Eyes Wide Open
2018 was a tough year for me. For starters, just a couple of days into the new year, I had major heart surgery. Despite the fact that I had walked a thousand miles around Japan the previous spring, and run a competitive half-marathon in October, in January nurses were high-fiving me for walking 25 meters down the hallway mostly on my own. One time I didn’t make it, passing out in a heap, tubes and wires flying, while panicky nurses tried to soften the fall. A physical therapist did an assessment of me walking up two stairs and down two stairs. I got very high marks on that one.
My mother had dementia. Several years ago I noticed that she bought a box of cat food. She didn’t have a cat. Turns out she thought it was breakfast cereal. Once she passed out and broke her ankle, and it was only because she was in a wheelchair that I was able to convince her it was time to move to assisted living. While clearing out her condo, I found 43 bottles of Gold Bond foot powder. After five years of requiring systematically more intensive assistance due to the progress of the dementia, she passed away about three weeks after my surgery.
My physical recovery was slow but steady, measured in steps per day and minutes per mile. The psychological impact was less obvious, and the recovery not so easy to measure. A counselor told me recently that although in the West we believe that the center of our feelings is in the brain, in other cultures they believe that the psyche lives in the heart. There is evidence, he told me, that if you cut into someone’s heart, you are likely to fuck up his head.
I spent most of 2018 on blood thinners. After my valve repair surgery, I spent several months on Coumadin. The purpose of this blood thinner is to prevent any blood clots from being tossed into the current by my healing heart. I was all in favor of that, but Coumadin makes your skin feel very fragile. Just looking at pictures of sharp things made me bleed. Flossing my teeth was living on the wild side. I had to go the lab every few days for a blood test, to make sure I was taking the right amount of medicine, and afterward I’d find streams of blood running down my arm from the tiny needle mark. Just as my Coumadin course was coming to an end I did a Holter test, which requires wearing an ECG monitor 24/7 for a month. You glue three stickers to your chest. The stickers have snaps. There are three wires that snap onto stickers. The other ends of the wires converge in a plastic box about the size of an old fashioned pager. I usually kept the box in my front pants pocket. When I sat on the toilet sometimes I’d forget, and rip the stickers off of my chest. The Holter test revealed that an unfortunate side effect of my surgery was a heart problem called atrial fibrillation (abrev: annoying AF). In a normal heart the various parts beat together in a synchronous harmony. With atrial fibrillation, the parts become uncoordinated and inefficient. It can get worse, my doctor warned, so we should treat it aggressively.
Aggressive treatment meant having another surgical procedure. The second one was less invasive and less traumatic, and didn’t require making a new hole in my chest. The procedure did require poking a hole in my heart though, possibly causing further damage to my already compromised sense of self. This time they put me on a different blood thinner, Pradaxa, which was more convenient (no need for lab tests, and my skin felt less fragile) but caused me to have ocular migraines almost every day. I’ve had these before, maybe once every couple of years or so on average. I see a weird jiggly dot in my visual field, and it turns into a vibrating, jagged sort of ring that gets bigger and bigger, then dissipates, leaving me with a dull headache for the rest of the day. It can be a startling experience. On Pradaxa, I had them so frequently that I learned to just ignore them. I had them while I was driving, or in the middle of a meeting, and I just ploughed through. Smoking pot took the edge off of the headaches.
2018 was a year of internal focus. Sometimes all I could think about was what my heart was doing. I focused on how fast it was going. I was sensitive to any irregularities in the beat. I wondered if every little dust mote in my vision was the beginning of a migraine. I meditated. I bought tech to help me monitor how my heart responded to exercise. I bought tech that allowed me to take my own ECG whenever I felt an odd sensation in my chest, which I could then send to my doctor for analysis if it looked funny.
Wilson, the family dog, is close to 15 years old. His vision is impaired, he’s almost deaf, he has a heart murmur, a chronic nighttime cough, and a large tumor growing in his abdomen. He also seems to have some dog version of dementia, and one day decided that it was okay to pee and poop in the house, instead of waiting to go outside. He can no longer be left alone inside, and requires constant supervision.
My second surgical procedure was a cardiac ablation. They snake tubes and tools into my heart through arteries in my legs, identify the cells in my heart that appear to be responsible for causing the arrhythmia, and freeze them dead like warts. Recovery started over again. I continued to have bouts of atrial fibrillation, which was, according to my doctor, not necessarily a cause for concern. Sometimes the surgery for stopping atrial fibrillation causes temporary atrial fibrillation. The surgeon gave me odds of 50 to 70% for total recovery. That sounded about like a coin flip to me. My cardiologist was more confident, and said he hadn’t yet picked a loser for this particular procedure. I often felt the sensation of my heart skipping a beat, sometimes many times in a row.
There were several more months on blood thinners, and another month wearing a Holter monitor. I counted the days until I could unplug myself from the little machine, and find out what was going to happen next.
The Daruma doll is a Japanese “toy,” loaded with cultural symbolism. The image is reportedly inspired by a 6th century monk named Bodhidharma (aka, Daruma Daishi), who is credited with bringing Zen Buddhism, among other things, to China. The doll’s face has a determined expression, and both eyes are white. The doll is balanced in such a way that no matter how you knock him over, he will always bounce back upright. He reminds me of the Bozo “bopping clown” of my western youth, but more spiritual, and without the pointy red hair. A common Japanese practice is to color in one of the white eyes with black ink when setting a goal, or making a wish. Evidently politicians make a big show of this, their version of “throwing their hat in the ring.” When the goal is achieved or the wish granted or the votes are counted in your favor, you ink in the other eye.
Ann helped me pick out a daruma doll just after my first surgery, and guided me in the ceremony of coloring in the right eye using a calligrapher’s brush and Japanese ink. Fifteen months later, one week after I stuffed the parts of my Holter ECG monitor into an envelope and sent it back to the manufacturer for servicing, my cardiologist called. “We’ve detected no incidences of atrial fibrillation,” he told me. Knowing that I often use the ECG function on my apple watch, he asked if I’d seen anything suspicious. I emailed him a couple of samples where I saw an unusually high heart rate, which my watch had categorized as “inconclusive.” He responded a couple of hours later: “ I reviewed them both, and they both show sinus rhythm (normal) with premature heart beats, which may explain why the Apple Watch characterized them as "inconclusive." The premature beats may also cause the watch to calculate a falsely elevated heart rate, as the algorithm averages beats to estimate the beats/minute. We did not see any episodes of heart rate that fast during your event monitor, so I suspect the watch readings may be inaccurate.”
Premature heart beats have come up in our conversation before. Sometimes referred to as PVCs (for premature ventricular contraction), they don’t seem to bother my doctor at all. I can feel them, and they seem to occur more often when I exercise, and all this time I’ve assumed that the fluttery feeling in my chest was a symptom of atrial fibrillation, but I was apparently mistaken. Here is an example of an ECG taken with my watch that looks exactly as it should.
Here is one of the tracings that I sent to my doctor.
Here is another example of PVC, but they occurred in a regular pattern, as if my heart were stuck in a waltz rhythm instead of the usual 4/4 time. My doctor tells me that the phenomenon is called “trigeminy.” Trigeminy could be a Disney character, maybe even a princess, or a popular new baby name.
Anyhow, annoying AF is bad, but PVC seems to be neutral. No one in the medical profession seems to care if my ventricle contracts prematurely, and it doesn’t seem likely that I would suffer any public embarrassment as a result. But before accepting the possibility that any current misbehavior on the part of my heart was harmless, I asked my doctor for an exercise stress test. I wanted to know what happens when I red-line the sucker.
I showed up for my appointment with running shoes and shorts, and was ushered into a room with a treadmill and a couple of work stations. A technician greeted me, asked me to remove my shirt, and stuck 12 wires to my chest and sides. He explained that this wasn’t his usual department, but he was assigned here this morning because he didn’t have any regular patients scheduled. We waited for the cardiologist to arrive, and we chatted, mostly about his six-month-old daughter, his constant state of sleep deprivation, and the difficulty people his age have getting settled in the Bay Area, with the high cost and limited inventory of real estate. I asked him how the test worked. He explained that I would get on the treadmill, and every couple of minutes either the speed or incline would increase. He said that in many facilities the test ends when your heart reaches 85% of your predicted maximum heart rate. (The formula for determining that predicted heart rate is 220 minus your age, which in my case would be 157. ) But in this hospital, the machine keeps running until the patient is exhausted. That’s exactly what I wanted to hear. The cardiologist arrived, introduced herself, warned me to report any pain or discomfort in my chest, spent a few minutes trying and failing to log in to her work station, and finally gave the signal to start. I had to grip a horizontal bar with both hands throughout the test, which was a little awkward. While I was running I was able to watch the screen showing my heart rate, blood pressure, and ECG tracings. I asked questions a couple of times about what was happening, but talking became difficult. I could clearly see variations from the normal sinus pattern on the ECG, extra loops, some going up and some going down.
I’m not sure how long I’d been running, ten or twelve minutes maybe, and there was a quick conversation between the white coats behind my back. The man came back into my view and told me that they were going to stop the test in 45 seconds. I wanted to object, and tell him that I could keep going longer, but I was sucking too much wind to spit out a whole sentence. He counted down by tens, then fives, then three, two one. The machine came to an abrupt stop. I sat down, and the doctors continued to watch the screen and monitor my recovery.
The cardiologist told me that there was no evidence of any abnormal blockage in the blood vessels of my heart, and no instances of atrial fibrillation. I asked about the loops, and she said that those were premature beats, some ventricle, some atrial, but that they were nothing to worry about. I asked if over time, there was the possibility of the premature beats increasing or decreasing in frequency. “It’s hard to say,” she said. “Is there a connection between exercise and the premature beats?” I asked. “It’s hard to say,” she said. I got the feeling that she wasn’t being entirely forthright, but I couldn’t think of another way to ask the question. Later that day I received an email from my regular cardiologist.
Your resting blood pressure looked good and responded normally to exercise, and there were no concerning changes on your ECG. Most importantly, the amount of work that you completed was far above that of what an average 63 year-old can do, which indicates that your prognosis from a cardiovascular standpoint is very favorable. It's been a privilege partnering in your care; as always please don't hesitate to contact me with any questions or concerns.
It sounded official; I’d been kicked off of the cardiac patient team. With Ann’s help, I inked in the other eye of the Daruma doll.
There are things I still wonder about. Will I ever feel as fit again as I did before my surgery? Will the premature heart beats eventually turn into something troublesome? Does worrying about premature heart beats cause premature heart beats? But most of all, I wonder how long I could have kept going if they hadn’t stopped the treadmill test.