On Having Heart Disease, Part II

Leave a comment

The discovery that I have coronary artery disease and the resulting two stents has been, in some ways, a great blessing. Now I know why I have had symptoms for fifteen years—the calcium buildup was narrowing three of my coronary arteries. The stents have helped me feel better, and I have been eating lots of veggies, fruits, and nuts, with the only meat being white meat from chicken or turkey. Exercise on my treadmill is now up to four to five days a week, and distance and calories burned have been steadily increasing.

One of the strangest benefits for me is that when I was in the cath lab, I knew there was a slight risk of death, but I was ready for whatever happened. For a few moments I was not afraid, and I trusted in God. While I still have my moments of fearing death is annihilation, those moments do not come as often as they did before my hospital stay. There are too many coincidences not to believe that God was involved in my recovery. I have tried to pray more, though the discipline is difficult, and I particularly like the early morning “Lauds” service on the Common Prayer I consciously think about God much more often and see God’s handiwork in the beauty of nature—even in this fallen world.

There are, of course, negatives. I know that coronary artery disease is chronic and that the battle against its spread must be thorough and constant—and there are no guarantees that more blockages would never occur or that my 50% blockage will never grow. There is also small vessel disease. My heart, the organ that keeps me alive in an immediate way more than other organs, is utterly contingent. Will a new blockage form? Will a clot form in a coronary artery and cause a myocardial infarction? Will the blockages already present make my heart electrically unstable and throw it into a fatal ventricular arrhythmia? While I work out and am not afraid, in the back of my mind I know these events are possible, and I keep my nitro handy in case I need it—hopefully I never will.

A few years ago, I read a memoir of a man who had suffered a heart attack—I do not remember his name, but the book was well-written. He said that his MI was a blow to his ego, especially to his sense of sexuality—he felt “less sexy” for having a heart attack. Perhaps it is the myth that a man has to be strong, and his heart attack seemed to reveal him as weak. In me, the effect was stronger due to some peculiarities of personality, most likely related in part to my mild autism (Asperger’s Syndrome). Now these are personal matters (read no further if you want to avoid sensitive topics) that I explored in my novels, End of Summer and Unpardonable Sin.  I have always been fascinated with the heart, and when Daddy brought a stethoscope home (he was a dialysis technician), I was mesmerized when I listened to my heartbeat or to other’s heartbeats. With the onset of puberty, the sound of a woman’s heartbeat became a fetish of sorts (actually “of sorts” puts it almost infinitely too mildly) for me. I also liked a woman to listen to my heart. Having a strong heart for me was part of my sexuality, and when this current situation with my heart took place, I felt (and still feel) very unsexy, even though there was no heart muscle damage. It is like a flaw in my manhood. This is irrational, I know, but given that it is tied to such powerful feelings, it is almost impossible to shake. But I am willing to take this small negative for the positives, especially the continuation of my life, for which I thank God every day. I trust that He knows what is best for me, in life or death.

On Having Heart Disease, Part I

2 Comments

I knew my genetics sucked, but I thought that somehow I would avoid my family’s scourge of heart disease. For twenty-plus years I jogged regularly until arthritis slowed me down to a brisk walk. For most of those twenty years, I did not eat too much unhealthy food—but unfortunately that had changed lately, with too many trips to the fast food joints. For years sudden exertion had made me breathless, but since I could walk at a brisk pace for 45 minutes on a treadmill I thought my shortness of breath was from getting older. Last month woke me up big time—I felt chest pain on exertion. I passed a stress test with flying colors in June, so the cardiologist thought my problem had to be something other than heart disease. I had to be sure, so I hooked myself up to my portable EKG, got on the treadmill, and started walking, keeping an eye out for the S-T segment depression that would reveal a lack of oxygen to the heart muscle. It did not take long for that to happen—within three minutes there was deep S-T depression. I stopped and foolishly waited for my wife to get home. I did not reveal any alarm in my voice, so she told me to call the doctor’s office to talk with a nurse (this was in the evening, and the office had a nurse manning the phone). The nurse told me to get to the ER immediately, so Karen took me to Cape Fear Valley Hospital in Fayetteville, North Carolina, where I was seen. All the tests came out normal—EKG, cardiac enzymes, and the rest of the blood work, though my bad cholesterol was too high and my good cholesterol was too low. I showed the EKG to a cardiac physician assistant, who had enough doubts to get the staff to admit me to the chest pain unit. This was on a Sunday, and Monday I chilled out with a heparin drip and waited for the angiogram scheduled for Tuesday. The cardiologist did not expect to find anything other than, perhaps, small vessel disease which is treated medicinally. I remember how cold the room was where the test was done and the skipping of my heart (probably a short run of ventricular tachycardia) when the dye was injected. It took only seconds for the doctor to say, “You have three major blockages: a 99% blockage in the right coronary artery, a 75-80% blockage in the “widowmaker” (the left anterior descending [LAD] coronary artery), and a 50% blockage in one of the circumflex arteries. Initially the doctor wanted to do bypass, but I told them when my mother had bypass surgery all her bypasses failed. The doctors ran the statistics, and stents vs. coronary bypass had about equal results. Of course I chose stents. The first stent was put in later that day (Tuesday afternoon) in the right coronary artery. The doctor was brilliant in cutting through hard calcium with the “roto-rooter” to clean out the artery. He had great difficulty, and I think any other doctor would have given up, but Dr. Daka is an extremely skilled interventional cardiologist, and I thank God for his fine work. My chest hurt for about thirty minutes, and my body went into mild shock, causing me to sweat through my pillow. The right side of my heart had adjusted to low oxygen, and with the vessel open it asked, “Where the hell is all this oxygen coming from?”

The second stent was put in on Thursday. It was much easier to place, and I slept through most of the procedure. I returned home Friday to rest and allow my arm and groin to heal. After I was able to walk, I found that I could handle sudden exertion. I could walk up the stairs at the university at which I teach without getting out of breath. I feel so much better.

I am grateful most of all to God for working with the doctors and nurses to save my life. Dr. Daka and the staff at Cape Fear Valley Hospital were excellent, and even the hospital food was good. There was no heart damage, and my ejection fraction is a high normal of 60-65%. I have made major changes in my diet and exercise for an hour almost every day on my treadmill. As of today I have lost 24 pounds. So many things had to work out perfectly to get me into the chest pain unit, to get the cardiologist to order an angiogram, to get a master interventional cardiologist to do my stents, to avoid a myocardial infarction despite the 99% blockage. I was probably hours away from a major heart attack, and God spared me. My faith is stronger than before, and I thank God every day for saving my life.

Part II will deal with some of the emotional reactions I have had to living with heart disease, both positive and negative.

The Great Egg Yolk Debate

2 Comments

Three yolks from two chicken eggs; one of thes...

Image via Wikipedia

A study at the University of Western Ontario (http://www.medicalnewstoday.com/articles/206481.php) says that egg yolks increase the risk for heart disease with their high cholesterol content. The argument over whether egg yolks will help you or kill you has gone full circle–from “eggs will kill you” in the 1960s and 1970s to “eggs are really good for you and won’t kill you,” and now back again to “eggs will kill you.” I must be lucky, for the only eggs I can stand are either scrambled (thoroughly) or eggs that go into a (very large) omelet. But what about those poor souls who love eggs and just can’t do without them? Are they destined to die young, felled by a soft, yellow egg yolk that looks like sunshine itself?

This is the dilemma that occurs as a result of conflicting scientific studies: Whom do you believe? Americans tend to love Puritans, but since they don’t believe in Puritanism regarding sin, they become food Puritans instead. “Don’t eat that egg! It’s a moral imperative!” For those food Puritans who believe that eggs will kill you, their battle against the demonic yolk is a moral crusade. The Puritans will not rest until eggs have been eliminated from every American’s table.

Since I don’t care much for eggs, I believe I have some moral authority to tell the anti-egg crown to take their Puritanism and stuff it in a dark spot that perhaps they could light up with a bright yellow egg yolk. Even if eggs have high cholesterol, I doubt that an occasional yolk will form the fatal clot that clogs a major coronary artery. Some people, unlike activist scientists and medical doctors, actually prefer to enjoy life without scientists berating them for what they eat. Humpty Dumpty needs to lead a protest movement against those who so unkindly insult him. I will inform you, in case you were worried, that Humpty Dumpty has fully recovered from his injuries. His diet also includes more than tofu and yogurt.

Food is required for our life, but enjoying food is one of the simple and great joys of life. As long as any food item is enjoyed in moderation, it will not harm most people. There may be some genetically vulnerable individuals who had better avoid eggs, and scientists will continue to argue about the dangers of the yolk, but for those who can eat them and enjoy them I say, “Bon Appetit!”

Ethics and Resuscitation

1 Comment

CPR training

Image via Wikipedia

Contemporary medicine brings with it ethical problems that human beings have not faced before. With the advent of modern resuscitative techniques, issues arise of when to start and stop cardiopulmonary resuscitation. In the 1950s, doctors in hospitals often carried a scalpel that was used when a patient went into cardiac arrest–the chest would be opened, and the heart massaged directly. This method saved the lives of many surgical patients as well as generally healthy pregnant women who had reactions to the anesthesia then routinely given during labor and delivery. It is still used today on trauma victims and on some heart attack victims. In 1960, William B. Kouwenhoven and his associates published an article in the Journal of the American Medical Association on closed-chest heart massage, which is still taught to the general public in CPR classes today. In the early days, doctors would sometimes work on a patient for over an hour, and some of these patients recovered without significant brain damage. Over the years, many other patients suffered severe, disabling brain damage. As CPR spread beyond drowning victims and victims of cardiac death due to a medical condition (such as a myocardial infarction, a “heart attack,” debates over when to use it intensified. CPR might, for example, bring back briefly a dying cancer patient, but what would be the point (unless the patient was waiting for a family member he wished to see before he died or another personal reason)? “Do-not-resuscitate” forms came into vogue, in which the patient or a proxy could let his wishes be known on whether he should be given CPR. I have had several relatives and friends die in peace because they did not go through CPR and advanced cardiac life support after cardiac arrest.

But what about the following scenario: a young woman collapses while jogging at a marathon. CPR is immediately started, along with advanced cardiac life support by the ambulance crew, and the patient is taken to a hospital. It is twenty minutes after her cardiac arrest. Doctors immediately pronounce her “dead on arrival.” This is an actual case; I am leaving out the names of the marathon, the city, and the hospital. What troubles me is that even today some doctors do not give up after twenty minutes, and patients do recover after an hour of CPR and ACLS. Some of these patients fully recover, physically and mentally. Why pronounce a young woman dead twenty minutes after cardiac arrest–maybe her heart only had an electrical glitch that, with treatment, could be controlled, or she could be given an implantable defibrillator and live for many years. We would not know–but twenty minutes seems so short in a decision that guarantees that the woman is dead.

One reason I feel strongly about death being pronounced so quickly in such a case is that my mother suffered a cardiac arrest. Doctors worked on her over two hours (and she did have some times in which her heart would beat off and on during that time), and eventually put one pacemaker line in that did not work; the second line did. She recovered without neurological effects and received a pacemaker and implantable defibrillator.

It seems that too many CPR decisions, both by paramedics and by hospitals, are more based on triage than on what could help patients (albeit a very small percentage of patients). I once asked a PA student who had worked at a hospital whether doctors would work on a trauma patient in cardiac arrest (which they sometimes do if the patient had signs of life at the scene). He replied it depended on how much time they had. I wonder if this is the same for patients in medical cardiac arrest. Now some of these patients may have had a DNR order that was discovered, so when the newspaper says someone was pronounced dead after a short ride to the hospital the DNR is the real reason. But when I read in the paper about drowning victims who were in the water less than five minutes being pronounced DOA twenty minutes later, this is troublesome. Would not there be a moral obligation, in a life or death situation, to try a bit longer, especially given the existence of some successes in the past? If a fifty-year-old man has his first MI, a witnessed arrest with bystander CPR, is twenty minutes’ effort enough for him? I am sure doctors mean well and are looking at “evidence-based medicine,” and studies that say the success rate of ACLS after 20 minutes is extremely low. Because of such studies, paramedics are calling codes over after 20 minutes of CPR and ACLS in the field. In an unwitnessed arrest, this may be justified. If the arrest is witnessed with no CPR given before the ambulance arrived, it may be justified. I am not so sure if the arrest is witnessed.

In the case of trauma, I know of at least two instances, one in Tennessee, the other in North Carolina, in which paramedics said that a patient was dead–and the patient was not. I can understand triage at a trauma scene; the chance of CPR and resuscitative thoracotomy (opening the chest and massaging the heart directly, which is done with some trauma victims) have such a low chance of success with trauma victims) is almost nil (although, contra most articles, there have been survivors of blunt traumatic arrest who fully recovered–check out Woodbury, Minnesota). So if the number of paramedics is limited and someone else with a pulse and severe injuries needs to be treated, in those cases it is acceptable to consider the person in cardiac arrest dead. Otherwise, outside of severe head injuries with brain matter, obviously broken necks, obvious severe bodily trauma, and clear signs that too much time has passed, why not try CPR? Sometimes trauma victims swallow their tongues or get debris in their mouths, and they arrest due to asphyxiation. What is wrong with clearing the airway, trying CPR for a few minutes, seeing if there is any rhythm on the monitor. If not, what harm does it do? It doesn’t harm the patient. And a life might be saved.

I realize that physicians will say, “You’re not a physician and have no right to say anything about these issues.” No, I am not a physician; I volunteered as an EMT-Basic for eight months, but the knowledge from the training is extremely small compared to a physician’s. But I can read articles in medical journals, I can use a dictionary, and I can interpret the data and cases I read. I do know that there is a difference between someone with a shockable rhythm and someone whose initial rhythm is PEA or asystole, and that death will be pronounced more quickly in the latter situations unless a readily reversible cause of the arrest can be found. But the clincher for me is that my mother would have died if the doctors had given up on her. Thank God for them, and for my brother, who pushed the doctors to continue CPR even after they had considered giving up. It is too bad that other patients do not have such an advocate.