Prognostic Indicators

"What’s your prognosis?”

I get asked this all of the time. When did this become socially acceptable? Lucky for you, I’m an open book with a loud mouth. I'm inquisitive. And I have been trained to think scientifically.

I can go through many different percentages for you. According to a paper published by Dr. Anyanwu in 2003, 20% of heart recipients die within a year of the transplant operation. Afterwards, the death rate is 4% per year for the next 18 years, so that 50% of patients can expect to be alive after 10 years and 15% after 20 years. 

Or I can take a stroll through downtown Philly (with my Nikon in hand), while taking photographs of the skyscrapers that overlook the city that I’ve called home for the last three years. During this stroll, there is a small chance that I will get hit by a car. According to national statistics, there is a 1 in 572 chance that I will die after getting hit by that particular car. It will likely be from blunt force trauma. I will hemorrhage internally, and die a fast or slow death (depending on which organ has been lacerated).

I can carefully search the internet for the descriptive statistics regarding heart transplants— the medians, the maximums, the minimums, the averages of life expectancy. I can educate myself about our mortality rates. My own mortality rate. According to UpToDate, the median survival for heart transplants between 1982 and 2015 was 11 years for adult recipients. Many adult patients die about a decade after transplant. Younger patients usually live longer than that. I can anxiously look up the definition of “young” in two separate peer-reviewed articles. 

Or I can take the time to tackle my next feat. I have always wanted to get my pilot’s license. I was going to do it at some point after my medical training was complete. So, I can sign up for a course and start flying through the horizon, checking off another one of my life’s ambitions. But did you know that there is a chance that I will die while conquering this goal? According to Statistica, 561 people died in air crashes around the world last year. So my plane may crash from some sort of incorrect measurement, perhaps the plane’s fuel will be miscalculated. Most likely (55% of the time), it will be from pilot error— my own ignorance. I will die from penetrating trauma or pressure-related injuries, and my body will burn, slowly, into charred nothingness. 

I can rummage through my desk and find my ripped-up medical textbooks. Or my old notes and Powerpoint presentations from medical school. I can look through the high yield facts that we quickly glanced over about heart transplant patients and their medical histories, the few scribbles I had written down about their terrifying complications. I can remind myself that many heart transplant patients die a slow, painful death after being diagnosed with metastatic cancer. Usually by lymphoma, squamous cell carcinoma, or basal cell carcinoma.

Or I can take the next train to New York City. Or Baltimore. Wherever I feel like going. I can drag someone with me, or I can go alone. But this comes with a potentially fatal risk. According to the US Department of Transportation, there are about 5,800 train-car crashes each year in the US. These cause 600 deaths and injure about 2,300 people in total. So, there is a chance that I will die on the train after an awful collision with a car that just didn’t see us coming. It will be an instantaneous death, after a handrail gets jammed into my chest causing a bleeding gash right through my heart. My cardiovascular system will come to a sudden stop. And then I will die. 

I can ask my doctor about my future co-morbidities. Academic discussions, or as I like to call them, “doctors doctoring doctors." By the sixth year after transplantation, most heart transplant patients will have hyperlipidemia, or high cholesterol levels. About a third will have a rise in their creatinine levels, aka failing kidneys. A third will suffer from coronary artery disease. A fifth will have experienced some sort of cancer. 

Or I can call my parents. I can talk to them to pass the minutes this evening, because I just can’t seem to fall asleep. I can listen to their voices telling me to make sure that I eat, make sure that I stay warm. There is a chance that an unknown someone will then barge into my apartment. I will tell my parents to hold on, and I will open my bedroom door to find a person burglarizing my home. That person will then kill me, most likely with a gun. A gun shot wound to the head, or maybe (more likely) a gunshot wound to the chest. According to 2014 national databases, there are 15.9/100,000 random homicides yearly in Philadelphia, one of the most dangerous cities in America. So I will become a fatal statistic. Random home invasion, random homicide. Cause of death: (most likely) gunshot wound to the chest.

I can Google the longest someone has lived with a heart transplant for. 33 years. That can’t be right. I can Google it again. 33 years????? Perturbed, I can then think about how I won’t even make it to 65. Holy s&%#.

Or I can listen to Tribe’s Beats, Rhymes, and Life in my apartment (on volume 11). I can decide to invite a few people over for a game of Cards Against Humanity. Maybe I can have a beer with them, too. But, damnit— alcohol intoxication can also kill. According to the CDC, about 6 people die of alcohol intoxication every day in the US. So there is a chance that I will die from one too many beers that interacted poorly with my transplant medications. And it won’t be pretty, either. Altered mental status, hypothermia, respiratory depression, cardiac arrest, death. 

I can look up the fancy prognostic indicators— the things that put me at risk for early death. They say that prognosis depends on things like ischemia time of the heart (174 minutes). It also depends on how old you were at the age that you were transplanted (30 years, 49 weeks old) and how young the donor was at the time of death (unsure).

Or I can go for a jog, feeling the early spring wind against my face. Feeling every muscle in my body slowly get stronger after months of being deconditioned— I can take the pain. My determination and my willpower speak for themselves during these moments. However, there is a chance that I will suddenly die during this invincible jog. In medicine, we call it sudden cardiac death. I will begin experiencing an arrhythmia that my transplanted heart was statistically more prone to than a healthy native heart was. I will clench my chest, fall over, and die. Someone will find me in a few minutes. They will try to save me. But, according to national prehospital data, I will likely be dead upon arrival to the emergency department. 

I can spend hours upon hours meticulously punching in the numbers, searching the resources in our medical libraries, asking the cardiologists and the epidemiologists— what exactly is my prognosis? 

Or I can take the time to breathe. To live. To laugh. To cry. To love.

To write my thoughts out and think about the beauty of life, the irony and the mystery of this thing that I’ve been given (twice actually, technically).

To smile.

To be grateful. To be happy. To be angry.

To feel.

To remember that, for all of us-- not just for me-- life is finite. 

The scientific values and prognostic indicators and the medians and means and the what-if's and why-not's don’t change this one thing that we all have to remind ourselves (unfortunately) more often than we should:

that, ultimately,

life

is

finite. 

Until next time, from William Saroyan’s The Time of Your Life:

“In the time of your life, live—so that in that good time there shall be no ugliness or death for yourself or for any life your life touches. Seek goodness everywhere, and when it is found, bring it out of its hiding place and let it be free and unashamed.

Place in matter and in flesh the least of the values, for these are the things that hold death and must pass away. Discover in all things that which shines and is beyond corruption. Encourage virtue in whatever heart it may have been driven into secrecy and sorrow by the shame and terror of the world. Ignore the obvious, for it is unworthy of the clear eye and the kindly heart.

Be the inferior of no man, or of any men be superior. Remember that every man is a variation of yourself. No man's guilt is not yours, nor is any man's innocence a thing apart. Despise evil and ungodliness, but not men of ungodliness or evil. These, understand. Have no shame in being kindly and gentle but if the time comes in the time of your life to kill, kill and have no regret.

In the time of your life, live—so that in that wondrous time you shall not add to the misery and sorrow of the world, but shall smile to the infinite delight and mystery of it.” 

One Thousand Visitors

“MOM THERE ARE LIKE A HUNDRED PEOPLE AT MY APARTMENT RIGHT NOW, CAN’T TALK!”

“LIKE THIRTY OF US ARE GOING TO THE BASKETBALL GAME ITS GONNA BE SO FUN.”

“I WANT TO INVITE A THOUSAND PEOPLE TO MY GRADUATION PARTY!"

For years, my parents would say things like, “Alin, you can’t possibly even KNOW a thousand people! You exaggerate so much.”  I proved them wrong while I was hospitalized.

I had a lot of visitors when I was hospitalized. A lot.

My program director would come by multiple times a week with candy and gifts. He’d be patient with my parents, who would ask him both medical questions and questions about what was going to happen with residency. I’d wake up after long naps to other ER attendings in my room, just sitting there with my parents— sometimes crying, sometimes laughing, but always there for me.

“I can still be an ER doctor, right?” 

My attendings would reply, “Absolutely."

One of my ICU attendings would come by on her days off with People and In Touch magazines. “This will help you get your mind off of all of this.” She would take the time to ask me how I was *really* doing. “I feel fine! I really do!” And then she would stare at me until I said what I *really* wanted to say.

“Chest tubes hurt so much more than I ever thought they would,” I’d admit while looking away.

Priya, my favorite surgical resident, would come by with a bag full of anything she found at CVS Pharmacy on her way home from work every night. She’d be tired as hell after doing a liver resection or a laparotomy for hours. “Today, I got you a neck massager and these scrunchies." She’d lay in bed with me. I would have to force her off because the bed weight alarm would sometimes start beeping. “I don’t care,” she’d say. 

Every day, Matt would sneak in muffins and watermelon juice, sit down next to me, and work on his fellowship research with his laptop. Every day, I would tell him that I felt like a burden, that he should go back to fixing ACLs. Every day, he’d tell me to shut up. “You need to stop pushing people away. We all care about you a lot.” I’d roll my eyes and take a sip of my juice.

One of my attendings, known for his stoic demeanor and strict ways, once surprised us all by walking into my room. He stayed and chatted for a long time, in complete shock about my whole situation. When he was leaving, he almost made it to the door before he turned around and looked at me. “Alin, I want to tell you one thing. You have been so strong throughout all of this, it’s been unbelievable … and I just want to say that I would expect absolutely nothing less from one of the best residents I’ve worked with.” 

The whole room teared up. But I held my tears back. Instead, I said something along the lines of, “You’re just saying that because I’m dying!” 

He shook his head. He walked back to my bed to give me a hug. “You can’t die. We have to clear the waiting room on every shift when you’re back.” 

I teared up.

One of my close friends would always bring me breakfast bagels after being on 24-hour-call at the hospital. We had a rule: to not talk about my illness, and to treat me like he would on any other normal day. “When are you coming back to work to admit patients that probably don’t need to be admitted, you dork?” he’d ask. We’d laugh. We’d hug. I appreciated that.

My best friend from medical school flew in from sunny Miami and surprised me. She sat down next to me, and we joked about all of our old times. I sighed. “I miss coming home with you on Thanksgiving breaks."

“You’re gonna still come home with me on every Thanksgiving that you’re off, don’t worry,” she replied.

My girlfriends (aka my sisters) from Los Angeles, Linda and Ateena, even flew in. Ateena would help me with my daily walks around the ICU. She would hold onto my milrinone pump, and I would make jokes about how my life was always in her hands. Linda, who is one of my only friends not in the medical field, walked into the room and asked, “Wait so what's a Cardiac A-ha! diet?” 

My brother, cousins and relatives flew in and surprised me as well. “We cannot wait until you’re back in LA,” they’d tell me. My cousin and I would go down the list of everything we were going to do when I was back home on vacation some day.

A former attending of mine, someone I looked up to dearly, once came by with a David Sedaris book and a sketch pad (which really made my day). We laughed so much at my old “intern year” memories. She then showed me a part of her sternotomy scar from a valve replacement years ago. “You’re gonna be in the Zipper Club with me when you get out of here. Pretty cool, right?” 

My good friend, a cardiologist, would come by after working long hours (no matter what time it was). He knew that I was always going to ask him all of the super specific cardiology questions that my little brain had thought about all day. “Can we go over the Fick formula? Where exactly is this catheter sitting? How do they check wedge pressures?” One time, we drew out the human heart together on my iPad. I think he knew how nervous and anxious I really was deep inside. He watched me color in the ventricles. 

“So, as a cardiologist, not as my friend, but as a cardiologist … am I gonna make it out of here alive?”

“YES! Like no other! You’ll be back at work with a new heart! We’re gonna be going out so soon! First drink’s on you, though, because coming here after being a cardiologist at the hospital all day has really been taking a toll on me.” 

I wish I could tell you a story about each visitor who dropped by, but IT WOULD BE LIKE A THOUSAND PAGES OF READING BECAUSE I HAD SOOOOO MANY VISITORS EVERY SINGLE DAY!

Then came New Year’s Eve.

On this particular day, I went to the Cath lab for the umpteenth time only to come back to, literally, ten people in my room. We didn’t have any champagne, but ginger ale worked just as well. One of my friends got me Sour Patch Kids (a real treat when you’re in cardiogenic shock) and I ate the whole bag. "Cheers to 2018. Hope 2019 is a little better than this,” I said, dryly, with SPKs in one hand & a plastic cup of ginger ale in the other.

“It’s gonna be so much better. Hashtag, new year new heart!” One of them said. 

“Hashtag, can you guys go out and celebrate FOR me? All of you know that I LOVE this holiday.”

“We know that you love this holiday. That’s why we’re staying."

I fell asleep sometime around 10 or 11pm. I didn’t want to, but I did. Melatonin is a helluva drug.

Anyways, let me tell you the best thing ever right now. Let me tell you that every single person stayed in my room until midnight anyway. 

I thought it was kind of weird that they wanted to spend NYE in my hospital room.

Nonetheless…

Thank you.

My dad asked me the next morning, “You remember when you were younger, we’d always hate that you were exaggerating so much? You still always say things like ’There are forty people coming over so I have to get dinner ready!’”

“Yes."

“You were never exaggerating that much. There are a lot of people besides me and your mom who love you. You’re lucky."

Yep. And during that time in my life, I felt extra loved. My support system was actually the reason why I got through what I got through. My “enablers,” as I liked to call them. They were constantly asking the techs to get me blankets, to get me some tissues. My friend once told my nurse, “Her teeth are sensitive. Do you have any toothpaste for sensitive teeth?” (** face-palm ** SO embarrassing, I know.)

They would answer all of my medical questions when I wanted to talk about what was going on. But they would pretend like there was no invasive central line jammed into my little neck on the days that I didn’t want to talk about what was going on. 

They would hold the back of my way-too-large gown and walk around the unit with me. When I looked short of breath, they’d say that they’d want to sit down for a second (because they knew that I would never admit that I was short of breath). I knew what they were doing. 

They would bring me all of the sweets that I wanted. They’d pretend like it was theirs if my doctor or nurse walked in. Ugh, that Cardiac A-ha! diet…

They would tell me that I looked so good, even when my hemoglobin was 6 and I hadn’t waxed my eyebrows in three weeks. They would sit down and do manicures with me— even the guys who had never had their nails painted before. 

They would watch everything on TV with me on the days that I felt down and just didn’t feel like talking. They would pretend like they wanted to watch the 3rd run-through of early 1990s Forensic Files. “We’ll watch these when you’re discharged, too. I’m coming over with popcorn every night."

They would let me vent about how much my F&#(ing arterial line kept F*#$ing up. I rarely complained, but this was one major complaint of mine. “F*$& that line. It’s gonna be out in no time,” they’d say.

They would bring me flowers when they weren’t supposed to. In fact, they would bring me gifts, so many gifts, every day. I couldn’t wear shoes in the hospital, but one time, I told my friend that I badly wanted a pair of Doc Martens. “It’s gonna be the first thing I buy when I’m out of here,” I told him. He came by one day with a neatly wrapped shoebox— Doc Martens. “This is for when you get discharged. You’re gonna wear them on the day you’re out of here.”

“AHHHH! YES!!! Think I can wear these to the OR when I get my transplant?” I asked, as I checked for pitting edema before trying them on.

“You can do whatever the hell you want to do. You’re Alin.”

You see, my support system gave me a lot of hope. They’d give me hope about being out of the hospital “in no time.” We’d talk about being at work again, and how we’d be reminiscing about these terrible (but darkly humorous) times at future get-togethers. They’d tell me that, very soon, I was going to be in California and watching the sunset from my favorite secret spot in Venice Beach. And very soon, I was going to be a New Yorker living the life in the Lower East Side (my dream since I was practically five years old). According to them, I was going to handle all of this so well and so gracefully because "I was Alin” and nothing was going to stop me.

With their validating words and their incessant love for me during this incredibly insane experience, I became a little bit less scared and a little bit stronger each and every day.

I hated it at times, because I would feel like a burden. I would push them away. In fact, I got into arguments with my enablers on some days— I didn’t want them seeing me sick and barely able to walk. I didn’t want them being late to work because of me. But these crazies just kept coming back. 

So where I’m at right now in life (still smiling and still determined to kick ass)— this is all thanks to them. So, thank you— all of you— for giving me so much of your beautiful, genuine hope during the absolute worst days of my life.

And to my nurses who were taking care of me (if you’re reading this), I’m sorry for ALL OF THOSE THOUSANDS OF PEOPLE in and out of the unit every day for me.

To end this post, here are some photos of me and several of my enablers from when I was hospitalized.

Full Code

At first, it was easy. Every day, I would wake up and hope for a heart. “Today might be the day! Come on, Heart!” I’d tell people. I had my sick days, but I also had my good days, and my mind was only set on one thing: getting a heart. However, when you’re stuck in a hospital bed, you start thinking a lot. 

I was waiting for someone to die so that I could continue to live.

Let me say that again.

I was waiting for someone to die so that I could continue to live.

If someone didn’t die soon, then I would die. 

This kind of thinking really f*&%s with your head. You start thinking about how much your life is worth, who you’d want dead instead of you. And then you’d start questioning your own sanity-- if you were a sociopath or a narcissist to be thinking such thoughts. You’d feel guilty. These thoughts are raw, and they only creep up on you when you’re alone and waking up from cold sweats in the middle of the night (“It’s just the medications," they’d say). I would call those few who were closest to me (even at 4am— thanks, Matt and everybody else, you know who you are). “My cardiac index went down. What if I die tonight? Nobody deserves to die, so why am I waiting for someone else to die? What if she’s some 30-year-old in an ICU right now, and we’re just in a race to see who can die first to become the other’s donor?”

These panic attacks were terrible, but anxiolytics helped at times. Hydroxyzine 25 for mild panic attacks. Ativan 0.5 for major panic attacks. But I finally decided that I needed to really sit down with my thoughts and ask myself the real question instead of magically making them disappear for the short term with medications.

I had become really scared of Death. But why?

One of my best friends was going to do a fellowship in Palliative Medicine. I remembered her and I talking extensively about death one night, several months ago.

Death is a part of life. I told my own patients’ families this at times. I would sit down, quietly, in the family room with my attending. I would tell them everything that I was taught to say over the years, things that I had learned from different attendings. I liked talking to families. I always felt like I knew what to say wholeheartedly. So … why couldn’t I accept this easy fact, that Death was a part of life?

I was 30 years old. I had done so much with my life already. I had worked very hard to get to where I was. But remember, I had my share of fun, too. I had done my traveling, my road trips. I had explored Zion in Utah and had seen the world’s largest thermometer, the nation’s first merry-go-round, and almost all of the dreamcatcher shops in New Mexico (ask me about those later). I had tried all sorts of foods— I never said “no” to any type of food, even those that sounded gross (Anthony Bourdain was always my second favorite Anthony, next to Anthony Kiedis). I had taken more photos of the world than I had room for on my iCloud. I had jumped into so-and-so's rooftop pool (many times, in many cities) at midnight, no matter how cold it had been outside. I had gotten my degrees from several wonderful institutions, had even seen some amazing people lecture (like Dr. Jared Diamond … I’ll never forget that talk). I had been taught by the Greats of my time. I had met my favorite artists and singers (“I don’t care, we’re sneaking in backstage,” I’d say). I had read all of my favorite books over and over again. I had really never been the one to say no to anything— “Regret is the worst feeling ever,” I would tell my friends. 

I had been in love many times, and that feeling was always beautiful. I had helped save a few lives at work, and that feeling was always beautiful. And, you know, I had always come to terms with my not-so-beautiful emotions and thoughts as well. I had been comfortable with sadness and anger and the anxieties that came with this whole “life” thing.

I had been loved and supported by so many people, and I had grown into who I was today because of my family, my friends, and every single person I that had met along the path of life for these three very sweet decades. 

I guess ... the only thing I hadn’t done at this point was find that new sepsis biomarker as a freshly trained ER and ICU doctor (see last blogpost). 

Oh, also .. I had really, really wanted to go to Jackson Hole, Wyoming some day. Hadn’t made it there yet.

But I was thankful for the time that I had had. And if I had to go, I would go. I had lived a life so pleasantly that if I had died, I’d be content with Death. But if I had made it through this hospitalization, man, I would embrace the crap out of life even more than I had already done. Jackson Hole was going that much more beautiful.

There was no point in thinking too much about who’s life was more important. Thus, I came to peace with Death about 13 days into my hospitalization. 

One day, someone came in with more paperwork. She wanted me to “think about” my resuscitation status, my healthcare power of attorney (aka POA), and my advanced directive. I took the paperwork from her hands with ease, but had so much difficulty filling everything out. I thought I had made peace with Death. Why couldn’t I do this? 

I thought about all the “Code Blue”s I had helped with over the last few years. I recounted the last few moments of so many of my own now-deceased patients— from the 18-year-old gunshot wound victims to the 50-year-old cardiac arrest patients.

“He was fine just five minutes ago! I was talking to him!” a tearful sister would say.

“DON’T DIE ON US! PLEASE DON’T DIE ON US!” a crying husband would yell.

We’d push epinephrine and continue compressions and ultrasound their hearts and continue compressions and put in those chest tubes and continue compressions. It was always difficult to choose a “stopping point," no matter what the circumstances were or who was running the code. Perhaps I was lucky that I’d be able to write out who should make my decisions or what I wanted done. And those doctors wouldn't have to worry as much about when to stop resuscitation measures. 

I started thinking.

Obvious "Full Code"— I’m young. 20 minutes of CPR, that’s it. 

No wait. 

25 minutes of CPR, that’s it. 

No wait.

30 minutes of CPR, that’s it. No PEG. No trach. No, maybe just for one week. Two weeks?

No wait.

30 minutes of CPR. Make my father my POA, let him decide what to do next. 

That wouldn't work. He wouldn’t take me off of life support even if his own life depended on it. Mom? No. I literally made a list of everybody I was close with-- friends, family, colleagues included. The medical people surely would be good POAs. Maybe my best friend, the surgical resident who lives close to the hospital … no, she wouldn’t either. 

How lucky I was to not be able to appoint anybody to make my own healthcare decisions. 

How lucky I was to be that loved. 

I thought about me, braindead, with a PEG tube and tracheostomy, swollen everywhere, laying in the ICU for months. And these loving visitors would still be here every day with blankets, gifts, magazines, hugs, kisses. They’d discuss what I would have wanted. “She would have said take her off the breathing machine after 1 hour. She would have said she’s being a waste of resources,” my mom would say. “No. She wouldn’t. She’s a fighter. We can’t do that,” my dad would argue. 

I thought about the residents rounding on me every morning. "She’s an easy one to round on. No acute issues at night ... ever. She may be braindead, but nobody wants to let her go. It’s becoming a social issue at this point.” 

I was going to become a Social Issue.

How lucky I was to be that loved.

Full Code. 30 minutes of CPR. One week of life support. Donate the organs that can be salvaged.

Until next time, I suggest picking up a Dostoevsky book if you’re bored.

“Only through suffering can we find ourselves.”

— Fyodor Dostoyevsky

The Transplant Talk

One morning, a medical intern came into my room to examine me, before morning rounds (which is when the team discusses each patient and the patient’s care plan for the day). He put his stethoscope on my chest and listened for what seemed like an hour, but was probably more like a minute. He then apologized. “My attending today, he’s going to ask me about murmurs and gallops and he’s very strict about physical exams.” I told him that I was tachycardic, so the murmur was probably difficult to appreciate. “Don’t feel bad, man. You did a great physical exam.” 

A few hours later, the Critical Care team walked into my room. The attending asked me a few questions and then proceeded to do The Very Strict Physical Exam. 

"She has an S3 gallop. Severe mitral regurgitation. You didn’t hear it? Take a better listen.”

I quickly interjected, and told the attending that many others also didn’t notice it, probably because of my heart rate being so high. The intern had done his best to take care of me all night, and he got a perfectly detailed history on me, too. Everybody chuckled. The intern then nervously put his stethoscope back on my chest while the rest of the team left the room. “Don’t feel defeated. I know exactly how hard it all is, especially after being here all night,” I told him. 

“Alin, you know exactly what we go through. And now you know what your patients go through. I don’t know how you’re handling this so well, but you’re an inspiration to all of us.”  

An inspiration!? I’m laying on my death bed with a barely functioning heart. I thought I’d become an inspiration in Emergency Medicine or Critical Care, after doing some groundbreaking research on early sepsis biomarkers or perhaps by saving hundreds of people after an unforeseen natural disaster… 

I said thank you, and he left the room. He came back with some cookies from the resident lounge, probably something their attending had brought them. That was nice— I guess because it made me feel like a resident again (even the oatmeal cookies the attendings bring us make a hell of a difference during those long shifts). It’s the little things…

A few days later, I had a new intern taking care of me, I told her that I had this S3 gallop from my severe mitral regurgitation, and to make sure to tell the attending that. She appreciated my help. 

At that point, my heart wasn’t getting any better. I kept requesting more echocardiograms to see what we could salvage from my heart. Nope, ejection fraction still terrible. Walls still thin. Heart still looks awful.

I knew what this meant. I needed a heart transplant. I knew that this was coming, but it was hard to tell my parents this.

The cardiologists came into my room one day and sat down (they’re ALL here and they’re SITTING DOWN— this was definitely going to be The Transplant Talk, I thought). I told them the situation. “Listen, I know I need a transplant. I know you’re going to talk to me about it. I want to get enlisted as soon as possible so I can get the heart and get out of here. But the hardest part is going to be explaining all of this to my family. Instead of talking to us together, can you please just explain all of this to my parents later in a separate room? They are going to have too many questions. And I just need to be alone after we talk. I’m really sorry.” 

I hope my doctors and nurses appreciated my directness (throughout my whole hospitalization, and also my whole life— not everybody appreciates this).

We talked about the heart transplant. My blood type was B+, luckily one of the more common blood types. I would be very high up on the list, considering my circumstances. If it didn’t happen quickly, they were ready to put an emergent balloon pump in (a mechanical device that would help my heart pump, along with the medications). There was no hope in trying home infusion medications— I was too sick to leave the hospital. Things got even more complicated. I was anemic, but couldn’t get a blood transfusion (since I was going to be enlisted for a transplant). My kidney function was slowly worsening. And, remember that whole “afterload” problem? It was getting worse, no matter which medications they tried. I took it all in, and made some dry jokes about how truly ironic this all was.

“Welp, the GOOD thing is that if I ever go to the ER with a heart transplant, I’ll be an obvious admission. My colleagues are going to love my door-to-admit times. And I’ll always get to be in the Intensive Care Unit. Probably even for a both bone fracture!”

I found that the interventional cardiologists & intensivists appreciated my sense of humor more than some of the other specialists.

Finally, the Transplant Team gave me some paperwork to sign, and asked me how I was feeling. 

“Can’t go home with a milrinone pump. Yes to heart transplant. I understand the risks and benefits. Let’s do this.” And I signed the papers with confidence. I felt good. I felt like this was a step forward in my recovery— one of the hardest steps, sure, but at least we had a plan. Plus, I wouldn’t be short of breath anymore.

I swear, if you could take one thing away from me, just know that it really is a blessing to be able to breathe.

Everybody was surprised at how I handled the news. I mean, I already knew it was going there, so maybe I had subconsciously prepared myself for The Transplant Talk. But also, I never saw it as bad news. I saw it as good news— another chance at life. Look at how far medicine has come— had this been decades ago, I would’ve died (like my grandfather did, somewhere in Bulgaria, from "a strange heart condition"). But here I was consenting to get another heart. I was given this genetically defected heart that almost killed me, and I still happily used the crap out of it, and now it was time for a better one. 

My parents, on the other hand, didn’t handle the news very well. I had tried to prepare them. They were in denial, especially my dad. They came into my room a couple of hours after I signed the papers (thank you, Care Team, for taking the time to explain everything to them for that long). They were both crying.

I’ve never been a parent, but if you are one, I suppose this is hard news to process. I suppose raising your daughter for 30 years— seeing her go through grade school, seeing her stubborn personality come out at an early age, seeing her through her several Spelling Bees, seeing her the first time she drove a car (terribly), and the first time she had her heart broken, seeing her tell you that some day, she’s going to grow up & save lives, seeing her grow into everything she said she’d become ("and more," according to them) …

And then, seeing her in the Intensive Care Unit in critical condition, hooked up to monitors that beeped too much and living on multiple medications that you had never heard of, with doctors talking about shock and heart failure and the fact that she needed an organ transplant, a critical surgical procedure that would take several hours, and that her whole life would change afterwards.

Again, I don’t know what it feels like to be a parent, but I suspect that this was harder for them than it was for me.

Was I a waste of life? Was I a waste of all the love, support, time, money, and resources they had given me for three decades? Was I wasting their time? Should I ask them to leave? This was a strange feeling, but it was something that I had asked myself so many times. I had always been a practical thinker, a realistic optimist, but also a pusher-awayer. That day, feeling like an 8-year-old asking her parents why the sky is blue, I asked them, “Do you feel like I’ve been a waste of your time and resources for the last 30 years?”

They were both shocked by the question.

“You have never and will never be a ‘waste’ for us. Look at how much joy you’ve brought us. How could you even think that?”

“And what if I die before they get me a new heart? Will I have been a waste of resources then?”

Again, they were quiet.

“If you had to die, you would’ve died already,” my mom pointed out.

Then my dad continued, “Having children comes with its struggles, but there’s nothing in the world that makes me happier than my children. Anything you do, everything you do, makes me so proud. Thirty years with you was a blessing, and there are still a hundred years to go,” said my dad.

I think I knew that, but I just needed some good ol’ parental validation. I felt vulnerable. I felt so useless in this stupid bed, and not in control of my stupid, ironic life. I needed them to be my strong, superhero parents who had seen me go through it all for the last 30 years. 

And they couldn’t have done it more gracefully.

We were silent for a few minutes. There was some crying, and some hugging. And then I closed my eyes.

Now, I don’t know if the following was attention-seeking behavior, but it always made me feel at ease: When I was a child, I used to pretend to be asleep on my couch sometimes. My mom would kiss me on my forehead, and then my dad would carry me to my bed and tuck me in. They’d both say that they loved me, and then they would shut my bedroom door and tiptoe out.

Now at age 30, in my hospital bed, I pretended to be asleep. My mom walked over to my bed, and tucked me in. I heard her ask my nurse for another blanket— “She might get cold,” she said. She placed a fresh, warm blanket at the foot of my bed. Then, my parents took turns kissing my forehead. They silently stood in my room for a moment, but it seemed like a long time. And then, they both said that they loved me, and quietly shut my sliding door on their way out. 

Thank you for continuing to read my posts. Until next time,

“As happens sometimes, a moment settled and hovered and remained for much more than a moment. And sound stopped and movement stopped for much, much more than a moment.”

— John Steinbeck, "Of Mice and Men"

Ventricular Tachycardia

(Disclaimer: I was transferred to different hospitals a few times during my month-long battle with heart failure — hospitals will remain unnamed. Some of these stories are not in chronological order.)

In order to see how my heart was doing, the team decided to slowly wean me off of milrinone, which was the medicine that was helping my heart pump. Unfortunately, with every slight wean, I would get sicker than before. My cardiac index would go all the way back down to “Almost Death” level, and I would have trouble breathing. 

When they increased my milrinone back up, I started having bouts of “ventricular tachycardia.” We tried to explain to my parents that this was an abnormal (and dangerous) heart rhythm.

“Is this like when they shock patients in movies?” Dad asked.

Without having to go into the whole “pulse vs. no pulse,” “stable vs. unstable” explanation, I just said, “Yes.”

“No. You don’t have that.”

So, there was that. 

Sometimes, throughout my hospitalization, I would get pacer pads placed on my chest before sleeping (the ones that they use in movies to shock patients). I didn’t want my parents seeing this, so I figured out a way to use two gowns to cover up the stickers on my chest. There’s a lot you start doing in these situations so that those around you don’t feel bad for you (you’ll see what I mean).

One night, I was started on intravenous amiodarone, a medication that would help temporarily suppress these abnormal rhythms, which were becoming more and more regular.

I woke up at 2am and began vomiting profusely— on my bed, on the floor, all over my beautiful hospital gown. I couldn’t find the call bell to call for help, and so I just started screaming for something to help with my vomiting. “Zofrannnnnnn!! Please!!!!” Luckily, someone heard my calls for Zofran. My wonderful nurse came in with a basin, and told me that she had to call the resident to put the order in. 

“Can you please make sure that she also orders an EKG! I don’t want to be on two QT prolonging meds at once! Tell her I have no pain! No chest pain either!” 

And then I went back to vomiting my chicken soup and chocolate pudding. The resident came to see me, listened to my lungs, sat with me for awhile until the Zofran was given. I asked her if she would call her parents in this situation and we talked about how difficult this all was for me— trying to balance being a doctor with being a patient, trying to balance how much I was hurting with how much I wanted to show that I was hurting. I also jokingly asked her if they needed help with saving any lives out there, and she jokingly replied, “We’ll come get you if anybody needs to be intubated.”

If you’re reading this some day, I appreciated that a lot. You were probably on hour 22 of 28 with no sleep, and this patient just kept throwing up and you had so many charts to sign. But you made me feel normal, and that order of Zofran was one of the best things that ever happened to me that week.

The vomiting subsided after the medicine was given. I asked my nurse if I could try to wash my hair in the shower. She said that I couldn’t because I had a Swan-Ganz catheter in my neck. It couldn’t get wet. 

After an aid helped me clean up with a new gown and fresh bed sheets, I decided that I was still going to wash my hair. First of all, it had been over 10 days since it had been washed. Second of all, there were chunks of dried vomit creeping out of the ends. I walked over to the bathroom with my portable monitor and IV pole in place, and told my heart to please not go into V-tach while I did the almost impossible. I took a comb, wet it, and ran it through my hair for a few minutes. I used hand soap to wash out anything I could. Better than nothing. My nurse walked in and asked if everything was okay by the sink. 

“Yeah just … washing my face!” Washing the hair on my head connected to my face. 

I went back to sleep for a few hours, and woke up to my family at my bedside. They said that I looked pale and asked if everything was okay. 

“I had that weird heart rhythm again so they started me on some other medicine. Made me throw up.” 

“WHY DIDN'T YOU CALL US!!” 

My mom grabbed her purse and took out a salt shaker. She proceeded to pour salt around my bed, right onto the hospital floor. “This is to ward off evil so that doesn’t happen again. You should’ve called us."

Mom, this is for vampires I think… what are you doing…

But I let her pour a little bit of salt on the floor. She then went on to tell me that I shouldn’t have washed my hair because I was going to catch a cold (don’t even ask about this myth I’ve been dealing with for 31 years). I nodded my head, and then noticed that my dad was quiet, almost in tears.

I told him not to worry about the rhythm, that it was all under control now. My aunt called my cell phone, and then she started crying because she had heard about what had happened that night. “I’m okay! Look! I’m talking! Really! Just a side effect of the drug,” I told her.

I found myself consoling those around me way more than the other way around. I was never looking for pity, but I had to tell quite a few loved ones to stop crying and that, although I wasn’t in the best shape health-wise, I was in good spirits and wouldn’t lose my positive attitude. I had to listen to people tell me things like, “Oh, you poor thing. You had your whole life ahead of you!” and “You’re such a good person and you always have the worst luck!” and “I am SO SORRY that YOU have to go through this!”

I had to take it all in. Some days were harder than others. Just a couple of those closest to me were the only ones who would hear me vent once in awhile, after my parents had left for the day. We’d laugh and cry and be angry and laugh again about the awkward things that were constantly being said to me. My dry humor would come out with comments like, “Sustained V-tach with an index of 1.3 and all the inotropes are maxed out, dudes. They may as well get Palliative WITH Transplant consulted at this point.”

Those same close friends, all with backgrounds in medicine, would sometimes get quiet after my snarky comments. Then I would tell them that I was okay, and that I would stop joking around so much.

So that’s the thing about life. These crazy things happen. You can only control your reactions and your actions around these experiences, be as strong as possible to keep fighting (but give into your weak moments too— it’s a part of the process), and accept the fact that you need to take these damn experiences and make something of them. In my opinion, there is no point in laying around and sulking all day. There is no point in letting others’ words get to you. It won’t change the situation.

Besides, I’ve always been good at consoling others.

To end this post, here’s a quote that goes with this theme— I've always been a fan of some principles of Stoicism. I don’t think Marcus Aurelius actually said this directly because he didn’t speak English, but it sums up Stoicism pretty well:

The Anti-Coreg

There I was, laying on the Cath lab table, the same one my own patients had laid on throughout the years while they were experiencing heart attacks or needed quick cardiovascular interventions done. I was in a surreal daze, perhaps caused by a mix of anxiety, frustration, fentanyl, and midazolam.

This is probably how my own patients felt, I thought. Sometimes, I’d go with them to the Cath lab during transport, and would wonder why they were so scared. “The cardiologist is going to take really good care of you. You’re at the right place and we caught the heart attack right on time,” I told one of my patients once. “Ah but you don’t know … this feeling … you’ll never know, Doc,” he reluctantly told me, as we pushed his gurney into the elevator.

If you’re ever reading this, Sir— I kind of know the feeling now.

Something went into my neck. 

I remember numbers being called out. I remember getting back into my hospital room, and learning that I now officially had to be transferred to the Cardiac Care Unit. I remember having uncomfortable central lines (large IV catheters) on both sides of my neck. I remember asking a resident doctor if one of them was going to come out. “There’s a risk of infection. Take one of them out, please!” I demanded. I remember someone pulling the left one out, and explaining to me that the right one had a Swan-Ganz catheter, which they were going to need to use for the rest of the hospitalization.

Swan-Ganz. This is what my attendings used to do on all their patients “back in their residency days.” Now, the cardiologists usually do them, but “we” don’t. It kind of looks like a swan, hanging out of my neck like this. When is this fentanyl going to wear off?

The attending cardiologist came into my room and explained to me that my “sats were not looking good.” After discussing my results and talking to me about our plan, the team started me on milrinone, a medication to help improve my heart function, for the time being. 

Another doctor came in to tell me some more great news. “Your SVR is over 4000, okay?”

Okay. “Cool man, thanks.” 

What’s normal though? I tried to Google what “normal ranges” were (by the way, SVR, aka systemic vascular resistance, should be no more than 1200). I had forgotten some of those basic cardiology concepts from medical school, but I was too tired to figure this all at that moment. 

I was started on some more medications to lower that great SVR of mine. I had a friendly yellow swan in my neck. I just wanted all of this to be over, so I decided to fall asleep. This was all surely all just a dream!

I don’t know how long I had fallen asleep for, but I woke up to my parents in my room with their luggage. “What is going on with our daughter!!?!"

I sobered up to reality. “I’m fine. I’m in something called ‘shock.' But they have me on medications.”

My dad then asked, “Shock? You said it was your heart, and at first it was a pneumonia…” 

Take a deep breath, Alin. 

“Look, let’s just wait for the doctors to come talk to you guys. Basically, my heart isn’t pumping well, so I’m on these medications to keep it pumping until we figure out the cause.” 

“This is probably like what I have. Remember I told you that I have cardiomyopathy? They need to put you on Coreg. 3.125mg.” 

And this became my father’s word of advice to every single physician who entered the room, from the interventional cardiologist to the transplant psychiatrist.

(One of the cardiologists patiently explained to my dad once that I was actually on the "anti-Coreg" regimen right now because my heart was in a different situation than his heart had ever been, and that this Coreg, which is a phenomenal drug for some patients, would probably kill me. He didn’t care. He was on a mission to get me on Coreg for the next few weeks. It made all of us laugh, and I appreciated how calm and pleasant the physicians always were with him.)

The team came into my room. They began going over my results.  Apparently, my “sats” were in the 30s, my “wedge” was over 40, and my “cardiac index” was 1.3. This is all Medical Speak for “We’ve confirmed that your heart is officially failing miserably.”

A lot of the work-up was pending, but the etiology of my miserably failing heart was probably familial. My father had cardiomyopathy, diagnosed around age 40. And his father, my grandfather, had “some kind of abnormal heart,” and subsequently died of sudden cardiac death in his early 40s. All of this from a mutated sequence of “ATCCTAGCCCC”s that had been brewing in my DNA for years, replicating, and waiting for the perfect moment to show itself (along with other environmental factors, but we won’t go into that).

I thought about how my genes were probably talking amongst themselves, “Why don’t we wait for her to be at the PRIME of her life, right when she’s the happiest she’s ever been, right before she moves to New York City, and then just F$&! everything up?” I chuckled and went back to listening to the physicians.

They explained to my parents that I was in a critical state. I had to be transferred to another hospital for “advanced heart failure measures” … in case the milrinone didn’t help my heart. 

I explained a lot of this to my parents as best I could. 

My parents continued to be in denial, and would ask things like “Why is the critical care doctor saying that you’re stable, but the cardiologist is saying that your labs are abnormal?” 

Because I’m stable from a Critical Care perspective, but not from a Cardiology perspective. 

And yes, my dad continued to ask about adding the 3.125mg of Coreg to my medications, despite being told that I needed the “anti-Coreg” to stay alive. 

So glad those days are over. Until next time!

Today’s End-of-Blogpost Treat will be a book recommendation, since I’ve been reading a lot lately. Mark Manson’s “The Subtle Art of Not Giving a F*ck” is not your average self-help book. It’s hilarious, and gives you a new perspective on life.

“The desire for more positive experience is itself a negative experience. And, paradoxically, the acceptance of one’s negative experience is itself a positive experience.” That quote (from the book) resonated with me throughout my hospitalization.

Inconsistencies & Ambiguities

I had just seen my terrible echocardiogram, and had diagnosed myself with a sad, failing heart. I waited patiently. The cardiologists came into my hospital room and sat down. One of them asked, “Is there any personal or family history of heart failure, Alin? What exactly were your symptoms?”

For what seemed like the hundredth time, I explained. I had this cough around Halloween and it never got better. I had a cold. I was feeling short of breath over the last few days, perhaps it was due to post-viral reactive airway disease, I don’t know. I feel fine. I want to go home. 

“Any weight gain?”

“No.” But the ED nurse said that my weight was 110 pounds. I’ve never been over 90 pounds. The scale was wrong.

“Any decreased urine output? Swelling in your legs?”

“No. No.” But Matt did say my legs looked kinda swollen. Wasn’t pitting though, I don’t think. 

“Were you using more pillows at night?”

“No.” But I always use two pillows to sleep. The other night, I woke up to catch my breath. Thought it was a panic attack.

“What about significant family history?” 

“My grandma has high blood pressure. My dad has dilated cardiomyopathy from myocarditis. I think his dad died suddenly when he was in his early 40s. That’s all.” Grandpa died of sudden cardiac death at age 40…

They all leaned in. “What did he die of?”

“We aren’t sure, nobody knows. Something with his heart? It was sudden, and he wasn’t around much. It’s all unclear.”

And then we stared at each other for a few more seconds. Something in his heart, sudden cardiac death, dad has dilated cardiomyopathy, but his is from myocarditis, I think that’s what he said. Where’s my dad?! 

I frantically called my parents, who were on their way to Philadelphia. They were at the airport, waiting nervously for their plane to board. 

“Dad, I think I have to go to the cath lab. It's my heart. It’s failing. Do you remember what your dad died of? And why do you have cardiomyopathy?” 

Between my father’s hindered tears and my mother’s silence, I realized how much of my character had just spewed out. I’m straightforward. I like to get to the point. It’s the Emergency Medicine mindset, and I had always been that way. I had to go to the cath lab so that the cardiologist could check my pressures, and then something about Swan-Ganz, a possible balloon pump. Risks? Bleeding, inflammation, infection, etc. Yeah, yeah. I had consented for everything. Now, I just needed these questions answered so that I could move on with my life.

I broke the silence. "Don’t cry, I’m fine. I feel fine. I’m breathing better now, too. These people know what they’re doing." I wasn’t breathing better, but they probably need to give me some Lasix or nitro. No wait, my blood pressure. How do I do this “doctor-patient” thing?

Dad interjected. “They told us that you had a pneumonia. Are you still on life support? What are you talking about?”

I almost rolled my eyes. How could I be on life support if I’m talking. I’m on pressors-- I guess that’s life support. I stopped myself mid-thought. I put myself in their shoes for one second.

And thus came the challenging beginning of being the first and only critically ill patient (and also the only medical professional) in my family. I realized the difficulties of patient care quite early— the ambiguity, the unknowns, the constant changing-of-the-plans, the various care teams saying different things. As a doctor, I understand this completely. What I never understood was why my own patients didn’t understand this. But that day, I finally began to grasp the difficulties of being a hospitalized patient with family & friends who cared too much, had too many questions, and couldn’t grapple with the uncertainty of modern medicine.

I took a deep breath. “I’m not on life support, but I need you both here. I have to get a procedure done to see how my heart is doing. It may not be pneumonia. I’ll call you after.” 

And off I went to The Legendary Cath Lab, where I’d get all of my answers while laying flat on a cold, hard slab of metal. Where the cold, hard slab of reality would suddenly hit me.

And with that … here’s a quote (by anonymous) I recently found while “surfing the web” (like its 2001).

“Fear, uncertainty, and discomfort are your compasses toward growth.”

Ejection Fraction

Disclaimer: The first few days of my hospitalization were quite blurry. I don’t recall some of it because of the medications & sedatives I was on, but I do have notes written down from how I was feeling during those times, so I will be alluding to the notes occasionally.

Anyways … continuing with my hospitalization:

Nobody knew what was going on. I was extubated and breathing on my own (barely). My heart rate was too high, my cough wasn’t getting any better. My liver function tests were abnormal, my electrolytes were off. My chest x-ray showed complete "white-out" of both lungs, which is Medical Speak for “Something serious going on in the chest.”

I had almost every consulting service seeing me. I’m on my way to becoming an Internal Medicine resident’s winning case report in the New England Journal of Medicine. If you can’t tell, my dry humor got me through a lot of this.

One of the doctors in the Intensive Care Unit came to my room during the morning of Hospital Day 3. He was determined to solve the puzzle. He asked me a few questions and then proceeded to do a full physical exam on me— probably the 8th or 9th one in the last 24 hours. He spent some time pontificating about what this could’ve been, and what we should’ve done, and what the next step would be. 

He was in deep thought when suddenly he realized that he may have figured it out.

“I think it’s your heart, Alin.”

He turned to the resident physicians and calmly said, “Get Cards on board. Someone send a troponin and a BNP.” 

This is Medical Speak for “I think that your heart is failing.” He then asked me a few more questions, and we talked about the plan. The team left the room quietly.

My HEART!? My heart? My lovely heart! The one that got me through the last 30 years of my life! The one that kept me going. The one that helped me physically exercise every day. The one that helped me at work, while I ran around room-to-room in the ER trying to convince patients to stay in the hospital for their own good because I genuinely cared about them. The one that I wore on my sleeve. The one that was “too much” at times. The one that loved everything so passionately, and was always loved in return. 

I took a look at my lines and my tubes. I stared at the intravenous medications— “the drips." I was getting all sorts of antibiotics, antivirals for this possible infection of mine. My blood pressure had been running low, so I was put on a medication to help my heart pump. I had a catheter jammed into my radial artery that was reading my low blood pressure, my low mean arterial pressure (that’s the one I always look at … why’s it 60? We need to up my Levophed, guys). I then came to the conclusion that I was … pretty sick.

I picked up my pen and paper and wrote down: Heart???? I still can’t breathe. Why can’t I breathe? I feel like I’m drowning. Dying. 

A very long hour passed. One of the cardiologists walked into my room. We joked about how this definitely could not have been my heart. He then proceeded to place an ultrasound probe on my chest wall, something we do often to check a patient’s heart function.

And there it was.

Global hypokinesis. Thin walls. Dilated chambers. Chronic changes. Terrible squeeze. Severe mitral regurgitation. Ejection fraction? 5-10%. 

This is Medical Speak for “A poor, poor heart walking on thin ice.” 

He quickly put the probe down, noticing that I had seen the images already. We were both quiet for a few seconds, but he broke the silence. “I’ll be right back with a couple of the attendings, hold on." That’s Medical Speak for “You are … pretty sick.” 

I didn’t need him, or any of the attendings, to interpret anything. I knew how bad this echocardiogram was. That was, by far, one of the hardest parts of my whole experience— trying to be a hospitalized patient while, in reality, I myself was a medical professional. I had completed 9+ years of school, had finished almost 3 years of training in Emergency Medicine, and I was just about to start a specialized fellowship in Critical Care Medicine. I was supposed to be the doctor pontificating & telling young, healthy, scared, sick patients that “it" was their hearts. I was supposed to be putting the ultrasound probe on their chest walls, and ordering the serum troponin levels.

I knew how dire my situation was. I didn’t need anybody telling me this. 

I screamed a little bit, internally.

My heart, you’ve given up on me! 

To end this post, here’s something lighthearted. A direct quote from one of my attendings in medical school— a mentor of mine, a one-of-a-kind radiologist who recently texted me after hearing about my situation.

“I remember you and your energy, Masha’Allah. Going through a few months of residency with a 5% EF? Only you could have done it.”

That Which Does Not Kill You...

Continuing from my 2nd blog post, “Dyspnea."

Let’s go back to the night of December 21, 2018. Imagine me, nervously sitting there, in my own emergency department, waiting for my doctor to come assess me. I had just been at work 24 hours earlier, and I kept telling everyone I was fine. “My review of systems is negative other than this little cough. And don’t even worry about getting a lactate on me. It’s going to be high because my work of breathing is terrible!” I told my attending. 

If you didn’t know, doctors make the worst patients.

A few tests were done, and with some pushing and convincing, I was admitted to the hospital for a work-up of my shortness of breath. Everybody was very concerned for me. The diagnosis, initially, was that of a multifocal pneumonia— an infection of the lungs that I had probably contracted from one of my critically ill patients. What else could it be in this young female with no medical problems? No need for a lactate! She’s fine! She has work tomorrow night!

There was one major issue, though. My heart rate was too high. Anti-anxiolytics, anti-hypertensives and intravenous fluids— all useful at lowering heart rates for reasons I won’t go into right now— weren’t working for me. Instead, I found myself face-to-face with the most horrifying moment of my life. 

It all started about 30 minutes after getting settled into my bed on the inpatient floor. I remember suddenly feeling very lightheaded, as beads of sweat trickled down my forehead. The beads of sweat turned into drops of sweat. Large drops. I was feeling cold, clammy. I couldn’t think straight. I looked up at the monitor. My heart rate? 40. 39. 38. 35. 

(FYI, a normal heart rate is between 60 - 100 beats per minute.)

Suddenly, a group of doctors and nurses rushed into my room. I remember apologizing to them. A surgical resident asked if I needed to “be lined.” This is Medical Speak for “She’s crashing and needs a large intravenous line in her neck right now for special medications that need to get pushed right into her heart.” One of the medical residents gently grabbed my forearm and asked if she could check a “gas” on me. This is Medical Speak for “We are so worried about you, that we need to stick a needle into your radial artery to see what’s going on. And this is going to hurt.” I remember staring into a nurse’s concerned eyes. He was in disbelief. Please help me. 

Someone said that my heart rate was decreasing. Someone else called for the crash cart. This is Medical Speak for “She’s about to die.”

A nurse rushingly placed pacemaker pads on my chest, but I was so diaphoretic that they weren’t sticking properly.

I heard someone ask if they should turn this into a “Code Blue.”

And that’s the last thing I remember from my almost-death-day.

I woke up one day later in the hospital's Intensive Care Unit, not being able to recall anything that had occurred. I was intubated— tube in mouth, breathing on the ventilator machine. I was sitting up, barely. There was a parched, dry feeling in my mouth, and I was coughing up and gagging on secretions. I felt like vomiting. Restrained to my bed like a prisoner, I was in distress. Everything was so surreal. I had catheter lines coming out of my neck, my forearms, my right groin. My friends, who happened to be the wonderful nurses and physicians taking care of me, were tearfully staring at me.

My heart rate was 140. Better than 35, I thought. Cough. 

I will tell you— there is something compelling about near-death experiences. Your feelings are all over the place. I was so uncomfortable in that moment— I had no idea what was happening to me. But I was so grateful to be alive. I wanted this tube out of my mouth, and then I wanted to hug and kiss and thank everyone. I wanted to dance. Potential Code Blue, you lost!

I was shackled down, physically. But I had never felt so liberated, emotionally. 

To end this post, a classic from Friedrich Nietzsche (one of my favorite philosophers). Remember, folks:

“That which does not kill us makes us stronger.”

Celebrating Life

The story of my almost-death-day will continue later. Today, I want to celebrate life. You see, today is my 31st birthday.

I celebrate my own birthday every year, no matter where I am or what I’m doing. I think I read on a cheesy card once: "Life should not just be lived. It should be celebrated." I thought everybody did this.

When I turned 22, I organized my own “Totally 80s” house party, complete with a Pac-Man cake & cheap, colorful wayfarers for my guests. I spent the night of my 25th birthday at an extravagant restaurant in Atlanta, with a group of first-year medical students (then, strangers; now, best friends). I learned about Stylish Buckhead, and tried Waffle House waffles for the first time in my life. For my 27th birthday, I bought myself a very large lime green cake and rented out a party space in Western Arkansas. Fifty people joined me. It was the party of all parties-- fully equipped with an open bar, lots of delicious appetizers, and slices of lime green goodness for dessert. I had even invited my Rural Medicine attendings to join me. We danced. We laughed. It was a good night.

Last year, for my 30th, my boyfriend & I spontaneously took a trip to Las Vegas for one night. Our plane landed in the city at midnight. By 1:30am, we found ourselves in the VIP Section of some crowded, sweaty club listening to what kids call "House Music" these days. I spent $20 on a slot machine at approximately 3:30am at The MGM Grand Hotel— slightly inebriated, but absolutely happy. 

This year, I can’t go out to a fancy restaurant in Nashville to blow out candles, nor can I roam the colorful streets of Barcelona with friends while signing Happy Birthday to myself. Why? I’m only 2 weeks post-transplant surgery (“It’s flu season! You’re immunocompromised!” they say). But I don’t need to. I will still celebrate life.

Today, the water that I’m drinking is so pure, so clear. So delicious. I feel every drop slowly trickling down my esophagus, and I can swallow with ease. My mouth is satisfied. You see, there’s something delectable about being able to freely moisten your throat with ice cold water after being strapped down in two-point restraints, unable to clear your own secretions while forcibly breathing on the ventilator machine (twice). 

The view I’m looking at of these lovely, busy streets is phenomenal. The dark clouds overlooking the horizon, the cityscape, the flurries. I’ll be walking alongside you and your Toynbee Tiles shortly, Philadelphia. You see, there’s something sweet about even being able to look outside to gaze at something *other* than the hospital plumbing system. Liberty 1, Liberty 2, especially at dusk— I see you and I love you.

And how about those piercing, loud city sounds? To the old man who plays the same rhythmic patterns on his saxophone down my block every single night— I adore you! Wake me up at midnight, like you always used to. I was just trying to sleep soundly after those evening shifts in the ER, but I was never mad at you. Play it louder. You see, there’s something wonderful about the little sounds that you are used to, no matter where you live. The ones that don’t consist of the BEEPs, the BOOPs, and the ANESTHESIA STAT TO THE FOURTH FLOORs.

Today, I am surrounded by my family members— I’m so thankful for the ties that bind that I want to scream! Backstory? My mother has selflessly moved her life to Philadelphia for the time being to help me check my blood sugar level every morning (even though I could do it myself, MOM). 

On Friday, she heard me cry for the first time in years. I couldn’t sleep. Everything was hurting. I had stinging muscle cramps in my legs from becoming so deconditioned on that hospital bed (I was jogging every day just a month ago, MOM). There was an unbearable, raw pain in my chest from the sternotomy-- it worsened with every wincing cry & every breath I tried to take in between (Go to sleep because I’m fine, MOM). She sat next to me for two hours, slowly massaging my legs without saying a word. She let me cry. You see, there’s something special about having your mother there next to you, holding you, during those late nights when you had otherwise become accustomed to feeling cold monitor leads and wires stuck to your chest wall. The only thing you felt on those nights was the artificial touch of the blood pressure cuff clinging to your right arm, cycling itself every half-hour & reminding you of how critical your condition truly was.

Today, I honor the little things in life, and I urge you to do the same. I was never one to take advantage of these moments. But today, they complete me. You see, there’s something celebratory about being able to live after coming almost face-to-face with your own death, multiple times, in a 30-day-period.

Thank you for completing me, Everything Around Me. And thank you, My Organ Donor, for letting me continue celebrating my life.

To end this post, another one from the great Oliver Sacks, from his opinion article “My Own Life” in The New York Times. I recommend reading the whole piece here … because it will change your life.

“...My predominant feeling is one of gratitude. I have loved and been loved; I have been given much and I have given something in return; I have read and traveled and thought and written. I have had an intercourse with the world, the special intercourse of writers and readers.

Above all, I have been a sentient being, a thinking animal, on this beautiful planet, and that in itself has been an enormous privilege and adventure.”