Another day, another doctor visit, another deductible... and a joke!

Since our last installment, I've had two doctor appointments: one with my primary care physician, and one with my cardiologist (who is part of the cardiology group that was involved in my treatment at the hospital last week). Neither visit was particularly revealing; in fact, both seemed more a waste of time and money (deductible) than informative and useful. That said, I probably would do both again if this happens again (at least in part because the cardiologist, while saying he didn't believe any additional tests were needed at this time, said that were it to happen again, he would order additional tests, likely to include a 30-day (or longer) heart monitor). I think perhaps my primary care physician was overbooked, as it seemed she had a lot of patients come in all at the same time as my appointment (she's usually pretty good, but it seemed quite rushed this visit).

Since those visits, however, I did a little research on my own, and I believe that what I experienced last Monday (that is, Monday of last week) is "post exercise syncope" or "post exertion syncope" - as can be described in this article (an interesting read, where a pacemaker was eventually implanted to prevent post-exertion syncope in the 29-year-old case study) or this article. I don't think what I experienced was "exertion syncope," as can be found in this article, which describes both post-exertional syncope and during-exercise syncope:

Post-exertional syncope frequently occurs when exercise is stopped suddenly and reduction of lower extremity muscle pumping results in less cardiac venous return and cardiac output. In such a circumstance, an acute increase in myocardial contractility can lead to activation of the cardiac depressor reflex inducing concomitant paradoxical bradycardia. As a result, the athlete may develop acute loss of postural tone, hypotension, and therefore transient global cerebral hypoperfusion – this is termed the Bezold-Jarisch reflex. Contributing factors likely include dehydration and reduction in plasma volume. Syncope immediately post-exercise which occurs when the subject is still standing, is usually less concerning than syncope during exercise.

Syncope which occurs during exercise raises concern for structural heart disease and can serve as the only symptom that precedes sudden cardiac death. The differential diagnosis for life-threatening causes of syncope in athletes includes hypertrophic cardiomyopathy (HCM), anomalous coronary artery, arrhythmogenic right ventricular dysplasia (ARVD), ion channelopathies such as Long QT Syndrome (LQTS) or the Brugada Syndrome, myocarditis, and even previously undiagnosed congenital heart disease such as noncompaction cardiomyopathy. Although not necessarily associated with underlying native structural heart disease, commotio cordis is an important cause of syncope and is characterized by sudden cardiac death attributable to cardiac contusion from trauma to the precordium. Heat stroke or hyponatremia must also be considered in patients with exercise related syncope.

Although my "symptoms" seemed to start during exercise, it wasn't until I'd stopped exercising (and some small amount of time later, in particular, after stopping all movement altogether and sitting in a chair to rest) that the syncopal episode occurred. That said, given that I had a myocardial infarction (heart attack) just over two months prior, it's still cause for concern, although apparently not really to the cardiology group (having observed my ECG over two days in the hospital and performed a tilt-table test prior to discharge). But it was concerning enough to the cardiac rehab center that they didn't want me to return until they had direct confirmation from the cardiologist that I was approved to resume cardiac rehab. In general, it seems the cardiac rehab team are more concerned about the episode than the cardiologist group; in fact, it turns out, they had been monitoring my case remotely throughout the day on Monday after I was taken to the ER via ambulance. A short, expensive ride (although the ambulance claim hasn't been submitted to my health insurance yet). Also, there was a period during the syncope of bradycardia, which can be quite alarming; for about 24 seconds, my heart rate was about 20 beats per minute. That's one beat every 3 seconds. And it dropped to that from over 100 bpm very quickly; and after about 24 seconds, just as quickly rose back up to over 100 bpm. But, near as I can tell, I think that's not necessarily uncommon with vasovagal syncope, but it is a bit disconcerting when you see it on an ECG (I was being monitored at the cardiac rehab center at the time of the episode).

All that said, overall, I think I'm doing well. We'll see Monday how it goes on my return to cardiac rehab; I do plan to take it a little easier than I had last week, and will follow whatever guidelines the cardiac rehab staff want to put in place. I can tell you this: I will be tired Monday morning, even before the exercise begins, since Daylight Saving Time starts this Sunday, so Monday will only be day #2 in the "earlier to rise" setting (so, doubly-early: earlier than I used to rise before starting cardiac rehab, and earlier than the prior week by an hour due to DST). I think I may end up in bed much earlier Monday evening than usual.

As for the deductibles, I really wish preventive appendectomies were a thing. I would sign up the whole family. And maybe go ahead & take out anything else that might be a future issue waiting to happen: gallbladder, one of the kidneys, a tonsils if they haven't been done... let's get all the things done while it's on the dime of my insurance instead of me. After all, the Dec 31 timing of the heart attack meant twice the deductible in early 2021 (because of starting and finishing 2020's deductible all on the last day of 2020, to be paid in 2021). Fortunately, it's better than the $63k that was billed for the initial heart attack, along with the over $6k for the episode last week, and the more than $5k for cardiac rehab (when all is said and done). We'll be OK, and surprisingly, we've managed to get some of our credit paid off over the last year plus. Eating in seems to be a lot cheaper than eating out (not to mention much, much healthier!). Also, I promise you, my wife is going to be blogging about all of this in the not-too-distant future, too; she's very busy recently (what with caring for a cardiac patient, learning about cooking low sodium and low saturated fat and all the other things, attending cardiac rehab three days a week as my "heart mate" - at a much lower cost than my own attendance, and going to school to study elementary education with an eye on becoming a teacher in the future... she's super-busy! but she's been noting things down, and considering plans, and we'll get her a blogging address set up for her to put to the public everything she's learned, tips and tricks, helpful suggestions, and general encouragement for those in similar situations).

So... did you hear about the butcher who accidentally backed into his meat grinder? He got a little behind in his work.

Later, all...

A Little About My Week...

So, my week started as normal as any other: an early Monday morning visit to Cardiac Rehab. Ten sets of ten reps with ten pound hand weights (one in each hand), check. Ten minutes on the rower, pulling 100 watts (I don't recall the strokes per minute), check. Fifteen minutes on the treadmill, but feeling it this Monday morning, so I've backed off from 3.6 mph to 3.5 mph, still running the 5% grade; heart rate is getting up over 150 bpm, sweat is building, and the calves are burning, but we got it done, check. Start on the evil arm machine, fifteen minutes in my sights at level 5, but not really pushing it as hard this time, settling on maintaining somewhere between 35 and 40 watts. Instead of half of it forward and half backward, swapping it up: 2.5 minutes forward, 2.5 minutes backward, and repeat toward the 15 minutes goal. After ten minutes, really starting to feel it, but I press on; at the 12.5 minute mark, starting to reverse direction, but then I'm really feeling not so well, a little weak, and light headed, so I decide to call it: stopping at 12.5. Sit at the machine for just a moment, then get up to go get a cleaning wipe to wipe down the machine. Rest against the center pole desk (where the wipes are) for a bit, then back and clean the machine. Then I head to the chairs (where you check in and start your cardiac rehab) to take a break.

One of the nurses (April) comes over and asks if I'm done for the day, but I reply that I'm just taking a break. I put my head down a little, as I'm really starting to get light headed, and then I remember dreaming a bit which morphed into staring up (from the ground) at a bunch of faces hovering over me. It takes a moment for me to realize where I am, but slowly it starts to come back, and I realize that I've passed out (per my wife, April caught me and helped lower me to the floor to prevent any hard falls, and then the whole cardiac rehab nursing staff and on-site doctor all spring into action). Before long, I have an IV in my arm, and then paramedics have come in with their gurney. (Just that morning I'd seen this on Facebook: why do EMTs always go out in twos? Otherwise, they wouldn't be pair-o'-medics!) The cardiac rehab staff print off the portion of the ECG around my syncopal episode, where it seems my heart had suddenly (less than 20 seconds) slowed from over 100 bpm to around 20 bpm, which lasted for about 15 seconds (and overall, the bradycardia episode lasted around 24 seconds). After that, my heart rate just as quickly ramped back up to well over 100 bpm again. (I do have the recording of the ECG from the entirety of my cardiac rehab session on Monday, which is certainly an interesting thing to view.)

The next portion of my Monday was a very expensive taxi (ambulance) ride around the corner (the cardiac rehab center is behind the hospital, but not directly connected, hence the ambulance ride essentially a block or two to the ER). I spent the rest of the morning in the ER, where every test seemed to come back normal (ECG, x-ray, troponin level; note that ECG and x-ray also came back normal in the ER when I was having a heart attack on Dec. 31, but in that case, troponin levels - an enzyme released from the heart into the bloodstream when it's under stress or actively being damaged - were initially elevated to the point of "watch" and then quickly elevated throughout the morning, while in this case, troponin levels remained below the detection level). With that, I was no longer a priority cardiac patient, and quickly fell down the urgency list (unfortunately, the cardiac ward at the hospital was quite slammed with patients, urgent needs, and surgeries that day). Upon reviewing (and pointing out) the bradycardia, they decided to 1) stop the beta blocker (Metoprolol) that I was taking; and 2) admit me to the hospital for overnight observation on ECG telemetry (the ER nurse practitioner didn't think this was necessarily any big deal, but with my having had a heart attack and stent placed just in December, she really wanted cardiology to make the call, and cardiology had been backed up most of the day and finally got to my case, and wanted to do the overnight observation). They had also talked about the possibility of a loop monitor.

Because I came in due to a syncopal episode, I wasn't allowed to get up out of the bed without someone else present (so that, if I were to pass out again, someone would be able to alert the facility staff, either my wife, during visiting hours, or a nurse that I would have to call to attend my rising). In case you're fortunate to never have had the pleasure of being a cardiac patient, I'll let you know that they want to keep tabs on your fluids in and out, meaning they track the amount of liquids you're ingesting (or taking via IV) and also want to know how much urine you're producing, so you get to tinkle in this fancy plastic measuring device:

Then you get to tell the nurse how much urine you've gifted them (I just noted the amount, poured it into the toilet and flushed, and wrote it on the board in the room). Speaking of those visiting hours, they were quite silly, in my opinion: 8-11 AM and 4-6 PM. Apparently Covid is less contagious during those hours? But, seriously, you'd think having the visitor have to leave and re-enter the hospital and room twice daily would be more likely to bring infection than simply staying in the room without leaving (and/or entering/leaving once/day).

So, back to Monday. Never saw another doctor after getting to the hospital room, only the nursing staff. Already, though, I knew they were going to observe overnight. Tuesday morning, almost into noon, shortly after 11 AM, the hospitalist (doctor) stopped by, anticipating that he'd noticed a little bradycardia overnight, but nothing he's concerned about. From that, he expected that they would likely have me discharged, but again, he was deferring to cardiology.

And the wait begins. Cardiology was, once again, slammed, and it wasn't until after 7 PM Tuesday evening before the cardiologist came by. He said they wanted to do a tilt table test in the morning. Unfortunately, this also meant (per the nurses, I later found out), back to the "NPO" ("Nothing Provided Orally" - which includes water) after midnight; fortunately, at least they had decided that I could get up on my own, which made it easier to get up to go to the bathroom instead of having to call and then wait for a nurse. Further unfortunately, however, the cardiac group was again slammed on Wednesday, and it wasn't until about 1:30 that I went down for the tilt table test (so, nothing to eat or drink, even water, since midnight the night prior). On the way down to the tilt table test, I heard "code blue" and a room number, and a lot of nurses and physicians running (literally) back in the direction from which I'd come, and so I realized there are definitely worse things than having to fast for nearly 14 hours.

The tilt table test was interesting, but didn't really seem to show anything - it was "normal" per the cardiologist (who I didn't see until well after 6 PM). And they finally discharged me, Wednesday evening, with instructions to follow up with my cardiologist and primary care physician next week. There really wasn't that much info provided, certainly nothing definitive to explain what happened, just some possible ideas. They seemed to attribute the passing out to vasovagal syncope, possibly aggravated by the beta blocker (Metoprolol), which is why they wanted to observe the ECG after stopping that medicine (but, to note: I haven't had such an episode at any point prior to Monday morning, despite being on the beta blocker since Jan 1, about two months prior). I suspect I may have a stress test after vising my cardiologist Wednesday, and possibly a Holter or loop monitor for some period of time as well, but it's still odd, having this episode now, two months after the heart attack and stent. I also hated having to take yet another week of paid time off from work - I'd already planned to be out of town on Friday (as my lovely daughter, 8 months pregnant, was performing an opera that had been postponed from last year due to Covid), and I was in the hospital Monday through Wednesday, and took Thursday as a day of recovery from the hospital visit (I was tired from "hospital sleep" and had been away from home, unexpectedly, for three days). Alas, it is what it is, and I suppose it's better to be using the PTO now than to have it added to a "final paycheck."

Take care of yourself. Get your cholesterol checked, eat better than you think you should, exercise, and pay attention to any abnormal signs - back pain, chest pain, jaw pain, unexplained tiredness, etc. Better safe than sorry (even if you have ginormous deductibles on your insurance that you're paying too much for in premiums).

What Time Is It?

I know you know what this is: 

It's a watch. Obviously. But it's also a heart rate monitor, step counter, sleep tracker, and activity tracker, and it does silent, smart alarms, too (smart: if you set the option, it will trigger its alarm based on your sleep pattern and state to attempt to wake you at the optimal point in your sleep cycle within your smart alarm window). It also has notifications from your phone (text message, caller, date, watch info like steps and alarms and heart rate, etc.) in the small upper window (which is a tiny, monochrome LCD), as well as noting the percent toward your defined step goal in the lower small circle (yeah, I'm a bit deficient in my steps today; I could say I'm over, but I don't want to lie to you, my faithful reader). 

Big deal, you say. My Fitbit does all that, or my Apple watch or Galaxy watch does that and more, with a larger screen. But, I ask you, how often do you have to charge your watch? Every five days (Fitbit), every day (Apple or Android watch)? Not me... I only have to charge my watch once every three weeks or so (and it doesn't require any particularly long recharge time). Granted, the heart rate tracking isn't continuous (it can be, if you're working out, but throughout the day it's intermittently doing heart rate tracking). And, it looks like "just another nice looking watch" rather than either a fitness device or a high-tech wearable. Which I kind of like, and it doesn't really tie me to my device like some of those others might. Withings Steel HR (I have the 40mm version). 

But, oh, that battery life. Oh, and they fit standard 18mm or 20mm watch bands (depending on the watch face size), not some custom band connector.

And it's about to get better: Withings (the company that makes this watch) will soon release the Scanwatch, which will include ECG and blood oxygen saturation monitors, and will do respiratory monitoring as well. Still with an "up to 30-day battery life" (I get 3+ weeks on mine; I don't think I get quite 30 days out of it, although the current Steel HR information only shows to have a 25-day battery life, so I think I'm on track with that). Withings also offers an ECG watch/activity tracker called the Move ECG which uses a standard, replaceable watch battery to provide a year of operation without having to charge, ever.

I think I'm get the Scanwatch when it's released. 

I also have to say, customer support from Withings has been really good. I bought one of the first release Steel HR, which had a problem with the watch face fogging up. I had contacted Withings customer support, and they reassured me that the watch was still waterproof, and it should clear on  its own. It never really did, and I'd contacted them a few other times, both before and after Nokia bought the company (the second release of the watch changed the branding from Withings to Nokia). Then the founder of Withings bought the company back from Nokia, and I contacted them once more. They said that without a receipt, they would have to go from the device production date, which unfortunately made it out of warranty, but they did offer a 25% discount on a new one. But when I mentioned that I'd contacted them within the first year of ownership, the rep said that made it a claim under warranty (I'd already sent them a picture of the cloudiness in the face), and if I'd send back the current one they'd send me a new one. Which they did. About two years after I'd originally purchased it, and after the company had been sold and bought back. What great customer support!

I like Withings, and I like my watch, and thought maybe you'd want to know.

Tomorrow starts week two of my cardiac rehab, week two of getting up much earlier than I'm used to. Week two of the evil machine. I may not write much tomorrow. See you in a few days!