The Etape de Tour Saved My Life - lessons for cyclists (and others)

The 10 things I learned from Open Heart Surgery

The afterword to the 5 part 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.

Feel free to make an appropriate hand gesture and go "well, duhhhhh!" at any of these:

1. You can find a way to keep riding bikes after open heart surgery - you do not have to give up your passion, or wrap yourself in cotton wool. Racing - probably not, and you should own the best protective gear possible plus carry some extra equipment (see part 5). Ride with friends who know what to do if there's a tumble, and avoid drafting complete strangers.
   
2. Not all serious health problems have visual, external symptoms. As a fit, active cyclist I had no symptoms at all for what should have been a debilitating condition. My heart took a year on drugs to shrink back to its normal size after surgery. Get an annual medical checkup. I'm talking to you guys out there, mostly.
3. $600 (about $300 after an Australian medicare rebate) spent on a full ECG and stress test is the best investment you can make in your cardiac health if you are in your 40s. Contact your GP or someone like the Victorian Heart Centre at Epworth Hospital in Melbourne. Don't piss around with this stuff, monitor your blood pressure at the very least.
   
4. Get a personal trainer with rehabilitation credentials (like Trewrehab) to manage your physical recovery program after big surgery. Being in a gym with all those athletes around will be much more motivating than being in a class sharing a few exercise bikes and tips on giving up smoking, and I think it's more likely you will avoid the dreaded cardiac depression.
5. If you're ever given the choice of suffering the acute embarrassment of an early in the evening pain-killing suppository by the pretty, charming blonde nurse with tiny, delicate fingers; or waiting until later that night so it doesn't wear off by 5am - take it early. I did, and the night nurse/former Soviet bloc weightlifter with fingers like a rolled up Saturday editions of the New York Times will never know my immense relief at that decision.
   
6. Do what you are passionate about before you suffer a major health problem, so that when you are questioning the meaning of your life afterwards (brought on largely by the avoidance of the opposite condition!), the answer comes fairly easily. Hopefully it was "doing what I am already doing" as I was lucky to discover.
7. It took me 12 months to recover fitness after open heart surgery (valve replacement). They'll tell you 3 months so as not to depress you, but don't count on it. See item 9 as the corollary to this lesson.
   
8. After 2 months, whilst you feel so much better, you are not back to normal. Beta blockers (like Sotalol in my case, to prevent cardiac arrhythmia), anti-coagulants (Warfarin), Panadol and the healing process will combine in ways you never imagined to make some job requirements as a Manager almost impossible. You NEED high blood pressure to 'pop' new ideas from that brain! Get more sleep as you are learning to listen to a whole new set of signals from your body as to what 'tired' and 'enough' are
   
9. It does get better every single day. Celebrate that.
10. Hug your family every day (and your friends whenever you can) because there is a chance in this world you might not see them tomorrow.

The Etape de Tour Saved My Life - part 5

50 Rides to do Before You Die - suggested recovery reading for open heart surgery patients.

The final chapter in the story of how a perfectly innocent medical certificate 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 4 was here if you missed it.

The last days at Epworth Cardiology Unit had involved some excruciating rehab sessions. The physical stuff involved rolling and coughing, 2 things you really don't want to do with dozens of stitches in your chest. All that caused was physical pain however. The counselling was far worse, having to sit through textbook learning sessions, including the aforementioned 'resuming sexual activity' and discussions about giving up cigarettes, fatty foods, and other vices.

Seeing my keenness to leave, and frustration that my INR levels were not coming up quickly enough, I received some great advice - 'dress like you are already home'. Not only did it take me out of my 'pyjama'd patient' frame of mind, it clearly altered the perception of the professionals for the better. I loved the look on nurses' faces when they came in to check on me and found a shaven, well-dressed visitor instead - "so where is he?" they'd chime. "That would be me" I'd reply, smiling at the deception.

Finally running again (for a couple of minutes), with Adam Martin at Trewrehab in late July 2008

All of this left me determined to take a different approach to my rehabilitation. 'Healthy grocery shopping' is not a subject that needs much study when you live in a gluten-free, no dairy household anyway.

My descent from a high level of fitness (brought about by long miles on the bike) to pathetic zombie shuffling around Middle Park shops (quickly followed by exhaustion) was shocking and complete. Every ounce of my body's energy was being absorbed into the healing process, the organs trying to settle back into position and wounds heal. It was all I could do to keep up with the weekly blood test cycle as my Warfarin dose was perfected to a healthy INR range.

My magazine pile for the recovery. Robbo delighted in sending me Procycling's
50 Rides To Do Before You Die with a bookmark on page 46 - the Tourmalet in the Pyrenees where
I should have been climbing in the Etape de Tour on 6 July 2008.

Initial estimates of how long it would be before I recovered to a level of fitness I had enjoyed before were all suspiciously short. Three months, maybe four. It just didn't seem right from where I stood - I was still stuffed walking up the stairs at home.

I finally twigged as to what was going on - as the Adam's Heart Valve Surgery blog notes, the onset of depression following cardiac surgery is epidemic, and is counted one of the most significant side-effects. Nobody was going to tell me 'be patient, it'll take a year' for fear of sending me into depression and examining the meaning of life. So let me offer other sporty open heart surgery patients some advice - be patient, it will probably take a year.

I found that I was having out of body experiences, watching me unable to open the marmalade jar (left and right sides of your body being joined together at the sternum has all sorts of strange benefits you might not have considered!), and shuffling at tragic pace to the tram, then 100m down to the Albert Park Medical Centre for a checkup in the weeks after surgery.

I felt 90 years old.

The only major pain I was suffering was in the 2 places where the operation invaded my muscles - the twin drain tubes for the chest cavity which were routed through the diaphragm and out the abdominals; and my neck where the matrix-like spider device had been connected. Despite the occasionally frightening 'click', the chest bone was no real source of discomfort. My utter sympathies go out to those recovering from cesareans or radical surgery like mastectomies - that would be the definition of pain.

My first assessment at Trewrehab was 2 May. Getting past the usual BS "but you must be feeling so much better these days" was not an issue - Adam had met me before the operation and could see the demolition job the surgery had done on me. We scheduled my first session for 6 May, with a clear goal of getting back on the bike in July, for at least a short ride around Albert Park.

With a 'program' and surrounded by fit athletes I never had time to feel sorry for myself. The beta blockers were leaving me in a daze, but they were gone by the end of July. Some people stay on those forever! The arrhythmia that had seen me condemned to these damned pills was a fairly frightening experience, my heart rate racing out of control to 180 bpm whilst lying quietly in a hospital bed trying to be zen and stay calm.

We visited my surgeon Peter Skillington on 29 May - he had a strong message for me - for god's sake slow down! He was not thrilled I was aiming to resume cycling, having recently attended to a cycling buddy who had come off second best with a parked car descending a hill in the suburbs. I examine every one of these tales with an eye to the avoidability, what could have the cyclist done differently to miss the crash altogether.

My cycling buddies won't thank me for this, but I suspect that many accidents are avoidable if you assume homicidal intent on all car and truck drivers' behalf, and that a surprise lurks behind every intersection or parked or stationary car. It's a tactic I've been using for 30 years on my motorcycle.

I assembled a "Warfarin-special' first aid kit with the help of the local pharmacist (someone you'll get to know well) to ride with that includes cold compress (to reduce bruising); antiseptic powder, antiseptic wound cleaning pads; tape; stretch bandages; and wound covers. It fits in an airline toilet bag in my middle pocket at the back of most cycling jerseys.

I wear a Medic Alert bracelet and a fancy ICE necklace with a built in USB device that holds records of my medical condition. My colleague Mark, who is also a CFA volunteer in the rural fringes of Melbourne, assures me if he attends any bike crash I'm in that it'll make a nice souvenir as they're not due laptops in their vehicles until about 2019. Ah well...

As my INR settled into an acceptable range, I made the big decision to avoid alcohol entirely. Simplify, simplify, simplify. That NZ Pinot Noir Lesley and I had drunk on the day of discovering my faulty aortic valve was a fitting departure point for a lifetime's enjoyment of fine wine and beer.

The surgery and the recovery period that followed brought some surprising benefits - once I got fit enough to walk, I was able to spend a lot of daylight time with our 7 year old boy that high pressure corporate Dads just don't get these days. I was very sad to go back to work and lose the thrill of dropping Noah off and picking him up, sharing a pie at Annabels in Albert Park before guitar lessons, and a joke about the day's schoolwork.

Now, in September 2009, I ride most weekends, have turned rehab at the gym into a weekly personal training session with Adam (which I am thoroughly addicted to), am back to full speed at work and enjoying it more than ever.

I made a list of things that looks a lot like that great cliche 'the bucket list', the first of which I have already ticked off - playing in the Lonely Planet Band at the Espy in June this year. Little things bring memories flooding back - the anniversary of my operation which is now my second birthday; and Paris-Roubaix will always be special to me now.

Which, to circle back to the start of this 5 part epic, sounds like a bloody good reason to go to Europe and knock off a couple of those 50 rides before we die.

Note: if you'd like to read about how Robbo and Slim's trip to the 2008 Etape de Tour went, it's all documented on the Robertson Communications blog here. There are times I think Slim drew the short straw! Here's Dave climbing Hautacam with 10km to go.

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.

The Etape de Tour Saved My Life - part 3

How to spend $50,000 on titanium components and have everyone feel good about it.

The continuing story of how a perfectly innocent medical certificate 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 2 was here if you missed it. It'll all make much more sense if you read the earlier ones first.

The 3 weeks between diagnosis with a failing aortic valve and dangerously enlarged heart muscle (March 12, 2008) and being admitted to Epworth Hospital for open heart surgery (April 7) flew by in a blur.

I found myself awake at 2am on more than one occasion, looking out from our house on Canterbury Road with that clarity of vision that is the fabled gift for those facing their maker.

What kind of dumb crazy luck had caused me to enter the first bike race in my life to require a medical certificate for entry, triggering a trip to a GP who just happened to pick my symptoms as worthy of a second opinion from a cardiac specialist, who had caught me weeks or months from certain expiry?

How could I be suffering no symptoms? I ran 3 stories up to the Lonely Planet cafe 2 steps at a time most days, with not a hint of breathlessness or chest pain. I was riding well over a hundred kilometres a week.

I wish I could say the artistic photographs I took whilst sitting there were as lucid - though apparently, my time was not up yet.

Looking at my Palm Treo with my work calendar was very disorienting - 'Nigel Sick' it said (code words to enable meeting cancellations while my life was sorted out). I was never sick! Sick is for other people. I dwelled on the ignominy of not even being able to say "I feel so much better nowadays" after surgery.

My angiogram on 26 March clued me in to what I was about to experience as a hospitalised human being. A relatively simple day procedure, it was a gentle introduction to Ward 6 at Epworth. How they work out where a long wire goes from your groin to your heart, and drive it down all the cardiac alleyways by remote control beats the hell out of me. I was pretty embarrassed having 8 people work on my groin, most of them sassy, good-looking young medical professionals, teasing each other about their footy teams. It was like being on House.

The results came through clear, and I was confirmed as a good candidate for a Ross Procedure to be undertaken by Peter Skillington.

The bruising left by the angiogram gave me a spectacular groin - coloured not dissimilar to my attempts at artistic photographic expression above! Now a 'born again' fanatic of the General Practitioner I raced to show John the result, fearing I'd suffered something untoward. He sent me home reassured, though I think the scale of the bruise did impress him somewhat!

I was now off the bike completely (angiogram induced groin injuries included!), venturing out for walks was the most athletic excursion I dared to do. I paced out some recovery strolls for when I came home and I'd need to walk every day as part of the rehabilitation process. On April 1st I went to visit the Trewrehab team at the MSAC facility near home in Albert Park.

That was a critical moment in the whole process, when I look back in reflection. Recommended by a friend, the choice of a private, gym-based rehab program over the hospital program put me straight into a mind-space that was great for recovery. More on that later anyway.

The last decent training ride around the hills (and gravel roads) of Alexandra and Eildon, Victoria

The other critical moment was the way Lonely Planet treated me as an employee. If you suffer what I did, pray you have an employer like mine in your corner. I'd tried to be staunch and head back in the day after the discovery (March 13th). I gritted my teeth through the walk to HR to outline the facts, and barely managed to blurt out "it's bad.." before collapsing in fits of tears.

The facts were upsetting, but not on the scale of my reaction. It was plain, old fashioned shock, which had taken 18 hours to set in, and among the people I spend most of my waking life with (which is kindof a sad reflection of modern life, but...) I felt it all collapse in on me. To have suffered zero symptoms, and be dropped from a great height into the 'gravely ill' bucket was too big a transformation for 18 hours.

It set in train an amazing backstop for me, knowing that my job was covered at a critical time on a critical website project, and that time off work would not be an issue. I went home that morning, and apart from a trip back to have lunch with a few of the team, I focused entirely on achieving a sense of health that would get me through the operation. I thank them all.

Google was a good friend in this preparation time as well. Through it I found an amazing blog called Adams Heart Valve Surgery Blog, complete with a book the blogger had written covering pretty much every question that was arising in my mind about open heart surgery.

The author had been through almost exactly what I was expecting to experience. His Ross procedure went smoothly, and I was able to read (actually wince through) snippets of detail on a regular basis before being somewhat overcome by the discomfort of knowing all this was about to happen 'at a store near you'. The power of a blog where people could share stories and get advice from others with their particular age, health and life circumstances was amazing. I still read this blog today.

Being 44, fit and with no major vices I was high on the list for a donated heart valve. I learnt that many of Australia's heart valves come from deceased people who have had brushes with the law (terminal brushes with the law in fact), and a disproportionate number of their families make an effort to balance the world by giving the ultimate gift.

It would have to be a crappy conversation to have as a medical professional, to ask a family if they would donate body parts that can save other people's lives, when the worst news possible about the failure to save the life of your loved one has only been delivered minutes before. Solve it now everyone - sign up for a donor card NOW.

Anyway, I was about to get a little bit of Australian in my heart.

One thing the reading about Ross Procedures gave me was a 'thank goodness I'm not going mechanical' attitude, and the drug Warfarin seemed like a lifelong habit that was worth avoiding. This would come back to haunt me in a couple of weeks.

The bureaucracy of major surgery also had to be battled. With GP, surgeon, cardiologist and hospital all lined up, my Health Insurance company HBA now needed to be consulted. Crap! April 8, the scheduled day of surgery was 3 weeks short of my stand-down period for major surgery, having only arrived in the country in April 2007. Panic! This is a $50,000 operation.

Too often all we read about insurance companies is their faceless inhumanity, with business plans and 'shareholder-value' strategies where their mission becomes to turn down every claim possible on technicalities, or stretch people out for long periods of suffering. Not HBA folks - they could not have been better. I spruik them without conscience to anyone I meet now. They approved the surgery in record time, recognising the need (and opportunity) to move quickly.

Thus, on Monday April 7, at lunchtime I checked in to the Epworth hospital (checked in is right, it's a lot like a hotel in a lot of ways), hung my dignity on a peg in my locker and lay back to read bicycle magazines and meet the team who would do the surgery.

I'd never even known the existence of a Perfusionist before. Apparently if you finish top of the class in anesthesia school, you stand a tiny chance of being selected into the inner circle of specialists who keep your blood circulating when a heart is stopped for open heart surgery. I was speechless - the final point of a week in which I reflected that I had grown quieter every day, withdrawing into the inevitability of it all.

The dreaded 100% body shaving exercise was entertaining. It didn't happen until about 8 at night, when the dayshift person doing it had long left and the after hours substitute was called out especially for me.

Ironically, he was about the hairiest person I had ever seen, and with minimal English he managed to communicate that he was deeply puzzled that my legs were already shaven ("cycling, shaving, go together, go faster ..."). Three sets of clippers later (all blunt from a day's hard work) and all the possible conversation exhausted, I took the iodine shower and retired, suitably yellow, to watch my last TV for a couple of days.

I might be lurid yellow, but there was no chickening out now.

The Etape de Tour Saved My Life - Part 2

Quite the cycling injury - and the mother of all registered niggles.

The continuing story of how a perfectly innocent medical certificate 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 1 was here if you missed it.


That little scar, is what is referred to among the cycling fraternity as a 'registered niggle' - a certified (among your mates, bugger the UCI) excuse to perform poorly while racing or training. It's no use complaining after a ride about the injury you were carrying or feeling poorly, you have to register the problem in advance.

The photo is the only shot I have of the 'ouchy bit' as my little friend Harrison Rowe would say. Then again, if you did read Part 1, I have jumped ahead for dramatic effect. We left me in the waiting room at the Victorian Cardiac Centre at the Epworth Hospital in Richmond, confident of setting a new record on the treadmill stress test and having a medical certificate signed off the very next day for last minute submission to the good people of Bikestyle Tours.

Being a busy place, the cardiac nurse got me shaved in small circles where the electrodes needed to go, stripped down and lying on the bed with all manner of electrodes attached for the ECG part of the test. There's 3 parts to this test - the scan (like a baby ultrasound, but of your chest); the ECG where they measure all the electrical charges that make your heart work in a regular fashion; and the treadmill test, where the heart's response to exercise (aka stress) can be viewed using ECG and ultrasound scanning.

With wires attached, she brought up the first pictures up on screen. Despite the strange circumstances, imagine I'm managing to maintain my 50-something rest pulse and composure for being half-naked in a cold room. Within 30 seconds the nurse picked up the phone and asked for someone to come in as soon as possible. Within 30 seconds of their arrival, they are in turn, calling for Doctor Seow.

Their collective (but hushed) "ohhhhhh, very clear..." as the screen is flicked to a mode that allows blood flows to stand out among the muscular grey blur of the ultrasound. Dr Swee Seow, who has clearly been in this situation before, turns to give me the news.

"Your GP, who is he? He's a pretty smart fellow - I've not known a GP to diagnose so accurately a problem. Why did you see him again - out of breath? Feeling faint all the time? Bad chest pains?"

"A bike race entry form ..." I managed to utter - the cool, composed, cyclist evaporating fast. Not a common symptom of heart problems apparently. I explained the Etape de Tour as best you can in such circumstances - France, hard to enter, months of training, big mountains...

"Sooooo ... you booked your ticket yet?"

It wouldn't be the last time that Swee's humour carried me through an awkward moment in the next few months. Swee explained how when a heart valve malfunctions by not closing properly, high pressure blood leaks back into the aorta, quite often causing that side of the heart to swell as it copes with the extra work loaded on the 'exit' chamber of the pumping mechanism. And that in my case, it was a valve in very bad shape, severe regurgitation, and severe swelling of the heart muscle.

Thus I needed surgery urgently. Major surgery, cut open the chest cavity, risky and complex surgery. Surgery you see on TV and look away from. Surgery that happens to other people.

Flabbergasted, I lay there thinking "that wasn't supposed to happen" (I work in IT, that is a common phrase at the time of disaster). "Come on then" says Swee, "we've got a stress test to finish". I looked at him like he was a murderous madman - treadmill? After that diagnosis? You have to be joking!

As it happens, a good set of data from the stress test is vital in the process of assessing the problem (in particular the health of the heart muscle overall), so with mind and heart racing I took the treadmill to Level 5 as I had long anticipated, feeling no ill effects from exercise as usual, and the scans were completed.

Swee's plan was to engage Peter Skillington to try a procedure he was world-renowned for called the Ross Procedure, where the patient's own valve on the 'low pressure' side of the heart is substituted for the highly stressed aortic valve. The pulmonary valve is then substituted with a human donor valve.

The alternative would likely be a mechanical valve, as being of middle years, I'd need it to run for perhaps 40 years (here's hoping!) and they were highly reliable. The downside of mechanical was the need to take Warfarin for life, a blood coagulation controller. With thin blood, there are things you think twice about doing. Like cycling.

Swee would contact Peter and my GP immediately, schedule an angiogram, while I was to work out health insurance details, what do to with my job, and get ready for a lifestyle change. Two months minimum off-work, probably three.

A bit dazed, I dressed and left the hospital. I txted work to say I wasn't coming in that afternoon, and rode home. I walked round to the local wine shop, bought the most expensive bottle of NZ Pinot Noir they had (knowing it quite likely would be one of the last I'd enjoy), two Reidel glasses, and opened it in preparation for Lesley arriving home.

After breaking the news at home - needless to say I lacked Swee's calm bedside manner - I called my parents (who were already booked to come over after Easter weekend for a visit), and rang Robbo to register the mother of all cycling niggles.

That night I also sent the following email off to Bikestyle:

Dear Natalie, Had a bit of a shocking day. A routine stress test for my Etapes entry form medical signoff turned into a drama - it turns out I have a heart murmur, the aortic valve is not working correctly and I need open heart surgery to replace the valve as soon as possible. My fitness has apparently been disguising the defect for a while. This is not the outcome I was expecting from today! I have a good friend, with a racing license who I have asked if he will take my entry for me. Though shocked, he's considering it and will let me know tomorrow. He lives in Milan, so is on a different time zone. We should be able to pull together the necessary paperwork quite quickly via email and fax to you. Strange day for me, please let me know if this is going to be an issue to enter Andrew instead of myself. Regards (I'm not quite up to 'cheers' this afternoon) Nigel

Dave quickly decided he would make the France trip in celebration of our stated mission in life to record many more epic tales of cycling days out, and with luck Slim was now going to ride the Etape in my place.

I would have a different Tourmalet to climb.

The Etape de Tour Saved My Life - part 1

This is the finest piece of cycling equipment I possess.

How I came to have it installed is an interesting story - of incredible good luck, of incredible bad luck, and how by attempting to fulfill a dream borne of a longtime friendship and a shared passion for bike riding I cheated certain death at the roadside, on top of the Tourmalet.

The tale began in Autumn 2007 with the visit of friends from NZ, coming to Melbourne to stay with us in our ramshackle bikeshed of a dwelling, half demolished, leaking but spacious for 2 families.

Apart from the usual tourist gigs, David and I also managed a Sunday ride around the Dandenongs, following a course pointed out to me by my colleagues at Lonely Planet as the loop to undertake across from the 1 in 20 and back via the Silvan Reservoir, Mt Evelyn and the Hors Categorie Inverness Road climb.

The ride turned into something of an epic day out, which Dave has documented on his blog, one of those rides where you start to worry a little whether the cramps being endured are going to let you get home, and how a mistake in navigation could be quite costly in the cold and rain.

Dave was forced to ride my vintage Fausto Coppi, with pretty average bottom end Campy groupo. The tyres were hissing and sprayed rivers as he bombed past me descending the other side of the 'Nongs, bravely braking deep into the bush-clad corners he had never seen in his life before.

We missed the vital turn at Inverness Road (thank God) and climbed the Tourist Road instead, making it feasible for me to stay on my bike the whole way, then rolled along the tops before descending like madmen to the car at the Basin. Coffee was ordered in the posh suburban tea-rooms and our eyes glowed with the joy of surviving a mad day out.

With the rain soon forgotten, talk turned to finding some more epic rides to do, and how jaded we were of the annualised Round Taupo, Round the Bay 'rinse and repeat' nature of our cycling. So when I picked up a cycling magazine in June and saw that Australian based Bikestyle Tours were accepting entries for the 2008 Etape de Tour I threw caution to the wind and laid down the credit card immediately for 2 entries.

To my amazement I was emailed back with the news I was first in the queue, and that while official entry forms would not be released until December, I was assured of participation.

I gingerly phoned Dave.

The psychic connection had already been at work - he was absolutely committed. With a a scientific power based training program developed by our mate Smiley from his company Performance Labs HC in California aimed at the NZ National Age Group road title, he would be well prepared for a mere 165km around the Pyrenees in a year or so.

That gave me the jitters somewhat, as I had nothing like that planned as a training regime. My planning centred around a new bike and a triple crankset!

Entry forms finally arrived before Christmas, with a submission deadline in March 2009. My training started in earnest with the Victorian summer, even managing a few hill rides including a trip back to the Dandenongs with Kleppie where he introduced me to the dreaded Inverness climb to the top of Mount Dandenong. Horrible as it was, I rode the whole way and was rapt.

Christmas in NZ, a trip to the UK and USA for work, the start to the new 2008 year was busy. I wasn't stressed about training, which was planned to begin in earnest on return from overseas. The other complex details of planning a trip to a foreign country to race bikes were falling into place with alarming efficiency. Bike riding buddy Glen had a lifelong mate Jay who lived only an hour from the race start in Pau, providing the opportunity to turn this into a multi-family holiday in a beautiful part of the world.

In the following weeks I rode an early morning speed trial from Melbourne to Flinders in the hot Victorian winds, and when farm-staying near Alexandra in late February completed an epic ride through the hilltops of Eildon climbing relentlessly all morning.

All of this, with no knowledge of the ticking time-bomb in my chest.

Dave and I had joked about the entry form and the pain in the ass requirement for a medical sign-off. "Too many fat Englishmen having heart attacks on the climbs" we laughed. Dave was slightly worried he would be prejudiced by his Type 1 Diabetes, but since cycling was part of the management of that, and his race results were exemplary, we figured there would be no hurdle to getting a GP's signature in the box.

The key phrase was 'fit to take part in cycling races'. Huh, it was an insult to us.


Finally, on February 25, 2008, with the deadline for submission of the entry form looming, I booked a session with the local GP at the Albert Park Medical Centre to get my form signed. Having not seen a doctor for more than a dozen years, enjoying fantastic health and racing bikes all that time, I was slightly nervous but accepting of the need to follow the process. I needed this box signing!

John, having recognised me as the sort of bloke who would probably happily avoid doctors for another 12 years, booked me in for a set of standard blood tests, stamped the form, then putting it (unsigned) on his desk came round to check my blood pressure.

My blood pressure was weird. 165/60. He checked again. "Probably nothing" he reassured, "but since you're over 40, and seem so averse to visiting we people of the medical profession, I'm sending you for a stress test with one of the best people I know up at Epworth".

My heart sank. How was I possibly going to make the March 15 deadline for posting the entry form if I had to undergo that bloody bureaucracy? It could be a waiting list of weeks - this isn't just any old bike race, we were dead lucky to get entries, it's the easiest the course has been in years, and everything is worked out for the trip!

I rang the Victorian Heart Centre at Epworth immediately, begging for an early test date. Best they could fit me in was Wednesday March 12th, in the afternoon. Weeks away!

That afternoon, I emailed Natalie at Bikestyle with the following message:

Dear Natalie,

Just a quick note to let you know not to panic that my entry form hasn't reached you yet.

Training is proceeding well, but my doctor has decided I should do a Treadmill Stress Test, for which the vacancy is 12 March. I'll turn the results around in time to get them to you for the 15th.

Talk about fussy - this more than doubles the cost of entry! Doctors with Google on their office desk are a pain - a quick look at Etapes convinced him he needed his conscience covering.

Cheers

Natalie emailed back:

Thanks Nigel.

Its good to have an attentive Doctor.

Natalie

I spent the next few weeks stomping around moaning about 'bloody doctors' and the need to get my blood pressure down to ensure my entry went through. Kleppie kindly offered to sit the treadmill test for me, which given his gazelle physique and ability to climb the Dandenongs (and hoover donuts afterwards) seemed like a fine idea - but my conscience got the better of me.

Three little words in scrawly handwriting on the referral got the better of me too. "Possible systolic murmur". Googling it gave me a couple of momentary panics that something serious might be lurking, and that a regime of aspirins might ensue, but how bad could that be? A stressful job and a family history of heart disease pretty much assured me of some arterial tax to be paid in my life, but I was confident that at 44, my fitness and diet were serving me well.

When the 12th finally rolled around, I rode the KTM690 to Epworth and parked out front. Sitting in the waiting room for the ECG/Stress test filling in the forms, I surveyed my fellow outpatients. Not exactly the picture of health - some needing post-surgical ECGs, others clearly taxed by a lifetime of cigarettes and obesity.

I arrogantly wondered what the output record was on the treadmill test, and checked my diary as to what time I was due back in my next meeting back at Lonely Planet.

Continues in part 2.