It is almost two months to the day that I woke up at 6:30 AM to my wife coming into the bedroom with our little man in her arms. It was a Friday, which meant an early start and no nanny; it was to be a daddy day. For months Denise had been sleeping in Carson’s room since she would be up at least once in the night to nurse him and we had decided early on that there was no point in both of us getting up. For the moms out there, I’ve always offered to take night duty but our little guy has been a good sleeper and Denise has always felt it just easier to sleep in his room and nurse him. Something about her boobs hurting if she went the whole night without his attention! I won’t argue with that and certainly don't mind getting a full nights sleep. But I digress.
As I awoke I could feel my heart was racing. At times just below my Adams apple it felt like something was going to jump out of my chest. I didn’t immediately freak out. I’ve had episodes of rapid heartbeats before. Many people do, it’s not that unusual for your heart to race for a second or two or to have one or two beats stronger than the rest. But this was not one or two beats or one or two seconds. This was not going away.
Now I’m a pharmacist and I’ve had a pretty extensive medical education. I knew immediately that I was in what is called Atrial Fibrillation (AFib). Besides the medical background I’ve also experienced this condition once before nearly 15 years ago while studying and completing my hospital residency training. At the time that episode was ultimately chalked up to a combination of being a young male, late nights with high caffeine intake and the stress involved with getting through the residency. Following a process of chemical cardioversion (they gave me drugs to put my heart back into normal sinus rhythm) I passed a stress tests and was given a clean bill of health.
So, as I say, I didn’t immediately freak out, instead I calmly got out of bed and told Denise what was happening. I then suggested that if my morning dump didn’t take care of it that we had a problem. For those that don’t know, the process of a bowel movement or bearing down has an effect on the hearts electrical conduction and can often stop some types of arrhythmias including Afib. In this case I had no such luck, with stopping the Afib that is!
What to do? I did not have any chest pain or any other symptoms of a heart attack and I was pretty sure this was a simple case of Afib similar to my previous experience. Afib on its own is rarely life threatening, scary yes, but in almost all cases your heart continues to pump sufficient amounts of blood. Thanks to the SA node (part of the electrical conduction pathway that passes electrical impulses from the atrium to the ventricles), only a fraction of the electrical signals from the atrium actually cause the ventricles to contract otherwise you would have one big twitching mess incapable of sustaining blood flow to vital organs.
A couple of other things came into play that morning. Denise was to open one of the PHI pharmacy stores at 7:30, she tried calling the manager but there was no answer on his cell phone. If she doesn’t go in, the store remains closed. Not something I was too worried about but she is a dedicated employee and this idea did not sit well with her. We also did not have anyone immediately available to take care of the kids and Morgan would be up very soon. In the end we somewhat calmly decided she would take them to work and I would drive myself to the emergency room. For those of you who live on Saipan you can relate to the fact that if I had called an ambulance it would have likely have taken 2 to 3 times as long for someone to get there than it would for me to drive myself. Again, I wasn’t feeling any symptoms other than a very rapid heart beat so off I went!
When I arrived it did not take long to be hooked up to an EKG. Despite not looking like I was in any real distress, the staff in the emergency room understood the potential seriousness of what was happening. I don’t think the familiarity with the triage nurse from 3 plus years of working across the hall hurt the situation either! It was comforting to know that things were moving along pretty quickly.
The EKG confirmed that I was in fact in Afib and that I had a heart rate of more than 130 beats per minute. As the Dr. reviewed the EKG and we waited for the blood work results my heart rate began to come down on its own. The plan to give me some intravenous medication was discussed; the PHI pharmacy manager came in from across the hall to see how I was doing. He told me someone was being sent to relieve Denise and that she would be down shortly. A quick text message from her told me our good friend Sheila had arranged to have her nanny take care of the kids. One less thing to worry about and by the time she arrived my pulse had come down to the point where IV drugs were no longer indicated. I was given some oral medication to further slow my heart rate. The blood work came back with everything in normal range and no indication of a current myocardial infarction (MI/heart attack). The ER doctor was satisfied with sending me home on the medication and an appointment was made for me to see my GP that afternoon.
It was beginning to look more and more like this was an anomaly similar to that of 1991. Then almost as an after thought the Dr. ordered a bedside thoracic (chest) ultra sound. I was taken into a very cold room where Dan, the head of the radiology department, told me to lay down on my side as he prepared to take a look at my heart. That’s where everything changed. After a few minutes of watching the screen with Dan pushing buttons and moving the handle of the ultrasound machine over my chest I asked him how it looked.
He first told me that the right side of my heart was larger than my left and before he could say so, I said, “that’s not good”. He then showed me how my left ventricle (the work horse of the heart and the chamber responsible for pushing blood out to the rest of the body) was not contracting properly. Rather than contracting concentrically like a fist one side was moving away from the other. More buttons and a few measurements later he told me that my ejection fraction was 35%. That’s well below normal especially for a 42-year old man in relatively good health.
In that short time on the table it became apparent that this was not a simple Afib event caused by stress or too much caffeine. Instead my own medical training told me there was something seriously wrong. The atrial fibrillation was a symptom of a much larger problem. The question was what? The right side of the heart does not get bigger than the left overnight. It takes time for that to happen. The clinical term for what I had was cardiomyopathy. The fact that it involved the right side of my heart immediately made me think of my lungs as a potential problem because the right side of the heart pumps blood to the lungs. Did I have pulmonary hypertension? Was the enlargement due to the fact that there was increased resistance to blood flow to my lungs? What the hell was going on?
As I was taken back to the ER my heart rate was responding nicely to the medication. I was still in Afib but the rate was now down to a reasonable 90 beats per minute. As I mentioned Afib on its own is rarely life threatening and with the rate under control there was really no immediate risk to me being discharged from the ER and followed up by my GP later that day. We now knew why the atrium was misfiring; it was a symptom of the increased size of the heart since electrical disturbances are common in the setting of cardiac myopathies. The problem was we did not know why I had the enlarged heart and reduced ejection fraction both of which do not bode well for a long and healthy life span.
Denise took me home and I waited for my appointment that afternoon with Dr. Ada. My mind raced with the possibilities and the possible ramifications of what this meant. In the span of 4 hours I went from being calm to concerned to down right scared of what all this meant and what was to come.