Heart--A History

by Sandeep Jauhar

  Like many patients with post-traumatic stress disorder, she started taking Ativan, which helped. But one night, lying in bed, she saw a man in a black suit and a hat standing at the foot of her bed. Hallucinations are an uncommon side effect, but that was it for the Ativan.

  Psychologists have come up with two theories to explain the post-traumatic stress disorder after implantable defibrillator shocks. The first, classical conditioning, refers to the psychological pairing of a previously neutral stimulus (such as taking a shower) with a noxious one (painful shock) so that they elicit the same fearful response. As in Flood’s case, as well as for other patients at the support-group meeting—and, presumably, the young woman who survived at Ground Zero—fear can heighten arousal and result in even more arrhythmias and shocks. The fear subserves itself.

  The second theory derives from experiments in which dogs were repeatedly subjected to electrical shocks. Compared with controls, animals that are powerless to regulate their shocks become physically exhausted and quickly cease to struggle, despite being given opportunities to avoid the shocks. Researchers have concluded that animals acquire a state of “learned helplessness,” like the wild rats trapped in water-filled jars in Curt Richter’s experiments described in chapter 1. Humans who experience frequent shocks develop a similar response.

  The key to avoiding such a hopeless state is to take away the element of surprise. Rats repeatedly shocked without warning develop stomach ulcers, a sign of intense arousal. However, rats that can predict when they will be shocked because of a warning buzzer develop significantly fewer ulcers. Moreover, rats that can prevent some shocks by pressing a lever develop fewer ulcers than those that receive the same number of shocks but have no control over them. Ulcers are further reduced when the rats, after pressing the lever, are given a signal that the shock has been successfully prevented. In other words, predictability, control, and feedback about the effectiveness of coping all reduce shock-induced stress.

  Piggybacking on such research, researchers at Wake Forest University investigated how to mitigate the startle response of humans to sudden defibrillator shocks. They delivered 150-volt shocks to the arms of twenty volunteers and asked them to rate the pain. Some shocks were delivered alone; others following a tiny, painless “pre-pulse” so subjects were prepared. The pre-pulsed shocks were rated less painful than the ones applied without warning. The analgesic effect was greatest in the subjects who felt the most pain to begin with.

  However, nothing has proved more effective for anxious patients than simply reducing the number of shocks they receive. Reprogramming a defibrillator to make it less sensitive to arrhythmias is the mainstay of treatment. Most patients are also put on an anti-arrhythmic drug, like amiodarone, which can have serious side effects like lung and thyroid problems but which most cardiologists find acceptable if it prevents the occasional errant shock and subsequent psychological cascade. Patients also often work with a clinical psychologist who specializes in shock-induced anxiety and provides cognitive-behavioral therapy. Many (like Flood) require antianxiety medications or antidepressants. For some, the best treatment is simply refraining from the activities that induce the shocks in the first place—for example, the patient who kept getting shocked during vigorous sex. (His partner claimed to feel it, too.)

  But despite efforts to make them more user-friendly, defibrillators, like any medical technology, are always going to involve a compromise: What are you willing to give up to live a little longer? Ultimately, I think my maternal grandfather died the right way for him; he wasn’t a burden on his family, and he was walking and talking until the very end, listening to the BBC every morning. He wouldn’t have wanted to live with a donkey in his chest ready to kick him at any moment. A defibrillator might have given him another year or two. But what would he have traded for the extra time?

  * * *

  Not long after our meeting, I went out to New Jersey to see how Lorraine Flood was doing. It was a cold, drizzly December evening. Her two-story home in Colonia was on an upscale, tree-lined cul-de-sac. We sat down in her living room, where she had laid out a generous spread of shrimp cocktail and fruit salad. Dressed in tan slacks and a cream-colored sweater, she looked calm, at peace. I could hear the sounds of soft jazz coming from upstairs. “I got shocked over there,” she said, pointing to a rocking chair. “I still can’t sit on it.”

  Though her fear was not as incapacitating as it once was, she said, it was still a daily ritual. She still went “panicville” when a cell phone came near her. (The fear that a cell phone could make a defibrillator go haywire is common among patients, but unfounded.) “There are days the defibrillator is constantly on my mind,” she confided. “Sometimes I feel my heart thumping, turning, going topsy-turvy. It frightens me because I’m not sure if it means I’m about to get shocked. At times like these, I forget I’m supposed to be a big girl and overcome it.”

  When the fear hit, she used simple techniques to divert her thoughts. She sang songs to herself that she learned when she was a girl. She chanted a Sanskrit mantra that she learned in her younger days as a yoga instructor. And she prayed.

  Flood had started driving again, but she said she wouldn’t go more than four miles from her house, the radius encompassing her office, the shopping mall, and her church. (When she had to go longer distances, a driver took her.) She was, however, back to taking showers every day. “But even now, when I go in the shower, I say to myself, I better face this way in case I get a shock, so I won’t fall out the shower door.”

  As hard as she tried to overcome it, the fear of being shocked still occasionally unnerved her. “If you knew me before, I was such a happy-go-lucky free spirit,” she said. “I’m very reserved now, very cautious. I’m afraid to do things.”

  In the end, I wondered, was the defibrillator worth it? “Yes,” she said, “because I feel it could give me another six months or a year.” Then she paused and added, “Every once in a while, my mind runs rampant, thinking that this is going to be my last day. I say to the Lord, ‘If it’s my time, let me go in my sleep, please.’”

  * * *

  A couple of years ago, I finally took my children to see the 9/11 Memorial in downtown Manhattan. For more than a decade, I’d avoided reading almost anything about the 9/11 attacks, so I had no idea what to expect. Approaching the main square, near where I had cataloged body parts at Brooks Brothers, I started to feel queasy. My armpits became moist, and my heart started to race. A crowd was packed at the viewing wall, surrounding the granite reflecting pool where the South Tower had once stood. I thought once again of the young woman with arrhythmias who was rescued the day after the attack. I never did find out what happened to her. Maybe her arrhythmias eventually responded to medications (or meditation). Maybe she underwent the radio-frequency procedure that Shapiro had mentioned, or even surgery to cut the sympathetic nerves that mediate the heart’s response to emotional stress. More likely, she was implanted with a defibrillator to protect her from her heart’s meandering vortices. Whatever the case, I wondered whether she was still alive to see the monument. We pushed our way through a gap in the mass of people. I pulled my children up to the stone wall. And then I saw it: the black stone, the bottomless pit, into which water swirled. It looked like a reentrant spiral wave, the signature of a heart’s death. I closed my eyes. My head was spinning.

  13

  A Mother’s Heart

  In certain circumstances death may come like a thief in the night to a susceptible person living with circulatory conditions that approach the danger line.

  —John A. MacWilliam, British Medical Journal (1923)

  My mother loved to sleep. Sleep was her balm for the daily irritations of an old-fashioned husband, a full-time job as a university lab tech, and three demanding children. But her nights were rarely restful. She suffered from a sleep disorder that was never precisely diagnosed. She’d wake up screaming, kicking, thrashing about, sometimes even jumping from her bed, as though being pursued,
landing, with a racing pulse, heavy breath, in cold sweat, on pillows we placed on the floor for her protection. My father would try to comfort her, but she was rarely consolable, largely because she never knew what had happened. We took her to a psychiatrist, who asked my mother if she was unhappy in her marriage. (My father, speaking for her, quickly rejected this possibility.) The doctor put her on Valium and other sedatives that left her groggy and unproductive and did not help besides, so my mother discontinued them. Eventually, my parents took to sleeping in separate bedrooms whenever my father needed to rest. My mother continued to have terror-filled nights for most of her adult life.

  I don’t remember ever thinking that my mother’s dreams could be fatal, but in retrospect, after she got her coronary stent, we should have been more concerned. In a seminal 1923 paper, “Blood Pressure and Heart Action in Sleep and Dreams,” John MacWilliam, the Scottish physiologist who identified ventricular fibrillation as the major cause of sudden death, wrote that there are sharp rises in blood pressure, heart rate, and respiration during sleep that exhibit a “suddenness of development.” The physiological changes, he wrote, are often more marked than those that occur after running up flights of steps. In his paper, MacWilliam noted that animals experience both sound and disturbed sleep. In the former, blood pressure, heart rate, and respiratory rate decrease as the animals relax into slumber. The latter type of sleep, in contrast, often has violent manifestations: groaning, biting, growling (in dogs), and verbal outbursts. Such changes “imposed sudden and dangerous demands on the heart,” and MacWilliam surmised that sudden death could occur, even though the body should be in a state of repose. “In a heart susceptible to fibrillation,” he wrote, “a sudden call on the heart during muscular exertion and excitement in the waking state is often fatal. In the disturbed conditions of sleep and dreaming, a similar mechanism is sometimes brought suddenly and strongly into action.”

  The belief that intense dreams can cause sudden cardiac death is embedded in folklore. In Thailand, for example, “widow ghosts” take men away in the dead of night, according to local legends, and the men have been known to disguise themselves as women at bedtime to protect themselves. However, research into this phenomenon only began about a hundred years ago. We now know that 12 percent of cardiovascular deaths and 14 percent of myocardial infarctions probably occur during sleep, even though victims are ostensibly resting. Intense changes in sympathetic nervous system activity can take place during rapid eye movement, or REM, sleep, when most vivid dreams occur. REM sleep can result in surges of adrenaline that disrupt atherosclerotic plaque, stimulate clotting, and cause coronary spasm and ventricular arrhythmias, which may manifest only after awakening and thus be wrongly attributed to the early-morning period rather than to sleep itself. Especially vulnerable times are 2:00 in the morning, when coronary events seem to peak; 4:00 a.m., when patients with sudden arrhythmias most often die; and the last episode of REM sleep before awakening, which is frequently the most intense of the night. In the latter, breathing often becomes fast and irregular, and blood pressure can rise dramatically. Heart rate may increase from 50 to 170 beats per minute just a few seconds into a nightmare. This is likely what killed my mother.

  My mother got her stent in 2006, when she was sixty-four. I often worried she’d be the first in our immediate family to succumb to a heart attack. Heart disease was not her biggest problem, however. In 2011, after several months in which her movements slowed as if she were passing through viscous oil, she was diagnosed with Parkinson’s disease. Sinemet, the anti-Parkinson’s drug, helped to relieve her muscle rigidity, but her condition quickly declined. She became forgetful. Conversations, once so easy with her, stopped flowing. She stammered, her lips pursing as though she were slurping a thick beverage through a thin straw. Parkinson’s also caused dangerous drops in her blood pressure, resulting in frequent falls. After about a year, we pressed our father, who was having his own memory trouble, to retire his genetics professorship in North Dakota and move to Long Island to live closer to me and my brother. When my parents arrived in August 2014, it was alarming how much my mother’s situation had deteriorated.

  She had become virtually helpless. Nights when I’d visit, my mother would be sitting at the dinner table, papers strewn about, spilling food on her bib. Her precipitous decline no doubt overwhelmed my father, who frequently became enraged, a big change for him. The friend who helped my parents move took me aside after they arrived. “Your father has to have hope,” she said.

  “Hope for what?” I asked.

  “That one day your mother will be able to do the things she can’t do right now.”

  We wanted my mother to remain in her own home, which meant that we—my brother, my sister, and I—were going to have to chip in to help. It was a small price to pay, we thought, for our parents’ continuing to live independently. When my sister visited from Minneapolis, she would bathe and dress my mother. I administered her medications and helped with groceries. My brother took care of household issues. Still, my parents’ home, like my parents, was in a constant state of disrepair.

  Of course, we wanted to do more, but my mother, embarrassed by her disability, felt guilty. One night I was helping her up the steps to her bedroom. She was walking slowly; after several recent spills, she was terrified of falling again. But even as she struggled, her hands turning white as she gripped the banister, she turned to me and said, “This must be so hard for you.”

  As the workload increased, we hired caregivers—as much for ourselves as for our mother. But after some thefts, we realized we had to be more careful about whom we allowed into our parents’ home. One caregiver took an iPhone, silver spoons, and my mother’s diamond earrings. I furiously drove to her home in a run-down section of Queens to retrieve the items. She lived in a basement with her two children. The sink was filled with unwashed dishes. Any sudden vibration and tiny roaches would scurry into cracks in the wall. The children watched fearfully as I demanded before an outsized poster of the goddess Lakshmi that the woman return the earrings—my mother was despondent without them—but she steadfastly denied she had taken anything. In the end, I stormed out empty-handed.

  My mother’s disease progressed. She broke her foot in a fall and spent half a day in the emergency room. She developed staring spells in which she would become unresponsive, causing a new round of panic. More than once we took her to the ER to rule out stroke. Because of Sinemet, she started to have visual hallucinations of insects crawling on her bed or people sleeping on the carpet. She resisted using a bedside commode, so my father was constantly walking her to the bathroom, even in the middle of the night, when we feared she’d fall and break her hip. My mother still had nightmares, but because of the Parkinson’s, she could no longer jump out of bed. Eventually, she required a live-in aide to help her with the basic activities of daily living: bathing, feeding, walking, dressing. She once said to me, “Son, do the things you want when you are young. The decline will happen faster than you realize.”

  We added more and different medications—fludrocortisone for low blood pressure, Seroquel for hallucinations, drugs to treat the side effects of other drugs—with little benefit, never knowing whether our mother would have been better off if we hadn’t adjusted the medications in the first place. Even as Parkinson’s robbed her of the life she’d enjoyed, a full life raising successful children and managing a household that was always running on overdrive, my mother never asked, why me? But we always said, why her?

  After each stepwise decline, she’d insist, “If I can stay like this, it’ll be okay.” She was able to recalibrate her expectations as her condition deteriorated, leaving her spirit mostly intact. But it was painful to watch. One day my brother, Rajiv, ever the pragmatist, said he wished our mother would die quickly. It was how our maternal grandfather had died, of a myocardial infarction just after his eighty-third birthday, and I remembered my mother had been grateful for the quick and painless demise. But I tore into my brother. I wa
sn’t ready to lose my mother. I wanted her to remain alive for as long as possible.

  The morning she died, Rajiv called me from his car. It was an odd hour for him to be calling—I was getting ready to go to work—so I knew something was wrong. “Mom isn’t doing well,” he said calmly. “I think you should go over there.”

  I told him I’d go after dropping my kids off at school.

  “Go now,” he said. “I think Mom just died.”

  It was a sunny April day. A mild breeze was blowing under a light blue, nearly cloudless sky. Speeding down the road, I called my father. He answered the phone coolly, but when he heard my voice, he started sobbing. He couldn’t tell me anything—other than to drive carefully—so I told him to hand the phone to Harwinder, my mother’s aide. She told me that she had been awakened at five o’clock in the morning by groans. She called to my mother from her cot across the room, but my mother did not respond. She was about to get up to check on her when my mother took three deep breaths and went silent. She assumed my mother had gone back to sleep—this had happened before during a nightmare—but in the morning when she tried to wake my mother, she did not react. She wasn’t breathing; her skin was pale and cold. “She has completed, sir,” Harwinder said before I heard my father shout that an ambulance had pulled up outside.

  I’d visited my mother the night before. She was having a harder time walking than usual. When I asked, she admitted to feeling mild pressure on the left side of her chest, which I attributed to a recent fall. Now, maddeningly stuck on the road behind a school bus, I realized the chest pain had probably been coronary angina and that my mother had likely died of a heart attack in her sleep. Nothing else could have killed her so quickly.

  When I pulled up to my parents’ house, there were no cars in the driveway. I ran up to the front door, but it was locked. I frantically rang the doorbell, but no one was home. When I called my brother, he told me the medics had taken my mother to the Plainview Hospital Emergency Room a couple of miles away. He had arrived just in time to prevent them from administering CPR in the back of the ambulance. They had insisted on it—my mother did not have a do-not-resuscitate order—but my brother was adamant, even pulling rank with his hospital ID. He was not going to let them assault our mother. It was plain to see, my brother told them, that she was gone.