Monday, March 29, 2021

Cars, cars, cars...

 So, my son's 2009 Mazda 6 shredded its serpentine belt a few weeks back. It looked something like this:

After pulling the belt off, we found that the tensioner wasn't spinning, which was what was shredding the belt. So we pulled that off, and it looked like this:

Pretty sure that outer circle should be concentric with the inner one, not offset. That's a lot of rust, too. So, we ordered these parts:

Now, my son had to go out of town, so we borrowed my parents' van, which he took to a D-Now that he was leading. That Saturday, with a little help from my wife, we put the tensioner and the new serpentine belt back on, and everything seemed to work great! I also installed the replacement washer fluid reservoir, to replace the one that was damaged in an accident last year. During that process, I had to hammer a little of the steel back into place that had been twisted during the accident. I managed to clip my thumb at one point with the hammer, through the glove I was wearing and across/under the thumbnail. Do you recall that I'm on a dual anti-platelet treatment? Here's the result:

A week and a couple days later and it's still looking pretty much like that (just waiting on the under layer to heal and push the dried blood blister out). Still, I got it done, got the car put back together, and all seemed well. Took the car to get a couple new tires (as two of them were quite worn; it needs an alignment pretty badly) and filled it up with gas, too. It was a good, productive day. We even replaced some of the black tape with red tape after reinstalling the passenger headlight (which we removed to 1) replace the washer fluid reservoir; and 2) make it easier to get to some of the areas where the serpentine belt went). The red tape isn't a perfect match, of course, but it's nicer, I think, than the black (which is still present on the front, as we didn't replace all of it yet), and looks something like this:

My son got home that Saturday evening, and took his car to church the next day... and it was making an awful rattling sound (which it hadn't made the day prior). After we got it home, I made this recording:

After sharing with a few mechanic friends, it's pretty much been determined it's rod knock. My only question for my friend Murphy is why it couldn't have started that knock the day prior, before I filled it with fuel and put two new tires on it or even before we put the time, effort, and money into replacing the serpentine belt and tensioner (close to $200 for just the tires, well over $200 with tires, fuel, and the new tensioner and belt). That was an irritating day.

But, we still had the borrowed van (my parents were out of town for a couple of weeks), and that was quite useful in the interim. Since then, the boy has bought his first car on his own,  2021 Hyundai Kona. Looks a little like this:

He really likes that car (but got a nail in the left rear tire sometime yesterday; he did get that patched today, as it was cleanly in the tread). Also, it was a good experience at Allen Turner Hyundai in Pensacola - highly recommended if you want a new Hyundai (or Genesis, as they also sell those). Or perhaps a Chevy at their dealership in Crestview which is where we bought our Chevy Volt a few years back. I've also heard good things about Terry Thompson Chevy in Daphne, which is where we get our Volt serviced (the reason we went over to Crestview to buy the Volt is because of the fact that, when we bought it, they had both 2016 and 2017 Volts on the lot there, and the one 2015 Volt at a significant discount - in fact, it was the same price new as a used 2015 Volt with 10 or 20 thousand miles on it, and the new one was a Premiere model (uplevel) vs the base model used one, and the used one was also in Pensacola, whereas Terry Thompson didn't have any Volts in stock at the time we were shopping).

Anyway... anyone want to buy a 2009 Mazda 6 i Grand Touring - that probably needs a new engine, but has two literally brand new tires on it? It has all the goodies - heated leather seats, automatic dual-zone climate control, sunroof, blind spot monitor, automatic HID headlights, automatic rain-sensing wipers, heated auto-dimming side mirrors, etc.

Monday, March 15, 2021

Hmm... the drug post

I've recently discovered that there is a potential negative interaction between Proton Pump Inhibitors (omeprazole - AKA Prilosec or Zegerid, esomeprazole - AKA Nexium, etc.) and Clopidogrel (AKA Plavix), which is an anti-platelet drug typically administered post myocardial infarction (heart attack), especially after coronary stent placement. Specifically, the proton pump inhibitors reduce the effectiveness of the anti-platelet drug, which probably isn't a great thing for someone depending on the anti-platelet drug to minimize likelihood of a recurrent myocardial infarction. Now, the studies, such as noted in this article (from 2010), are mostly retrospective studies, and there are some other studies which indicate there is not an interaction. At any rate, the current FDA info on Plavix (Clopidogrel) indicates that proton pump inhibitors, especially omeprazole, reduce the effectiveness of the anti-platelet drug. For those needing clopidogrel, a good recommendation would be to switch from omeprazole or esomeprazole to something like famotidine (Pepcid) or ranitidine (Zantac), although ranitidine is now subject to a voluntary recall due to potential cancer causing agents.

So, why am I blogging about this? Because I had a myocardial infarction, and was prescribed clopidogrel, and also have gastro-esophageal reflux disease (GERD), which I have been over-the-counter treating with Nexium (esomeprazole) for many years. I included "daily Nexium" on my list of medicines, both at the hospital when I was having my heart attack and stent placement, and at my primary care physician at the post-heart attack follow up visit (and it was already in my records there, too), and at my cardiologist when I started seeing him at my first cardiology follow up visit. None of these (nor any of the three pharmacists where I've filled the clopidogrel prescription) gave any warning of interaction between esomeprazole and clopidogrel. I only just found out about this interaction this week. Now, my GERD has been quite severe at times (I'll spare you the rather nasty details from occasional bouts of really bad reflux), and I've (mostly) managed it with the daily Nexium (over the counter dosage, not prescription dosage). 

Probably at least a portion of my GERD is a result of my poor dietary habits and my growing waistline. Both of these have been significantly improved since the heart attack; starting on the DASH diet once we left the hospital (with a stent in one of my coronary arteries) has helped on both fronts (along with tracking both my nutrition and my overall intake via My Fitness Pal) has reduced both the frequency and intensity of my reflux. With that in mind, it seems that a switch to a less potent acid reflux medicine, such as Pepcid, would be a viable thing to do, especially in light of the fact that I'm currently taking clopidogrel to minimize the likelihood of another heart attack (especially related to the stent, which the platelets might otherwise want to adhere to, I guess). 

I'm just wondering why none of the doctors suggested switching away from the Nexium to something that doesn't have any demonstrated negative impact on the clopidogrel. All the doctors had a full list of the medicines I routinely take, and all knew that I had a stent placed, and all knew that I was taking clopidogrel to minimize the risk of having another heart attack, or stroke, or adverse reaction to the stent which opened up my right coronary artery from 95% blocked to less than 10% blocked. Interestingly, in the hospital two weeks ago, they gave me Pepcid to combat any acid reflux instead of Nexium, so someone knew something. But they said nothing, and sent me home to continue taking both the clopidogrel and the esomeprazole. Until I came across this info on my own (and while actually looking for something else, looking into the drug interactions of clopidogrel, and saw omeprazole and esomeprazole on the top of the drug interactions list; then again, perhaps I should have paid more attention to the drug facts sheet from my first filling of the clopidogrel prescription, but I was also recovering from a heart attack, and the prescribing facility, although new to me and I to them, knew of my daily OTC dosing of Nexium, as well as any other medicines I took on a regular basis, so I didn't think I had any reason to need to question the prescription of the doctors there).

I guess the moral of this story is: don't take anything new for granted, especially when it comes to medicines. Be sure to read the whole pamphlet, and/or research the drug online, especially interactions if you're taking anything else (or want to take anything else). I suppose it should go without saying that illicit drugs shouldn't be included in any collection of medicines you're considering to take. But, there, I said it. And I'm about to go order some Pepcid on Amazon.

Saturday, March 13, 2021

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...

Saturday, March 6, 2021

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).