Open Heart (11 page)

“Do sense mortality,” I write. “These things happen—and if something in an artery, valve, whatever, suddenly stops fcning, then it does, and i need to take care of it, manage it. all the lessons of [
Transforming Madness]:
that finding out i may have what is called coronary disease is not a death sentence (except ultimately)—it simply means i will have a condition that needs care and management.”

On the day before the stress test, I treat myself to a massage and come away “encouraged by fact that the massage gave me my best day in weeks!” I experience no pain in my back, no shortness of breath, no fatigue. I have dinner with a friend, Doug Whynott, who was Massachusetts state javelin champion in high school and who thinks my problem is muscular—he says he had similar problems a few years back: pain between his shoulder blades that came on slowly and cut into his breathing.
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I am both very frightened—convinced my condition is as advanced as, within a week, we will learn it is—and encouraged: what I have is merely a muscular problem (so-called swimmer's shoulder?) resulting from all the years of swimming and playing ball.

“V v scared,” I write on Friday, February 5, 1999, the morning of the stress test, “tho less so the last day or two. I made it! no crises from time of check up to time of stress test—3 weeks.”

At 11:15 I walk to Dr. Flynn's office a block away, fill out some forms, and when I am called in to the examination room, talk with the doctor for a few minutes, after which the nurse hooks me up to an electrocardiograph machine to get a reading before I step onto a treadmill.

The heart is, as Rich has explained to me, partly an electrical organ, but even when there are severe blockages within the heart's arteries,
the electrocardiogram may not reveal tell-tale abnormalities. By placing electrodes at and across various points on the heart and recording electrical activity, it becomes possible to get information concerning the location and extent of changes, or of damage. When there has been a heart attack (what physicians call myocardial infarction [MI]: the death of part of the heart muscle), the part of the heart that has died is replaced by scar tissue, and, since scar tissue does not conduct electricity, the EKG may reveal this development. But though the EKG can uncover problems, Rich explains, it is a crude, often inaccurate means of evaluating the heart: it will sometimes suggest abnormalities that, upon further investigation, prove nonexistent or of no consequence—and often it will not recognize problems, minor and serious, that require attention. In addition, whatever the EKG reveals must be read and understood, always, in the larger and more specific context of the individual patient.

Dr. Flynn's nurse performs the EKG and brings the results to Dr. Flynn. I am left alone for a while, sitting on the examining table, from where I watch Dr. Flynn talking on the phone. As the minutes go by and I continue to sit by myself, in my underpants, wondering what the delay is about, I feel strangely intimidated: if I walk into the reception area to ask if they've forgotten about me, I imagine them scolding me and ordering me back into the examining room—asking me why I am bothering them, and what I am doing in their office without any clothes on…

I am anxious, frightened, and worried, especially when I try to figure out what I might say to my children if the news is as bad as I fear it will be.

After about ten minutes, Dr. Flynn returns to the examining room and tells me that we are not going to go ahead with the stress test.

“I think you've already had a heart attack,” he states.

“Oh shit,” I say.

“Something happened,” he says. He has called Dr. Katz's office to get a fax of my most recent EKG in order to compare it with the EKG his nurse just performed. There is no need for a stress test now, no matter what the previous EKG reveals, since the point of a stress
test would be to determine if there were any coronary problems that needed attention. (In a stress test, a continuous EKG reading, along with blood pressure readings, is taken while the patient walks on a treadmill whose speed and incline are gradually increased so as to raise the heart rate and enable us to see what happens when the heart is subjected to “stress”—to a greater and greater need for blood and oxygen.)

Something happened, Dr. Flynn repeats, though it is not clear, from the EKG, exactly what—but he tells me that it
is
now clear why I have been having these episodes of shortness of breath and pain in my back. He asks if I can meet him, within fifteen or twenty minutes, at Cooley Dickinson Hospital—about a half mile away—so he can do an echocardiogram. He expects that the echocardiogram, a film of my beating heart (much like the sonograms a woman undergoes to monitor the developing fetus during pregnancy), will show us exactly where the heart attack occurred, and how extensive the damage is. What he will look for in the pictures of my heart are those portions of the muscle that, when the heart contracts, do not move.

I walk home in a daze, yet feel curiously relieved: at least I know what the problem is—
I have had a heart attack
—and then drive to Cooley Dickinson Hospital.

Dr. Flynn and I meet in a small room crowded with equipment. Dr. O'Brien, one of Dr. Flynn's colleagues in their cardiology practice, is in the room with us. He is the doctor Aaron has been seeing for his heart problem, and though the three of us, along with the technician who will perform the echocardiogram (anointing my chest with vaseline-like gook and tracing paths along my skin with a hand-held instrument that looks like a detachable shower-head from a bathtub), are shifting around in a very small space—the two doctors and the technician talk with one another and often refer to me by name—Dr. O'Brien never says hello or acknowledges my presence. This confirms the dreamlike sense I have that I am both very much there (
I've had a heart attack I've had a heart attack
, I keep repeating) and that I am not there at all—that what is happening is happening to somebody else who happens to look like me and is also named Jay Neugeboren.

Dr. Flynn studies the echocardiogram on the monitor while the technician performs it, and when it is completed he runs the film through again. He seems puzzled. To his surprise, he tells me he cannot find any damage—any portion of my heart muscle that is not moving. Instead, what he does discern is a general weakening of the heart muscle.

“Your heart is not contracting as strongly as it should,” he tells me. I have already taken a beta-blocker he prescribed in his office (beta-blockers are medications that slow the heart rate and the force of contractions, and lower blood pressure by blocking the beta-adrenergic receptors of the autonomic nervous system—that part of our nervous system over which we have no conscious control), and he says that this fuzzes things up a bit. He looks at the film once more, and still cannot find any area of dead muscle.

In his letter to Dr. Katz, dictated after the EKG and before the echocardiogram (again: how memory transforms events! I thought I had gone straight from his office to the hospital, and have no memory of doing anything else—of the hours in between—yet the letter indicates I had the EKG in the morning and the echocardiogram in the afternoon), he begins, “Mr. Neugeboren came to the office today for an exercise test.

After noting that my blood pressure was 150/80, my heart rate 70 and regular, he states: “Cardiac exam was unremarkable.” The EKG, however, is “suggestive of a possible recent anteroseptal infarction [MI in the septal portion of the left ventricle],” which he suspects occurred before the first episode of shortness of breath on December 21. “Other potential etiologies for these EKG changes include a
cardiomyopathy [disease of the heart muscle] which is certainly less likely.”

After the echocardiogram, however, Dr. Flynn comes to an opposite conclusion. “Findings cannot exclude coronary disease,” he reports, “but seem most consistent with a cardiomyopathy.” In the echocardiogram report, he also notes other findings: no evidence of aortic stenosis (a narrowing of the aortic valve), mild mitral regurgitation and borderline left atrial enlargement (of no consequence), and overall left ventricular ejection fraction “calculated at 40–45%.” He now tells me that he does
not
think I've had a heart attack, but a cardiomyopathy, most probably from a virus that is slowing down and weakening the force at which my heart is pumping blood.

He recommends catheterization and tells me I should call his office when I get home and arrange for his partner, Dr. Beck, to perform an angiogram at Bay State Medical Center (a half-hour away, in Springfield, Massachusetts) sometime soon, so we can find out exactly what's going on. In the meantime he gives me prescriptions for Atelenol (a beta-blocker) and for Vasotec (a vasodilater, so called because it dilates blood vessels, thereby reducing pressure within the circulatory system), tells me to use nitroglycerine if I have discomfort, and—as I've been doing for several years—to continue taking one aspirin a day. (Blood clots in our arteries are formed by a complex interaction between clotting elements in the blood and small cells called platelets, which are designed to patch up tiny holes in our blood vessels. We have been using aspirin, a derivative of willow bark, as a medicine for at least two hundred years, yet it is only since 1971 that we have learned that a small amount of aspirin, by reducing the stickiness of blood platelets, makes them less capable of generating blood clots, and thus is of great help in reducing both heart disease and strokes. This property of aspirin was first noted in 1950 by Lawrence Craven, a family physician in Cleveland who, observing that giving aspirin to children following tonsil removal resulted in increased bleeding, suggested in a series of papers which, during his lifetime, went unnoticed that aspirin might also reduce the tendency of the blood to clot following coronary thrombosis.)
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“I think it's viral,” Dr. Flynn tells me again just before I leave.

Back home ten minutes later, I telephone Dr. Flynn's office and
say that Dr. Flynn said I should set up an appointment with Dr. Beck for an angiogram. The secretary tells me that Dr. Beck is booked for several weeks. I can make the appointment now, or call back. Although I am wild with anxiety and rage, I remain outwardly calm. Talking on the phone with a stranger who works for a doctor I have never seen, and feeling mildly panicked—if I let the anger fueled by my helplessness show, will they simply tell me to go to another doctor? will I have to go through the whole routine again?—I am persistent and insistent: I want an appointment as soon as possible. When the secretary looks through the schedule for a third time, she tells me she can squeeze me in for a brief office visit with Dr. Beck in the middle of next week—not for the angiogram, but to confer about setting up an appointment
for
an angiogram.

I hang up and telephone Rich, who had called earlier and left a message asking me to call him as soon as I got home, and to have the doctor fax him the results of the exam right away. I go over what has happened, beginning with Dr. Flynn telling me, first thing, that I've already had a heart attack—and when I get to the end of the story and tell Rich that the last thing Dr. Flynn said to me was that he thinks the problem is viral, Rich explodes.

“It's not viral, goddamnit
—I want you in the hospital as soon as possible!” he exclaims, and he now insists I go to Massachusetts General Hospital, and not Bay State, because Massachusetts General is “the best” and because he knows several excellent cardiologists there. He will call ahead and help with arrangements. Catheterization is no big deal, he says, but if they have to go beyond catheterization and do angioplasties or a bypass, he wants me where he knows the doctors and knows they are “the best of the best”—the most experienced surgeons, the best diagnosticians.

(“My medical antennae were tingling with that sense I always get when I know something's terribly wrong,” Rich will later tell me. “My initial goal was to keep you from total panic while getting you to Mass General, and as time went by, my anxiety deepened—thus the more frequent calls. But I knew how serious the situation was, and there I was, three thousand miles away, agitated as hell. I knew the clock was ticking, and I knew where you could get the best help—two hours down the road.”)

We talk for a long time, and Rich goes over everything with me carefully, continuing to insist that I go to Massachusetts General Hospital. He is concerned about my ongoing discomfort, but—to reassure me?—says that the fact that I have been able to swim so strongly is a good sign.

“I want you to know I am here for you one hundred percent, Jay,” he says, but, alas, “here” is southern California, and what is imperative now is “to get the very best and most expeditious help” for me he can, and as soon as possible.

He also talks about how fortuitous our reconnecting after many years apart has been, and about how much this has meant to him. (After having read
Imagining Robert
, Rich wrote me a long letter—not only about how moving he found the book, but also about how touched he was by our many affinities, and how close he felt—much like a brother—to me.)

In my memory, Rich—high scorer on our synagogue's basketball team, undefeated in singles through three years of varsity tennis at Erasmus, hard-hitting third baseman for the Tufts College baseball team, and a guy who helped put himself through college and medical school by winning substantial sums of money at poker—was a tough, fiery ballplayer, as competitive as any guy I knew. Though he had a most winning smile off the court, in the schoolyard he was all business—all elbows, hips, butt, and shoulders under the basket—a guy who would go through the proverbial brick wall after a loose ball—and, on the perimeter, a guy with a soft, deadly touch on his jump shot.