Due October 24: Beginning of second long essay

Heart Attack

           

            During the summer of 2005 I had gotten into really good shape.  I was regularly lifting weights and running three miles at the Kean University track.  Suddenly, during a workout I felt a shooting pain deep in the lower portion of my right calf.  It took several weeks to get better, and when I resumed walking, a new pain (probably related) began to appear in my right heel.  The bottom line was that, from late that summer until February 2006, I barely exercised.        

            I did not go to a doctor to find out what was wrong with my leg.  Like forty million other Americans, I had no health insurance.  An orthopedic surgeon would probably want an MRI and other tests to determine a diagnosis and course of treatment; I did not have $2,500 in discretionary income.  As I type this I am thinking, “When did medical care become discretionary?” 

            I hoped it was nothing serious and would get better on its own.  I was an atheist who was engaging in faith-based medicine, which is dangerous on several levels.  No one hears the prayers of a non-believer.

            On Sunday afternoon, February 26, 2006, an unseasonably mild day, I decide to resume my exercise program with a vigorous one hour walk.  After about one hundred yards, I start to feel pressure in my chest—the same pain that I occasionally feel while walking to the train on my way to my part-time employment as an adjunct professor of English at Kean.  I see a cop, who is parked and observing traffic, and I wave hello, but as I walk past the police car, the pressure in my chest gets a little worse.  I decide that before I am too far from home I will head back for an aspirin. The officer, who knows me casually, rolls down his window and asks, “Out for a fitness walk?”  I answer, “Yes,” but I am not happy with the whole process of talking. The pressure has now radiated to my right shoulder, and by the time I arrive home, as I try to open the aspiring bottle, my hands are shaking.  Gail, my wife, is food shopping and my kids are away at school, so I am alone.

            I decide to sit for a bit.  As I chew on the aspirin, I notice that I am sweating more than my minimal walk would account for, so I get the telephone and keep it in my lap.  I am thankful that the police car is parked only a block away, and I rehearse dialing 911 in case I start to keel over.

            I am fifty-three.  Fifty-three year olds drop dead of heart attacks all of the time.  My friend Larry Gibson, an oral surgeon with whom I used to workout, could not be resuscitated after a three mile run.  In 1997 he and I were training together for the New York City Marathon. Now he is dead.

             As I continue to sit on my couch thinking of Larry, I say to myself, “This is nuts.  If I black out I will not be able to dial even 911.”  So I dial.  If it were not for the money I would not have hesitated.  As I press the numbers on the phone I assume I am automatically incurring, minimum, a thousand dollar debt—a debt I have no present ability to pay.  On the other hand, if I do not call I might never have to worry about any other obligations other than to my maker, whose existence I seriously doubt.  My uncertainty in that regard may soon be resolved—a variation of the old joke, with Larry Gibson saying to me, “Good news and bad news, Lew:  yes, there is golf in heaven.  Unfortunately, you will be in my foursome next weekend.”

            I have barely hung up the phone when cops and EMS are in my living room; I think five people in all.  Everyone is concerned, but they are talking mostly among themselves.  “BP 190 over 130,” one says to the other.  They snap an oxygen mask over my nose and spray what I later learn is nitroglycerine under my tongue.  But the funny thing is just before the first police officer arrived, the pain subsided and now I feel like a total fool.  Someone asks me, “Sir, on a scale of one to ten, how would you rate your present chest pain?”

            “Zero.”

            They hook me to an EKG.  I tell them, “Don’t be alarmed by the tracing.  Apparently I had an old MI that shows up and is sometimes read as an acute heart attack.”

            When asked if I know I have high blood pressure I reply that I had stopped taking my blood pressure medication more than a year earlier.  Later I would read in the EMS report, “Patient is non-compliant with BP meds.” 

            Non-compliant?  Diovan HCT costs ninety bucks a month—which I paid without fail for a year following my first (and only) consultation with a cardiologist.  That was back in the day when I had health insurance through my wife’s employer (that cost us almost her entire paycheck).  I was about to undergo orthopedic surgery to remove a calcium deposit from my shoulder—at the time, I could barely lift my arm—but I failed the preadmission physical.  The internist said, “I want you to see a cardiologist,” and when I assured him I would, he insisted, “No.  I mean now.  I have made the appointment and he is waiting for you.  Here is the address.”

            The internist’s computer had interpreted my EKG as “Myocardial Infarction”—heart attack—and when I was examined by the cardiologist it is he who explained to me about the scar in my heart tissue that shows up on the computer program as “Rule out acute MI.”   I do not recall ever having had a heart attack.  Was it the time, at Yankee Stadium when I felt dizzy after two hot dogs, a knish and a jumbo beer and then walking up the ramp from the mezzanine to the upper tier?  Who knows?

            For a year I religiously took the Diovan that kept my blood pressure under control. Even though the prescription was for 90 pills, the last few refills were only for 30 because, when we canceled my health insurance, I could not afford $270 for the three month supply so I only got 30, and then continued to refill at the lesser amount.

            The last time I tried to refill my prescription, the pharmacist, a friendly woman who I have known for years, told me my prescription had expired. I was certain that she was mistaken. The doctor had written for 13 refills of 90 pills each; the prescription was good for at least two more years. 

            She shook her head.  “That may be, but prescriptions are only good for a year.”

            I was incredulous.  “Are you telling me that two weeks ago I could have gotten 90 pills, but this week I can’t get any?  Can’t you back date the prescription?”

            She replied, “I am not going to violate federal law for you.”

            Can’t you call my doctor?”

            She told me that she had already telephoned him. “He won’t renew your prescription without seeing you.”

            I did the calculation that every citizen without health insurance is forced to perform: My visit with the cardiologist, with a mandatory EKG, would cost about $750.  Without the examination he would not renew the prescription.  I know. I called him, or rather, I called his office and his staff would not let me speak to him.  His twenty-something receptionist told me that, without a full exam, my prescription could be extended for only 30 days.

            Here’s a question:  Which exposes a physician to greater liability: issuing a prescription without an examination, or denying medication to someone with a chronic condition who needs it?

            What I did when the medication ran out was to dust off Dr. Joel Fuhrman’s book, Fasting and Eating for Health, and go on a fourteen day fast—nothing but water—that I hoped would force my body to consume the atherosclerotic plaque in my blood vessels that was contributing to my high blood pressure.  Sure enough, throughout the fast my blood pressure was a salutary 110/70.  But not even Gandhi can fast forever, and I neglected to follow Dr. Fuhrman’s advice for a post-fasting diet.  I did begin to exercise and watch my weight, but then I had the leg injury.

            I did not continue to monitor my blood pressure.  What was the point?  Head firmly in sand, I resumed my faith-based approach to medicine by steadfastly refusing to know.

            As I sit on my living room couch with helpful people attending me, I know my wife is going to kill me.  With no health insurance even the most minor emergency room visit is going to wipe us out. Plus, I now feel fine from a heart attack point of view; but my mind is whirling as I weigh the numbers associated with my blood pressure against those of my bank account.

            When I inform the assembled that I am not going to the hospital, the three EMTs and the two cops all begin to bulldoze me with psychological manipulation.  I am frank.  “I have no health insurance, and I can not let a sissy-boy overreaction saddle me with a thousand dollar ER bill.  If I go I will really wish I were dead.” 

            Things that are said include “Charity Care” “Abnormal EKG” “190 over 130” and lots of other stuff, but the bottom line is that they are not going to let me refuse.  On my end it is really just “Gail is going to kill me.” 

            “Can I leave a note for my wife?”

            “Yes. Wait. Don’t get up.  Where is the paper?”

            “There is a pad on the dining room table.”

            “OK, what do you want to write?”

            “This is ridiculous.  Give me the pad.”

            I start to write, and am freaked out by how difficult it is to hold the pen and to get it to make a mark on the paper.  Maybe going to the hospital is not such a bad idea after all. “Hi Gail,” I write.  “EMS took me to Overlook.  I’m fine now, but I had chest pains while walking.”  The EMT tells me, “Give her the ‘phone number of the emergency room,” so I add, “Overlook ER # = 908 522-2232.” 

            She is going to kill me.

            “Look, I am fine.  Can I at least walk to the ambulance and sit up?”

            “The regulations require you go by stretcher.”

            Another spray under the tongue and now I ask, “What is that stuff?”

            “It is nitroglycerine; [pause] don’t worry, you are not going to blow up.”

            I have never felt as fat as when the three of them were trying to load me into the ambulance.  The cop had to help.  Thank god I will be cremated—no embarrassing strain on the pall bearers.

            Next comes a series of typical questions, but one of them is “Religion?”  Answering “None” might earn me a priest; “Jewish” is just too hypocritical—and I do not feel like getting into an argument over Palestine with some schmuck visiting rabbi—so I reply “Atheist.”  Sure enough, I have not thought things through properly.  I get ham for dinner.  The spelling of my last name may be ambiguous, but didn’t anyone check out the size of my nose?

            At seven-thirty that Sunday evening Gail shows up in the emergency room without the Sunday Star Ledger crossword (I had completed the New York Times Sunday puzzle, in ink, the previous day—some sections of the Sunday Times are now delivered on Saturday).  Gail does not need to explain herself to me.  I fully understand her bad reaction to finding me feeling fine in an emergency room intensive care setting.  I know we have no money for this, she knows we have no money for this, and I am just too chipper to suit her at the moment.  Mercifully, she has brought a change of underwear and some toiletries (and my Commit nicotine lozenges).  After nearly thirty-two years of marriage we are at the stage where we have the same thoughts at the same moments, and not just at moments like this, when the shared experience might be expected to produce shared reactions.  We frequently are amused at unexpected congruities in our thinking—simultaneous odd-ball thoughts that would come to no one but us.

            Gail has only been there a minute or two when the nurse pokes her head in the room and says, “I just wanted you to know that I am going off duty,” and then comes Tammy’s double whammy:  “You have had a heart attack and are being admitted.”

            For the moment Gail and my reactions diverge.  I feel smugly vindicated that I have not been a “sissy-boy-cry-baby.”  I am also thinking that the heart attack I have been dreading since I was twelve years old, when my father had his, was not that bad.  The descriptions one hears of “pressure” are so vague that I have always been curious about what it was actually going to feel like.

            Gail, my adoring bride, screams at the nurse, “Noooooooooo.  We can’t afford for him to have a heart attack,” and storms out.

            After my wife leaves, around nine o’clock, blood is again drawn from me and then I am left completely alone until nearly eleven.  I understand why no one is attending to me because I can hear that the emergency room, quiet all afternoon, has become pandemonium.  There is a flurry of activity in the corridor outside of my room.  People are running.  I hear loud, excited voices but cannot make out precisely what is being said.  Then there is the sound of the prolonged wailing of a young woman—a teenager.  Clearly someone has died.  When the commotion dies down, I take a nap.  I have no TV and can barely move due to the IV and the leads of the EKG.

            I am awakened by another round of keening, this time of an older woman, a grandmother perhaps.  I lay in bed thinking how different the sobs of an old woman and a teenager are.  This elderly woman punctuates her rhythmic wailing with phrases in an unknown tongue.  One does not have to understand the words from the Balkans, or somewhere else in Eastern Europe to know that what is being said is, “How could this have happened?  What am I going to do now?  How can I live without him?”

            What sort of a man could provoke such emotion from both a teenager—a lover perhaps—and the spouse of an elderly man?  I conclude that there must have been two deaths.

            With plenty of time to think, I consider another death, that of my Aunt Marian, my mother’s youngest sister, in 1984.  She was a sixty-one year old somewhat obese diabetic who occasionally snuck a cigarette after assuring everyone in the family she had quit.  She suffered a heart attack on a Friday afternoon, and when I visited her in the hospital that evening, she was her usual cranky self.  As a child I remember her scolding me for playing indoors too vociferously.  She had two daughters and apparently when I came over to play, I turned my younger cousin into a “wild Indian.”   It was shocking when my aunt, while still in the hospital, suffered a second coronary, and died Sunday morning.

            It just did not seem possible.  Dying at home or in the ambulance because they could not get you to the hospital in time was one thing; dying of a heart attack in a coronary intensive care unit raised new possibilities.

[I have found among my papers the chart of my hospitalization, including the EMT notes in the ambulance—it is helping to jog my memory. With the chart are my contemporaneous notes including the text of the message I left for Gail on our home telephone answering machine. I think I could easily write the rest—including my conversations with the doctor who wanted to admit me, my attempts to get “discharged against medical advice,” and threatening to pull out the IV if no nurse would do it. I do remember teaching World Lit the next morning and telling my students that I would no longer accept feeble excuses for absences—“I had a heart attack yesterday, and I am here.”]