congestive heart failure – Use What Exists

The Road is Now Calling, And I Must Away.

I wrote this on Friday night, July 30^th before I went to bed. I kept delaying putting my head to pillow; not ready yet for this last night to end. This past weekend was bittersweet. We held my mom’s one year memorial service; her final instructions to me and the Greek tradition now fulfilled. While we raised a glass in her memory, I looked around the circle of friends and family gathered in our garden, glasses in hand waiting for our son Richard to speak, as he so eloquently does. They’ve all been on this rollercoaster journey with us since Rich’s first diagnosis in 2004. As have those who couldn’t join us but have sent their messages of love and support. For seventeen years we’ve been surrounded by a family created over the years who have kept us afloat mentally, physically, and spiritually. They have celebrated and cried with us. It’s hard to relocate far from their warmth although we know it, and they, will be with us always wherever we are. So below are my thoughts on that last night as I walked through the house with only the lights from the street coming through the windows. As I did, the final song of Peter Jackson’s movies ran through my head. Although this is not the last goodbye, they did seem fitting.

July 30^th, 11pm:

It’s a bit surreal. As I have been since Covid started, I was working remotely. Only today the house is near to empty. The rugs, lamps, photos, furniture is for the most part gone. What made this house our home for the last thirty-odd years is on its way to Rochester, NY. There waits our new house. In the area of the city known as the South Wedge, we can walk to the river, parks, pubs and restaurants. Initially it was to be our getaway-near-to-the-kids; a charming 1888 brick townhouse that would host grandkid sleepovers and visiting guests.

And then the reality hit. Rich’s health is better up there. The brick house has always been a two family. Our space on the first floor offers one level living. Without those stairs, Rich’s BP remains steady even as we tackle the expected projects to make this place our own. We’ve tested this for months, alternating weeks up and weeks on Long Island. Every time, within 24 hours of being downstate, Rich’s BP would drop. There is no way to live on one level in this cape style house without some major changes. Our heart failure guru said it best: “You’ve found the problem and you found the solution. You need to implement it.”

News travelled fast. An hour later, we’re at the office of our kidney failure guru. “I hear you’re moving.”

And so here we sit in a near empty house. To our chagrin, we find even the toilet paper has been packed and shipped. The time between decision and today has flown by. What we refused to consider a few months ago is now a reality.

Our files from NSUH will be transferred to University of Rochester Hospital system. What a read that will be, to be brought up to date for our new health care group! Appointments and meetings will take place in the coming months as we learn to navigate this new mental and physical reality.

Tomorrow at 6am we load up the car with some things that we didn’t trust to a truck and for the last time as Long Island homeowners, we cross the bridges and head up to our future.

…Many places I have been
Many sorrows I have seen
But I don’t regret
Nor will I forget
All who took that road with me

To these memories I will hold
With your blessing I will go
To turn at last to paths that lead home
And though where the road then takes me
I cannot tell
We came all this way
But now comes the day
To bid you farewell

I bid you all a very fond farewell

(Billy Boyd, The Last Goodbye)

Delicious Ambiguity

As America enters the final days of the 2020 election, as we enter the eighth month of the Covid19 pandemic, we all face uncertainty. With the addition of the CardioMem last week, we thought our days of the uncertainty of Rich’s health were at an end. This little paperclip-like device was implanted in my cyborg’s pulmonary artery. There it would, via a talking pillow, send a report to the staff at the heart failure clinic. Every day, we’ve received a call to let us know how we were doing on that fine line of fluid retention. Drink more water? Take a water pill? What a wonderful tool to have in our arsenal! The guessing game would be over and done. We have a team behind us getting solid data every day.

Yesterday morning – was it only yesterday? – Rich was advised to take a water pill. At noon he was feeling well but tired and the water pill seemed to be doing its job. When I checked on him at 4pm, his tongue seemed thick and his words hard to articulate. We checked his blood pressure and it was on the mildly low side. But all the other side effects he’s experienced to date were there… unsteady on his feet, cloudy thinking, swings of emotions and that major tell, the struggle to carefully pronounce words with a tongue that didn’t seem to want to cooperate.

We called our team and the singing, chatty pillow was brought down to take another reading. The nurse practitioner called us back. The arterial pressure reading went from a high in the morning of 23 to a current low of 13. That water pill packed a punch! He sipped water as advised and there was a modest rise in his blood pressure. The team asked Rich a series of questions and told us to go to the ER. They were concerned it may have been another TIA. They didn’t like his difficulty with talking.

In these days of Covid, I’m sent home once I get Rich done with his registration intake at the hospital. It’s frustrating to walk away from the hospital, leaving Rich behind. These episodes are not remembered by him. There is a vulnerability to that amnesia. It’s hard to make solo decisions about your treatment when you don’t remember why you are there. The ER calls me to get answers to their questions. He doesn’t know what went on.

At home, I sit with my phone, waiting for a call with an update. I jump at each notification that comes on the patient portal, hoping for some information that will give me an idea where we’re going. More often than not, it’s bloodwork. Once again, Rich tests negative for Covid. Another ping of my phone. They’ve uploaded his medications list. Ping. Dx: Dysphasia. That speech difficulty.

And I sit waiting. I wait to call, wanting test results or consults to be done before I tap the number of the ER desk in my contacts list. The nurses are patient with my phoning, but there isn’t much information. They tell me he will be in overnight for observation. Rich texts me with small updates. An MRI is ordered. He’s had the CT scan. I keep watch on the patient portal. He texts he’s hungry. I text him to ask someone to get him a dinner. At some point, we both fall asleep; miles apart.

Gilda Radner, who knew a thing or two about cancer and chemo and dealing with illness, wrote “I wanted a perfect ending. Now I’ve learned, the hard way, that some poems don’t rhyme, and some stories don’t have a clear beginning, middle, and end. Life is about not knowing, having to change, taking the moment and making the best of it, without knowing what’s going to happen next.
Delicious Ambiguity.”

While we hope for answers to why these episodes happen and what triggers can we avoid, I wonder if we’ll know. Or if we will need to learn to live and find joy with this particular delicious ambiguity.

Come Home ‘Cause I’ve Been Waiting For You For So Long

Funny that my last post ended with talking about planning meals. On Friday (as Rich says, “Why always Fridays?”) I came down from my remote office for lunch and found Rich leaning forward fast asleep. While napping is innocuous, his position was not. Any time I see that posture, it’s a good indicator that we’re in for a bit of a ride.

I woke him up and we chatted for a bit about lunch and then segued onto a discussion on our plans for dinner. As we got up to check the freezer and make some decisions, Rich was a little off balance. It happens. So, we wait for his BP to stabilize from the change in altitude. Called orthostatic hypotension or positional hypotension, Rich is used to this and generally will take a moment when getting up from a chair to allow everything to equalize. Walking behind him as we made our way through the house, I could see he was lightly touching the furniture he passed to orient himself upright. Not a good sign.

Before I knew it, his eyes rolled back, and he began to crumble into himself. Syncope. While trying to catch him, I also pushed him up against the nearby bookcases to help me keep him from hitting sharp corners until I could get myself under his arm properly to support him. With the canon of Ray Bradbury practically up his nose and his nose on the shelf pretty much all that was keeping him from crashing down, I kept saying his name louder and louder to bring him back to consciousness. He’s not a small guy and I needed more than some dead weight to keep him from some serious damage. In his confusion when he began to become aware again, he kept saying he was fine. Fine. Nose hooked onto a bookshelf filled with the yellowing seventy-five cent mass markets of Bradbury’s nostalgic science fiction. Truthfully, there are worse places to be.

Once settled, Rich’s blood pressure seemed elusive. Finally, some readings start to show we’re in low blood pressure territory again. Since his last hospitalization, we’ve had a few of these episodes but with some additional fluids and rest, we’ve been able to bring it back up to the norm. Now was not one of those times. When we finally got a reading, it was 78/45. A call to the heart failure doctor’s office confirmed a trip to the ER was needed.

Once again, with covid protocols in place, I dropped Rich off in a way that felt very much like dropping off some dry cleaning… albeit some with some pesky stains that needed special attention.

As they ran tests, they inverted Rich to keep his brain well supplied with blood. Through some trial and error to get needed data, they took his BP lying down, sitting up and standing. Lying down and standing up our guy was in normal range. But sitting, SITTING, his BP dropped to a low of 70/43. None of this made any kind of sense.

Saturday morning, they ran some blood work specific to heart related issues. These were tests that we’ve never seen before, but we do know that the doctors were looking for any kind of infections that would preclude surgery. Because it looks like Rich’s CRT-D implantation into the Borg collective was getting moved up.

In addition to this expected device, we’re also advised that there is another device that is being considered in addition to the pacemaker/defibrillator. This one is called a Cardiomem. This little piece of magic measures pressure in and around the heart to help control medications having to do with the congestive part of congestive heart failure. By measuring that pressure, it is measuring the indication of fluid buildup before our patient has any sense of water retention or bloating. As it’s constantly monitoring and in communication with the health care community, we can be advised to begin taking lasix to forestall any buildup that can be problematic.

Our consults are via phone; Rich and the doctors in his hospital room on one end, and me at home on the other. The waiting, never my strong suit, is maddening. I’m allowed to visit now that some covid restrictions are lifted. I wait on a long line of visitors. My temperature is taken. A timed visitor badge is given to me. I’m told my visit is limited to two hours.

I’m supposed to check in at the nurse’s station in Rich’s unit. I bypass that protocol, I really don’t want a record of when I came in. I stay for eight hours. At one point, six hours have passed, and I ask Rich’s nurse when she will kick me out. She looks at me and meets my eyes. “I don’t think you want to ask me that.” Got it.

At the end of hospital-wide visiting hours, I leave. There will be no overnight stays yet. We had hoped a doctor would be stopping by while I was there, but the room has been quiet as we binged our current TV show. We treasure the time.

Sunday morning the latest news is that electrophysiology is working to schedule Rich for his CRT-D device on Monday at the earliest. After I hang up from the teleconference, the house is once again too quiet. As is my norm, I turn to music to fill the emptiness and the first of the mix is an earworm that has been stuck in my head these last couple of days. A duo from Ireland that we’ve followed from their days in the The Choral Scholars of University College Dublin. It feels like they’ve been along with us on our CHF journey where we kept insisting in 2018: we have a trip planned to Ireland, we’re going. Their harmonies soothe and, as always, lift us at those moments when we need our spirits to soar beyond the now.

And yes, soon, it will be time for Rich to come home. Not yet, but soon. Because there’s someone I’ve been missing. Who is the better half of me.

Thank you to glenn&ronan for this cover of Come Home.

Hello world
Hope you’re listening
Forgive me if I’m young
For speaking out of turn
There’s someone I’ve been missing
I think that they could be
The better half of me
They’re in the in the wrong place trying to make it right
But I’m tired of justifying
So I say to you

Come home
Come home
‘Cause I’ve been waiting for you
For so long
For so long
And right now there’s a war between the vanities
But all I see is you and me
The fight for you is all I’ve ever known
So come home

I get lost in the beauty
Of everything I see
The world ain’t as half as bad
As they paint it to be
If all the sons
If all the daughters
Stopped to take it in
Well hopefully the pain subsides and the love can begin
It might start now
Well maybe I’m just dreaming out loud
Until then

Everything I can’t be
Is everything you should be
And that’s why I need you here
Everything I can’t be
Is everything you should be
And that’s why I need you here
So hear this now

App Fatigue Is Real

There is an app.

There is always an app. This one is a link to Rich’s medical records in abbreviated form. Results of blood work. Results of MRIs, CAT scans, X-rays. Reports of his implanted loop monitor. A little microcosm of our journey in abbreviations and code numbers assigned by health care professionals.

In that app are ambulatory documents that pop up after each visit to a specialist. There we find whatever changes to medications or protocols that were discussed. But before you get to that, there is a list of every single side effect and problem that has come Rich’s way. There are listed forty-five issues. When we first saw our oncologist seventeen years ago there was one. A diagnosis of Non-Hodgkin’s Lymphoma. At that point, the specific type was not yet known. Our first visit with the oncologist had a humorous moment when, lifting up a single piece of paper from his file folder he said “This is it? This is all you have?”

And it was.

As we’ve discussed before, our journey began in 2003 as we were getting ready for a family vacation along the St Lawrence Seaway in a rented houseboat. To make things easier on the water, the guys were all getting a buzz cut, no flyaway hair for my men!

As I began Rich’s barbering, there were two tiny raised bumps on his scalp. Little cysts that I said casually he should have looked at. A few weeks after our return from the locks, islands, bays, passing cargo ships, lighthouses big and small, swimming, fishing, cooking and stargazing into the night, Rich had those cysts removed. The surgeon said they looked like nothing to be concerned about. That single page report begged to differ.

We’re now seventeen years since that trip on the river. The one little piece of paper has grown one by one, and now forty-four of those problems have been addressed. Like that river we boated on in 2003, Rich keeps on keeping on, sometimes with a bit of a stop and wait like the locks along the way.

In a few weeks, what we hope is the last of these problems will be taken care of. Rich has had a left bundle branch blockage since he ended his first rounds of chemo in 2004. It was never really on our radar until it was discussed that heart issues can come from the chemo proposed in 2014. Anyone who has been a reader here, knows that the last two years, that LBB has been problematic and compounded by the beneficial poisons that brought Rich to remission.

Our doctors have been talking about giving our former Borg an implanted CRT-D device which is a combined pacemaker/defibrillator for a couple of years. CRT stands for Cardiac Resynchronization Therapy… it works to get the heartbeats from the ventricles to work in sync. In this case, the D indicates a defibrillator is part of the package as well.

When he had his ketamine infusions this May, our pain relief guru shook his head and consulted with our cardiologist… “his heart wants to go into a-fib, but then it refuses to.” Ever the fighter!

A couple of weeks ago our patient ended up in the ER overnight from a combination of factors affecting a combination of his issues. A hot day, congestive heart failure, gardening work, reduced kidney function, sweating, how much water intake was viable… a fine line of where the tipping point involves several decisions. Staying outside in the heat, doing just a bit too much yardwork, drinking the limited but recommended amount of daily fluid yet not accounting for sweating brought Rich’s blood pressure down to 71/41. We tried to bring back up but he needed a bit more than we could provide at home. This time, even the walker couldn’t get him to the door; our doctor arranged for an ambulance. We had immediate thoughts of another TIA, but what it boiled down to is that his LBB is making his heart work too hard against himself.

That ER visit showed that now it was time for Rich to go full on Borg again. In two weeks, his loop monitor will be removed, and the CRT-D will be installed. This pacemaker/defibrillator will help his left and right ventricles beat at the same time. That LBB will not be able to have that little blip where the left ventricle doesn’t quite contract at the same time as the right. Resistance is futile!

In the meantime, we’re working on getting the little room on the first floor set up as a neutral level place to relax and recuperate. Testing is in progress now as Rich is a little more tired, a little more out of breath, retaining a little more fluid. Thankfully, we can now release it into the beta level… planning our meals out and figuring which streaming platforms might be fun for after. Because, ya know, there’s always an app.

TIA: Thanks In Advance

There has always been a certain serendipity to our journey that started in 2003. Moments when I was exactly where I needed to be at a very specific nanosecond of time. Moments when Rich ultimately was in distress and would have been alone if I hadn’t changed my plans for no reason I could have explained.

One such moment was this past week.

As we have been sheltering in place since the Covid19 pandemic hit New York in March, we’ve turned to tasks and projects around the house that usually get tossed on the back burner when the spring weather draws us elsewhere to join with family and friends for holidays and gatherings and outdoor activities. Slowly has Rich been clearing, cleaning and organizing the workshop in the basement. On this particular day, he set himself the task of labeling various tool cases; drill bits, chisels, socket heads. Certainly not tiring, playing with a label maker.

You would think that spending eighty-three days of covid lockdown we would be bumping into one another throughout the day, but as I work remotely from home, I’m in an upstairs bedroom/office. My usual schedule is to grab a bite and continue to work through lunch, emerging at 5pm to join the rest of the household. For some reason, I left my desk and went downstairs to sit with Rich in the porch.

He seemed tired and his words were a little slurred as if his tongue was thick. I advised him to stay hydrated and drink a little more on this warm day. It’s a thin line we walk with congestive heart failure and kidney failure- the line between too little and too much water. With not enough hydration, his blood pressure drops so we decide that we need some information. First I ask him to use his loop monitor wand to tag this moment on his implanted monitor as an event. We check his blood pressure and oxygen levels. And another adventure begins.

From 226/129 to 84/43 his BP is all over the map. Rich becomes fascinated with the numbers and keeps hitting the button to take another reading as the roller coaster of results continues.

His O2 monitor shows a reading of 99 and we’re content. Until it then drops to 77 and then back up to 96… another roller coaster.

Rich’s phone rings; our order from the local shop is ready. He stands to get payment information and barely makes it into the next room. I finish the call while he sits. We both wonder what is going on. It’s time for the ER.

Suddenly he complains of a headache. It is the first description he can give me of how he is feeling. His response until then is “I don’t feel right but I can’t explain it.” He has to use a walker to get out of the house. His legs don’t want to hold him.

We are so indebted to Amy who doesn’t hesitate to take us to the ER despite being unable to socially distance in the car. Rich’s numbers are still fluctuating wildly throughout the ride.

Like everything, it seems, covid has changed this ER from what we are used to. Masks have always been present, but it is eerily quiet. Social distancing at its best. No one wants to be here regardless of how badly they’re feeling. But most telling, when Rich and I complete his intake and he’s taken to be seen, I’m asked to leave. I’m given a number to call; they have my cell to call me. And the waiting begins.

From the very beginning, Rich and I have taken this journey together. However long he was in the hospital, I slept in the same room; whether on the floor or on my various broken vinyl recliners, I was there. It was the oddest feeling to walk away and leave him behind. In my place, he grasps our red book that holds all our notes, calendars, business cards, meds lists, latest reports… all our records of who what when where how. With Rich’s confusion, it was his lifeline to being able to answer the questions he would be asked.

Throughout the day I’m called to answer the parts Rich can’t remember and aren’t yet in our book… what happened today. I’m told they did bloodwork and a CT scan. They’re waiting for an MRI. I find out later they also download the recording from Rich’s loop monitor to check for the event moment he marked.

His web portal pings on my phone. He is covid negative. I keep refreshing the portal hoping for more results. And I wait.

At 10pm, the nurse calls to discharge Rich. I ask to speak to the doctor; I still don’t know any of the outcomes from the tests. At this point, the doctor who has just come on shift is unaware that the loop monitor readings have been reviewed. The disconnect being home instead of with Rich is thrown into sharp relief.

The tests have shown that Rich has had a very probable a TIA: a transient ischemic attack. The doctor explains that there are two areas where microvascular irregularities were detected. The transient or temporary near blockage was the cause of the weakness, headache and slurred speech. We are thankful to hear that there is no lasting damage. This warning is again serendipitous. Usually undetected or unnoticed, these TIA are usually an indicator of probable massive strokes in the future. This micro stroke is more than enough for us, thank you very much. But, ya know, thanks for the heads up… thanks in advance.

Now we add another specialist to our list of gurus and some new prescriptions to our list of meds.

Despite the lateness of the hour, Rich is standing around waiting for us outside the ER doors; looking for Amy and I to arrive. He looks and sounds as robust as he was in the morning as if nothing had happened.

Thank you, Universe. We accept this warning with much gratitude as we settle down for much needed sleep in our own bed. Together.

His Power Is In Your Hands!

When we were about the age that our grandchildren are now, our upbringing was of the free-range kind. Basically, we were sent out to play and admonished to come in when the six o’clock siren went off. Usually Saturday mornings were spent watching cartoons while we ate breakfast and doing our chores before we were free to set off on our adventures. Wildly different than anything we had ever seen before were the early anime offerings of Speed Racer, Astro Boy and Gigantor in the mid 1960’s. No Looney Tunes these! Wide eyed kids with an almost James Bond arsenal at their fingertips. Their theme songs were simple earworms that would not give up.

As Rich had limitations while his meds were being optimized, we figured a Roomba would help take care of what are still, in our adult lives, Saturday chores. So it was fitting, that, given the option, our little self-propelled vacuum would be named after one of those anime characters: “Gigantor the space aged robot, He’s at your command….” Yes, please vacuum.

My phone could and did set him on his path around the house, sucking up debris and dust. If I was at work and Rich activated him, I would get messages when my space aged robot got into trouble and these would make me laugh, “Gigantor needs your help” or better yet, “Gigantor is stuck near a cliff!”

Screenshot_20190516-105200_Gallery

A cliff.

Lately, it has been feeling like our household is stuck near a cliff; a precipice that may or may not be the way we want to go.

A couple of weeks ago, Rich had another episode of syncope; he blacked out without warning while walking through the house; no cliff dive this… he was walking on a flat surface without obstructions. He has taken care when getting up from sitting to center himself before moving to avoid any dizziness or lightheadedness. But there are times when a quick drop in blood pressure will manifest and hit unexpectedly. Or was it an irregular heartbeat?

This time, his fall landed the bulk of him relatively safely on the dining room rug. His shoulder wasn’t so lucky. A huge open scrape went down his arm, his shirt having ripped. From what we can tell, he hit the outer corner of the baseboard molding of the bookcases. Sharp. Mom heard the fall and sat with him and did her best to help him, bringing a chair to his side for him to push himself up on. When I got home, we cleaned the sizeable wound and did what we could to get him comfortable. Bruises began to blossom.

We meet with an orthopedic and he tells us that the floating calcification he sees on the x-ray may have been in his shoulder before; we have no slides to tell us when this occurred. His take is that we just need to allow the inflammation to go down and see how Rich’s shoulder feels from there. A well placed cortisone shot helps in the days to come and Rich is advised to do mild exercises as home physical therapy to avoid frozen shoulder syndrome.

20190530_064146

We had a follow-up with our Heart Failure guru regarding the fall as well as to discuss the results of the CPET testing to see if a pacemaker may be of benefit to him. She spouted numbers and statistics as I frantically jotted down notes. Then she went into the down and dirty bottom line:

The overall test results indicate something called oscillatory breathing… almost a type of apnea… while exercising. This ties in well with her previous decision to have Rich evaluated at a sleep clinic. Oscillatory breathing is very much associated not only with CHF but also with the centralized sleep apnea she suspected. The guru offers to see if she can get us an earlier appointment than the July one we currently have. Then she’d like to have another CPET done after to see if there is improvement with whatever suggested therapy the sleep group has. CPAP or BPAP therapy in the overnight are generally the solution. And this helps the heart to rest and heal. The option of a pacemaker for support that we discussed in our last post is now a stronger contender given the results and Rich’s fall …and we’re getting closer to yes!

To add to the data and to perhaps help find a definitive cause to the syncope episodes, we discuss heart monitoring options. The best choice seems to be a loop monitor which would be implanted below the skin (Borg once more!) and will provide downloadable information on heart rhythms. After her discussion with our cardiologist, it’s decided to go forward with this. In two weeks, our One of Ten (formerly of Nine) will get this procedure done and another level of data will be added to the pacemaker decision. We will now be welcoming a cardiac electrophysiologist to our list of experts. There is a measure of relief with this; to have the support of some monitoring and get some real-time information as issues occur. If needed, again, a pacemaker will add to the ongoing support.

We also find we should revisit one of our meds that had been with us since we began prednisone at the beginning of this journey but was dropped two years ago. Zoloft had helped with the depression that prednisone brought upon the adrenals. When the pain management group gave Rich Cymbalta to help with neuropathy pain, they kept the Zoloft active as well. For a year he took both. And then we slowly weaned off, keeping only the Cymbalta for the neuropathy. But Rich has felt the difference.

Now that we’re coming to a year of continual med changes and tweaks, non-stop testing to optimize energy and healing, and a whole lotta everchanging rules, we think it’s time to consider Zoloft again. The cortisone shot Rich received in his shoulder could not have helped; steroids always depress his adrenals. And it is well known that chronic illnesses of all kinds can bring a discombobulation that is tough on the patient and that is detrimental on this path. Again, we welcome this available support.

Lastly, our doctor admonishes us to keep to the clean way of eating we did when we first met last year. With all the changes in the last six months, we’ve gotten a little off track. It’s time to pull back from that cliff we, like our Gigantor, were stuck near. If we need to send out a distress signal, we have a whole bunch on our team to respond, but ultimately, we are responsible for doing everything we can on our end… like our vacuum, we need to be reset onto firm ground, set the big button to GO and start anew.

Bigger than big,

taller than tall,

Quicker than quick,

stronger than strong.

Ready to fight for right, against wrong.

Gigantor the space aged robot,

He’s at your command.

Gigantor the space aged robot,

His power is in your hands.

Don’t fight forces, use them.

20180923_082816.1

As we drove out of Belfast for the last time six months ago, we passed under a sculpture of a sphere within a sphere. Two geodesic wire creations, one nestled within the other. The guys had gotten waylaid on their way to park the car as we checked into our hotel and this was a landmark that they recognized. I couldn’t help but think what that visionary, designer of the geodesic dome, Buckminster Fuller would have thought. His words are the title of this post. Smart man, B.

That the sculpture, named RISE, represents a new chapter and seems to be apropos today as well.

When Rich first went through chemo in 2004, he was advised by an oncology nurse to keep moving… whatever he could do, keep moving. She went on to explain that he would feel better and could help with side effects.

As always, Rich took this to heart and, once he wasn’t able to work any longer, he walked. He walked the trails at our nearby park as the neuropathy took hold and he couldn’t feel his feet. He kept walking those paths until the numbness was up to his knees. He said, “It’s not very busy at the park when I go. If I fell, I don’t know how I could get help!” So, he began walking our neighborhood instead. When that got to be too tough, he walked our small garden. He walked laps throughout the house. He kept walking.

When we began our journey again ten years later, he walked. He walked from the train to the office. When again he had to stop working, he continued his walks at home. Whenever in the hospital, we walked the halls. The nurse had said to keep moving and move he did.

When we entered the stem cell isolation unit, he walked, counting his laps and trying to improve each day. For four weeks we strolled up and down the hallway within a hallway, marking our pace and distance. In all that time, one day he missed walking. One day, when his counts were the lowest and his stomach was protesting the assault of the beneficial poisons. But always he remembered… keep moving. With a shaky hand, he reached for the two bottles of ensure that were on his meal trays and began arm exercises using those bottles as weights. Keep moving.

That has been his way throughout our journey.

Movement will help. Push past the fatigue and fog and keep moving. Leg lifts in the recliner, exercises with a walker, using household objects to work the arms.

And then congestive heart failure comes to roost and he’s limited. Limited in what he can lift, push, pull, carry. Inclines can’t be traversed. Care to be taken.

The universe has changed the rules and accepting these changes is hard. The ramifications of pushing past is no longer simply a day of rest and recuperation. His heart isn’t cooperating. After overdoing, his blood pressure drops. Less oxygen to the brain leads to confusion, slurred words, frustration, fluctuations in mood. Anyone who didn’t know better, would think he was drunk. Days are needed to recuperate.

It took us a while to put two and two together on this. At first we thought it was the meds as these episodes seemed to happen whenever there was a change in dosage. What really seems to be the case, is that the change in dosage gave Rich a bit of a boost which gave him a false sense of healing. So, he walked. And lifted. And had these episodes of ataxia.

For close to six months, lifting more than he should or exerting himself with exercise that formerly would have done more than send him for a nap, now had him on a different kind of roller coaster… one that set our house into chaos.

The hardest part of this carnival ride was for Rich to accept limitations. Our conversations with our gurus seemed to always include discussions on fatigue. Rich would bring up his disappointment in the backward progress of his energy levels. And what we would experience if he did too much. Like many a four-year-old, he tested his boundaries and not often to a good effect. Our conversations at home were like nagging on my end and whining at his. This isn’t the way we expected our lives to be although, honestly, the man IS still technically a toddler! But how to put a grown man in time-out?

With any disease or injury that has lasting effects, there is a mourning period. No longer is the person who they once were. Physically, mentally, emotionally, there are changes. And the mourning is not just limited to the patient but encompasses all who know and love them. The trick is to not let this mourning dictate the future. Our wise man of the geodesic domes Buckminster Fuller said, “You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete.” It was time for that change. It was time to act for that change. As always, it was for us to change and fit into the existing reality in a way that would work for us.

To that end, Rich and I puzzled the differences over the past year. We looked at his energy camping with Jake in July… hiking in Ireland in September. The decrease in abilities for distance. The walking had stopped. We looked at the episodes of seeming ataxia. We tried to figure out causes…. And solutions. How to make that change we wanted actually to happen?

This month something clicked. One year since the idea of congestive heart failure was brought up, it was like a light switch went off.

When we visited the heart failure guru, we were thrilled by her comments on Rich’s progress; he’s now maximized and optimized on his medications. He is tolerating them well. His kidney function is still off but stable. All what she and we hoped for. And yet, she had concerns. His fatigue. It was time to address it.

First, she suggested we see a sleep specialist and set up an appointment to see if Rich had what is called central apnea. Unlike obstructive apnea, this is a failure of the brain to transmit the proper signals to breathing muscles. It literally forgets to say “breathe!” While this type of sleep apnea is uncommon as compared to obstructive apnea, it is a risk for those with congestive heart failure. The symptoms seem to fit. She sends a request for an appointment to the proper department.

Next up, we discussed a more interventional solution. On the current medications, Rich’s ejection fraction (EF) has improved to where it is now close to the 40% it was and has been following his 2004 chemo. The cut-off for an implanted defibrillator is 35% and we are well past that. Now a normal EF is generally 65%; meaning 65% of the blood in the left ventricle is pushed out with each heartbeat. Below 35%, the heart needs some internal help.

Our heart failure guru feels that Rich may benefit from, not a defibrillator as originally had been discussed, but a pacemaker. That extra boost would help him maintain his energy. Other patients like him have. To see if it would be an effective protocol, we’re advised to have a CPET… a cardio pulmonary exercise test. This, unlike a stress test, would be on a stationary bicycle and would monitor, not just his heart and breathing rates, but the amount of oxygen his body, his muscles, are using and how much CO2 he is producing. Enzymes, mitochondria, heart, valves, lungs… the data that it can gather is stunning. And will answer questions… many more than we’ve had answers to before. And all from a simple bike ride.

And, she suggested, that if we were to go with a pacemaker, if the test indicated it would be helpful, then we should have the coil wiring implanted at the same time as well that would be viable for a defibrillator… in case in ten years or so it may be needed, it would be a simpler procedure just to switch out the box.

Ten years. Ten years. TEN! Instead of the heart transplant she first discussed with us, now we’re talking a quick change of a small box… if necessary. Y’know that stinging feeling you get when tears are imminent but you’re trying to keep it all in. Yeah, that. Suddenly, we’re talking a whole new outlook.

But first, a little reality hits. Rich is buoyed by the doctor’s assessment and, in doing so, goes overboard on activities the next day. By the time I get home, we’re in ataxialand. And we’re in deep. There is a double-edged sword to this; on one side, anything I say he will forget and on the other, anything I say he will forget. If marriage is a series of compromises, then sometimes we all bite our lip and are careful in our words. But to paraphrase the question of that tree in the woods, if a wife yells and the husband forgets it, does it exist? This could be a very cleansing opportunity!

Do we take advantage of this? We do. But the yelling is of truths and frustrations and despite the volume, they are heard. Yelling becomes talking and the talking builds from the truths and the frustrations that were said. And time passes and we keep talking. We revisit activities he has enjoyed in the past and discuss how to make them fit his current reality. We talk about possibilities. We talk about patience. We talk about us. Whether this is the pivotal moment or other factors are at play, acceptance is in the house. It was a long night.

Two weeks have passed without an episode. Rich has become active in the garden. Small tasks that are within his current wheelhouse are being done daily. He is more in tune with when he is reaching the tipping point. He takes those moments to stop and rest. Due to a knee injury he can’t take the CPET testing yet. He also delays his cardio rehab that was scheduled to begin next week. Setbacks but otherwise making progress.

Setbacks. I get home from work after writing these words and again we’re in the land of ataxia. This time we surmise it’s carrying a heavy box from Amazon and some solo food shopping the associated bags that weigh more than they should. BP drops, wonkiness rises. It’s another long night. But it’s just a blip… it doesn’t feel like it but we learn from it and move on. Keep moving.

So as the weather begins to warm and the days are noticeably longer, as his knee begins to heal, walking will happen again. In preparation, we work to schedule ketamine infusions to stem the neuropathy pain that is beginning again. We’re getting ready. The park is waiting.

“How often I found where I should be going only by setting out for somewhere else.” ~ BF

Determination and Courage

Maria R. Conklin, writer of the blog Journey of a Tired Heart, writes of exhaustion beautifully and gets to the crux of what it is like to experience a fatigue that only those with a chronic illness or going through devastating treatment for a disease can understand. Those of us whose hearts are with our loved ones on these journeys can only nod and think “Yes, this is what I see. Here is truth.”

What resonates most, as Rich and I inhabit this place where living is a world of bright spots interspersed into a continual fog, are the closing paragraphs:

“Is exhaustion an emotion? I don’t think so, but is there a state of being more intense than exhaustion? I can’t think of an appropriate word to describe it, but it’s the state of physical exhaustion to the degree of leaky emotions. You know what I mean: when your eyes are tightly closed and you finally fully exhale, relaxing every muscle in your body and a warm teardrop slides down your cheek. Then another, and another. Just a few though – and it cannot even be defined as crying.

It’s not crying. It’s all that determination and courage you had to employ to get through the past four hours – at least what is left of them anyway. You let them flow, take in a deep breath and then let it out slowly. Just as quickly as they began, they end. No more tears. Just a sweet, wonderful, lifeless kind of surrender that can only be understood by those who have walked the tightrope between life and death.”

Truth.

Since Rich’s hospitalization in August for that exercise related tachycardia, we’ve been traveling a very fine line between medication and wellness. As we’ve discussed before, the triumvirate of the main heart meds introduced over the summer are problematic for Rich when all three live in our world. Less so than when taken together at the same time during the day, but even the staggered dosing we follow now brings more fatigue than we’ve had to deal with for a while. After months of his energy failing more each day, we wonder for the first time if we’re with the right heart doctors. We try not to despair.

Unlike all our previous journeys, our goals are now ambiguous. We know that we’re not optimized on heart failure medications. But what is optimized? We’re told we’re on the lowest dose of entresto. So where do we ultimately want to be on doses? We know that there are variables that make this question tough to answer. How Rich’s blood pressure, kidney function and ejection fraction respond all need to be taken into consideration.

Even well aware of these variables, at this point, the frustration we feel makes us want to shake our doctors and scream “For fuck’s sake! How long are going to continue on the lowest dose of everything and feel like shit?”

Apparently, no shaking and screaming is necessary. Sometimes it’s finding the right time and the right person. We meet, as we do every two to three weeks, with the nurse-practitioner at the heart failure doctor’s office. We discuss wellness and issues. We discuss blood pressure and blood work. We discuss holidays and everydays. The conversation alone heartens us and happens organically when the nurse practitioner casually mentions a dosage goal. This gives us an opening to enquire about the other cardiac meds and get the answers we were so looking for.

We have a plan. We have a goal… or a set of goals. As per the heart failure guru, we want to max out on entresto and metoprolol. We want to adjust up/down/sideways any of the others to optimize heart function. When we hear that those other meds may be, can be, eliminated, we rejoice. If we can stick to two, Rich can once again feel that rush of energy as he did this summer. That feeling of “before cancer” that makes all the difference. We now hope for that goal.

Blood work is taken. EKG recorded. We wait for the news… can the meds be tweaked this week? And with blessed relief comes the phone call we waited for… raise the entresto. Finally, we’re moving in the right direction. The nurse gives us hope. She tells us perhaps when we see them again at the start of the new year, we can raise it to the next… the last… dose. Other meds have been halved giving rise to more rejoicing. This lifts our spirits and we’re ready to face the holidays. Glad tidings indeed.

Of course, we also brace ourselves. Each dosage change of the heart and heart related medications has an adjustment period that is brutal. It isn’t so much the water weight gain from the changes, it’s more an emotional roller coaster.

It doesn’t last long but seems an eternity when we’re in the middle of it all. Fatigue hits like a ton of bricks. The recliner is the only place Rich can be. And then comes the end of the first full new dosage day. We’re told that Rich’s reaction can be normal but it surprises us each time. He runs through what seem to be drunken manic-depressive episodes every five minutes. On the one hand, he’s laughing, way too much, about nothing and everything in such a way that it becomes a concern. It feels forced and indeed it is, but not in a way that Rich can help. Seconds later, he’s in the depths of despair, apologizing for all this trouble while he tries to maintain composure. And it generally is less than successful.

During these times, his blood pressure drops… crashing to numbers like 81/41. His gait is troubled and unsteady. The meds are playing and playing hard. Pickles help. They balance his electrolytes and bring up his blood pressure gently. We monitor his BP continually. The night is long and we’re both exhausted by the time we fall asleep. The one saving grace, we agree, is that the morning will have brought better balance.

Rich’s Determination and Courage.

My Complete Awe.

Let’s get this new year started!

Living in a Postscript

A week ago, we woke to the stone edged green patchwork that is the hills of Ireland. We were towards the end of our fifteen day stay; travelling with friends and filled to the brim with life, laughter and love.

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That we are on this trip is miraculous in and of itself. Since Rich’s hospitalizations this year, there has been a big question mark on whether we would be boarding the plane at all.

We began the entresto in earnest while in the hospital. It had been hammered into us that this was THE drug for heart failure. We’ve had difficulties with it but were ready to be on board and do what we could to tolerate and embrace this medication. The positive results by others were giving us strength. The goal was to have Rich on three heart medications to keep his kidneys happy and to help heal his heart. Entresto, Hydralazine and Isordil started slow and easy. Half doses, spaced timing of meds and the slow introduction of each of the super three. We found any two, in any combination, dose or timing was fine. When a third, again, of any of the combo, was introduced, we found the low blood pressure numbers returned, the fatigue beyond bearing. With our heart failure doctor texting and calling, we tried and re-tried the combinations. Finally, we had to come to a stop. Each modification had brought days of unbalance in all its forms. We had one week before we boarded our plane… we had to allow two meds to settle in and hold off on the third. There was no other choice if we were to travel.

Rich was advised to stop his cardiac PT until after our return. And as for our travels, he was told to avoid hiking. Avoid the very thing we went to do! How to not plod through rock strewn fields, along windswept cliffs, by Guinness-colored churning rivers and streams, through changing autumn woodlands? To walk the city streets of the Troubles and in the paths of writers, musicians and artists? We’d have to find balance as we have all along this journey. As we continue to try to find with medications. To temper the eagerness of travel with the realities of the physical heart.

As with all things, Rich welcomes our travels with gladness and intentions to experience it all. We prepare with the trekking poles that saw good use in Iceland… the 2016 trip we took to successfully test our post-transplant travel waters. We laugh that just one letter changes the names of these two countries… as if a simple typo took us from one instead of the other. We continue to pack as wisely as we can. Wind and weather provided for. Plans for keeping to our way of eating as much as possible to maximize heart health. We look for all the variables that may trip us up and discuss modifications that we may need to use.

The itinerary that Arlene and I work through is a wonderful mix of history, food, landscape, food, music, food, architecture and, yes, more food. We try to find an equilibrium between forts, castles, abbeys, tombs, hills, cliffs, stone circles and waterfalls… although we do seem too excited by food! We dissect travel times and try to figure how long we’ll spend where. We wildly miscalculate our interests but even that ultimately becomes part of our adventure.

With Kevin steering on the wrong side of the car, and the car on the wrong side of the road, we make our way around Ireland. We lay our heads mostly in country-side B&B’s and castles at night. We meet and chat with fellow travelers. We enjoy the music of the pubs, share experiences with strangers and find we keep the memories of all we’ve met with us on our trip. Songs follow us in our travels. We embrace the Céad Míle Fáilte… the hundred thousand welcomes we experience. The lilting cadence of the Irish speech offers us surcease like a lullaby.

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We have a few reminders of health issues along the way. Despite our best intentions, it is not easy to keep carbs low in a country where root vegetables reign and salads are not the norm. Where time differences can be felt, where landscapes are rugged underfoot and where excitement overcomes caution. The northern Wild Atlantic Way tests Rich and with a few exceptions, he comes through unscathed. Our pace is more measured, and I keep an eye on the small cues of distress. A few unexpected hillside trails cause us to take a thing or two off our itinerary and offer us instead time to relax or enjoy some views we otherwise may not have found. A bit of weather meets up with us as two storms, Hurricane Helene and Storm Ali clash above us and buffet us around the Slieve League Cliffs. The sea was swept up the 1,972’ high mountain cliffs in a flume of spray and holding a camera still in the 100mph+ winds is near to impossible. As Arlene says “we could have come on a beautifully sunny day and had a wonderful time and taken great photos. Now we have a story!”

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A story. Our story. Stories intertwined with friends, family and those unknown that spread like a web and embrace us.

Two weeks yet also too soon we’re back home. Time changes once again. Congestion begins. Rich’s chest is heavy.

Is this a bug that Rich’s still-compromised immune system has picked up? Is it a response to the too-many carbolicious meals? Is it too much fluid from a tired, and so less efficient heart? Lasix is boosted, rest is sought. We’ve been too long without an infection. We’re not ready to travel that road again.

Tonight we plan, for the first time in the week since our return, to enjoy the photos we took and relive the goal reached. A magical respite. Years in the making, we’ve now, with a little help from our friends, sailed the clear blue waters, walked the high cliffs, strolled the country lanes, and sang the old songs of a welcoming land. Always will these days be in our hearts.

Postscript
By Seamus Heaney

And some time make the time to drive out west
Into County Clare, along the Flaggy Shore,
In September or October, when the wind
And the light are working off each other
So that the ocean on one side is wild
With foam and glitter, and inland among stones
The surface of a slate-grey lake is lit
By the earthed lightning of a flock of swans,
Their feathers roughed and ruffling, white on white,
Their fully grown headstrong-looking heads
Tucked or cresting or busy underwater.
Useless to think you’ll park and capture it
More thoroughly. You are neither here nor there,
A hurry through which known and strange things pass
As big soft buffetings come at the car sideways
And catch the heart off guard and blow it open.

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It is a truth, universally acknowledged

So begins Pride and Prejudice. In the BBC mini-series Lost in Austen, the female lead begins the story with the same phrase…. It is a truth, universally acknowledged…

But, being obsessed with all things P&P, finds herself in what she calls a post-modern moment and in many ways, it disturbs her. She is to try to keep the story going as Austen wrote despite the fact that she seems to have switched places in time with Elizabeth but as herself and her very modern presence sends the various story lines spinning off in unforeseen and unwritten directions. New truths develop.

We’re finding unforeseen circumstances and truths following us on our current journey.

And the last few days, truths have been coming at us a little more strongly than one would like. As Rich and I walk the halls between specialist visits, we overhear the PCA telling a nurse “… but you aren’t going through what SHE is going through. That’s the difference.”

When we’re in these rooms in these halls in this hospital, it’s very easy to forget, or ignore, the journey that others are on. And that their outcomes may be very different from what we are experiencing. Or they are your possible future. The remarks of this one PCA strike home. None of us knows what the other is going through. There are similarities, there are strengths and weaknesses that affect outcomes. There is the way each situation is approached that can impact one’s stay. Or one’s leaving.

The reminder of compassion and patience is one that is needed right now as well.

This is a hospitalization of waiting. While the leads taped to Rich’s chest are gathering data, Rich himself has little to do. As the v-tach leaves no blips of pain, no stumble of the feet, no dizziness in its wake, the wait seems pointless. But it’s necessary. It is a truth. We must have patience. As Rich feels nothing during the v-tach, there is a truth to his health that we have not, til now, acknowledged. There is a danger there. We have to recognize that it exists. Waiting. Lurking.

Day two and our Heart Failure doctor brings us more truths. Entresto, a medication that did not sit well with Rich and stopped after a few days, is to be started again. We’re hesitant. We’re not convinced. And then she hits us with a solid truth. Humor has left her eyes. Those eyes bore into Rich’s. They will not be ignored.

“People DIE from the heart condition you have. They DIE. Not YOU. Not on my watch. We will find a way for this medication and we will find it NOW. Waiting until you return from Ireland is not an option. We can’t wait that long. This is your LIFE.”

Yes ma’am.

She is not to be denied! Her truth, our truth, cannot be denied.

Having had issues with this drug, we uncharacteristically agree to stay overnight so that Rich can be monitored and his reaction gauged so that dosage intervals and the timing of other parts of his CHF cocktails can be modified to bring the best possible optimization of all meds. That is our goal. Once we reach that optimization, Rich will need to be on these doses, yet to be reached, for three months. At that point, more tests, measuring heart function and ejection fraction, will determine if the internal cardiac defibrillator will be needed. For now it is too soon. Despite the v-tach, it is too soon in the process.

That we have chosen to stay rather than self-monitor at home, is unusual for us. The truth is, this medication scares us. The side effects hit Rich hard. They don’t afford good quality of life as they were taken before. Our ability to take this home and travel through it on our own doesn’t sit well with us, though it is offered to us as an option. Our doctors know us well. But we feel this truth that they have so eloquently urged on us… We need to be here now. The timing of when this medication is to be taken and when the others should be dispensed is modified. We need to follow this protocol as much as possible. No longer will Rich be able to tip a handful of meds into his palm and take them en masse. Patience. Your truth now guides this new process… we need to stagger meds and avoid overlap for optimization.

We give in to the sleep that is so needed. But as in all hospitals, the time to wake will come soon. And repeatedly. There is a price to allowing others to carry your burden. It is a price we gladly pay this night. The truth, our truth, is that we gladly hand this burden to those who do have our best interests in mind, although their plan isn’t always what we wished. They don’t know what we are going through, but take on the responsibility so that we can rest. For now.

The morning’s tests and data will give us a new truth. We hope it is one we can swallow!