Or, The End of the Angina Monologues and On To Something Completely Different

I always knew I was going to have a heart attack. Following the diagnosis of my stable angina condition in 2004 and the steady state of my condition, of which I was reminded every time I strenuously exerted myself, the possibility of one of those throat-tightening, chest-pressure instances lasting more than the usual 15-to-30 seconds was always a possibility. I always knew a heart attack was likely coming. What I didn't know was when, where, and just how bad it was going to be.

The best analogy I've discovered for my heart experience is that it is like an earthquake. In 2004, the doctors discovered that my heart had developed enough blockage to classify it as a major fault line, but given its geographic age, only cautioned the resident and provided some drugs to keep him calm to try and prevent any stressing of the fault, avoiding for the nonce the engineering options of structural fortifications or bypasses. But as anyone who lives in California knows, tremors happen. For me, tremors happened typically during my tennis play, if a point was long and had me running from side-to-side or front-to-back. The pain wasn't much--typically a shortness of breath, or a tightness in the throat, and simply taking a little extra time to rest afterwards would put the system right back to steady state. For those few times in the last four years where rest didn't seem to be going to cut it, I could take a hit of nitroglycerin which causes an immediate rush as it instantly dilates your blood vessels which solves the pressure issue but gives you a humongous headache.

But I knew that some day the fault line was going to slip, and for me, that was Friday, 1 August.

I actually started feeling bad the night of Tuesday, 29 July. Over the weekend, J and I had a discussion about how much all this eating we were enjoying with the total absence of any exercise was not doing us any good, so we made a pact to get exercise every night after work before retiring to the club lounge and heading out for dinner. She was going to do some walking around the KLCC park while I opted for swimming laps in the pool. We did this on Sunday, Monday and Tuesday. Getting out of the pool on Tuesday, however, I told her that three days of exercise after not getting any at all had really taken a toll on me and I was sore all over. We opted to return to a known restaurant (Ozeki) that was quite close that night rather than trying something new, especially given that our meal on Monday had been the worst we had had in KL.

Getting up on Wednesday morning, not only did I feel sore all over, I also had a sore throat and a fever. I went ahead and showered and dressed, for this was the day of the big group meeting, a 30-min huddle to finalize the big presentation, and I was in charge of the meeting agenda. Halfway through the meeting, though, I felt like I was about to pass out or throw up and had to excuse myself. I eventually drove myself back to the hotel and fell into bed for the rest of the day. And the rest of the next day.

I was feeling better on Friday, but I still hadn't eaten much in the last 48 hours, as the sore throat was so bad that I could hardly swallow anything but liquids (warm soup was ok, as long as there was nothing chunky in it). After sitting around the hotel for two days, I was ready to get out. And it was the day we were to meet up with the landlord's representative to go over the villa and get our keys so we could finally begin moving in. The walk through began at 9:30 and I was good for about 30 minutes, then started to lose steam. I passed the checklist paperwork to Jill and sat down on the stair steps (there was no furniture in the house as of yet--the outdoor chairs, which we were going to put inside until our ground shipment, weren't due until 11am). I'd get up every now and then to walk around, but I was definitely still not feeling well. I even took some aspirin around 11:30, feeling that the fever might be returning. When the chairs arrived, I moved to them and also got up when the walk through was complete. After that, J and I were due to stick around until 1pm when the Telekom installer was to arrive to hook-up our telephone land line.

The heart attack started at noon. At first I didn't recognize it, thinking that I was just uncomfortable in the new chair, so I tried laying down, first on the marble floor, then on the wooden floor in what would be my study. That felt better, but I realized I was still uncomfortable. I got up and went back to the chair and that's when I realized the chest pressure for what it was--my heart. On the Richter scale, this was fairly low. If the tennis angina attacks were 1 or 2, this was only about a 3. Still, it was chest pressure, and in this case I hadn't been doing anything to exert myself, and that's what should have really clued me in that this one wasn't normal. I pulled out my nitro spray bottle and did three or four quick spritzes under my tongue.

And I sat there, expecting the pressure to go away. But it didn't. As minute after minute passed, I realized that this was something I wasn't going to be able to ignore. J was on the other side of the house, on the phone with a work colleague, so I just sat there by myself going through the options. We had only been in Malaysia for a couple of weeks and I wasn't really sure how the medical insurance worked here, or even where I should go. The emergency room, I guessed, or at least a hospital somewhere. I recalled that there was one near KLCC but I couldn't recall exactly where. And all along I kept waiting for it to stop. When J finished her call, she came to sit beside me in the new chair and she knew I wasn't feeling well.

The pressure was still there, at the same intensity. That's when I said, "I think we have to go to the hospital."

It's easy to look back at this string of events and illuminate every wrong decision: That I didn't go to the doctor earlier when I was so sick I couldn't eat. That as soon as the nitro didn't work, I didn't immediately get J to end her call and take me to the hospital, or even that we didn't call the emergency number and get an ambulance out to me immediately. The problem all along that I, and J for her part, was in denial. While I knew that I was going to have a heart attack someday, I couldn't believe it was happening right then, right now. Not just as we had gotten the new keys to the house in a foreign country that we were going to be living in for at least three years, a lifelong dream for both of us. Surely it was just because I was starving, having not eaten hardly anything for 72 hours. It was kind of like when the quake happens and you stare down at your drink to see if the reason the world just wobbled was because you had been drinking too much, then realizing everyone in the room had just looked down at their own drink too. Except, in this case, I was the only one feeling the quake and had to report what it felt like to J. It also didn't help that by 1pm, a full hour after it had started, the pressure finally began to ease off, the tremor subsiding.

We called our relocation company and they were able to give us directions to the hospital, which turned out to be just down the road (literally, about 300m) from our hotel. I directed J to it, and we were able to navigate into the car park. By the time we stepped out of the car, it was around 2pm. When we stepped from the car, the pressure had basically ceased and I was feeling bad still, but it was due to my original illness rather than my heart. I hesitated. Before we headed to the hospital, we had gotten something to eat just in case the problem was my need for food instead (see, denial), and I was thinking that perhaps the food that I had eaten (not much really--I had forced myself to swallow about a dixie cupful of french fries) had solved the problem. But we were there, and all-in-all I couldn't deny to myself that I hadn't felt the quake or that it hadn't gone on for such a long time.

When you mention chest pains in a hospital, no matter what hospital it seems, they don't mess around. You get immediately led to a bed where they put the blood pressure cuff on you, draw some blood, and began asking the questions: when did it begin, how long has it lasted, what does it feel like, have you felt this before, does your family have a history, are you a smoker, diabetic, are you feeling any pressure now? Then it's the EKG, where they attach the electrodes to your chest and the insides of your arms and the insides of your calves. All along you try and remain calm and tell you story to each and every one: I have angina, I've never had pressure that went for this long, I'm not feeling it right now, it started around noon and lasted an hour.

In 15-30 minutes, the emergency doc came by with the bad news. The blood test confirmed an increase in Troponin in the blood. As he was telling me, the staff were fitting the oxygen up to my nose and getting ready to insert the IV to start saline drip and that's when I knew that I had both my the right decision to come to the hospital as well as a sinking feeling knowing that this might not be the end. The cardiologist showed up shortly to explain that elevated Troponin meant that I had suffered heart muscle damage, i.e., a mild myocardial infarction commonly called a heart attack. I had two options: (a) I could undergo a cardiac catheterization to see how bad the damage was and to determine if immediate angioplasty or stenting was required or (b) thrombolytic treatment, where a very strong blood thinning drug would be administered over an hour's time to help break up any clots that had formed, to be followed up with additional anticoagulant and blood-thinning medications.

I chose option (b). I wasn't ready to undergo a surgical procedure, especially not laying there feeling fine.

They immediately wheeled me up to the Intensive Care Unit where I was transferred to a bed and hooked up to the heart monitor by connecting additional sticky electrodes on my chest, a clamp placed on my left index finger that measured the amount of oxygen in my blood, and a saline drip connected to the IV for hydration. After that, they wheeled in the sonogram machine and proceeded to do the "look, it's a beating boy" routine on the heart, which I normally found, er, heartening, but wasn't actually in the mood for levity by this time, especially after the cardiologist and his sonogramic friend pointed out the places they could see where the heart muscle was being moved rather than moving itself, which is evidence of damage. (And not prior damage, as scar tissue shows up as white, and this was dark.)

After that, it was time for thrombolytic treatment itself. Replacing the saline drip was a drip of streptokinase, a clot-busting, fast-working anti-coagulant. Halfway through the hour-long process, my throat began burning. Like a brand. A cattle brand. Fresh from the coals. Applied to my throat. Constantly. I started to worry that maybe I was having an allergic reaction to the drug, or that my sore throat was actually an open wound and the streptokinase was going to make it burst into a gushing torrent of blood. I mentioned the burning sensation to the monitoring staff, but no one seemed concerned so I just lay there in pain. Believe me, there's no sore throat I've ever had that's ever come close to how bad that felt for ten minutes. When it finally began to lessen, and I could swallow again, I felt that it had indeed been a trial by fire.

I had to stay in the ICU for two nights, mainly for follow-up observation to the thrombolytic treatment. I can tell you that it's not two nights I want to repeat soon, not to disparage the wonderful staff or service at the Prince Court Medical Center. It's just that in the ICU, with all those wires hooked up to you, with someone constantly monitoring you, with all the beep-beeps of the monitor, and, frankly, having to relieve yourself from a bedridden position, you realize just how good it is to have a "normal" hospital room. The entire time I was in ICU, I kept mentioning the fact that my throat was still sore, and had been since Wednesday, and that I was unable to eat anything beyond soft foods (which basically meant soup--although I found out after moving out that I should have been requesting the "soft diet"). After J and I inquired about the possibility of it being strep throat, partly because of the swelling of the lymph glands. The cardiologist pulled out a tongue depressor and had me do the "aaaahhh" routine, then got a bit of surprise when he hit my gag reflex. Luckily he jumped back fast and I hadn't eaten much due to the fact that I couldn't swallow anything. He agreed to refer me to an Ear, Nose and Throat (ENT) specialist on Monday and instructed the nurses to take a swab sample for lab analysis in the morning.

I finally got to leave the ICU on Sunday and transferred to a normal room. The Prince Court Medical Facility only has two types of rooms in its medical ward: a suite or a single room. I took the latter, which was as tastefully appointed as the hotel room over at the Traders, except that it had a bunch of staff call buttons. The couch even makes a single bed, in case your spouse wants to stay in the room overnight (I told J that wasn't necessary, since we still were paying for the suite over at the Traders). After the ICU, it was heavenly. Before an hour was up, I had already stripped and taken a shower, the first I had gotten in over 48 hours (really, sponge baths are only romantic if you were dying of heat in the Sahara). I ended up getting the bandage of my IV wet, which required that they remove it (you would have thought I did that on purpose), so I was also free of any interface between machines and my body since I had entered the Emergency Room on Friday.

As for additional chest pain? None. I was still weak, and the throat continued to be a bother, although with the discovery of the soft food diet, I had finally downed enough food to consider a meal on Sunday night. On Monday afternoon, I got to visit the ENT, who carefully avoided the gag reflex on warning, and gave me the final piece of the puzzle. Although I had my tonsils removed when I was young, either the surgeon had not removed all of them or, more likely, the tonsils were trying to grow back. I had 1-2% of normal size tissue on both sides of my throat, and each of those had white, ulcerish growths. He sprayed some topical anesthetic on them and gave me some high strength anesthetic lozenges. I discovered later that tonsils are actually the inside throat version of your lymph glands, and thus instead of a cold, I had actually acquired a viral tonsilitus, which likely weakened my body's system enough to trigger the heart attack itself.

And so I sit here on Tuesday night, still in the hospital. The cardiologist has said that he will discharge me tomorrow, but I'll need to come back in a week for a follow-up checkup. I'm also not supposed to exert myself for the next four weeks. While I'd like to return to the medical treatment I had been undergoing for the angina, now that I've actually had the heart attack I probably need to follow through on determining if now is the time for a stent or two. I'll be contacting my DC cardiologist and will probably undergo a catheterization there or elsewhere in the States, depending on a number of variables like proximity to family and agreement of the insurance company.

I knew I was going to have a heart attack. Right now, I'm counting myself very very lucky that the one I had was so mild.