Dreaded Purple Master

Owner of a Purple Heart

Hoo-boy, has this been an interesting summer for medical.

I’m of two minds about this. On the one hand, I don’t want to become one of those Old Farts who sits around talking about their medical problems at length as if anyone cares. I particularly don’t want to do so since some of you have already encountered them: It’s not like I invented them.

On the other hand, I don’t want to trivialize it to the point of “my chest hurt, but the doctor fixed it and I got better.” I can’t help but think my experience might be helpful to those of you who haven’t been there yet, but who someday might if current habits continue unchanged. (Maybe all Old Farts think that’s true.)

Well, I’ll write what I’ll write. The only unique thing I can contribute is what was going through my head at the time. If you get bored, I won’t be offended if you skip. The end of the story is, I got better.

Heart attack

By now you probably know that I had a heart attack on Monday, July 8.

Now that I know, unmistakably, what a heart attack feels like, I must tell you that it wasn’t the first. I’d felt two or three minor pains in the weeks preceding, but I’d dismissed them as so many people do. I took an aspirin, and they went away after a half hour or so.

It feels like someone is sitting on your chest. You can take deep breaths, but it doesn’t relieve the pressure. It may not even hurt. Taking an aspirin and laying down helps. It could have been anything: Unusually high smog levels, heartburn, anything.

Don’t take chances with chest pains. A lot of heart attacks go undiagnosed. Emergency medical personnel are beginning to err on the side of treating for angina, hence John’s (the kids' godfather) recent procedure. One nurse told me about a woman who had experienced several attacks, but had attributed it to heartburn and an ill-fitting bra. When she finally had a Big One, they found numerous blockages. Another friend recovered quickly from his cardio-cath because he had the good timing to get it done before he actually had a heart attack.

Don’t take chances with chest pains.

Monday 1:15pm

Anyway, I was on my way to work early Monday afternoon: I had stopped at a Publix near work to get a boxed turkey cobb salad for supper.

As I got out of the car, my chest began to ache.

When I got to Publix’ front door, I realized I had left my wallet in the car. Did I recognize this as a sign that I wasn’t thinking clearly? No. I just got it and went back in.

By the time I reached the checkout counter with my salad, I was leaning heavily on the check-writing stand. Yes, I know, a sensible person would have told them why, and asked them to call 911.

I didn’t, for reasons that made perfect sense at the time. It all came down to one simple statement from which everything else followed: I know I can count on Jake.

If I call for an ambulance myself, I’ll have to try to tell them where I am while I’m going through this. If I tell Publix to call on my behalf, they can do that – but how safe will my car be in their parking lot for an indeterminate length of time? Plus I’ll have to call Jake anyway (Jake is my immediate supervisor).

If I can just manage to drive the couple of hundred yards down the street to work, I can park where my car will be recognized by my co-workers. Then I can use my cell phone to call Jake to let him know my situation. If Jake doesn’t have Oreta’s work number on him, his wife Nancy will have it handy.

I didn’t really reason any of this: If I’d been thinking clearly, I would have called 911 before I ever left the house.

Everything pretty much happened as I intended. I never lost consciousness, and I never felt that I was going to. But the person sitting on my chest had become an elephant.

I made it to work, realized I wasn’t going to be able to walk in (!), and got out the cell phone.

Jake’s line rolled over to voice mail. Great. He’s on the phone. (That’s not unusual.) I left what he later told me was about a thirty-second message. I was trying to be casual about it, but somehow “I think I’m having a heart attack” doesn’t lend itself to that approach.

It still didn’t occur to me to call 911 myself. One of the disadvantages of parking where I did is that it would be more difficult for the EMTs to find me. I was stuck on “reach Jake”, and I couldn’t change tasks now.

I called the center’s main number, the one that by contract we always answer. Or, I tried. “Network failure”, said the cell phone.

Oh, so this is how it’s going to happen, is it? I thought. Free nationwide roaming and long distance, and I can’t call someone less than fifty yards away.

Two more network failures. And one wrong number. By now my hands are shaking so badly I can’t dial the number straight. And it’s not like it’s a complicated number, it’s on my speed dial. It’s three keystrokes, 2-“yes”-“yes”. Work is number 2. Isn’t that a clever mnemonic? C’mon, you idiot. Dial 9-1-1 already. What does it take?

Ah. It’s finally ringing. “For purposes of quality control this call may be recorded or monitored.” I’ve never been happier to hear that.

I explained my situation to Teena (our call screener), who told Jake, who stuck his head out the back door, took one look at my gray face, and told her, “call 911.”

I didn’t perceive myself as moving slowly, but everybody else was on fast forward. Jake in particular is startling at that speed. His normal stride is something of a leisurely amble, which works well in our workplace. Everyone who calls us has an Emergency: Just ask them, they’ll tell you so. Store’s too hot. Store’s too cold. Stockroom light is out. Need overnight lights for floor maintenance. Customers are leaving the store! Jake’s body language reassures everyone around him that it really isn’t that big a deal.

Now I’ve seen how he moves when he thinks the situation actually is urgent. Now I’m worried.

Jake came out to do a quick layman’s triage. “Do you have any aspirin with you?”

“Yes, I always carry some. It’s in my book bag in the back seat, but I can’t reach it from here.” (For some reason, old-fashioned aspirin seems to have gone out of style. The first-aid box in the break room stocks only Tylenol. Everyone who carries some kind of pain reliever carries something weird. Nobody has plain old aspirin anymore. That’s why I had it.)

Jake retrieved the bottle for me: Julianna brought me bottled water to take it with. I don’t think I’ve ever seen a black woman go pale before.

Jake tells me that my color improved dramatically when I took that aspirin. Hm. So maybe all those advertisements for aspirin as heart therapy aren’t just another sales tactic. Maybe it’s not just another way to sell aspirin to people who don’t need it.

I heard a siren from nearby Johnson Ferry Road. “Is that my ride…?” Within a half-minute – well, I want to say it’s a half-minute, but my time sense can’t be trusted – a fire truck rounded the building.

“I’m only in pain, I’m not on fire.”

Jake heard me say that and concluded that I was in good spirits. One could as easily have concluded that I was delirious. I guess Jake knows me. (I had a brief Captain Kirk moment: When I really do go crazy, who’s going to be able to tell?)

The fire truck, of course, brought the Cobb County EMTs, closely followed by an ambulance from Northside Hospital.

Far too many people for me to keep up with now. One wrapped an oxygen hose around my head (it stayed there for a day and a half), two more verified my identity and condition, mostly asking the same questions. I considered it a good sign that I was aware enough to answer them all—

“Where do you want to go?”

I have no idea. I’m open to suggestions. A hospital seems appropriate.

I don’t know who said “Kennestone”, but Kennestone Hospital it was. Jake said he would call Oreta, the EMT started rolling up my car window and locking my door, they strapped me to a gurney and loaded me into the ambulance, and we were off.

Kennestone

The ambulance ride was moderately uneventful – for me. The EMT put an IV needle in my left hand for an aspirin drip (installed an IV in a moving ambulance!), and administered a dose of aerosol nitroglycerin. He wasn’t very talkative until we got close to Kennestone when he contacted their ER dispatcher and started rattling off my vital signs.

However, he was able to establish that my attack was following the textbook pattern: shooting pains down my arm, up to my shoulders and neck, to my jaw… A second dose of nitro…

By the time we arrived, it was standing room only in the Kennestone ER. I was transferred to a gurney and left in the corridor at the nurses’ station (!) until Dr Crews got to me.

Which is not to say I was abandoned. Nor that I was the center of attention, either, but I had enough.

I have no clear memories of anyone. I know that I was never anything less than fully alert: It’s just that so many people poked at me and asked me the same questions that I couldn’t keep them straight. I suck at names and faces.

About the same time they cleared an actual examining room for me, and hooked me up to an EKG (and a second IV in my right hand). Oreta found me during all this. I was startled to see her, if only because I couldn’t understand how she’d gotten there so soon.

I found out later that it had seemed like a monumental delay to her. Oreta had called Kennestone the moment Jake told her I was being taken there. I probably wasn’t there yet: I certainly wasn’t in their computer records. This probably didn’t reassure her. She had John collect kids and herself and head northward to Kennestone, continuing to call the hospital on her cell phone.

Anyway, Dr Olmstead (their cardiologist) realized that although they could run a diagnostic procedure on me at Kennestone to determine the location and extent of the cardiac blockage, they would have to send me elsewhere to actually do anything about it. Rather than have me endure essentially the same procedure twice, he transferred me.

Crawford Long

Crawford Long, located in midtown Atlanta, is a part of the Emory healthcare system, and one of the pre-eminent cardiac facilities in the country. Certainly everybody – the nurses, Dr Olmstead, the second ambulance crew – all knew of Dr Henry Lieberman, into whose care I was being placed.

The ride down was, again from my perspective, uneventful. The other cars careening out of the way of the ambulance siren might have had another perspective.

This trip, I had a much more talkative EMT, a Mr Amari. He explained to me exactly what cardiac artery blockage meant, and what Dr Lieberman would probably do. (The EMT’s father was undergoing the same procedure on the same day, half a world away in Israel.)

This is a good thing, because Dr Lieberman didn’t go into a great deal of detail himself.

The oversimplified version is, cardiac arteries don’t clot closed per se: The capillaries serving the arterial wall do. Occasional damage to these capillaries is not that unusual, and the body can work around it by increasing capacity in the surrounding area – within limits.

As the capillaries clot closed, the arterial wall thickens. This is what’s known as “hardening of the arteries.” If it thickens enough, it impedes the flow of blood to the heart itself. That’s what happened to me.

At least, that’s how it was explained to me. Blame any inaccuracies on me, the untrained listener. What do I know, I’m only the patient.

The procedure they’re going to perform on me is relatively new, yet it has become the definitive treatment short of opening the chest. Dr Lieberman is the man who developed it. Normally he sits in the observation room and advises the attending physician. He’s the doctor other cardiologists call for advice on cases like mine. He’s on call today. He will be working on me himself.

Have you seen those Office Depot commercials where the expert you need happens to walk into your life at the moment you need him? Remember those two women in the elevator, idly wondering “What is that song?” as the door opens and Dick Clark answers, “That’s the Cornelius Brothers and Sister Rose.”

All right, I guess it’s not quite like that. It’s not really much of a surprise to find one of the nation’s premier cardiologists on staff at Crawford Long.

In fact, when my father went to Crawford Long twenty-five years ago with the same symptoms, Dr Lieberman had been his doctor too. At that time, all of the options involved opening dad’s chest. This, I think, is why my mother was so upset when Oreta called her with the news about me.

Today, there are other, less traumatic, more effective treatments. (I mentioned John’s cardio-cath treatment about a month ago, prompted by a false-positive blockage reading. Dr Lieberman worked on him too. It’s a small world.)

Cath lab

They have so many names for these procedures that I’m going to settle on a couple, which I’m probably going to misuse.

Oreta caught up with me again at Crawford Long’s cath prep room, where they were checking my IVs, verifying my medical history again (when did you last eat, what are you allergic to, do you eat shellfish – why the hell are you asking that? Are you serving it? Is shrimp the après-cath snack du jour?) (Actually, I know: it’s the standard iodine reaction check), and taking away my clothes. That’s the point where you cease to be a Visitor and become a Patient: When they won’t let you keep your clothes. It's hard to pretend you're just visiting when you're naked on a table.

If you have any modesty, don’t get sick.

Corollary: If you get this sick, screw modesty. It’s the least of your problems.

Oddly, once my clothes were gone, it wasn’t a problem anymore. I thought it would be, since I really am a very shy person. Go figure.

Oreta got permission for my kids to come in and say hi, just to reassure them – by which time I was in good enough spirits to actually be reassuring. The room I was in might not have been so reassuring – It looked like there were five of us patients, in a room designed for two. Sarah helped gather my clothes and cheerfully pointed out that my shirt stank. I don’t wonder: I was sweating rather heavily.

And then they gave me some more drugs and wheeled me into the cath (short for catheter) lab. Here the last in a series of people apologized (again) that they were going to have to shave my pubic hair. Of all the things that are going on, everyone seems to think that this is the one that’s going to bother me. *shrug*[1]

My procedure involved three basic parts. The cardio-cath part meant they would reach my heart by going through my leg. The incision – do you really want to know this? – was in my right groin, in the fold between my leg and gut, at the closest approach to the right femoral artery. Dr Lieberman would thread a wire up the artery to my heart.

The angioplasty part meant they would open the blocked artery with a balloon, possibly the oldest part of this procedure.

Then – and this is the part Dr Lieberman invented – they would thread a small metal spring (called a stent) into the artery, then use a balloon again to open that up so it would hold the artery open. Over the next few weeks, the arterial wall will grow over the stent, which will stay in there permanently.

They used to do this with just the balloon, without the stent. The stent reduces a 30% recurrence rate to 10%: Proper care and good habits can lower the odds still further.

I was moved to an unusually skinny gurney[2], which was then moved between and inside a series of substantial metal arcs anchored from the ceiling. They were real-time x-ray video cameras: Dr Lieberman could see what he was doing almost as clearly as if I were open.

And so could I. The anesthetic was local: I was awake and aware for all of this.

I could watch him inject the x-ray-opaque dyes into my blood and see the shape of my cardiac arteries follow the shape of my heart. I was never able to identify the one he fixed: I think it was deliberately out of my field of vision.

At one point, Dr Lieberman said, “Turn your head to the left.” I did. “Now to the right.” I did. “Looks like you’re going to have trouble with that incisor on the left.”

*sigh* Medical humor.

I didn’t have the presence of mind to ask him if he thought he could take care of it from where he was.

On the other hand, what if he’d said yes? I’ve never had a tooth pulled through my crotch before.

I’m told that Skip Caray (Braves baseball announcer) was at Crawford Long at the same time, to undergo the same procedure on the same day I was. (There aren’t that many places you can go to have this done.) I never saw him, if so. But then, for him, it was scheduled, and not an emergency response to a heart attack.

The only part of the procedure that actually hurt was the removal of the catheter at the end, and the pressure applied to the incision. Even that was nothing compared to the attack itself.

No stitches: The entry point was far too small to need that. These days, they cover the area with a sheet of adhesive pseudo-skin. Since it’s transparent, they can see whether, and how much, the incision drains. I’m still pulling the odd bit of rubber-cement out of odd places.

The procedure took about 45 minutes. They wheeled me out of the cath lab well before 6pm. It seemed like forever: It was still broad daylight outside.

Monday PM – Tuesday PM: Cardiac ICU

This part I’m foggy about. Through some combination of the continued effect of the drugs I was being given, the ability to relax somewhat now that my pain was gone, general fatigue, reaction to stress and lack of sleep (as you know, one thing no one ever gets in a hospital is uninterrupted sleep), I have few clear memories of the day I spent in the fourth floor cardiac intensive care unit.

I remember, finally, getting to eat (remember, I was on my way to get lunch when the attack happened). I know Oreta fed me. I didn’t remember what it was until she reminded me. (Mashed potatoes and spinach.)

I had also forgotten, until Oreta reminded me, that the kids came in very briefly (all the nurses would allow) to wish me well and be assured that I was being looked after. And that Father Tanghe had come by to pray over me.

I remember vividly that I could not urinate while lying down to save my life. I was connected to four, count ‘em, four IV bottles, and they kept that quart bottle of drinking water ever-full, so I really needed to go, but I simply could not do it. I was miserable.

Eventually, they bent the rules enough to prop me up close enough to vertical to manage it.

There’s no phone in an ICU room, and apparently one of my fellow patients had a huge family: The ICU waiting room was always full of ‘em, and always one of ‘em was on the phone. And if Oreta was in the hospital at all, she was probably in the room with me. So, if you tried to reach her on Monday or Tuesday, that’s why you failed.

In addition to the four IVs, there were the EKG and blood oxygen sensors tethering me to the bed. I couldn’t yawn without setting off an alarm somewhere. I guess that’s why they call it intensive care.

Tuesday PM – Friday: Room 4133

Blessed relief.

By Tuesday evening, they transferred me to a regular room (still in the cardio wing), and I was able to stagger around under my own power. I was up and walking a day after getting a patch on my heart.

More, although I was still connected to an EKG readout, it was now a portable unit that fit in a pocket of the hospital gown, broadcasting its readings to the nurses’ station. Thanks to wireless technology, I could now go anywhere on the floor. Not that I actually wanted to go any further than my own bathroom.

Do I seem to be attaching too much importance to that? I never appreciated so much being able to go to the bathroom by myself as during those 24 hours when I couldn’t do it.

Now, also, I had my own phone. Everyone who had been trying to reach me could do so.

Just as well the laptop doesn’t work any more: I might have tried to go online from my hospital bed.

I was watched and maintained, but very little was explained. Oreta finally said it best: Auto mechanics don’t talk to the car.

Apparently, my blood sugar is elevated, but not dramatically enough, consistently enough, to lead them to definitively say “you’re diabetic”. This is a subject I’ll have to pursue with my regular doctor.

They started sending me an extra bag of food at night, though, saying “diabetics need snacks.” I don’t know what they expected me to do with the cornflakes and mayonnaise the bag contained. Oreta brought me a zip-lock bag full of sliced bell peppers (which I love, and which are diet-friendly no matter what they’re worried about).

Under the surface, there’s a level of disorganization at Crawford Long. I hate to say that. But Oreta fought all week to talk to the hospital pharmacist, the nutritionist, and the diabetes educator, all of whom (our nurses said) we were required to see, none of whom could seem to find a few minutes to satisfy this requirement. Hey, they knew where I was.

Even my own cardiologist didn’t exactly wear out his welcome in my room. Maybe I should have had them disconnect me from the EKG so I could shower. Maybe I should have showered while connected to the EKG. I’ll bet that would have attracted some attention.

Friday: Free at last!

Free to find out what it’s like for real people to get drugs. Doctors command drugs and they appear. The rest of us take prescriptions to pharmacists and hope for the best, little suspecting how many ways it can go wrong.

Oreta didn’t learn until she arrived at the neighborhood CVS pharmacy that three of my medications weren’t ready, and weren’t going to be ready until Monday – if then. She had left two numbers at which she could be contacted: Pharmacists apparently don’t do the phone thing, even when they say they will. Not one of the several pharmacists we dealt with ever phoned us about any of the problems they encountered (and all of them encountered at least one). All of these questions could have been resolved in a matter of minutes, had they done so.

One drug wasn’t covered by Blue Cross: The doctor would have to call in an alternate. The doctor’s office was closed by the time we found out about this.

They were out of stock on my emergency nitro spray: They would be able to reorder, but it wouldn’t arrive until Monday. If we requested it, the prescription could be transferred to the Ansley Mall store, which had it in stock now – if we could get there before they closed. (By the time we knew it was a problem, we couldn’t.)

The third, lovenox (LOW-vuh-nox), is an anti-coagulant that prevents blood clots from forming around the stent. This is administered by injection. Many patients self-administer: Oreta is doing mine. (I’m OK with needles as long as I don’t have to watch.) This continues until the pill I’m taking for the same purpose, coumadin, has built up to sufficient levels in my bloodstream.

(Coumadin, by the way, is actually warfarin sodium, a common rat poison.)

Apparently my dose is a new formulation: The manufacturer may have underestimated the demand. Few drugstores not associated with hospitals carry it at all.

Dr Gentry (Dr Lieberman’s associate at Crawford Long) knew that lovenox would be hard to find: He called my local CVS with the prescription on Thursday morning, while I was still in the hospital. When I called CVS back to verify that the medication had been ordered, they told me they didn’t have current insurance information on me, and that I would have to bring a card when I came by.

I now realize that I should have taken nothing for granted: I should have asked if they had actually ordered the medication, or if they intended to. Evidently they didn’t, nor did they make any record of the calls.>

I’ve told you the situation all in one lump, but I assure you, every scrap of that information was hard-won: The pharmacists fought not to tell us what was going on. Some of it I didn’t learn until the Wednesday after I was released.

So far as the pharmacists are concerned, the story ends with “we don’t have it, we can get it sometime next week.” They seem to feel we should be happy with that.

Trust no one. Verify everything.

Maintenance

I have an astounding array of pills to take daily: Cholesterol lowering (lipitor), blood thinners (coumadin, aspirin), ACE inhibitor (altace), beta-blocker (toprol), anti-clotting agent (plavix), diuretic (hctz).

The lovenox injections will stop once the coumadin reaches its proper concentration in my blood. (Note 7-19: That just happened.) In turn, the coumadin will stop when the risk of clotting at the stent passes. My daily children’s aspirin will become an adult aspirin at the same time.

In addition, I carry an emergency nitroglycerin spray, should I need it. Let’s hope not. Nitro tastes… well, like nothing I’ve ever tasted before.

The rest of the medications we’ll revisit once I manage to lose forty pounds. (!) Dr Lieberman expects me to work up to 30 minutes a day of exercise: Walking will do nicely.

Oreta is working hard on rearranging my diet. The home-cooked food Oreta serves isn’t all that far from what I should be having, it’s just that I rarely eat it. I’m never home at mealtimes, and it’s too easy to stop by the Taco Bell across the street from work. No more of that.

If I am diabetic, then it will also be more important that I eat regularly-spaced meals, and that each meal be more balanced. For an awful example, here’s my current schedule:

11am            Up

12pm            light lunch (a sandwich), sometimes (often nothing)

1pm              bath

3pm              leave the house: pick up two meals to eat at work on the way

4:30pm         Start work, eat lunch while working (fast food, often Taco Bell or Arby)

9:00pm         Dinner (usually Publix salad)

1am              leave work

2am              arrive home

2:30am         go to sleep

This could be why my blood sugar levels were so far from what they thought they should be: My day hasn’t followed a normal workday schedule in many months. There’s obviously a lot of room for improvement here. But habits can be changed. And they will be.



[1] Oddly, the day before, I’d stumbled upon a related bit of medical humor on the web. A young woman was brought into the ER for, it developed, an appendectomy. She had numerous tattoos and oddly colored hair. Once they had her on the table in a gown, the orderlies saw that she had dyed her pubic hair green, with a tattooed sign just north of it reading “Keep off the grass”.

The nurse who applied the dressings to the incision left a note: “Sorry we had to mow the lawn.”

I never had an opportunity to tell this joke at the hospital. Probably just as well.

[2] I say this because there wasn’t room on it for my arms. My left was wedged between my hip and a guardrail: My right flopped about for a bit until I found the only place I was allowed to put it: Behind my head.


Daniel Taylor: Saturday, July 20, 2002