The dance isn't typical by any stretch, but Opal Farmer still dressed for the occasion.
Wearing a gown picked just for the affair, the 87-year-old woman couldn't be more prepared for what is about to happen. Every detail is taken care of, right down to the festive red that colors her toenails.
All around her, people bustle about, preparing this or tending to that. Throughout, Mrs. Farmer smiles and warmly greets each one. They pat her, talk to her and encourage her. And when Mrs. Farmer finally begins to get sleepy, their pace quickens.
It isn't a typical dance at all, but it is a very important dance — one where every movement will count, where an off-beat step at the wrong time could even be fatal.
Scrub nurse Kathy Ingram reassures Opal Farmer before the 87-year-old woman undergoes off-pump coronary bypass (OPCAB) surgery. In the background, Bill McCaughan, anesthesiology technician, and Eloy Acosta, surgery tech, ready the operating room.
Opal Farmer is about to undergo off-pump coronary artery bypass (OPCAB), or "beating heart" surgery — a much-practiced dance that will not only extend her life, but improve the quality of that life.
"If everything goes right, it will just seem like a well-rehearsed dance," scrub nurse Kathy Ingram says before entering the cardiovascular operating room at Shannon Medical Center.
"It's a lot like a dance," says Dr. Ross McClellan, anesthesiologist. "You have to know what your partner is doing."
Thirty minutes before surgery, Opal Farmer is in her hospital room, waiting patiently for the big , event. Inside the OR, though, technicians and nurses are busy. A perfusionist — a blood-flow specialist — prepares the heart-lung machine that is used in standard bypass surgery but is on standby for the OPCAB. With any luck, the punip will sit to the side and remain unused.
Off-pump bypass surgery has been performed for many years, but until recently, it was limited to select arteries on the front side of the heart. With advances in technology and surgical instruments, surgeons now can reach multiple arteries located anywhere on the heart.
About 20 percent of the bypasses surgeons Staton Awtrey and Ralph Paone perform are off-pump. The rest are standard coronary artery bypasses that require the use of the heart-lung machine to stop the patient's heart and lungs during the portion of the operation when the surgeon sews the bypasses to the coronary arteries.
Mrs. Farmer needs one bypass on the front side of the heart — a "chip shot," Awtrey says later.
With the operating room ready, Mrs. Farmer is brought in on a gurney. She coughs a little and then smiles.
"You are going to take that cough out, too. Right?" she teases nurse Ingrain, who is inserting an arterial line in the woman's left arm. The line will measure Mrs. Farmer's blood pressure, heart rate and central venous pressure throughout the surgery.
Teasing comes easy to the elderly woman. Over the last few days, doctors have told Mrs. Farmer enough about coronary artery bypasses and the OPCAB, in particular, that she's comfortable with the decision. Just a few days before, Mrs. Farmer never would have dreamed she would undergo surgery. Heart disease didn't run in her family and until a year ago, Mrs. Farmer herself had suffered from very few illnesses.
Not long ago, though, she began having chest pains while doing strength training at a local health club.
"I am known to ignore pain, but one day I decided to look into it," she says. "... The pain got to be too much for me."
Mrs. Farmer went to her doctor and took an exercise stress test. Afterward, she was laying on a gurney, awaiting a thallium stress test that tells how well blood flows into the heart, when the doctor spoke to her.
While waiting to do the second part, the doctor a said. 'You will never get through this part because you're having a heart attack right now,'" she recalls. "If you've got to have one, it's good to have a heart attack under the doctor's nose because I came out without heart damage. When I say without heart damage, (I mean) I still have a healthy heart, but it did have a problem functioning."
Mrs. Farmer first tried using medications to help her heart, but they didn't help much.
"It became apparent that if I had any interest in living a healthy life, it would mean bypass surgery," she says.
With preparations seemingly almost finished and word that Awtrey has arrived in the hospital, McClellan begins anesthetizing Mrs. Farmer. He gives her oxygen to relax her and then administers a quick-onset general anesthesia.
"How are you doing?" McClellan gently asks Mrs. Farmer. "Are you getting sleepy?"
She nods, barely.
"I'll bet you are," he says. "We're gonna' take good care of you."
Then, the real preparations begin. Once Mrs. Farmer is asleep, Ingram and the techs apply iodine over her entire body. If the mammary artery isn't good enough or it turns out Mrs. Farmer will need more than one bypass, Awtrey and his partner, Dr. Ralph Paone, will use a vein from the calves of her legs. McClellan inserts a catheter into her heart.
On the other side of a window, Awtrey scrubs and then enters the room.
With festive Tejano music playing quietly in the background, Awtrey picks up a scalpel and cuts through the flesh of Mrs. Farmer's chest. Once he reaches her sternum, Awtrey uses a small power saw to "crack" her chest. He takes about three seconds to cut through the bone and reach Mrs. Farmer's chest cavity. He then begins the process of harvesting the left internal mammary artery.
A steel retractor opens the chest several inches, and an assistant stands nearby, suctioning the blood that flows into the cavity.
Staton Awtrey, M.D., prepares to harvest Opal Farmer's mammary artery as he performs a coronary artery bypass. Assisting Awtrey are Rueben Reyes (left) and Eloy Acosta.
Meticulously, Awtrey alternates between removing the artery from the chest wall and cauterizing the area around it to reduce bleeding. Irrigation and suctioning equipment along with surgical sponges are used to keep the line of sight clear as the surgeon calmly picks the artery away.
With enough of the mammary artery brought down, the thin, whitish vessel is clamped. And Paone and Awtrey begin the job of grafting — attaching the harvested artery — to a heart that still is beating.
The retractor that has been keeping Mrs. Farmer's chest wide open is replaced with a new retractor, one that narrows the opening and focuses on the Mrs. Farmer's beating heart. The system uses compression to immobilize the vessel.
Awtrey lifts up Mrs. Farmer's heart prior to performing the bypass.
Awtrey carefully cuts through the pericardium, the sac that encases the heart, keeping it both safe and lubricated. The heart pumps very vigorously, and a casual observer would never guess anything is wrong. But Mrs. Farmer's left anterior descending coronary artery is blocked, and Awtrey's job is to bypass that, to detour around the blockage and keep the woman as healthy as possible.
A tiny stabilizer is positioned on the retractor to depress the area of the heart Awtrey will graft onto. Despite the pulsating all around, the tiny portion becomes motionless. Wearing a loupe that magnifies 3 1/2 times, Awtrey gently makes a tiny incision in the left anterior descending coronary artery and inserts a shunt to allow blood flow downstream throughout the rest of the procedure. Magnification is important because the arteries measure only 1 to 3 millimeters in diameter.
Occasionally, Awtrey asks McClellan, stationed at Mrs. Farmer's head, to raise or lower the table, to tilt it slightly from one side to the other to improve both his access and visibility.
Then, Awtrey begins the painstaking process of stitching the open end of the mammary artery to to its new home below the blockage in the coronary artery.
During the OPCAB, McClellan serves a more active role than he typically does in standard bypass surgery. McClellan and anesthesiology tech Bill McCaughan are hard at work, monitoring every possible indicator of how Mrs. Farmer is doing.
Eloy Acosta works near surgical equipment while surgery wraps up behind him.
As surgery proceeds, the Tejano music is a little too busy for the delicate work taking place. A change is needed, Awtrey says, and soon the soothing sounds of Miles Davis provide background for the task, which utilizes thread barely visible to the naked eye. Quietly, steadily, Awtrey secures the new artery. Even before he finishes, the blood flow to Mrs. Farmer's heart is improved and her heart is beating more strongly.
It's been a little over an hour since Awtrey entered the room.
"And that's how we got to this point — I'm just lucky I guess," Opal Farmer says a few days after the surgery.
She looks well, sitting up and holding a heart-shaped pillow for when she coughs. The pillow bears the signatures of Awtrey and Paone, and on the left side, Awtrey has drawn a picture of the work the two surgeons did.
Several days after undergoing off-pump coronary artery bypass surgery, Opal Farmer talks about the operation. In the foreground, Mrs. Farmer holds a pillow autographed by her surgical team. Dr. Staton Awtrey, who performed the surgery, has drawn a picture of the bypass on the pillow.
S-T Photo by Thomas Butler
Mrs. Farmer was a good candidate for the surgery, Awtrey says later. Off-pump coronary artery bypass surgery isn't for everyone, but there "are certain circumstances where it is better than standard bypass," Paone says.
Mrs. Farmer's age combined with the location of the blockage made the surgery "technically simple," Awtrey explains. "It was less invasive, less of a stress on her body, on her organs."
Both off-pump and standard bypasses have the slight risk of stroke, but for people over 65, standard bypass surgery also includes a risk of measurable loss of cognitive ability. People who undergo OPCAB generally tend to recuperate a little faster, in many cases are off the respirator before leaving the OR and almost always leave the hospital a few days sooner. They also need fewer blood products while in surgery.
Despite its long history, the off-pump bypass has gained considerable popularity in recent years due to those reasons, Paone says, adding that OPCAB makes up about 20 percent of the bypasses he and Awtrey perform in San Angelo.
"The gold standard really is the conventional bypass," Awtrey says. "It's low risk for the average person. To say off-pump is better will take years and years of data and information gathering, but the early information is that the two are comparable. Off-pump definitely is here to stay. It's being improved and modified continuously.
"It's all just one line in the continuum, but off-pump is burgeoning and it's really dynamic."
As far as Mrs. Farmer is concerned, the surgery is life-improving, if not a lifesaver.
"It's supposed to take less time, much easier recovery," she says. "It seems like that might be true."
Mrs. Farmer moved to San Angelo with her husband in 1958. He was a livestock buyer at the stockyards in Fort Worth and visited San Angelo frequently. One time, Opal came with him.
"It was such a beautiful time of the year," she recalls. "And I said, 'If we ever leave (Fort Worth), I hope we go to San Angelo.'"
Eventually, the couple made the move. Once they retired, they traveled the country until his health began to fail. To pass time, Mrs. Farmer began volunteering with the Shannon auxiliary. Her time in the hospital was spent helping others until last year when Mrs. Farmer was diagnosed with breast cancer — her first real bout with ill health.
After battling breast cancer, Mrs. Farmer caught a bad strain of flu that took several weeks to shake. Once she did, the chest pain came along. After 80-plus years of healthy, relatively carefree living, Mrs. Farmer has spent much of the last year in the hospital.
"But I've decided this is the last one for me," she says of the surgery. "The good Lord has taken care of me for a long time, and I figure he may be tired. I may have to do something for myself."
With that, she smiles and begins to discuss cardiac rehabilitation. She's looking forward to it. Already, nurses have had her walking quite a bit and she has exceeded expectations. Mrs. Farmer was up and moving a little just a few hours after the surgery.
"I'm about to graduate from the inpatient part of it," she says proudly. "Everything is working so well for me."
