Blood Pressure Highs/ Catheter Ablation/The Transmitter

     The change from Ex-Forge to the new BP medicine worked out badly, and we had some real concerns about how high my blood pressure went. One evening we went to the Sibley Emergency Room after speaking with the duty doctor for my cardiology group. They found no basic problem at the hospital, but suggested checking with Dr. Vassallo about the medicine. After talking with him, I was switched back to the Ex-Forge, and I kept a careful record of my BP for a couple of weeks--and it was generally fine.
     During those two weeks we visited the doctor who specializes in catheter ablation. The upshot of that very pleasant session was the following advice: "Since you are asymptomatic--much as I love doing these operations--I cannot recommend it." This took a weight off my mind, as I had no wish to have wires threaded up from my groin and through my veins into my heart, so that they could poke around trying to find the right place to "ablate."
     St. Jude were supposed to be sending me a transmitter so that I could, from time to time, transmit to them how my pacemaker was functioning. First they sent it to the wrong address. Then, after a phone call from me, they sent it to the correct address. I had to plug it into the telephone jack--it has a splitter--and there was also a small power pack to be plugged into an electrical outlet. I stripped off my shirt, plugged in the power, held the recording device against my pacemaker, and followed the instructions as to which buttons to press. One icon lit up, showing me that the signal was going from my pacemaker to the transmitter. But the transmitting icon never lit. After a couple more tries, I phoned technical support.
The answer--they had sent me the wrong transmitter for my type of pacemaker. Which means--waiting for the replacement and then packing up the one they first sent me.

Next: Catheter Ablation?

     I saw my cardiologist on September 29, and he told me to stop the Multaq and to throw away the pills I had left. He decided to stop the ExForge--the blood pressure medicine--and to substitute Edarbi. He gave me a month's supply of the pills.
     He then explained to me a procedure called 'catheter ablation,' which he said might be particularly suited to my condition. Catheters are introduced in your groin and are pushed up the arteries (or it it veins?) into the heart. Some radio/electronic device is supposed to detect the area or spot where the fibrillation originates, and the spot can be 'ablated'--destroyed, zapped.
      I have researched this procedure and I have seen nothing that indicates under what circumstances it is called for--except when medications do not help the fibrillation, which seems to have been my case with the infamous Multaq. What eludes me is how serious is my fibrillation. In this session with my cardiologist he did get the technician who monitors pacemakers to check if I was 'in fibrillation'--and the answer was 'yes.' Which was a repeat of the result when I had the pacemaker tested at three months. On the other hand, when I check my pulse myself, it usually seems very regular.
What has concerned me since this consultation is that my blood pressure seems all over the place. Sometimes very high, and sometimes very low. I was told that the new medicine might take ten days or so to kick in, but the ten days are well past now, and the results are strange: highly variable. So much so that one evening, with readings upwards of 170 over 110, we checked with the doctor's office and the duty cardiologist suggested we go to the Emergency Room at Sibley Hospital, which confirmed a reading of 190 for the systolic. In the end, after blood and urine tests, they let me go with the message that readings above 220 over 120 were regarded as 'dangerously high,' and that I should contact my doctor about adjusting the blood pressure medicine. That was on Friday night--October 14--and since then all the readings have been on the low side. So heaven knows what is going on.
This coming Thursday, Joan and I will talk to the ablation doctor.

Multaq, Pradaxa, and Exforge...

These were the three drugs that I was prescribed before we went to England. Pradaxa is a blood thinner: Multaq is for the arrhythmia or fibrillation: Exforge for the blood pressure. Pradaxa and Multaq have to be taken twice a day, which is a nuisance because it is very easy to forget to take the evening doses.
    We went to England on June 1, and as time passed I did begin to forget that I had the pacemaker. In London we walked for miles and miles, but never very strenuously. In Wales, with Dan and Karen, we did some strenuous hikes along the coast. And in Devon we hiked the coastal path, which had a lot of steep uphills that had us both pausing for breath. I would check my heart rate, and usually it was in the range of 90 to 100 bpm.

    Here is Joan on a stretch of the South Devon coast, and you can see the up-and-down nature of the terrain. All this hiking was very encouraging, as it seemed that--heart problem or no heart problem--I was able to engage in vigourous physical activity. We returned to England on August 23--a significant date as Washington had an earth tremor, or earthquake, which lasted about 30 seconds and had everyone running out of buildings.
    Shortly after getting home I was trolling around on the Internet and did a search on Multaq. This is what came up:

    "FDA notified healthcare professionals that it is reviewing data from a clinical trial that evaluated the effects of the antiarrhythmic drug dronedarone (Multaq) in patients with permanent atrial fibrillation. The study was stopped early after the data monitoring committee found a two-fold increase in death, as well as two-fold increases in stroke and hospitalization for heart failure in patients receiving dronedarone compared to patients taking a placebo. FDA is evaluating whether and how the preliminary results of the PALLAS study apply to patients taking dronedarone for paroxysmal or persistent atrial fibrillation or atrial flutter. The PALLAS study results are considered preliminary at this time because the data have not undergone quality assurance procedures and have not been completely adjudicated. FDA will update the public when more information is available."

    I had an appointment with the pacemaker technician on Monday August 29, when he checked the operation of the pacemaker--which was working perfectly. I asked if I could see the cardiologist, and I showed him the FDA warning. I did not get the impression he had seen it before. He assured me that my fibrillation was paroxysmal and not permanent, and that the warning only applied to permanent fibrillation. The technician, who was monitoring my heart, cut in to say that I was, at that time, actually 'in fibrillation.'

    So I am left with a question mark--something like this: if X doubles the chances of death of someone whose fibrillation is 'permanent,' might there not also be a detrimental effect on patients with fibrillation that is less than permanent? And obviously the FDA think that could be the case, as they are going to evaluate what Multaq's effects are on patients with paroxysmal fibrillation.

    It was agreed I would remain on Multaq until my next appointment on September 29.

    I renewed my prescriptions: my share of the total cost was about $270. Aetna covers the rest. These drugs are expensive.

   

Change the Pills again...

     The next appointment left me feeling somewhat uneasy. Since the 'interrogation' and the change of pills, my blood pressure had been unusually high, giving rise to my earlier feeling that fixing one problem might be exacerbating another. Strangely, though, when the doctor took my blood pressure, it was very low. We did a brief EKG--amazing how quickly the nurse sticks these sensors on about ten places, switches the machine on for a minute or so, and then whips all the things off again--taking generous portions of chest hair with them. The EKG that I had on this occasion gave rise to the comment that I still have a minor amount of a-rhythmia--a finding that does not exactly cheer me up.
     The appointment led to yet another change in medicines. And that was that. "Call me from England if you have a problem. See you in three months' time."
      Tomorrow we go to England. I am keeping my fingers crossed that I will not have any further problem while we are there.

Pills, Pills, and more Pills.

     About a week ago I had two appointments--one with the cardiologist and one with a pleasant young lady--a technician from St. Jude Medical--who performed the much-heralded "interrogation." This was a non-event, totally unexciting, taking all of five minutes. I took my shirt off, and she draped a wire with some sort of sensor around the back of my neck so that it hung down over the bump of my pulse generator: sorry--I should say 'pacemaker' as you may not be one of the cognoscenti. The sensor was connected to a printer/reader device that spewed out a long roll of paper that would be reviewed by the cardiologist. "But don't expect to hear from him as I can see that everything is working perfectly," said the technician. End of interrogation, except for--"fix an appointment for a further check in three months time."
     The appointment with the cardiologist was less satisfactory as he decided to change my pill regime. In addition to the blood thinner (Pradaxa--the hugely expensive drug at $750 for three months' supply), he prescribed a beta blocker (Micardis), the function of which is not clear to me. He also changed my blood pressure medication to something called Multaq (sounds like a Taliban leader) and annoyingly it has to be taken twice a day. So now I have to take three pills first thing in the morning and two pills at night. The pill-taking is all getting to be a bit too much. Mornings are not so bad, but I do tend to forget in the evening, and sometimes before I fall asleep I suddenly remember I have not taken the required two pills. It's not so bad if we are home in the evening and I can take them with our meal; but if we go out to eat or travel it is only too easy to forget. And just the fact that I have this pill regime is a constant reminder to me that all is not well
     The cardiologist did emphasize that I should return to my usual exercise regime, and I have started to do so, getting back to my routine of treadmill, bicycle, and elliptical trainer for 40 minutes or so each morning. I cannot lift weights as my shoulder hurts if I attempt anything more than a five pound dumbbell.
     The good news is that I have begun to forget that I have the damn pacemaker, although from time to time, particularly if I raise my right arm higher than usual, I do get pain in the general area of my wound and shoulder just to remind me that it's there.
     I have also had the experience of being patted down twice at airports as I refused to go through the magnetometer. Next time, I think I'll risk it, as the patting down procedure is very elaborate. At Dulles Airport I had to wait while the expert patter down was found, by which time my jacket and shoes and the Macbook had all passed through the x-ray and were sitting there blocking the line of containers until Joan managed to scoop them up. The training for a patter downer is obviously very rigorous: put the blue rubber gloves on, explain the routine and the private parts that will be invaded, ask if you would prefer the patting down to take place in private, ask if there is any area that is sensitive, and then get to work--feeling with open hands, patting with the back of the hands, smoothing down this and that, and finally taking the gloves to a machine that presumably checks whether you have been in contact with explosives. Exactly the same routine--with exactly the same script--was followed at Santa Barbara on the return trip. I think I'll just speed through the magnetometer next week when we fly to England.
I suppose that I am coming to the end of this blog. I hope I am, although I am still somewhat anxious about my heart. First it was the fibrillation, from which, according to the cardiologists, I "got out of" naturally: my heart corrected the situation, leaving unanswered why it had fibrillated in the first place and  whether it would fibrillate again. Then it was the bradycardia--heart too slow and stopping from time to time--for which the pacemaker was installed. Now, it seems--that's it. Heart problem over and done with? Back to a well-tempered heart (?) that went up to 122 beats per minute on the bicycle and treadmill this morning. Or is there something else lurking there that has so far not been detected? One wonders.

Cutler Computer Art

An Address to the Heart...

       Over the last few weeks I have been recording, for The Library of Congress, the complete poems of W.B. Yeats, in which the heart--usually metaphorically--is often directly addressed. And, frankly, sometimes the results are quite banal, and one wonders why the winner of the Nobel prize for literature decided they were worth publishing.
Take the first verse of "A Song," for example.
    
        I thought no more was needed
       Youth to prolong
       Than  dumb-bell and foil
       To keep the body young.
       O who could have foretold
       That the heart grows old?

     The answer to the question is "well, pretty much everybody, unless they believed in eternal youth."
I quite like "dumb-bell and foil." But though W.B.Yeats might have lifted the occasional dumb-bell, I doubt that he did much fencing (the 'foil').
      You might also note that he is fairly liberal with his near rhymes ('prolong' with 'young') and doesn't worry too much about exact scansion.
       He is better in a direct address to his heart in "The Tower."
  
      What shall I do with this absurdity--
      O heart, O troubled heart--this caricature,
      Decrepit age that has been tied to me
      As to a dog's tail?

      I had a certain fellow feeling when I recorded those lines.

     Another tick he seemed to have was an addiction to long titles. Such as: "On hearing that the students of our New University have joined the Agitation against Immoral Literature." "I see Phantoms of Hatred and of the Heart's Fullness and of the Coming Emptiness.""The Poet pleads with the Elemental Powers."

    I thought: let's give it a try:

         The Poet addresses his Heart with the News that
               He has to have a Pacemaker Installed

          Old Ticker, why have you betrayed me,

          Fluttering, quivering, missing the odd beat,

          Shaking the stylus on the EKG?

          Is it revenge for my conceit,

          Feeling so fit for seventy-six?

          Did I push you too hard with the hiking and biking?

          Is that why you’re playing these cardiac tricks?

          Or was my diet not to your liking?

          Maybe it’s simply our DNA,

          Some maladjustment growing since conception,

          The genetic dice just rolled that way,

          Creating some electric misconnection.

          Possibly it’s just the wear and tear of years,

          The heartaches, strains, vicissitudes of life,

          Those disappointments and those fears and tears,

          Sorrow, regrets, omissions, anger, strife.

          But life has also been so rich

          With love and pleasure, beauty, music, art:

          These soothe the soul, but cannot stitch

          The tattered tissues of the aging heart.

          And now for shocking news, my dear Old Ticker.

          Down through our veins they’re threading wires

          To goose you into beating quicker

          To match the speed a longer life requires.

          Sorry to saddle you with this encumbrance,

          To make your pace beat faster than before.

          Consider it as life insurance,

          Covering the risk we both might suffer more.

         “Your heart will last a lifetime,” I’ve been told.

         “How true,” is all I can reply.

          You’ve been a bosom pal, a heart of gold:

          We’ll hang in there together, you and I.

          Forget the intimations of mortality,

          Just be very thankful we’re alive:

          Let’s rather focus on longevity—

          I think I’m going to shoot for ninety-five.

     It took some time to work this out, and I did reject two verses that maybe I should have kept:

                     Rejected Verses

          And now for shocking news, my dear Old Ticker.

          They’re going to make you work much faster,

          To goose you into beating quicker

          With an electronic blaster.

          Well, maybe ‘blast’ is just exaggeration.

          The voltage will be miniscule

          And only last a fleeting micro-sec’s duration,

          And with the power of just a milli-joule.

All for now. I have the interrogation appointment in a week's time. That should prompt another entry.

    

  

You'll Forget It's There...

     Two weeks into it (or IT in me), but I have not yet reached the stage of forgetting about it. Indeed, the thought that it is there is more or less constantly uppermost in my mind, or at most one layer down. And as I forget about the warnings against raising my arm and reach for a high shelf, or brush my hair, or try to dry my back after a shower, there is more than sufficient discomfort to remind me--that it's there, presumably sparking away at a rate of 60 bpm. And look at that little mound of flesh below my collar bone, which seems to move in a circular motion when I use my right arm to perform some repetitive action--cleaning my teeth, for example.
     But the reminders that IT is there go beyond that fact; they raise all sorts of worries that percolate through my mind about my heart. Is this going to fix the problem? We started with atrial fibrillation. That was to be fixed by shocking the heart back into regular rhythm. Then the diagnosis changed to heart block category two, and hence the pacemaker. But when I ask whether the atrial fibrillation problem is solved, the answer was, "probably, but we cannot be sure." Or was it--"most probably."? So there is a continuing level of anxiety, which I suppose will only go away with the passage of time and some assurance that nothing else is wrong--that the pacemaker has fixed the problems.
     Joan has suggested we need a name for the pacemaker. She draws an unlikely analogy between the pacemaker and our GPS, whose voice that guides us and bugs us ("recalculating ") we have named Agnes. I forget where that came from. We'll have to think about a name for the "device"--as the Manual insists on calling it--but perhaps we should wait until the technician interrogates it. He will probably know its name.

The Wound Appointment...

..was not an experience that lends itself to much humour or matters of interest. The tape over the incision had mostly stayed on, although I had showered each day, and the doctor--the surgeon who placed my 'device'--whipped off the remainder with an obviously well-practiced flick of his wrist. Apart from that, it was more a session of warnings and advice, although he did take my blood pressure (high--white coat syndrome) and listen to my heart and lungs, remarking that as a cardiologist he was obliged to touch the patient. We talked about 'twiddling' the device, and he said 'yes, avoid twiddling: sometimes we get patients who swear they have never fiddled with their pacemakers, but when we x-ray them the things have been turned upside down and the electrical leads are all tangled up: 'but, no, Doctor, I never touch it.'"

Let's have a look at the wound, shall we? What was that I said in an earlier post about narcissism and the urge to show scars.

"Then will he strip his sleeve and show his scar and say--this wound I had on the thirteenth of April" (Shakespeare, Henry V, amended).

And the picture does show the little bulge where the pacemaker is sitting. I must say it looks more like a pack of cards than a matchbox.

What else did we learn (Joan asks a lot of good questions). Exercise: be as energetic as you like as regards your heart rate, but wait at least until a month is up until you start with swimming, tennis, golf, weight-lifting--anything that involves your arm--even cycling up hills because you pull with your arms on the handlebars.

He did advise against going through magnetometers at airports ("I wouldn't do it: show them your card"). I asked if my pacemaker had a "patient notifier" that would play a tune or ring a bell if the device malfunctioned: answer--"No, and you are better off without that feature."

The next step is the Interrogation Appointment in two weeks' time. This does not mean I am going to be water-boarded or have my finger nails pulled out. A technician will talk to the device, and interrogate it--that is, ask it what it has been up to, how's it making out in there in the dark, how much it has had to work to keep the heart rate up, and how much of the battery has been used.

                                         Another view: not a pretty sight, but clean and neat.

                                                           

Well, That's Comforting News...

The long-term effects of cardiac pacemakers on the mental status and adjustment of an aged population were investigated. In an institution for the aged, 25 residents (average age, 85) in whom pacemakers had been implanted for an average of 53 months were compared to 18 residents of the same age and sex who had a slow heart rate. A semistructured interview was given to determine mental status, affective condition, perceived health, and other concerns. Cardiac status was rated for all subjects according to the criteria of the New York Heart Association. By the measures of adjustment and mental status, no differences were found between pacemaker patients and those with a slow heart rate. Cardiac status was somewhat poorer in the pacemaker group. When comparison was made between the pacemaker patients with uncompromised or only slightly compromised cardiac status and subjects with a slow heart rate and similar cardiac status, no significant differences were found in the foregoing measures. These findings suggest that although there may be changes in functioning in the acute phase following implantation of a pacemaker, there are no long-term effects on adjustment in subjects of advanced age. Adaptation in an institution for the aged may be more related to personality factors than to specific health problems.

Weight Loss?

     I have lost 5 pounds as compared with my weight before the pacemaker was inserted. This morning when Joan ran, and I walked, along the C and O Canal towpath near Great Falls, I pondered the fact that my heart was having to work harder than before. I reasoned that, if during six hours sleep at night my heart had been beating at 40 bpm and was now beating at 60 bpm, for 360 minutes of sleep my heart would beat 7,200 beats more than previously. Wouldn't those 7,200 beats translate into a good number of calories? I decided to Google the subject of "calories per heart beat" when I got home. The result was disappointing. Dozens of sites, of course--as there seem to be for anything one Googles, no matter how abstruse--but one site did come up with a figure. After a long description of how the result was obtained, the figure was 0.01 calories per heartbeat. So 7,200 would amount to 72 calories. So any contribution to my weight loss must be negligible--and negated by an extra slice of bread or half a cup of milk.

The Manual...

There is a picture on the cover of the Manual given to me by St. Jude Medical.
The cliche of the cover is, of course, classic Viagra or Cialis. Here is this oldish (not too old) man, bronzed, fit-looking, walking the beach hand in hand with his beloved and giving her a knowing look, as if to say, "Later, my dear." Designed to answer what St. Jude Medical seems to think would be the masculine concern uppermost in the mind of the recipient of their cardiac pulse generators: namely, "Will I still be able to ....." Fill in the blank.
For me, there were much broader questions--how much longer have I got to live? Is this really going to fix the problem?

   Apparently, one has to forget the word 'pacemaker.' The name is PULSE GENERATOR, or so it is referred to throughout the Manual, which starts with quite a long description of "The Healthy Heart." It gets into the atriums, the ventricles, the sinoatrial node, the AV node--with cute little cut-away pictures of the heart. Then we are into Arrhythmias--too slow, too fast--and ventricular fibrillation (which was the initial diagnosis for me).
   The Manual explains that the first pulse generators were the size of a hockey puck and the battery lasted less than a year: they are now about half the size, and the batteries can last up to ten years. Frankly, that does not make me much happier: whether hockey puck size or match-box size (my surgeon's description), I am not at all pleased at having anything stuck inside me, let alone with wires led down through the veins into the heart, giving it a nudge every second. We can skip over the descriptions of the operation itself and the warnings about avoiding stretching, lifting, and sudden movements. I liked the warning: "Do not play with or move the pulse generator under your skin. Try not to hit it it or bump into it." I found that wording somewhat odd: play with it, hit it, bump into it? Somewhere else I read, "Do not twiddle with your pacemaker: you may disconnect the leads." The warnings extend to boxing, wrestling, horseback riding, bumper cars, rugby, softball, weightlifting..the list goes on.
    But now we come to the the more interesting section: Living With Your Pulse Generator, in which are set out all the various manifestations of Electromagnetic Interference, or EMI as we insiders call it. Well, arc welding is simply out. Watch it with your electric razor or your vibrator. Don't hold handtools (they mean power-tools) directly over the pacemaker. Live in a home that has a properly grounded electrical system. Ask your doctor about using a mobile phone. Try to avoid security systems in shops, or go through them quickly (at a trot?). Better to avoid sleeping on the pacemaker, apparently.
   The final question in the Manual is, "What is a Patient Notifier?" I do not know if I am so equipped: I have to ask my doctor. But a Patient Notifier will notify you if something is going wrong, either by a vibration or a tone. "It may go off for a number of different reasons," says the Manual, "like a low battery or a fast heart rate."
"Is that your phone?"
"No, is it yours?"
"It's probably my pacemaker. Put your ear to my chest and listen."
"Yup--you're ringing like a bell. Where do we go to get it fixed?"

    Now for the Warranty--you didn't think of that, did you? But of course you have to have a warranty, one on which I am sure that legions of lawyers worked long and hard.

     Of course, if something goes wrong, I'll have to go into hospital and presumably have the defective pacemaker out and a new one installed, or a new battery installed, which will be expensive. The Warranty concedes the following: "Additionally, reasonable unreimbursed medical expenses of up to six hundred dollars ($600) associated with that replacement are offered for the benefit of the patient. The obligation of St. Jude CRMD to pay reasonable expenses shall be limited to $600 even if both the lead and the pulse generator are replaced." The use of the "unreimbursed" formula suggests that St. Jude Medical hopes that your own insurance, or Medicare, will cover the costs.

     This thing has now been in place for ten days, and in a week's time I have a "wound check" appointment with the surgeon. That will probably be the basis for my next entry.

This a bit of Cutler computer art.

   

"Keep That Arm Down...."

   On the first day home--the day after the placing of the pacemaker--I was somewhat subdued, mainly sitting around, resting, and occasionally dropping off to sleep. I sent an e-mail to the recording studio to say that  I thought I could resume recording the following Tuesday; I didn't think I should postpone it any longer than that because I am committed to do a very long book of Yeats's collected poems before we go to England at the end of May.
   The only serious problem was my inadvertent raising of my right arm. The orders had been strict: do not raise your arm so that the elbow is above the shoulder. I have some habitual 'poses' in which I do just that--without thinking. For example, clasping my hands together behind my head when leaning back in a chair and watching television. Even combing my hair or flossing my teeth seems to get the elbow up close to the level of my shoulder. And reaching right-handed for things on high shelves in the kitchen is something one does instinctively. Joan kept me under strict surveillance in this respect, and if that elbow approached my shoulder, a sharp remonstrance was always forthcoming, and rightly so.  The level of the remonstrance was perhaps a bit shrill, but reflected her justifiable concern that my wound would open up and she would have to deal with it. My excuse was--I do these things without thinking. ("Well--THINK")
   Sleeping has been a problem. My favorite side for sleep is my right side. Not possible. I have just had to sleep on my left side and lump it. As I have mentioned before, I cannot sleep on my back--'cannot' in the sense that I just do not fall asleep. So the left side it has been. An experimental turn to the right side this morning produced discomfort immediately.
   Mobility has not been a concern. I have walked several miles over the last few days. Joan has driven me around when we have used the car, with me sitting in the back behind her with the safety belt over my left shoulder. On a couple of trips on the subway, Joan has suggested--and I complied--that I wear the sling on my right arm so that I may be a bit protected from people jostling against me.
   As for "how do you feel?"--the answer is OK most of the time, but occasionally "strange" in an undefined way. And I often brood on the idea that my whole system had been adapted to my heart beating--at least on average--at a much slower pace than the pacemaker is dictating: do the various systems adapt to the new situation, or do they interpret it as something going wrong?
   One thing that clearly is NOT going wrong is the pacemaker itself. I was told to take my blood pressure several times on the first two days at home, and for the first seven readings the pulse rate was exactly sixty beats per minute.
   One disturbing effect, which I must control, is an urge to tell people about it. What is that? Is it pure narcissism? Look how brave I am? I always remember President Johnson exposing his operation scar in the Oval Office or at a press conference, and an acquaintance once insisted on stripping and showing his horrendous scar after open-heart surgery. Why do we do it--boasting, perhaps? My scar seems hardly worth showing anybody--just a thin, red line covered in so-called "steri-strips."
   We need to discuss all the precautions one must take with a pacemaker. This morning I went to the police station to report that one of my bikes had been stolen, and I was faced with a metal detector to go through. And later on in the morning, I was faced with another one at the Post Office. St. Jude Medical has given me a booklet about these things, and that will be the subject of my next pacemaker blog.

Discharged...

     Sunday morning and a beautiful Spring day. We did our usual exercise in Rock Creek Park--Joan running while I walked. The river was in spate after yesterday's rain, and the trees were turning that fresh, bright green of early Spring. The dogwoods and the red-buds were coming out, and the bird population was growing with the arrival of a few spring migrants.

     But the time has come to revert to the pacemaker saga. We left our anti-hero happy and relieved to see his partner, Joan, come through the door of his prison cell at about 7.00 am on Thursday morning. The first thing he asked her to do was to help him put on his underpants and the sweat pants he wore when he checked in the previous day. If he could have taken off the awful hospital robe, he would have done so, but the plethora of wires made it difficult, especially as the transmitter for the telemetry was in the pocket of the robe. But at least his rear end no longer peeped out from the back.
   We now revert to a first person narrative.
   The doctor arrived soon after and told us he had done all the paper work for me to be discharged. He said he had been required to sign 17 forms before I could be released. He warned me against raising my right arm in such a way that my elbow was above my shoulder--that could open the incision. Apparently, my veins were very deep, although the significance of that was lost on me. I said that I was disappointed that I had not remained conscious during the operation as he had promised: but he insisted I had been conscious, and that I had responded to things he had asked me to do. "You have simply forgotten it," was his explanation.
   I tried out my theory that perhaps my soaring blood pressure had occurred because solving one problem (my heart) might have exacerbated another (my blood pressure). He assured me the two were not connected...but then, he would say that, wouldn't he? "It is mostly because you are here," was his comment. And then he explained about showering, letting the strips on the wound drop off, and fixing a "wound check" appointment in two weeks. Apparently, I also need an  appointment with the St. Jude representative to "interrogate" the pacemaker in four weeks' time. Actually, the doctor deserves praise because he  was extremely solicitous about explaining things and answering questions.
   Once he was gone, Joan ordered breakfast for me, and soon after I had eaten it the nurse came to sort me out for leaving. Removing all the electrodes from around my body was not painful, but each one left behind a lump of sticky goo that resisted all attempts to clean it off with alcohol, and the nurse disappeared for ten minutes to try to "find the proper wipes." But these proved inefficient, and for days after I got home I was cutting off lumps of chest and other body hair were the goo had coagulated into messy lumps. Then came the most painful part of my hospital stay--removing the drip shunt or valve from my arm. The plastic tape that held it in place seemed have merged with my skin, and the only thing the nurse could do was yank it off--but not cleanly in one piece, but in a series of increasingly agonizing rips.
   Joan went off to get the car and I asked for a wheel chair to take me down to the main entrance because I was feeling a bit dizzy and groggy. Before Joan left, I said, "You know, I won't be able to use the safety belt if you are driving as it will go straight across the wound." But like a flash, she had the solution--"You'll sit in the back behind me." In that position the safety belt goes over the left shoulder. And that is the way we drove home. It must have seemed very odd to anyone who looked at us. Normally a passenger will sit in the front by the driver. And if the car has a chauffeur, the passenger will sit in the back, but typically on the near side. And that is how we have been driving around Washington the last few days--Joan driving, while I sit behind her in the back.
  Being home was wonderful, but there were some difficulties...

                                         

Long, Lonely Night...

   It's Saturday morning, and the rain is pouring down. Joan is in the exercise room--she does not want to run in the rain. I have walked a mile in the corridors of our apartment building--from the stairs on the northwest side of the building to those on the south east, and down a flight of stairs to the next floor down, and so on for twelve floors. Each floor about 170 yards.
   I must now return to Wednesday night, with John gone home from the hospital and my sense of loneliness increasing. But at eight o'clock or so, the new nurse--Marquita, the night shift nurse--came in to take my vital signs--stethoscope on chest and back, deep breaths, blood pressure (still high), heart rate (an electronically steady 60), wiggle your toes, squeeze my hands, etc., etc. And she was gone.
   I tried to read, tried to do another puzzle but got stuck: I tried to sleep, but the light bothered me, and I spent fifteen minutes or so trying to find where the lights turned off. But with all the high tech stuff around the bed, something as simple as a light switch was not to be found. Eventually I buzzed Marquita, and she pulled up a hidden rail on the bed that had a control panel of the complexity you might find in the cockpit of an airliner. But the light button was obvious. I switched the light off, and tried to sleep. But it was like trying to sleep on a plane: couldn't get comfortable, cannot sleep on my back, could not sleep on the right side because of the sling--could not sleep anyway, in any position. More trying to read, try for another word in the crossword. Light out again. And the huge clock on the wall opposite me  seemed to be going at a snail's pace. Only eight more hours (only!) until the doctor was due to check me in the morning. I looked around the room and brooded on the fact that this was the way most people died these days--in the impersonal surroundings of a hospital room, most likely on their own and hooked up to this and that high tech machine. Not as pleasant a way to die as at home, surrounded by family, with the kindly GP overdosing the suffering patient with morphine, and the last goodbyes being said, and the last words recorded.
   I did drop off somewhere between eleven o'clock and midnight, and then I was woken with a start, with the door opening, light flooding in from the corridor, and this huge figure marching with heavy steps into the room. I was actually frightened, startled, not knowing where I was, and thinking momentarily I was in a prison cell and they were coming to get me...
   Marquita took my blood pressure, which was through the roof, and checked my other vital signs. "I'll come back in a few minutes and check your blood pressure again because you were startled when I came in."
    I kept the light on and did not try to go to sleep for twenty minutes, But she did not return until the fouro'clock check on my vital signs. At that time I was awake, as I had been on and off through the night, never quite knowing whether I had dozed off or not. I did sleep a bit after she had gone and awoke to the light coming through my window as the sun rose in a cloudless sky at about six o'clock. Another slow, slow hour--was that damn clock actually moving--and then at seven o'clock, and to my great relief, Joan came through the door. So we prepared ourselves for the surgeon's visit.
   I have been given a temporary ID card, to be produced at such places as airline security.  It describes my pacemaker and gives its serial number. It shows my name and address and telephone number and the name and phone number of my surgeon.

The Patient on I-Phone

Joan took a picture of me on her I-phone, which has been blocked out for reasons that are a mystery to me. So I must content myself with describing it. In my left hand is a lollipop. In my right hand is my clip-board with the crosswords I print from the Guardian web-site. The sling on my right arm is scarcely visible. The hospital gown, as always, is in a state of disarray. I look reasonably healthy, and indeed Joan commented that I had a good colour, and contrasted it with my pallor when I emerged from the excision of my salivary gland a couple of years ago. But I think the colour was illusory: I certainly seemed more pallid when we came home the next day after a bad night. Maybe the pacemaker was pumping more blood to my face than usual when I emerged from the operation.

Almost a Pleasant Day...

     After the turmoil of getting me into the hospital bed in my room, the taking of vital signs, plugging me up to the telemetry machine, having a sling put on my right arm, and trying without success to pop some of the poppers on the ridiculous hospital gown, I was comfortably settled down, and Joan was able to order breakfast over the phone. The menu was in the room, and we ordered breakfast, lunch, and dinner from a wide variety of choices. The results were better than airline food, though falling short of a decent restaurant.
   The day passed rather pleasantly, dozing, eating my meals, doing Guardian crosswords (one completed: one needing a few words when we left on Thursday morning), and reading Anthony Trollope (you intellectual snob, Cutler) on my Kindle. And, of course, chatting with the ever-solicitous Joan, who cheered me up immensely. Not feeling great, but--well--alright, more or less.
   The right arm was the problem. The incision for the pacemaker was just below my right collar bone, so that  movement of my right arm had to be restricted--ideally with my elbow tucked into my side, and on no account was my elbow to be raised to the level of my shoulder. This certainly restricted my mobility and made a number of ordinary tasks quite difficult, but Joan was always there with a helping hand and her presence was always comforting. I experienced very little pain, except when I made some move with my right arm that seemed to twist the incision or pull the dressing on it.
   My blood pressure was erratic: the nurse spoke with the doctor and I was given a pill. As the day went on, with vital signs being taken every four hours, the blood pressure readings went down, but then climbed back up. I began to wonder if the solution to the problem of my heart might not exacerbate my blood pressure problem. ("You can never do just one thing" is an adage to which I subscribe) After all, if my heart was now beating faster, wouldn't that blood being pumped around faster than before have some effect on the pressure?
   Joan left late in the afternoon, taking the car home and handing it over to John to drive over and visit me. He came after a couple of hours, and during those hours alone, I began to feel, well, lonely. I could certainly buzz the bell and get the nurse, which I did once, to ask her if I could now get out of bed and go to the lavatory.  Up until then, I had used the bottle, and Joan had immediately tipped out the bottle and washed it out, much to the consternation of the nurse, who was supposed to measure my "output."This came out well into the day, when the nurse asked, with a rather strange choice of words, had I "voided."
   Where was I? Feeling lonely for a couple of hours; and after John had visited, and I realized I had the whole night to face alone, I began to feel VERY lonely. I supposed that if any alarm signal was sent from my telemetry transmitter to the nurse's station, lights would flash and people would come running.
   So rather grimly, after a visit from a new nurse at 8.00 pm to check my vital signs, I tried to settle down for the night...

In She Goes...

Yesterday morning, at about 6.15 am, we parked a few blocks away from the hospital (they charge a lot for parking) and walked through the dark streets, with the rain coming down fairly heavily. Within minutes of arrival, after signing away my rights to everything, I was taking my clothes off and putting on one of those ridiculous hospital gowns that close at the back and have poppers all over them that are supposed--and fail--to make them wearable without exposing one's bum.
The first of the nursing staff we met was Nurse Becky, whose responsible task was to lean over me, with her face close to mine, and ask me my name and my birth-date. And then she said, "And you are going to have a ......?" And she looked at me, smiling, and waited. "A pacemaker, " I said, eventually. This must have convinced her I was the right patient, and she passed me over to Henry, who had been fluttering around in the background. "I am a male nurse," he said, "But I came in too late to put my uniform on."
It seems that Henry also works as a flight attendant for Delta Airlines. "I do the hospital work for a giggle," he said, which I did not find encouraging. He took me through several forms to sign and started me on a drip--or at least put in the valve or shunt, or whatever they call it, so that sedatives, anti-biotics, and a saline solution, could be dripped into me. And then two burly figures appeared, dressed in their blue scrubs with their little blue caps over their hair, and wearing surgical masks.
 "This is Kay," said Henry, "And this is Sean. They'll be prepping you for the surgery." Sean spoke a few words and was obviously Russian--a typical Russian bear of a man. "Hey," I said, "How come a Russian has an Irish name?" "Long story," he growled, "My father is Russian, my mother is Greek." As if that explained his Irish name.
These two characters pushed me into the operating theatre, rolled me onto the operating table, and went to work sticking electrodes all over me, from my upper body to my calves. They shaved away a bit of hair below my right collar bone, where the "thing" was going to go in, and stuck two little pipes up my nostrils to provide oxygen. The heart monitor started beeping, and I could see that the rate was jumping around above and below forty. The nurse said to the surgeon, "Look at the monitor, Doctor." His reply was, "That's why he's here." They covered my face briefly with a couple of cloths--why I know not--and when they took them away, there was a cloth screen that prevented me from seeing where the action was going to take place. Then I had a terrible itch in my right thigh. "Please someone," I said, "please scratch my right thigh." and someone did.
And the next thing I knew was that I was on a gurney, being pushed by Kay and Sean into a lift and up to my room, where I was the sole occupant. Joan arrived shortly after, having seen the doctor. He had assured her that all had gone well--no complications, everything wired up, power on, and the pacemaker was working properly.

Holter Test Result

We need to back up to the experience with the Holter monitoring of my heart, as that was what led to the pacemaker.
I wore the Holter for 24 hours. There were seven wires that were attached to me--mostly around my chest and upper body--and these were connected to the machine, which was worn around my waist. I say, 'machine,' but it was a small computer, about three inches wide, an inch thick, and seven inches long. I was also given a 'log,' in which I had to enter my activities. I tried to do all the things I normally do, including my daily exercising on the elliptical trainer, some fast walking, and some stair climbing.
I looked like a suicide bomber. I wore the thing for my recording session that day, and I kept it hidden when we went out to a restaurant with friends that night. It made sleeping very awkward.
We were off to England on the day I handed it in to the doctor's office, and I had been told to call from England on the following Friday. On that day, I went down from Paddington to Plymouth on the train and was met by my brother, John, and his wife, Mary, and we drove from the station to my sister Anne's house. From there I made the call to Washington. What I was told seemed reasonably reassuring, although there were the words "a bit worse than I expected." But seemingly there was nothing to alarm me and nothing to suggest that the original diagnosis of atrial fibrillation had changed. An appointment was fixed a day after we returned from London.
Once back in Washington, I saw the doctor again, and it became apparent that my heart rate was not just slow, but also irregular, and on occasions my heart would stop altogether for up to four seconds. "You need a pacemaker, David" And a few days later Joan and I had an appointment with the surgeon who does the pacemakers.  As I was very largely asymptomatic, our first question was essentially, "Is this an-open-and-shut case. Is there any doubt that I need this?" The detailed information that was given to us by the doctor left no doubt in our minds that it had to be done. And so we immediately set up the appointment for the operation.

Tuesday Morning 6.00am

After a night in which I was awake more than asleep, we are poised to set off for the hospital. It's pouring with rain. I am somewhat frightened, I must admit. It is the 13th of the month.

As Dr. Johnson Said...

9.15 pm  Tuesday April 12

Dr. Johnson said something to the effect that there was nothing like a man knowing he was going to be hanged the next morning to concentrate his mind. Now obviously, I am not going to be hanged at 7.30 am tomorrow morning. And many worse things could be happening. I could have stomach cancer with three months to live. I could have throat cancer. I know full well that I am having something that seems to be thoroughly routine; that works well; that people have for ten, twenty years; and so on.  I could count my blessings--that they found out about it in what seems to be the early stages (after all, it did not show on my last annual physical); that the treatment is known to be effective; that it's just one night in hospital...etc. etc. ad nauseam.
But still, the fact that I will have my chest cut open, an electronic device inserted under my skin, and wires run down through my veins to my heart to conduct electric shocks--it does indeed concentrate the mind.
Time for bed.

Stress Test

Tuesday April 12, 2011
 
 I just spoke with the Admissions Department at the hospital, and a charming lady quizzed me on my medical history and gave me detailed information about everything that would happen to me from the time I check in tomorrow morning until the time they throw me out on Thursday morning after the surgeon has checked my condition.
   (Joan on the phone to London--"no, not today: it's tomorrow he goes in...we hope for the best...")
   We certainly do.
   But to go back to the twists and turns of my cardiological history. I had to have a stress test. At the outset, they dripped radio-active isotopes into my veins or arteries, with jokes about glowing green in the dark. Then, settling me in a semi-reclining chair like a dentist's, I was instructed not to move a muscle for 17 minutes, which is a long time not to move a muscle when your nose itches and you fear you are going to sneeze. During those interminable 17 minutes a machine hovers over your chest, presumably recording what those isotopes are up to, and a computer is registering all the information from the electrodes they have attached to your chest.
   Then off to the treadmill, with the attendant carrying the laptop to which you are attached by numerous wires. Speed-- 4.5 mph with the gradient steadily increasing until my heart rate exceeded 122 beats per minute, which is 80 percent of maximum for a person of my age. We went well above that.
   And then back to the reclining chair and another 17 minutes of immobility to check again what the isotopes were doing.
   The doctor: "OK: now have the echo cardiogram, fix an appointment for next week, and I'll give you the results."
   The echo test was next, and I remember few details, except that the person doing it seemed to be embracing me from time to time and I kept hearing ominous gurglings.
   When I went back for the results after a week, the diagnosis of atrial fibrillation had become less clear.
   What was needed was a 24 hour record of my heart activity by means of a so-called Holter. I thought it was Halter, which seemed a reasonable description of what I would be wearing for 24 hours.

The Sorrows of Young Werther

Back from watching a German film about the young Goethe and his romance with Charlotte Buff, who married someone else, and their romance was supposed to be the basis for his greatly successful novel--The Sorrows of Young Werther, which ends with the hero committing suicide. Apparently its publication resulted in a rash of suicides of young men across Europe.

My first visit to the cardiologist after the referral by my GP resulted in a diagnosis of atrial fibrillation. The doctor was very dramatic, showing me with his hands how the upper part of the heart normally pumped blood into the lower part, opening and closing his fingers--pow pow--pow pow. But then he showed me what my heart was doing--one pow, but then the fingers flickered and fluttered around,  and there was no 'pow.' Very dramatic. Atrial fibrillation.

He prescribed new blood pressure medication, and added a blood thinner--pills that I discovered when I picked them up cost $750 for a three month supply. He told me that the thinner would reduce my chances of a stroke from 8 percent to 2 percent. And then, he told me, that after six weeks on the thinners, he would shock my heart, and there would be a good chance it would get back into normal rhythm. How long it would stay like that: well, he did not know. maybe twenty four hours, maybe 25 years--which would take me to 101.

But I had to have a stress test.

The Mozart Requiem

The Requiem was magnificent. What a legacy Mozart left behind him after his 35 years in the world. And here am I, more than twice his age, and what will be the legacy that I leave? Not much. This heart problem does bring home to me, more strongly than before,  that there may not be that much further to go. Of course, one always thinks about death, and that gets more significant as you get older, and you ask yourself, 'Have I ten years more?' Or, "Have I five years more?" Or could it be that when I have this pacemaker thing inserted that they will find something worse than has so far been revealed.

Leaving the Kennedy Center, we stopped at a small shopping place on the campus of George Washington University, and I bought myself an ice-cream cone that I thoroughly enjoyed. Four weeks ago I would not have bought it--too many calories, too much fat, too unhealthy. But now, what the hell? Buy it: enjoy it: forget about whether it's healthy or not.

Pacemaker

The time has come to start a new series in this blog. Or a new sequence. On Wednesday the 13th of April, 2011, a Doctor Dwyer will cut a hole in my flesh below my right shoulder, thread some wires through my veins down to my heart, connect them to a pacemaker, and sew me up and send me home after one night in hospital. (Why do Americans always say 'the hospital.'--as if there is only one.) And from then on, if my heart rate drops below a certain pace, the pacemaker will shock it to raise its speed. All very simple. Lots of people have them: nothing, really, to worry about.
This all started with my annual physical towards the end of February. These annual check-ups have rolled on from year to year with my taciturn GP telling me something like--"You're Ok," "You are pretty fit." Or some few words like that. This year it was different: "The cardiogram shows some atrial fibrillation and I think you had better see a cardiologist. Here's the name and phone number of one--he does the electric shocking procedure, which is what you will probably need."
It was like being mugged: like strolling along merrily on a nice day, admiring the cherry blossoms, when out comes someone from behind a tree and hits you over the head. The heart supposedly lies at the centre of your existence. Physically and, metaphorically, emotionally--although we all know that the emotions are in the brain and have no connection with that meaty muscle that beats away in your chest. And those health problems that attack your brain are more deadly to the essential YOU than problems with hearts, lungs, bowels, or kidneys.
To be continued. Now Joan and I are off to the Kennedy Center to hear Mozart's Requiem--that should cheer me up...