Saturday, May 2, 2009

ID, Please...

(NB: this posting has gotten corrupted and I've tried to salvage it a few times. Consequently the formatting is off. Hopefully, though, the wit and charm is on. Way on.)

The broad strokes of prognosis and intervention for an infected pacemaker are: extract the contaminated pacemaker and all its attendant wires; implant a temporary, external pacemaker while continuing to attack the infection with IV antibiotics; then within a week or two, and ideally with a completely sterile field, implant the new, permanent pacemaker. I don't know what the technical term for this series of procedures is, but when all goes smoothly, it looks like this:
The second jumper cable can actually be affixed anywhere on the body, but the nipple provides an extra tingling sensation. In some extreme cases, the cable is affixed to the genitals, earning the nickname "The Junk Buzzer."

This, of course, is assuming no complications. I refer back to the sage words of my favorite college history professor, 
Roger Lane. On the first day of Western Civ, he outlined his many Lane's Laws of History. Lane's First Law of History: Things Are Complicated. Indeed, Life is complicated. Let's talk about complications.
Pop philosopher Avril Lavigne has mused extensively on the nature of complications in her classic ballad "Sk8r Boi."

First are the predictable complications. Extracting pacemaker wires, or "leads," percutaneously (through an incision in the skin) can sometimes be difficult, depending on the degree of endothelization (how much scar tissue has grown over them). If possible, a 
laser lead extractionis performed, using an excimer sheath to burn the scar tissue off the leads.
Dr. Irving Cohen, Cleveland Clinic, performs a laser lead extraction.

Occasionally, however, the laser can't sever the scar tissue, and the leads must be removed surgically--with open-chest and potentially open-heart surgery. Or worse, extracting the leads, which sometimes requires 
violent pulling, can perforate a blood vessel or the heart itself, requiring emergent surgery.
Dr. Mola Ram, Pankot Palace Medical Center, performs his signature "Heart Burn" surgery.

These are certainly disquieting complications. But, as the old saying goes, "Complications love complany." An arguably more disconcerting complication is that there's some divergence of opinions between my cardiological team and my infectious disease (ID) team.
My cardiological and infectious disease teams discuss my treatment.

TEE (see "Prologue: the Beginning" for an anecdotal account) revealed conclusively that there is an infection, or "vegetation," on one of the pacemaker leads, and possibly on thetricuspid valve, through which the infected lead passes. (Subsequent blood cultures came back positive for coagulase-negative staphylococcus epidermis.)

The ID team feels a tricuspid-valve replacement--open-heart surgery--is therefore inevitable. The cardiological team, however, thinks the vegetation on the valve is minimal and the valve's function is unimpaired, which does not indicate valve-repair or -replacement surgery. It's odd that the bacteria people want to operate on my heart, and the heart people want to use antibiotics.

An interesting semantic point emerged, which I hope will be easily verifiable at some point--not that that would alter the objective facts of my infection or course of its treatment. One cardiologist told me that the TEE report said there was "possible" thickening of the valve, which could suggest vegetation, but could also merely be the result of years of the valve's rubbing against the lead that runs through it. This morning an ID doctor told me that the report said there was a "probable" infection. Maybe this distinction is not very illuminating after all, and I certainly hope the cardiologist's recall of the report is better than the ID doctor's. Still, I wonder to what extent physicians inductively read reports and charts and tests to confirm their own initial diagnoses. Here's to the scientific method!

Presumably the doctors will hash this out and come to a consensus, if albeit a reluctant and divisive one. Hoping that we start with the primary goal of a successful laser lead extraction, I know that I will be prepped for the open-heart contingency, and the procedure will be done in an OR with a full surgical team present and with me under general anesthesia. It's strange to think that it can go either way; that, whenever the extraction finally happens, one team will be proven right--while I'm unconscious and unable to either gloat or castigate.


Further complicating things is that my blood cultures are still coming back positive. This confounds my cardiologist a bit: he pointed out that, for almost a year now, my body has effectively and repeatedly fought this infection on its own. Certainly it should be able to do so in conjunction with powerful IV antibiotics. I'm not sure exactly what it will mean should my blood persist in testing positive. I suppose just that the pacemaker's still got to come out, and then the lingering infection, if any, still has to be blasted with antibiotics. Whatever else it means, it's already pushed the extraction back by a week--though I wouldn't be surprised to see this date continue to recede. It also guarantees me at least another 2 to 3 weeks in the hospital. A bit of a bummer, indeed.


Proponents of intelligent design (ID) argue that many bio-organisms are so complex, wondrous, and beautiful, that they could only have been engineered by a powerful sentient being. Like spiders,

The strength and structure of spiders' webs have long been seen as signs of divine design.

Or Hugh Jackman,

Hugh Jackman's Aussie hunkaliciousness isn't the only clue that he was smartly architected--he's also a devoted husband and father. Take that, evolution! 

Or the blind naked mole rat,

No, this is not a potato sculpture. Intelligent Designer, meet your handiwork, the blind naked mole rat. Note, not a photo of the author.

Some people like intelligent design.

Supporters of ID believe an intelligent, sentient being created humans in the act of performing a conga line.

Some people don't like intelligent design.

Atheists futilely throw their utensils at Dr. Manhattan--one prevalent theory for the personification of the intelligent designer. Too bad he didn't design himself some briefs. Jeez


But what happens when the complexity, wonder, and beauty of Life are corrupted or defective? Are the flaws by design as well? And, if so, wherein could the intelligence possibly lie? We can't all be spiders and Hugh Jackman. Some of us are blind naked mole rats. (I swear that's not a photo of me.)

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