Parashat VaYishlah – When Brothers Meet Again

In 27 March 2019, my younger brother, Stan, passed away. Just over twenty years ago, on 11 May 1999, my older brother, Al, died after a traumatic illness, a blastoma that riddled his brain and soon enough his mind; he died a horrific dragged out death. We were one year apart in age and spent high school together in the same grade, though only sporadically in the same form room. We walked to school together. We walked home together. We played basketball together. We sold ribbons at football games together at Varsity Stadium. We scalped tickets together at Maple Leaf Gardens hockey nights in Canada. And I delivered the papers on his paper route so he could be a star on our football team. And we played hooky together – hooky, not hockey. I never did learn to skate properly. When I was sixteen and he was seventeen, we had saved enough money to buy my mother, a single mom, a house on Ranee Avenue in Toronto. We did all this and more together.

But I got into trouble all on my own. And so did he. Al’s blastoma was probably the result of radiation leaking from the machine which he used for performing angiograms. A doctor from Western Hospital and a nurse working in the same lab also died, both of a blastoma, a very virulent and incurable form of brain cancer. He was a highly regarded cardiologist who had introduced angiograms and angioplasties into Canada. The procedure has saved many lives. Twice at least I watched him do the procedure. He was so fast that I was sure that he would kill the patient. He never did.  

My illness is the result of my own neglect and my own mistreatment of my body. I cannot blame it on a machine. I do not exercise. I do not even walk vigorously around the block. I do walk up and down the stairs in our home. I do walk back and forth to either the bus stop, two blocks to the west, or the subway stop, two blocks to the north. I was and remain the bookman. Al was always the sportsman.

This morning, I am going in to have my own angiogram, and an angioplasty if necessary. For those unfamiliar with the procedure, an angiogram is a diagnostic X-ray and is the gold standard for evaluating blockages in the arterial system serving the heart, providing that organ with the oxygen and the nutrients to keep that pump working every second and every minute and every day, month after month and year after year. Earlier in this week, I had a nuclear procedure to try to detect a blockage. The results were inconclusive.

An angiogram detects blockages using X-rays taken during the injection of a contrast agent (iodine dye). If a blockage is found, then an angioplasty can be used as part of the same procedure to clear the blockage and restore blood flow through the coronary arteries. In both procedures carried out in a hospital, the doctor threads a thin tube through a blood vessel, usually an artery in the arm and/or a vein in the groin, up and through the targeted artery or vein. Tens of thousands of lives in Canada have been saved by these two procedures which together are both diagnostic and therapeutic.

A doctor whom Al had trained and who gave Al’s eulogy at his funeral will be doing the job. The procedure will take place at the Western Hospital rather than the General where Al used the facilities for his practice. I would not care for the latter – too much memory. My procedure will take an estimated 35-40 minutes, the norm for both an angiogram and an angioplasty. (Al used to do the two procedures in 15 minutes. It was unbelievable watching him – the grace, the speed.)

I had the strong premonition that I will be meeting Esau – I mean Al – at the end of yesterday. Then, I woke at 2:00 a.m. with that conviction. I went back to bed at 4:00 a.m. I woke again at 5:00 a.m. A vivid, so vivid, dream woke me up. At one point in the dream, I was masturbating on the floor of the living room and looked up to see the room full of relatives and friends, some of whom I had not seen for decades. Exhausted, I went upstairs to bed and lay down. I woke because someone was lying next to me and kissing me. It was not my wife, Nancy. She was on the other side of this figure. Suddenly, I recognized the voice of my fourth child. And on the other side of my wife, there was another person in the bed. It was my fifth child, Daniel. Were my other children in the same bed?

I woke up to shake away the dream. My god, I hate dreaming. There was no one in bed but my wife. It was 5:00 a.m., too early to go to the hospital. I fell asleep at my desk writing this. It is now 7:05 a.m. and I am due at the hospital at 8:00 a.m. I quickly got dressed in a track suit to make the change into a hospital gown more convenient.  I am leaving now for my meeting with Esau. I have the strongest premonition that I am going to meet Al.

The Next Morning

It is 3:23 a.m. When I got home from the hospital in the late afternoon yesterday, I ate – I was famished – and I went to bed at 6:25 p.m. I was totally exhausted. Now I am sitting at my desk again, only this time with my right arm in sling. I was told not to use a computer as my right hand could not be bent at the wrist for 24 hours. I try very awkwardly to write this with one finger on my left hand. I am a righty and normally type pretty quickly with two fingers. In this one paragraph, I have already made a plethora of mechanical mistakes which I have had to correct. I will get faster and better with practice.

What happened yesterday? Before I tell you, let me go back about 4 decades ago. The first angioplasty had been performed successfully in San Francisco in 1977. Catheters have been used for five millennia to open pipes in the body, beginning with the Egyptians. About two-and-a-half millennia ago, the procedure was used by the Egyptians on the heart – then on cadavers to establish how the blood circulation system worked in general, and, more particularly, how the heart and its valves operated as a pump.

Under the sway of the dogmatic scholastics in thrall to the Greek philosopher Aristotle, established medicine claimed that the blood in the body operated on an ebb and flow system, contrary to the empirical conclusions of the Egyptians. Up until the Enlightenment, only four centuries ago, Europeans, including Jews and Christians, continued to practice medicine under the totally misleading intellectual frame of a balance of “humours” (black bile, yellow bile, blood, and phlegm) and an ebb and flow blood system.

Galen (Aelius Galenus), a Greek physician and philosopher of the second century B.C., dominated Western medicine for short of two millennia. He at least tried to practice empirical medicine, but he was never permitted to dissect the human body. His treatise was called, The Best Physician is Always a Philosopher. In spite of Galen’s enormously useful work, particularly in taxonomy, I have argued that philosophy can be very detrimental to medical practice, but that philosophers have much to learn from empirical medicine. My own creative work on the logic of discovery depended on work I did using my brother’s research on cardiomyopathy.

Thank God for William Harvey at the beginning of the Enlightenment in the seventeenth century. He was inspired by Middle Eastern medical practitioners in the thirteenth century (such as Ibn Al-Nafis) and other Europeans who came after. Though not the discoverer of the circulatory system, he was the first to correctly describe the circulation of blood in the body showing that arteries and veins provided a complete circuit with the heart and its contractions at the centre serving as a pump.

But it took until ninety years ago for a German physician, Werner Forssmann, who became a Nazi in WWII, to eventually and deservedly win a Nobel Prize for his innovative work in performing an arterial catheterization. This took place only after being branded as crazy. He was initially fired and driven out of cardiology by the mindblindness of the German medical establishment.

Two years after the Nobel Prize, in 1958, when I and Al were beginning our second year of medical training and I was living in Mount Sinai Hospital, Dr. Mason Sones, an American army vet, introduced diagnostic recovery angiograms. He, along with Drs. Dotter and Judkins, all pioneers in the field, died tragically in 1985. That same year, perhaps the most important innovator of them all, Andreas Grűntzig, died in a plane crash as he travelled incessantly to spread the word and the skills of this marvellous new technique that he had developed in Zurich. By then, Al had established his lab at Toronto General Hospital. As a cardiologist, he had flown to California to master the new, improved revolutionary procedure of angiograms and angioplasty and then returned to Canada to introduce the procedure here.

I am just boasting about my knowledge of the history of medicine. More significantly, I am stalling. Let me return to yesterday.

What a different experience than when I watched Al perform the procedure in the eighties. Then, there were only four people in the room – Al, a radiologist, a nurse, a technician and myself. I watched what was going on but tried to stay out of the way. Everything from beginning to the end was over in a half hour. In contrast, I went into a pre-op room with perhaps thirty beds or more. There were countless nurses. I counted at least nine who had seen me over the course of the day.  Four had asked my name and birthday to confirm that they were dealing with the right patient. They asked if I had traveled in the last two weeks. Had I had a fever? Sniffles? Food that morning? And on and on.

One time, bored, I offered my brother’s name. This threw the nurse off course. My wife intervened and said that they had no time for my nonsense and feeble attempt at humour. They had other patients to take care of. I let them weigh me, take my height, review my medications and prepare me for surgery. In my left arm, one nurse came by and put in an intravenous supply. Another nurse came by and shaved my groin. Another nurse inserted a needle and a tube in my groin to have access to my veins. A different nurse also applied a local anaesthetic to my right wrist and seemed to insert an even larger needle and tube there. It may not have been larger, but it grew in size as I felt some pain and even more discomfort from the process. They did other things I believe, but bored with assembly line nursing, I went to sleep.  

Just before the doctor came in, I had woken up. He greeted my wife – “Long time since I have seen you.” He then turned to me and asked how I was. He then asked some of the questions the nurses had asked. When had I eaten last. When had I last taken a blood thinner pill? When had I last had a diuretic? He then outlined the procedure. I would get a mild sedative, much more for discomfort for it was highly unlikely that I would feel pain. But I would not be put to sleep.  

He described how and where the catheter would be inserted and to what parts of the heart it would visit. If an angioplasty was indicated, he would perform that as part of the procedure. He then warned me ominously that there was only a one in one thousand chance that I would come out of this medical intervention worse than I went in. He did not specify how much worse. He then asked me to read and sign the consent and release form. I signed it without bothering to read it just as I had with the two forms the nurses had given me earlier.

After five more minutes, I was then wheeled on my bed into the operating room and asked to slide over onto the operating table. They gave me a needle and began to hook me up. I promptly fell asleep.

The doctor had just finished when I woke up. He would come and talk with me after awhile in the recovery room – the same place where I had the pre-op preparation. I slid over onto my bed and the nurses wheeled me back into my alcove. I promptly went to sleep. When I awoke, they were once again taking my blood pressure, my temperature and other vital signs. Nothing untoward.

My wife returned. She arranged for some food, an egg sandwich on brown bread and a choice of orange or apple juice. I asked for both. My wife fed me and let me drink the juices through a straw. I was not permitted to move at all, but they did raise the bed so that, although I was still lying flat, I was propped up. Finally, after another brief sleep and a wait for over an hour, a nurse came in to get additional results – my blood pressure, my temperature, etc. I asked her to read me my complete chart and eventually get me a copy. She obliged.

Evidently, it is highly unusual to get your coronary arteriographic report. Mine showed that a 78 vein and a 59 sized arterial catheter had been used. The contrast had been 75. My heart valve reading seemed normal 120/80/95, no surprise since I do not have stenosis or regurgitation and no heart murmur. This had already been established by my echocardiogram. I have had no indication that rheumatoid arthritis had affected my heart and the chart confirmed that.  

The pulmonary artery pressure results were 42/20/29, a little towards the upper end I thought, but was not sure. I believed that it was not alarming. In any case, as I told the nurses many times when they repeatedly questioned me, I am not diabetic. I will have to check these results with my doctor next when I see him, but I did not remember to query him in the short period of time that he had for me after the operation. My pulmonary capillary wedge pressure (PCWP) gave a figure of 17 and I thought that less than 20 was a warning, but I really do not know and will have to ask. As well, I had a CO of 7.8 and a CL of 3.4.

The most interesting part was the picture of the heart itself. I showed irregular dominance in the upper right quadrant (the left side in a heart diagram) but no stenosis in the arteries or stent, other than the collapsed arteries in the bottom of the heart were the muscle is inoperative from a very old heart attack that I never knew I had. There was also lyreplasia in the frontal coronary artery where the stent had been put in; at least it was not hyperplasia.

The doctor summed it all up when he came in. He did not have to do an angioplasty because everything was clear. I was good to go. I would have to ask him my detailed questions another time. After about three hours in recovery, the nurses got me ready to leave. That was when problems emerged.

They warned me that for a week, I was to:

  • walk slowly
  • take it very easy going up stairs
  • not lift anything over 10 pounds
  • not do any exercise (wonderful advice for a guy like me)
  • have no hot baths.

I could drive a car after a day, but that was irrelevant since I don’t drive.  My doctor said I could fly in a week, welcome news since that is when we are flying to Vancouver Island to see our youngest two sons. Today – later – I can take the bandages off my groin and wrist, though I might have a lump on my wrist that would disappear by the end of two weeks at the latest.

Then there were all the warnings about what could go wrong. They were dire. However, nothing was said about what happened when they stood me up. I was woozy. I saw double. I could not walk around the room as requested. I do not even think that I took a full step. They quickly put me back to bed and said I had better rest for another hour. I promptly went to sleep.

When I woke up I was determined to get out of the hospital. I was still seeing double but only if both eyes were opened. If I kept my left eye closed, I was fine. I wasn’t sure whether I was or was not lying; I told the nurses that the double vision had happened before because the left eye had been blind for about 40 years. The nurses had started going home at the end of their day. I was getting desperate. I was a little wobbly walking, but got all the way around the room without help. We got a wheel chair and my wife went to get the car and then helped me get in. I walked very slowly into the house and even more slowly up the stairs. I had some soup and went to bed.

No dreams. I had seen the hands of my brother when I had my angiogram in the operating room. My older brother was so delighted to see me. He embraced me. He cried. And I lied. I said we would get together again. Soon. But I went home to another place. I knew that I would never see my brother again.

With the help of Alex Zisman

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