CHAPTER 1
Are You Kidding? A Lesson in Denial
"Having a hard time getting through there?" I muttered as I lay partially naked on the cardiac catheterization table.
Doctors and technicians were bunched near my right groin, all of them wearing surgical gowns, their faces covered by masks. My question ignored, there was absolute silence in the room except for the regular chirping of my heartbeat on the monitor above my head. Everyone appeared to be frozen and speechless, as all eyes were fixed on the x-ray monitor that was well visualized by the group huddled around my groin, where the catheter to my heart arteries had been inserted. My own eyes were fixed on the monitor as well. In fact, I was surprised at how easy it was for me to view the x-ray images from my vantage point. The image of the blocked artery, after dye was injected into it, was not pretty, but the drugs I was being given suspended my angst.
The catheter tip was abutted up against an obstruction in one of my coronary arteries. Every time the doctor tried to burrow through it, I felt a gnawing dull ache in my chest. At that very moment, I felt impending doom; and yet I also felt very detached, as if at a movie theater watching someone else's possibly fatal experience, not my own. In retrospect, the doom was from my heart rhythm being disturbed from blocked blood flow through the affected coronary artery caused by the catheter burrowing into an already severely narrowed blood vessel. The changes in heart rhythm caused my blood pressure to transiently fall, leading to the pressure/pain in my chest and the feeling of impending doom. The cause of the artery narrowing was critical plaque buildup that caused a near-complete blockage of my coronary artery from processes of long-standing vascular inflammation.
In spite of this drama, the drugs made me not care much about what happened to the catheter. I was more or less an inquisitive bystander. My thoughts turned to a synopsis of my life as I knew it. In snapshot moments, it passed before me: my childhood, medical school, my family, my patients. It was as if I was suspended in animation, as my mind wandered aimlessly to the best thoughts of times past. And then, suddenly, the room went dark, and my consciousness abandoned me. I sank into a dark space, a black hole, as if in a deep sleep. I was out. Was this death knocking?
I woke up in a large well-lit room filled with noisy chirping monitors and surrounded by pulled curtains. I had an IV in my left arm, a blood pressure cuff on the right arm, an oxygen cannula in my nose, electrodes all over my chest, and a dull, pervasive ache in the right groin. I felt as if I were strapped onto the bed, as I could not move because of all the paraphernalia. Bewildered, my first thought was, Where am I?
Relief followed, as I realized that this room could not be the afterlife, which I was not prepared for. With some additional passage of time, I began to be aware of gnawing pressure and pain that centered on the right groin: a large heavy bag of some kind rested there.
I yelled, "Can someone get this bag off my groin?"
A nurse, businesslike but friendly in her demeanor, came to my assistance, quickly checked the groin bag, and with a smile explained, "The bag is there to keep the hematoma from getting bigger. Things went well; you are in the recovery room." With that, she left as quickly as she had come, closing the curtains as if I required isolation.
Mission not accomplished. The bag stayed, and the pain increased. Recovery was not all that it was cracked up to be.
All voices outside the curtains were drowned out by the incessant chirping of the monitors around me.
The next time the nurse poked her face around the curtain, I blurted, "I'm hungry. Got anything to eat around here?"
Amused, as if I was some type of drunken sailor rather than a doctor, she gave me a Mona Lisa smile. After once again checking my groin, she politely said, "Once you get to your room, you will get some lunch. Not too much to eat here."
I had completely lost track of the clogged artery and the intervention that had just transpired. Eventually, with postanesthesia amnesia fading and having been transferred to another floor and room, I came to understand that a stent had been placed where the critically narrowed coronary artery would soon completely occlude--and which would have likely caused my death. I was spared the details of what actually happened to get it open. The plaque that I had in the left anterior descending coronary artery of the heart is known as the "widow maker." Translated, this means that if completely occluded, absent blood flow through this artery would cause the heart to stop beating and result in sudden death.
That said, changing rooms did not improve my bed-bound dependency or capacity to move, as I was still hooked up to monitors, IV drips, oxygen, blood pressure cuffs, and the large uncomfortable bag in my groin. That night, still with groin pain, I had a glass of wine and a sleeping pill. My next conscious moment was to say hello to my cardiologist in the morning.
"How do you feel?" he said briskly, appearing rushed as he quickly perused my chart. Clearly, he did not expect me to answer with anything short of "fine." "I will let you go home today," he continued. "But you have to take it easy and let the hematoma in your groin heal. Continue the Crestor as well as the aspirin. You will need to take Plavix to keep your stent open. See you in a week."
Without giving me a chance to respond, he scurried out of the room almost as quickly as he had come. Although the exchange was curt, what he didn't say caused relief. The "to do" list that he rattled off was short, and I was going home. The medications I was to take included Crestor, a statin drug used to lower low-density (LDL) cholesterol, as well as Plavix and aspirin, which are blood thinners, to prevent the stent that was placed in my coronary artery from clotting.
Case closed. Or so I hoped. Could my life as I knew it continue? Was this just a bad dream?
As the cardiologist left, a parade of nurses and aides followed, checking my groin, unhooking the IV, and leaving me a lukewarm breakfast consisting of eggs and soggy toast.
Unbeknownst to anyone, with the door to my room closed, I decided to test my newfound freedom. Staggering out of bed with my swollen groin, somewhat dizzy and light-headed, I got to the shower, fumbled with the water controls, and eventually let the hot water pour over my fatigued body. I felt totally hungover.
After several minutes, the hot water relaxed me but did nothing for my fatigue. In slow motion, I stumbled out of the shower and managed to towel-dry myself. It was then I noticed the softball-sized bruise in my right groin. Unfazed, and knowing that I had been on powerful blood thinners overnight, I then proceeded to shave with a razor blade. I looked terrible in the mirror. The entire process had left me gaunt, pale, and old looking. After shaving, I shuffled back to the bed where I could sit and get dressed. With no reason to stay but with judgment impaired from the mix of drugs still affecting me, I then picked up the plastic bag holding my belongings, preparing to leave. Dizziness and groin pain made this difficult. I could barely bend to tie my shoes.
With a bag of clothes in one hand and a plant, courtesy of the hospital CEO, in the other, I slowly limped out, waving good-bye to the nurses at their glass-covered station as I passed it. They appeared oblivious to what I was doing and where I was going, and actually waved back in perfunctory fashion. I took the elevator down to the first floor, where I met my then wife in a waiting car. To this day, I can't remember how this had been arranged, but it was effective in getting me home seamlessly. As I found my way outside to freedom, I heard over the hospital intercom, "Dr. Buckingham, please return to your room."
It was then that some brain fog lifted, and I realized that I had miscalculated one small detail before leaving: my nurse was required to discharge me from her care and go over all the discharge instructions and follow-up. Not feeling any need to know about more details of treatment, and still lacking judgment from being under the influence of drugs, I mustered all the speed that my swollen groin would allow and limped briskly to the waiting car. As I got there, I felt myself swoon from the deep ache in my groin. I struggled to sit and get comfortable on the front passenger seat, placing my plant and clothes behind me in the backseat. At this point in our marriage, my then wife expected these kinds of shenanigans and drove me home without any meaningful verbal exchange. She seemed indifferent, almost detached. In retrospect, even in a failed marriage, she did care and was coping with fear from my stubborn behavior and from what could happen to me. Relieved to be going home, I was in a total fog as to what had just happened. I had no plan or purpose for dealing with a condition that could easily have taken my life.
What had happened? Or more to the point, how could this have happened to me? Just the week prior, I was grinding out twelve-hour days with my busy medical practice. Except for some arthritis, allergies, and asthma, which had gotten a lot worse recently, I had no known health problems. My cholesterol numbers were on the high side, but I thought not alarmingly so. I was not too terribly overweight, and I exercised up to several times a week. My diet on the surface appeared well balanced, but I had my share of cookies, ice cream, and pizza. Sure, I was under some stress, but at age fifty-four, with two teenage kids in high school, and with expanding professional responsibilities, I expected this. After all, who wasn't stressed? I did have some fatigue and heartburn, but I chalked that up to the stress of twelve-hour workdays, the extra cup of coffee in the morning, and not getting enough sleep from hospital night calls.
It would be an understatement to say that I was in total denial of my poor health and the fact that I was on the verge of sudden death. And, even though I had seen this pattern hundreds of times in my own patients, I did not recognize it in myself. My denial had rationalized insomnia, arthritis, difficulty breathing, grumpiness, short-term memory loss, and fatigue. These were all part of just getting older.
As fate would have it, I was very lucky. A few weeks prior to my stent intervention, on a typical morning of answering messages, making calls, and signing off on patient prescription renewals, I got a call from the hospital's surgery suite. "We need you here stat. Your patient is coding!"
I hustled from my office, about one hundred paces to the hospital, thinking about my patient. At age eighty-eight, this man was getting a permanent pacemaker. What could have gone wrong to cause sudden death in the operating room? After unsuccessful resuscitation efforts, he was pronounced dead, with signs pointing toward a pulmonary embolus (blood clot in the lung). I was emotionally drained and terribly upset by the outcome. And then, as I sat there in the operating room, mentally agonizing over the just then concluded resuscitation, I felt pressure in my chest.
Within minutes of our pronouncing my patient dead, someone called, "Code blue!" Another patient in the ICU (intensive care unit) had gone into shock and required resuscitation. As I opened the ICU door, there were people bustling around with crash carts, chirping monitors, and alarms. The usual chaos that accompanies a resuscitation ensued. After about an hour, the patient was stabilized: intubated with a breathing tube, placed on a ventilator machine, and hooked up to IV central lines and pressor drips.
I was exhausted like I had never been before at that time of day. The pressure in my chest became more like a constant ache. I dismissed it as chest-muscle or -wall pain.
I walked slowly back to the office, breathing deeply, now two hours behind schedule. I slipped through the private back door and quietly lay down on an exam table.
My plucky office manager found me with my eyes closed. "What are you doing?" she asked. "You never come in like this to lie down. I am getting an EKG."
Before I could get up, she had me strapped onto an EKG monitor, as she swiftly placed twelve adhesive patches on my chest and abdomen to run an EKG.
"Just as I thought," I said under my breath. "Nothing to worry about. It looks fine. Just give me a few minutes to catch my breath from this crazy morning, and I will be okay."
But she feared the worst. Before I could get off the exam table and get dressed, several more people came into the crowded exam room. I was surrounded by nurses and an echocardiogram technician; I could not leave. Too weak to resist, an echocardiogram was performed, nitroglycerin spray was shot into my mouth, and some oxygen by a nasal cannula was even lodged into my nose. All of this was occurring as a nurse friend of mine was summoned and then walked the eighty or so paces from the hospital to my office to begin checking my vital signs.
The echocardiogram (ultrasound of the heart) and EKG (electrocardiogram) looked normal, and after all the drama, I simply had enough. Thanking everyone for their concerns, I was ready to start my morning office hours, almost three hours late. I was sure there were at least a half dozen patients waiting to be seen and probably not too happy about my being late.
My frustration mounted as my persistent office manager proceeded to tell me that my morning patients had been canceled. Instead, she had me scheduled for a CT angiogram of the heart (this test is a special type of computerized tomography scan). In spite of my objections, she would not take no for an answer, and so I was stuck.
At this point, although frustrated and even angry, I had no recourse. My office manager, who had relayed all of the morning's drama to my then wife, did not trust the assessment I had given myself. That is, I felt the prevailing circumstances of the day were sufficient reason for fatigue, and that my heart and chest symptoms were from stress-related chest-wall pain. I was not very convincing.
I realized that to appease both my office manager and then wife, I would have to submit to the test. There was no wiggle room for negotiation. I would follow through and have the imaging heart scan that they had scheduled. After all, it was scheduled over the noon hour and would not interfere with what was really important: seeing my patients.
Even when scheduled and arriving on time, getting the test took longer than planned. Paperwork, explanations, consents, and inability to get an IV started all created delays and further added to the stress of a clock-driven individual like me. Finally completed and taking forty-five minutes longer than expected, my thoughts were not about the result, which I was sure would be normal, but about how I was going to manage my afternoon of patients an hour behind schedule.
I quickly got dressed, and on my way out the door, a staff member in a calm but firm voice blurted, "The doctor wants to see you in the consultation room. It is to your right at the end of the hallway."
The radiologist and I were acquaintances, and my first thought was he wanted to know about my kids and college plans, as one was graduating from high school. When I arrived in the consultation room, the atmosphere changed; it was as if air had been removed from the room. The handshake, coupled with an intense concerned look and furrowed brow, made it clear this was not about the kids. He paused, fumbled for his glasses, and then sitting and leaning forward, with measured words, he told me to look at the screen behind him.
Images of my heart scan appeared, and with a pointer, he beamed a light to one of my heart arteries. In a monotone, he hesitated and then grimly asserted, "You have a 90 percent narrowing of the left anterior descending coronary artery." Even in denial, the picture did not lie. I could see the dye in the artery and the subsequent abrupt cutoff. There was no way I could rationalize this away. He continued, "This has to be confirmed, but you need to see a cardiologist to have a coronary angiogram and stent placement sooner rather than later." With a look of concern and without much emotion, he shook my hand, led me to the door, and wished me well.
I slowly walked out of the office to the front door, head down, slumped over, speechless, and shocked. Driving the thirty minutes back to my office, I became oblivious to everything around me. I could not focus on any one thought. It was almost as if I were suspended in a vacuum. Thoughts wandered from retirement to planning my funeral. Should I be buried here in Ojai or back in Iowa, near my mother? At least I won't die with the indecency of being a confused, incontinent, and belligerent old man, I thought.
As I lumbered into the office, my office manager already knew the verdict. Paradoxically, she appeared relieved that her suspicions were confirmed. As I collapsed and slumped into my chair, her five-foot frame stood before me as her eyes made contact with mine. Before my deflated spirit could muster an effort to ask about my afternoon, she calmly said, "You have a coronary angiogram scheduled in three days, at 7:30 a.m. You need to shave your groin and not eat breakfast that morning. You are required to be there no later than 7:00 a.m. to register. Make sure to take your insurance card. I have canceled patients for the next week."
