Three reports from heart-care front lines

Tryphosa Pressley of Southwest Philadelphia places her hand over her heart, where an implanted defibrillator jolts her heart back to action when it seems to encounter problems.
Tryphosa Pressley of Southwest Philadelphia places her hand over her heart, where an implanted defibrillator jolts her heart back to action when it seems to encounter problems.
Posted: February 18, 2010

What does it feel like to be put into therapeutic hypothermia after your heart stops? To have a robot go to work on your beating heart? To be jolted out of heart trouble by a coin-size defibrillator that you wear just under your skin?

Here, three local patients share their stories.

Jim Nicholls:

After my heart stopped, they chilled my body to save my brain

For Jim Nicholls, 59, the morning of Dec. 21, 2009, began like any other. He awoke and started getting dressed for work as a facilities manager at Elsevier, a medical publishing company. The strange thing is, he doesn't remember any of it.

Nicholls' heart stopped beating that Monday morning in his Sicklerville, N.J. home.

Luckily, his wife, Ginny, and their 21-year-old daughter, Michelle, were around to call 911 and start CPR. Nicholls was brought to Virtua Health-Voorhees and quickly transferred to Cooper University Hospital.

There, he received therapeutic hypothermia, a relatively new treatment in which a patient's body temperature is rapidly cooled to 92 or 93 degrees Fahrenheit to reduce inflammation. The hope is to slow the brain damage that can be caused by a lack of oxygen after someone's heart stops.

Studies show that the cooldown increases the odds of a satisfying recovery after cardiac arrest, according to Stephen Trzeciak, a Cooper emergency medicine doctor who is doing clinical research on the technique. Patients stand a better chance of resuming life at home as opposed to a nursing facility than those who do not undergo the treatment.

Patients who get therapeutic hypothermia are cooled for 24 hours and remain unconscious while a system called Arctic Sun circulates cold water through a set of cooling pads that wrap around their thighs and chest. After the treatment, patients gradually warm up and regain consciousness - some, like Nicholls, with a short memory gap of events just before and after their hearts stopped.

Jim and Ginny Nicholls describe his cardiac arrest and big chill: "He got up for work. He got dressed," recalls Ginny Nicholls, 51. "He bent over to get his shoes. He said he felt a little pain, but it was going away. Then he was sitting at the kitchen table, and he started shaking. I was talking to him, and he was out. . . . My daughter called 911."

Within minutes, an ambulance arrived and took Jim Nicholls to Virtua, where he was stabilized and quickly transferred to Cooper.

Ginny Nicholls didn't see her husband for the rest of that first day because doctors were so busy running tests and treating him. By the time the family reunited the next day, he was in the middle of the therapeutic hypothermia.

"It was scary, kind of," she says. He was paralyzed by medicine administered to keep him still "because Einstein (her husband) kept trying to pull the [breathing] tube out of his mouth."

"He was cool to the touch, not ice-cold. I would say like taking the gallon of milk out of a refrigerator."

After 24 hours of hypothermia, it took Jim Nicholls 12 hours to slowly warm up and wake up. The medical staff had warned Ginny that Jim might come out it acting differently from his usual self, which can happen after being sedated, although it is not a hallmark of the hypothermia treatment.

"He was extremely nasty," she says. "He kicked me in the stomach a few times. A nurse tried to give him medicine, and he punched her. And that's not him. . . . He pulled out the IVs even though he was restrained."

"I'm magical that way," Jim Nicholls says now. He says he doesn't remember anything about the hypothermia treatment, including the way he acted just after awakening.

After two or three days, the hostile behavior subsided, and his speech, which had been slurred, became clear. He was exhausted, though, and had difficulty remembering much from the previous week or two.

He still has some memory gaps. Besides having no recollection of his heart attack, he doesn't remember the blizzard from the weekend before or the company holiday party he attended the previous Friday.

Other than that, his short-term memory is fine, and his long-term memory hasn't suffered at all.

"If you're gonna forget stuff, this is the stuff to forget," Ginny Nicholls says of December's traumas. "Not the important stuff, like family."

Jim Nicholls remained in the hospital until Jan. 4, two weeks after his cardiac arrest. While he was there, doctors implanted a defibrillator, which monitors his heart rate and will shock him if his heart begins beating at a dangerously abnormal rate. He also takes medication to control the abnormal heart rhythm that doctors believe caused his cardiac arrest.

When he returned home, he had difficulty with routine tasks. For a short time, everything he typed was gibberish.

"I was back to fairly normal," says Jim Nicholls. "But I was having trouble with simple tasks, like puzzles. I'm having a slightly easier time with them now."

"He couldn't concentrate or get interested in things at first, like reading," adds Ginny Nicholls. "Now, he's reading a little bit more."

Jim Nicholls is starting cardiac rehabilitation to build up his physical strength. His insurance will pay for the rehab.

But the events of Dec. 21 haven't just left him tired. He says he's been shaken by thoughts of what could have happened if things had gone differently after his heart stopped.

"I've been very emotional. More emotional than ever. I think about things and get teary-eyed," he says, especially when it comes to his family. Besides Michelle, he has two other grown children and a granddaughter.

Jim's cardiac arrest has also left Ginny Nicholls scared. It hasn't been long since that Monday morning, and she remembers every detail.

"I don't sleep at night because I listen to make sure he doesn't need me," she says. "The Friday after he came home, I called the ambulance because he had chest pains. I made them take him to the hospital. All they could find was that it was indigestion.

"This, too, will stop," she says of her fears. "It's only been a month."

Lt. James 'Pete' Fraley:

A robot was the copilot on my bypass

James "Pete" Fraley, a 49-year-old lieutenant in the criminal division of the Delaware State Police, had been told by his doctor that his cholesterol was getting high. His birth father had died at 52 of a heart attack. But Fraley discounted his own risks for heart disease until August, when some chest pain while he was running convinced him something was wrong.

Tests showed that Fraley had a blockage in his left anterior descending artery - the type of clog known as a "widowmaker" - and in two branch arteries.

Because of the location, a stent wouldn't work: Fraley would need bypass surgery. His surgeon said he was a candidate for a robotic approach called MIDCAB that could be done without putting Fraley on a heart-lung machine, and might spare him the cracked breastbone and foot-long incision that traditional bypass surgery entails.

The doctor, Lankenau Hospital's Francis Sutter, wouldn't know for certain until he got inside. But if all went well, Fraley's heart would remain beating throughout the procedure while two robot arms - guided by Sutter's hand movements - slipped into two small incisions to reroute his blood flow around the blockages. The robot's arms, about as wide as a pinkie finger, work with greater precision than a person can, Sutter says. A small camera inserted into a third 11/2-inch incision would let him see inside to guide the surgery.

Preliminary data on the robotic approach, first performed in 2002, show that it seems to help patients recover faster and with fewer complications than a standard bypass operation. The American Heart Association considers it a promising option but has not endorsed it, saying the short- and long-term benefits need to be studied further.

Fraley recounts how it went for him:

"Ever since high school, I've run and kept in shape. I've never smoked. I have a drink on average once a year. I run three or four times a week. To be quite honest, it was almost like a joke. If we go to Texas Roadhouse, I always ordered chicken. I thought I was doing everything right."

Then heredity and the elevated cholesterol "got me," he says. "I was running and got this discomfort in my chest. I didn't know what it was. I stopped running, and it went away." But every time Fraley tried to run, the pain came back.

A cardiologist at Milford Memorial Hospital, near his home in Houston, Del., did a diagnostic EKG, then referred him to Sutter. When they met, the surgeon described the robotic approach and drew a picture of his heart to illustrate, showing him how small the incisions would be.

With Sutter at the controls, Fraley had no concern that robotic arms would be operating on his beating heart. "I would have done it that day," he says. "To be quite honest with you, I wasn't nervous at all. I wanted to get it done and move on."

Within days, he was in the operating room and Sutter was set to start the early-morning surgery. "He told me, 'If this doesn't work, we are going to crack your chest open.' I asked how I would know it worked. He said, 'When you come to, if you don't have a big scar running down your chest, you'll know it worked.' "

It worked. After the surgery, Fraley spent two days recovering in the hospital. "They had me sitting up within six hours, and they had me walking within eight. I certainly wasn't turning cartwheels," he says, but the pain was "nothing that was unbearable."

"The first couple of days, you're tired. There's more discomfort on the left side" of the chest, he says. His biggest complaint was nausea from some pain medication. On his discharge day, "I carried my bag myself."

Not one to lie around recuperating, "I was up walking in the neighborhood the next day," Fraley says. "Within a week, I was doing two laps around my neighborhood, a mile. Within two weeks, I was back on the treadmill.

"I can't sit still. That's just me," he says. Before three weeks had passed, "I built an addition to my shed."

"The only thing about the first week at home was when I slept, you could feel things weren't where they should be inside. After three or four days, it went away. The insides just felt a little bit different. But it wasn't anything that certainly anyone can't survive."

On a follow-up visit, Sutter "gave me the blessing to return to work," Fraley says, and he was back on the job full-time just four weeks after the surgery. "To be honest with you, I felt ready at three weeks."

As a lieutenant in the criminal division, his job is mostly administrative. He oversees five crime subdivisions and 25 detectives who investigate everything from thefts to homicides. "I only spend about 10 to 20 percent [of my time] really out in the field," he says. "I go look for a bad guy about once a week."

His lingering fear was that the pain he had felt while running would return. "I was a little nervous," Fraley says. "Before I came back to work, I had a stress test. I ran and I ran, and I never felt it."

Today, he says, the only reminders of his surgery are the three small scars from his incisions, the largest of which is two inches long. "I see them in the shower, but they're just there," he says. "That's it. I'm very lucky to have the procedure I did.

"My family doc was talking to me about it, and he looked at my scars twice and said, 'I can't believe they can do that these days.' "

Fraley now takes medicines to control his cholesterol and blood pressure, plus fish oil and a daily low-dose aspirin. A follow-up EKG last month was normal.

His 50th birthday is coming up in May, and he's been reflecting on that milestone. "If I hadn't had this procedure, I really think I would have dropped dead like my father," he says. "I knew, if I didn't do something, my days would have been numbered.

"I told my wife now she has to put up with me for another 50 years."

Tryphosa Pressley:

My body has a defibrillator on board

Tryphosa Pressley, 57, knew something was wrong when she started feeling out of breath 10 years ago.

"I was so short of breath, I thought I was dying. I couldn't walk from the car lot to where I was working," says the Southwest Philadelphia resident, who worked as a lab assistant at Lankenau for 25 years.

Initially, her doctor thought she had bronchitis, but it turned out that her heart was filled with fluid. She was suffering from congestive heart failure.

Pressley began seeing Howard Eisen, first at Temple University Hospital and more recently at Hahnemann University Hospital. Medicines he prescribed helped for a while, but her condition worsened and Eisen suggested a defibrillator - not to hang on the wall of her home, but to be implanted under her skin near her heart.

Doctors implant defibrillators for patients whose heart problems can cause potentially deadly heart rhythms. Congestive heart failure is one such condition. Patients with significant heart damage from a heart attack and those who have suffered cardiac arrest often get one.

The devices monitor heart rhythm, Eisen says. If a patient's heart begins beating too rapidly, the defibrillator will try to "pace" it back to a normal rhythm, as a pacemaker does, with a gentle electrical correction. If that doesn't work, it will shock the heart back to a normal rhythm with a bigger jolt.

Similarly, if a person suffers a cardiac arrest and the heart stops beating, the defibrillator shocks it back to life.

When internal defibrillators debuted in the 1980s, they were the size of soup cans and were surgically implanted inside the chest cavity, says Eisen. But they've shrunk considerably and are now flat disks a little larger a half-dollar coin.

Pressley was initially resistant to the idea of getting one. "I just didn't want to walk around with something in my chest," she says. But Eisen told her she'd feel better if she got it.

She doesn't remember much about the implant procedure. "I was in a twilight zone," she says. On the other hand, "I will never forget that date: July 11, 2006."

Three months later, Pressley's defibrillator kicked into action for the first time - and not with a gentle buzz like a cell phone set on vibrate. "It almost lifted me off my feet," she says.

"I was watching David Letterman. I got really dizzy," she says. "I called my son. By that time, it had fired. It almost knocked me down."

It fired three times before an ambulance came.

Doctors and nurses had told Pressley that she would have 24 hours to get to a hospital after her defibrillator fired, but she wasn't one to wait. "Not me," she said. "I called 911. . . .. When I got to the ER, they told me the defibrillator saved my life. They reset [it] and watched me for a few days."

Since then, Pressley's defibrillator has fired on several other occasions, once so powerfully that it knocked her down a flight of stairs.

She can usually sense that something is wrong before a shock comes, but the jolt is still off-putting, she says. "It's a feeling you wouldn't want."

On the other hand, her defibrillator "has actually saved my life," she says. "I don't think I would be here without it."

"I'm a believer," she says, and she recently made a convert of her cousin, whose doctor had recommended one for him. "He didn't want one. I was able to tell him, 'Go ahead and get it. You walk around with a lifesaver.' It puts me at ease knowing that I have it."

Usually, she doesn't notice that the device is there. "I don't feel it unless I touch it," she says.

Even with the defibrillator, Pressley struggles with her heart condition. Her doctors tell her that her heart is operating at only 5 or 10 percent of a normal heart's capacity. She spends much of her time in and out of the hospital, often because of the fluid buildup associated with her disease, and needs intravenous medication 24 hours a day. She sees her doctor every two weeks, and nurses visit her at home.

On disability leave from her job at Lankenau, she combats loneliness and boredom by running errands, volunteering at her church, and attending Bible-study groups. "I have to go outside at least once a day somewhere," she says.

"At first it was hard for me not going to work," Pressley says. "I do miss the people." She spends time with her son, 35; her daughter, 29; and her two granddaughters.

On Jan. 7, her name was added to the list of patients waiting for a heart transplant. Besides the defibrillator, she now wears a beeper in case a heart becomes available.

Patients with successful heart transplants can lead normal lives, says Eisen, who has seen his own patients return to work, give birth to children, and run marathons.

"They told me I'll have a new lease on life," Pressley says. "I was thinking I could go back to work."

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