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May 25 2009

Pre-Transplant Testing, Lethal Injections and the “Truth in Advertising” Award

On Monday, May 18th, I completed several days of pre-transplant testing at the Medical College of Virginia (MCV) in Richmond, Virginia. There are essentially two purposes for this testing: (1) to determine if I am physically and mentally fit enough to endure the stresses I’ll undergo during and after the transplant, and (2) to establish baseline measures on a number of procedures so the transplant team will have a basis for identifying changes in my condition after the transplant. As diagnostic tests go, these were pretty routine: colonoscopy, liver ultrasound, nuclear stress test, pulmonary function test, chest x-ray, etc. There were also plenty of “interviews” with, for example, the social worker, financial counselor, psychologist, and transplant coordinator.

Other than some scheduling goof-ups, these tests were pretty uneventful, but I can’t miss the opportunity to share the delightful experience that is the Stress Test. This had been described in advance as a treadmill test, so I arrived with walking shoes, ready to hit the treadmill.  The transplant coordinator kept telling me how tired I was going to be after this test, but I dismissed that under the assumption that I was a little more fit than the typical stress test customer. This assumption was….what’s the word….uh, wrong.

During the typical stress test, the patient walks briskly and/or runs on a treadmill until their pulse reaches a predetermined rate. A nuclear dye is injected in order to illuminate the vessels of the heart which are scanned before and after exercise. Simple enough.

uglybuthonest

Complicating matters just slightly is the fact that the hepatology team prefers to have the stress “chemically induced” rather than created via some sort of strenuous effort like a brisk walk. I didn’t appreciate the impact that would have on the remainder of the day, but it was significant. It also explains why I give the Truth in Advertising award to the the accurately named Stress Test. It’s not a “Coronary Artery Test” or a “Treadmill Test”…it’s a Stress Test.

That should have told me something.

So, here’s the scene: I’m on a stretcher, a nurse is intently reviewing an electrocardiogram to my left, another nurse is on my right flicking a syringe of persantine (the chemical stressor), another nurse is by the door of the exam room (in case I make a run for it?), and a nurse practitioner is at my feet, armed with an antidote to the persantine in case things go poorly. They explain to me that after the persantine is administered, all of my blood vessels (let’s review…they said “ALL”) would dilate, causing my heart to beat faster, essentially creating an effect similar to vigorous exercise, especially if during exercise you are accustomed to your heart leaping from your chest and your eyeballs spinning in their sockets, in which case this is EXACTLY like exercise.  The nurse practitioner further adds that I might experience a headache, nausea, dizziness, and tightening across my chest.  She asks me to let them know if any of the symptoms become unbearable because, as she explains, “We don’t want your heart stopping.” I assured her I was onboard with the plan, especially the “heart-not-stopping part.” I was then instructed to “breathe normally.” Right.

So in goes the persantine injection, and everyone in the room immediately looks at their watches. Now, to me it seemed awfully premature to be recording the time of death but, given the description of the various risks and side effects that I might experience, not beyond the realm of possibility. As it turns out, the persantine’s effectiveness peaks at 2 minutes and 45 seconds after the injection, so they were all bracing for the precise moment when my chest might detonate. I have to admit that the initial impact of the injection was not altogether unpleasant, and I just felt a little flush. After that, though, the whoosh of blood through your body becomes increasingly louder, to the point that I felt as though it must have been audible to those around me. I thought a little chit-chat might help lighten the mood, but immediately discovered that “casual” was not a mood I could evoke with clinched fists and tightened jaw. I had overheard the nurse practitioner talking about her dog earlier, so I asked, “What kind of dog do you have?” At least that was the question that I expected to ask, but what came out of my mouth was a series of high-pitched squeaks and hisses that must have resembled panic more than curiousity, causing the nurse practitioner to lean forward intently in her chair. I quickly replayed the odd sound in my head, hoping to confirm that I hadn’t said anything that might have been misinterpreted as, “Please jab the antidote into my sternum.” Scrambling for a non-verbal solution, I gave everyone a quick, strained smile, and they each resumed their at-ease postures.

Well, I survived the test, apparently with flying colors, and was escorted back to the waiting area to enjoy my spent heart and nuclear headache. The nurse who brought me out suggested that I get a coke since that would help reverse the symptoms and the discomfort. One might expect that since it was common knowledge that a caffeinated drink would help expedite the recovery, the staff might have an ample supply of these on hand. One would only expect that if one hadn’t been to MCV before; these guys know as much about customer service as the Governor of South Carolina knows about hiking the Appalachian Trail.

As a quick aside, my favorite among MCV’s recently implemented customer service efforts is the WalMart-inspired “greeters” posted at the main hospital entrances.  I’m sure this idea looked great on paper, and I’ve actually seen it implemented effectively at other organizations, but MCV’s effort is enough to make you laugh. The greeters look as though they’ve been assigned to their post as a form of disciplinary action against them, or because they lost a bet. Most of them have a remarkable ability to avoid engaging patients and family members in any way possible, even if you stand 10 feet in front of them and look lost, which I have done in an effort to see if they could be baited into action. For the record, they can’t.

Anyway, back to my coke. At this point, it helps to understand that although the procedure is over, the blood vessel dilation is not, and that seems have a serious impact on a variety of functions: hearing, vision, stamina, balance, patience, speech, reasoning, etc. Essentially, any function requiring oxygen is impaired. So, while finding a coke sounds like an easily manageable task, to me it was an Epic Journey. I stumbled from the waiting room, with each step creating mini seismic events through my head, only to discover that three of the four elevators to the first floor were out-of-order, and the fourth was behind a long line of grim-faced patients and their families. It seemed noteworthy to me that no one else was as agitated as I was by the delayed trip to the first floor, so I opted for the stairs. Anyone who knows me well knows that I typically take the stairs if: (a) the building is on fire, or (b) I have been shoved. But in this case it was my only realistic alternative to the elevator. I finally made it to the ground level, found the machine (“Exact Change Only” of course…started feeling like I was being tested) and sat wild-eyed on the floor next to a trash can (no joke) restoring my blood vessels to their appropriately constricted state, one sip-at-a-time. Within a matter of mere minutes (if by “mere” you mean “just over 300”) I felt fine, fully restored.

This is a test I hope to not soon repeat. In fact, fear of a repeat performance of the Stress Test is enough to make me promise to choose from the Heart Healthy items on the menu next time I go out to eat.

2 comments

  1. Becca

    I had my first stress test ever yesterday. All part of my 1-year-on-the-transplant-list checkup. They had to give me atavan (I think) in addition to the other stuff because my heart rate was going no where. In fact, it was dropping. What happened was I had what I thought wa a seizure and started screaming. In all seriousness I can say that it is the worst pain I’ve had in my life. I was pretty damn sure I was going to die. After copious amounts of Imatrex and hydromorphone I can sorta move my head today. Ugh. I don’t think I’ll be having a stress test again. Ever.

  2. Lennie

    Thank you for your accurate account of the stress test. All I have been told about it is it is not fun. So thanks for prepairing me. I had a heart transplant in Nov of 2009 and have a dobutamine stress test at my annual.

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