A-fib in DC's FOH ER

I was in DC Monday-Friday for a training class, but wound up missing the last day of the class and spending half the weekend in the Inova Fair Oaks Hospital (a.k.a. FOH) in Fairfax Va.

Tuesday night, I felt a side-stitch-like pain under my left ribcage, but decided the best thing to do was ignore it and hope it was gone in the morning. It was gone (sort of) by Thursday but I still felt a bit under the weather and the side-stitch had become generalized to what doctors call the left "flank". (I always thought of flanks as being thighs, but I guess that's wrong. Those are loins.) So, Thursday night after class, I went to the Urgent Care across the street from the Hyatt where we were billetted. The doctor asked me a few questions and said, probably a kidney stone, no big deal. He took an x-ray and, sure enough, there was a little white speck 'way down near the bottom edge of the film, which the doctor said indicated I'd already passed the stone into my bladder. He sent me home (well, back to the hotel, that is) with a scrip for tylenol, instructions to drink plenty of fluids, and to call if I experienced any change in my condition. Per doctor's orders, I downed a large bottle of gatorade and a 22 oz beer and, deeming this to have been plenty of fluids, went to sleep on the couch.

I awoke about an hour later experiencing urinary urgency. I was standing over the toilet peeing, and thinking: 1. I had a funny feeling in my abdomen / chest, 2. there was a lot more pee than I had bargained on, but not much was coming out, and 3. it seemed like a good idea to maybe try peeing in the tub instead of the toilet. I don't know why I thought that. I was headed for the tub and had just changed my mind back to the toilet.

6 months later:

I awaken from a deeply peaceful sleep. I'm looking at a distant horizon. It is still. Eternal. Beautiful. No, it's a pattern. A nice pattern. It makes me feel sleepy and peaceful. A pattern that I've seen before. It's the pattern from the carpet in the hotel room where I stayed in Virginia six months ago. What is it doing here? Why is it so close up? I am on the floor, back in the hotel room. Why am I on the floor?

This has happened before. I remember a dream I had once when I was about 5 years old which included a large thumping noise. When I woke up, I was on the floor. How odd, I thought, that Mommy would have moved me from the bed to the floor. I wonder why she did that. It took me a couple of days to put two and two together. So, you see? It happens all the time. Further weight is added to the roll-off-the-couch theory, as I can remember going to sleep on the couch earlier in the evening.

But wait! The couch is way over THERE, and I'm over HERE, outside the bathroom door, near the foot of the bed-- not the couch. Also, I remember getting up to pee after the nap on the couch. How confusing. Humph. Maybe I peed, went back to sleep on the bed, and rolled off that. Endwise. From the foot of the bed. My cheek hurts.

It actually takes about that long to figure out that you have fainted.

I am alone in a hotel room in a strange city, and I have apparently passed out and hit the floor. This makes me very nervous. The adrenaline is starting to pump. My hands are shaky. The doctor said to call if anything happened, if there was any change in my condition. I think this counts. Maybe I should just go back to sleep, and I'll feel better in the morning. No, he said to call. I should call. I call the doctor, and he instructs me very unequivocally to get my ass into an ambulance and get over to the ER. I am not to drive myself. I am not to delay. I am to go, NOW.

I'm embarrassed to bother the hotel staff and make all the fuss an ambulance would create. I try to reach a couple of friends from the class to see if they can drive me, but they don't answer. Oh well. I know from past ER experience that you get better service in the ER if you're brought in by ambulance, so here goes. I make my way down to the hotel desk and I say, very meekly, "I fainted in my room and my doctor says I need to take an ambulance to the hospital." I don't look like a person who needs an ambulance to the hospital. I look fine. "Now?" says the hotel clerk. "Yes, now." I say, echoing my doctor.

The EMT's arrive. They diddle around with my vital signs. They see if my blood pressure changes dramatically between sitting and standing. This is called being something-o-static. It doesn't; I'm not something-o-static. They load me in the ambulance and drive me 5 minutes down the road to FOH. I am alert and responsive. My BP is one-fifty over one-thirty. Do I have a history of high blood pressure? I do not, though I would certainly be interested in reading one, if one were available.

At the ER, a very nice Dr. Gentry (how's that for a name?), probably a couple of years younger than me (but with gray hair, so there) explains, very gently, all the while with a wry smile, that there is a phenomenon called "urinary syncopy," a.k.a. "mictural syncopy" which means, fainting while you pee. Usually strikes older men. Maybe if women stood up more often when they peed, they too would suffer from urinary syncopy. So far, the ER people aren't taking me very seriously. Passed a kidney stone, urinary syncopy, no big deal. Outta here in an hour.

But first we have to do a CAT scan and an ECG; standard operating procedure if you've lost consciousness for any reason. I ask the nurse, an old tyme southern black woman named Gertrude, "what's an ECG?" "Heart monitor" Gertrude says. "What's that gonna show?" I ask. "Probably nothing." she says. A technician rolls a bulky machine into the room. He smears ointment on some plastic pads with snaps on one side, and sticks the pads in various spots all over my chest, snap-side out. He hooks up a bunch of wires from the machine to the pads on my chest. He motions to Gertrude with his head, come over here and take a look. "Hmm" she says, tears off the print-out and takes it over to Dr. Gentry.

Now Dr. Gentry doesn't have the wry funny smile anymore. Now he's grinning rather broadly. "Mr. ___, you're in atrial fibrilation!" He seems happy to have found something really wrong with me. "Oh" I say. "That explains it. I knew I felt a little funny."

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In the interest of brevity, I'm going to cut here directly to the Cardiologist's explanation of atrial fibrilation, (though the cardiologist did not in fact show up until some 8 hours later) thereby skipping over the rather less-satisfactory explanations of (listed in ascending order of satisfactoriness) 1. Gertrude, 2. Jimmy Hicks (another appropriate name), the cardiac nurse and self-proclaimed good ol' southern boy (he made this proclamation after I pointed out his failure to use adverbs), and 3. Dr. Gentry. I shall also be skipping, Dear Reader, over the experience (mild) and results (fascinating) of the echo cardiogram, a technology which allows one to see right inside the heart.

Suffice to say that the Fair Oaks Hospital emergency room isn't nearly as entertaining as the San Francisco General Hospital emergency room. I discussed this with Dr. Gentry, and he opined that SFGH was probably a better place to do your residency, but FOH was probably a better place to make your career and avoid burn-out. SFGH is definitely a more fun place to lie in the ER overnight. My memory of that night is vague, but I must have slept some. I do remember asking whether we could remove the external pacemaker from my chest, since it wasn't sticking too well through all the hair that Jimmy H. had failed to shave completely, and I was rather afraid of the shock the darn thing might give me. This suggestion met with an extremely stern look and a very unequivocal "NO!" from the chief resident, who pointed out that I'd "braded down" (i.e., my heart rate had slowed or paused alarmingly) three times already that night. I hadn't noticed.

- - - - - - - - -

Atrial fibrilation is where the top two chambers of the heart (the atria) are not beating regularly, just wiggling around (fibrillating). This causes the lower two chambers (the ventricles), deprived as they are of the electrical signal from the atria on which they rely as a "cue", to beat irregularly. Aftera couple of days of this, you get blood clots in the atria which can get pumped out to other parts of the body and can cause strokes and other bad things. Eventually, the heart enlarges and weakens. If you don't snap out of it on your own, they have to either medicate or shock the heart back into a normal rhythm.

I spent about a day lying in bed in the cardiac ICU of FOH, staring at the ECG monitor and learning what an atrial fibrillation rhythm looks like. I also found out they have monitors showing all the ICU patients' ECG readouts at the nurses' station, so if you're really into ECG's you can hang out at the nurses' station and just stare at them all (the ECG readouts, not the nurses), and actually begin to get a feel for what the various abnormal patterns look like.

Sometime Friday afternoon two of the instructors from my class came by to visit. I had all those little sticky electrodes glued to my chest with wires leading to the ECG machine, so I looked very authentically ill, though I felt pretty OK by that time. I really felt rather like a malingerer, skipping out of the last day of class for no reason, except I had the whole weight and medical opinion of Fair Oaks Inova Hospital behind me. Anywayz, one of the instructors is apparently one of those people who does not do so well with visiting sick friends in the hospital. He looked ashen and his skin had a waxy, yellow tint. He was stooping over a little and he was breaking a sweat. My nurse took one look at him and wanted to get him down to the ER and work him up for an MI-- a heart attack. He insisted he was OK. She didn't believe him. She wanted to take his vital signs. He again insisted he was OK. I didn't believe him either. He escaped before the nurse could hustle him down to ER, and apparently survived his bout with hospital-visit-induced anxiety (or heart attack, if that's what it was) as I spoke to him a couple of months later and he seemed in fine health. But, I learned that another way to get immediate attention in a hospital is to stoop over, turn gray, and break a sweat: classic signs of a heart attack.

Fortunately, I went back into a normal rhythm all on my own about 6:00 Friday night, so they let me out of the hospital Saturday afternoon. That was one long, dull Saturday.

In the end, I might just as well have stayed at the hotel and slept it off-- they never medicated me, never shocked me, never did any procedures on me at all, except for the ECG and echo. They sent me off with instructions not to drink coffee or take sudafed-- neither of which I had done before going into a-fib. Thinking this over later, I realized that the admonition not to take coffee was somewhat non-sensical, or at least, unscientific. After all, I've been drinking coffee for many years and have never gone into a-fib before. Now, all of a sudden, on a day when I didn't drink coffee (or not much), I go into a-fib. This strikes me as a pretty good statistical proof that coffee does *not* cause a-fib. So I laid off the coffee for a couple of months, then went back to normal.

Epilogue is that I've talked to a number of doctors and cardiologists about this incident in the years since, and the best I can figure is that the kidney stone prompted the urinary syncopy, which prompted the a-fib. Having a low resting heart rate and drinking alcohol could also be contributing factors.

24 Hrs in SF General ER

I had throat surgery, and it turns out some Naproxen I had been taking around that time for a sore shoulder was a bad idea. Either that, or it was some aspirin I took. Or both.

As I found out, aspirin and related drugs can interfere with blood clotting: I went to bed at 10:00 thinking I was just producing a lot of saliva, but I woke up at 12:45 a.m. feeling as if I were gargling on something. I got up and spat it out in the sink, and it was dark red. I started hopping around the kitchen, squeaking "I'm bleeding, I'm bleeding" to K, who shot out of bed and directed me into some sweatpants and a t-shirt. I think I started getting a little bit shocky-- I do not handle the sight of my own blood well-- as K hustled me, tottering, out to the car.

Luckily, our house is about one block from San Francisco General Hospital, and I had just pointed out the emergency entrance to her a couple of days before "in case we ever need it". One way to get immediate attention in the ER is to bleed profusely from the mouth.

I wound up sitting on a gurney in the ER from 1:00 Tuesday morning to about 10:00 Tuesday night, since no rooms were available "upstairs", which is what the ER staff calls the whole rest of the hospital. During my 20-hour stay, I witnessed a day in the life of the ER-- sort of like the TV show, but real and better-- including the results of 2 "MCA's" (motorcycle accidents). The first one, a bearded neanderthal Harley dude who had hit a retaining wall on the 101 and been thrown 20 feet, was groaning into the oxygen mask in such a way that, if you are familiar with pain, you knew he was battling a huge wall of it. He came out later with a bunch of casts and bruises, but conscious and feisty. He wanted a glass of water, which they wouldn't give him, nor would they explain to him why not. Finally I told him on my way to the bathroom "they can't give you water because if they have to operate and put you under, you'll vomit it up and suffocate to death." He was actually grateful for the information (why couldn't THEY tell him?) and we exchanged brothers-in-pain "hang in there, dude"s. They hadn't bothered to clean up his hands and arms, which were covered in black soot, and I wondered whether the soot was a result of his accident, and if so, how, or if he just always kept them that way.

The next MCA was quite a bit worse. The admitting/receptionist/coordinator person shouted "we got an MCA coming in from the 280, people, be here in about 2 minutes, put him in Trauma One, no, Trauma One, get it ready, here THEY COME!" MCA #2 was unconscious and naked on the gurney, handsome, with a good body and a tan, black hair dyed stylishly green, surrounded by a dozen bustling Docs and EMTs. They charged in scattering nurses everywhere. I could hear one of the technicians saying, his voice rising at the end, "his vital signs are in the toilet..." and later "he's gonna die on us, people...". (It's funny how you can tell when people are really serious because they use the word "people" in addressing other people.) After about 10 frantic minutes in Trauma One, a.k.a. TR1, the room right across from where I was parked in the hallway, and into which I had a very good view, they raced him back out and "up to O.R." "Now?" "Yes, NOW!" leaving behind just a sad pile of bloody swabs, tubes, EKG cables, betadyne and plasma. I had plenty of time to contemplate it before the Filipino man came by with his mopset and spray bottles and cleaned it all up. I wished I had a camera so I could send a photo to the Chronicle: this is all that's left of a handsome young man with green hair and a motorcycle.

One of the San Francisco Institutional Police had stuck on the butt of his Glock 9mm sidearm a happy-face sticker, so that it smiled at you when he turned away.

The CHP who came in with MCA #2 revealed in idle chat with the admitting/receptionist/coordinator guy that it had taken her several minutes at the accident scene to realize that a motorcycle had even been involved. She was very young and petite and not at all your image of a CHP officer and she was being very nonchalant about the whole thing-- the bravado, I thought, of the inexperienced.

You knew things weren't good when one of the nurses came around asking if anybody had seen a donor card amongst MCA #2's personal effects. Nobody had. The only effect anybody could produce was a helmet, strangely unscratched. All his clothes had been cut away by EMTs at the scene.

I heard later that they cracked his chest right in the elevator going up to OR, and thanks to electrical stimulation directly on the heart actually got his vital signs back at least for a while. I don't know what happened after that.

Even the old ER pro's seemed a bit shook up by the whole thing, and several people catching sight of the sad little pile of miscellaneous medical equipment and body fluids asked, "Jesus, what happened in TR1?" It took the Filipino man over an hour to get TR1 ready for its next occupant. I had been in there a short time before.

A tiny, skinny addict of absolutely indeterminate sex was whining from an exam room down the hall. "I need to see a doctor or a nurse NOW." Later, "If I don't get medical attention IMMEDIATELY I could very possibly die. We have a death situation here." Etc. Later I saw him/her ambling down the hall with IV tower in tow. He/She did not appear close to death, though he/she looked as if he/she had been trying to get there for a long, long time.

The reception/admitting/coordinator guy was being shouted at by some lowlife/patient in the waiting room who was apparently trying to leave without permission. "You're increasing my stress level!" I suppose doctor's orders against unnecessary stress gave this added authority. The r/a/c guy was nevertheless unimpressed. "You're increasing MY stress level, and if you try to leave, I'll have you restrained. I have the authority to do that." He not only had the authority, he had the physical ability. The principal features of the r/a/c guy were his height, his bristly mustache, and his muscularity. A lot of the staff at SFGH were clearly gay/lesbian, which no doubt helped them identify with the likewise heavily g/l patient population, and the r/a/c guy, tho clearly gay, was also clearly not to be fucked with. (I figured his height at 6'4", tho it's difficult to determine human heights accurately from a prone position on a gurney.) He then instructed the cop with the happy face sticker pistol to restrain the lowlife-patient should the lowlife-patient attempt to leave, and no more was heard from that quarter.

Anywayz, this whole time the bleeding in my throat was slowing, so I just popped Vicodins for the pain, which was unchanged from the entire previous week, napped, and watched the show. It was quite interesting and I was sorry when they finally wheeled me up to a room also occupied by a very articulate gentleman named James, with the bloated red face of a lifetime alcoholic, who had been struck by an automobile whilst crossing the street to seek employment, and who displayed amazing negotiating skills using the telephone all day arranging to borrow money to pay off his bill at the transient hotel where he had been staying before his hospitalization and for a room in a halfway house upon his discharge, which room provided courtesy of SFGH. "The problem is that I'm not ambulatory, so it's impossible for me to recover my belongings from the Krishna (?) and move them to the Alder without transportation of some type, so if you could help me in my situation..." He was so well-spoken and obviously intelligent, albeit with the ego-less deference of the longtime alky, that I would have felt strongly compelled to advise him, were I his career counselor, that he should pursue financial sales of some type: insurance, real estate, or negotiable securities, preferably in a capacity where he would not have to meet clients face-to-face too frequently. Perhaps he once was.

They let me out Thursday morning around 11:00, and I managed to stay away all of 12 hours. No shock this time, I'd seen the blood before. I even waited an hour or two thinking I could make it stop, but I couldn't. So back I went, the very same admitting nurse was there and said, "Weren't you here Tuesday night, and wasn't I sitting right here?" Yes indeedy. A young med student wrote me up, while a guy (doc? RN?) with a huge beard, a dead ringer for Jim Hansen, quizzed him: "What's the first thing you need to worry about with bleeding like this?" "Um..." "Airway. Anything you gotta do to keep that airway open. That'll be on all the exams." Right. Seconds later, I gagged and coughed up a huge blood clot. It looked like what's leftover when a cat is done with a mouse. K screeched and hopped back, the Jim Hansen look-alike said, "It's OK, it's OK, it's just a blood clot." K apologized and made I-feel-foolish gestures, I looked up at the med student and said, "Yep, airway. I could choke on something like that." By that time, I was getting pretty inured to the sight of blood.

To make a long story slightly less long, I spent only 6 hours in the ER this time, in the care of one very competent and likeable Doctor Abati, who laughed at all my jokes. But I felt a lot worse. I was bleeding pretty badly the whole time, and swallowing most of it, which nauseates. They would have taken me upstairs to cauterize the site, but they couldn't tell exactly where it was, and they would've had to wait until 8:00 a.m. anyway since I'd eaten the night before. It finally stopped about 6:00 a.m., and back up I went, this time to a private room in the same ward, where I slept most of the day. I came home the next day noonish, feeling weak. I was hoping to feel better today, but I woke up still weak, apparently from blood loss, so I'm on alert for any further bleeding. They tell me my "hematocrit" which is normally about 40, was about 30 when I left, so I've supposedly lost a quarter to a third of my red blood cells. The ENT doc on my case says if I get to 25 for any reason, they'll transfuse me-- not a very attractive prospect, considering SFGH is THE headquarters in San Francisco for AIDS and substance-abuse patients, and I understand they still aren't sure whether the filters catch every last speck of AIDS virus in whole blood.

So, I'm taking it easy, popping iron pills and eating spinach. When I start feeling better in a week or two, I can begin looking for a job. Hope that won't be as much of a bloodbath as the past week. It's been grand.