps. The same shower that had not penetrated this high-tech elastoplast from hell in the last 5 days...

Catherine, who was visiting from NZ to take some of the load at home off Lesley, hid in the bathroom. I lay on the bed in its lowest position, and hung onto the rails. Lesley, grabbing the painstakingly lifted 5mm corner of the bandage braced herself against the bed and did her worst.

Body-shaves, fear, shock, loss, indignity, injury, ticking, morphine fueled psychoses, horror, the embarrassment of suppositories, stress, 2am heart racing episodes, early morning eastern-bloc blood snatchers, death, machines, alarms, pain, frustration, the whole goddamned injustice of having open heart surgery at 44 combined with the joy of being alive came screaming out of my lungs as the bandage came away in one fell swoop.

With what appeared to be a piece of stubbled pigskin in her hand, Lesley rushed to calm me as I laughed so hard I might split my sides. Literally, perhaps.

My new best friends - the daily rituals of Coversyl (arterial and muscle flexibility around aorta) and Warfarin. Also pictured is my ICE necklace I wear when cycling.