The Pacemaker Blues

I would rather die than have a pacemaker! That was my reaction when it became a possibility. Forty years as a marathoner and triathlete and I could possibly have a heart issue?  No way! I had no family history, ate well and exercised more than most people on earth. The possibility just did not compute.  It all started during my Sunday mile swim when I couldn’t catch my breath after two laps and almost passed out on the fourth. It had to be a fluke. Maybe I was overtraining. In any case, I slowed my pace and finished the mile. I continued my longstanding exercise psychosis. Of course, my swim the next day would be better. Or so I thought. Years of running through walls and pain compelled me to push even harder on the next swim. Unfortunately, I had the same result. This time, I had to hold onto the side of the pool for a minute before continuing. My arms and legs became flaccid, I lost muscle control, but I could finish the mile at a snail’s pace. My psychosis was in full display, but I knew something was wrong. I needed help, not the psychiatric kind although it probably wouldn’t hurt. My best friend was my Primary Care Doctor, Patrick. Even though it was a Sunday, I knew he’d see me immediately and he did. He would be sympathetic. He was a fellow headbanger. We had completed many marathons and triathlons together. He was fifteen years younger and a much better athlete, but I knew he would do everything in his power to keep me competing. After all, it was probably my asthma and maybe all I needed was a course of steroids or an inhaler. My opinion carried extra weight because I was a well-respected Rheumatologist in the community. Diagnostic skills were my calling card.

As I suspected, Patrick told me to meet him at his office immediately. We met at its front door. I was accompanied by my wife Leanne.  After unlocking it, he led both of us to an examining room. Dressed in running shorts and a triathlon themed tee shirt, I wanted the world to know what or who I was. I was certainly not your typical patient. Patrick ironically wore the same themed tee shirt. However, unlike me, his mellow personality and gentleness hid the intensity he displayed during competitions. I wore my intensity like a badge of honor. My wife took a seat after hugging and thanking Patrick for seeing me on his day off.

“Patrick, you are a true friend. Thanks for doing this.”

“Of course. Rudy would do the same for me.”

He then turned to me and said: “Rudy, have a seat on the examining table and take off your tee shirt. How do you feel right now?” Patrick had a great bedside manner and had a way of putting you at ease. He had a twisted sense of humor while showing concern and empathy. His very thin but muscular six foot-three body gave him an aura of youth and vigor. His greying black hair, wrinkled forehead and thoughtful approach assured patients of his maturity and wisdom. I felt immediately at ease and began to joke.

“I feel old and decrepit. Maybe it’s time to put this old dog down. Seriously, I feel fine now but as I told you over the phone, I almost lost it in the pool. Two laps and I was done. It happened two days in a row. It wasn’t as if I was going for the world record either. I was swimming a fast geezer pace, nothing out of the ordinary for me. It’s probably exercise induced asthma.”

Patrick smiled, nodded and reached for his stethoscope. He listened carefully to my chest, front and back before remarking:” Your chest is totally clear now. Of course, it doesn’t rule out exercise induced asthma but let’s do an EKG.”

I respected Patrick’s acumen, but I just knew an EKG was unnecessary.

“Why? I have no family history and no risk factors. It’s probably exercise induced asthma as you said.”

“Let’s do it just to be sure.”

Leanne took my hand and said: “Let Patrick do his job. Stop trying to be your own doctor.”

I relented. “All right but I think it will be a waste of time.” I had typical physician hubris.

Patrick left the room and returned, rolling in an EKG machine. He placed the leads on my chest, arms and legs and turned on the machine. After a minute, he had a readout and looked up at me with a look of concern.

“Let’s run another one.”

Leanne and I looked at each other and I felt the need to joke again.

“What? Am I flatline? Let me guess-sinus rhythm with a right bundle branch block. It’s benign and I’ve had it before.”

Patrick smiled but concentrated on his reading of the second EKG strip. He raised his eyebrows and looked up at me.

“Both strips show you are in atrial flutter with a second-degree AV block. Your heart rate is forty-two.”

It took me a minute to digest this information. I was always proud of my low athletic heart rate, but this was different. In the meantime, Leanne asked: “What does that mean?”

I answered: “it means my upper chamber is racing or fluttering at a very high heart rate, but that rate is not being transmitted to the lower chamber because of a block. So, the ventricle is beating independently at a very low rate and my cardiac output is much reduced. It would explain why I felt like passing out and weak. My brain and extremities were not getting enough blood flow during exercise.”

Leanne was a bit tearful as she asked: “Is it dangerous?”

“Well, it’s only a second-degree block but if it become a third degree, I could drop dead but nothing serious.” My brain was screaming pacemaker! I did not want to become a cardiac cripple. It would cramp my style. My mortality flashed before me, but I needed to maintain a brave face.

Patrick interceded. “Let me contact Kent, our favorite cardiologist. I have his cell number. Let’s see what he says.”

After getting off the phone with Kent. Patrick smiled and addressed both of us.

“Kent says you need an ablation. It will probably take care of everything.”

I was skeptical but somewhat relieved. “No pacemaker?”

“Nope, he feels that if the ablation gets rid of the flutter, the block will disappear.”

Leanne looked puzzled. “What’s an ablation?”

Patrick turned to her and answered: “A cardiologist maps out the electrical pathways in the heart and finds the aberrant one that is causing the flutter. He then zaps it with an electrical current causing scarring and blocks the pathway.”

Leanne tilted her head and asked: “Is it safe?”

“In the right hands, very. Kent wants Rudy on a blood thinner for a month. He’s to wear a Zio patch for two weeks to monitor his heart rhythm. He’s being referred to an electrophysiologist who will perform the ablation in a month. While wearing the Zio patch, he can’t swim but he can bike and run.”

Patrick knew how to keep me sane. No exercise would mean extreme withdrawals. I was an addict and too stupid to be scared. I was ready for anything including death. At least I would get a nice long rest. I couldn’t resist asking Patrick about next Saturday’s planned bike ride.

“What about next Saturday’s ride in the Greensprings? You said it was a killer. Can I do it?”

“It’s a five-thousand-foot climb. It will be good data for your Zio patch. Just don’t fall. You’ll be on a blood thinner.”

That was my boy and fellow headbanger. I loved the guy. The ride would give the cardiologist good data or kill me. At least I’d be riding with my doctor.

***

The next day, I went to the hospital where they shaved my chest and placed a sticky patch under my right nipple. The wonders of technology! This patch would store my heart’s rhythms over the next few weeks. I could shower but not immerse the patch in water. At least I wouldn’t stink. That Saturday, six of us drove 20 miles, with our bicycles on bike racks to the start of the loop trail. As advertised, it was a wide dirt road with long steep rolling hills. I was usually the last one up each hill. At the top of each one, I was extremely lightheaded and on the verge of passing out. But I persisted. After all, I was a marathoner and headbanger. After 25 miles and the last hill, I turned to Patrick and asked:

“Were you trying to kill me?”

He laughed and said: “You made it, didn’t you? We probably got good data on your Zio patch.”

I smiled, nodded and wondered how psychotic we both were.

***

The ablation was a piece of cake, and I got a great sleep on Propofol. I loved that drug. Before any minor surgical procedure, they’d place the IV in your vein, roll you into the surgical suite and then you’d wake up all done. I understood why Michael Jackson was so addicted to it. The cardiologist told me that the ablation was a success. I was no longer in flutter, and I now only had a first-degree heat block. My resting heart rate was now 48. I would have to remain on blood thinners for another month, but I could resume all activities. Yippee, I could continue my headbanging lifestyle! There was one cautionary note I was at moderate risk for a recurrence. Bummer! I hoped I’d beat the odds.

I resumed my busy medical practice and triathlon training. My swimming improved dramatically, and I was able to run and cycle at my previous level. Still, I didn’t feel right. I bought an Apple watch and monitored my heart rate and rhythm obsessively. I had a lot of extra beats and a choking feeling. My heart rate would dip into the high thirties at night. I kept requesting EKGs. Each one showed normal sinus rhythm with frequent extra beats and a first-degree block. I was paranoid about my heart rate and rhythm.  I didn’t want to become a cardiac cripple. Still, I was able to maintain a vigorous training schedule.

A few months later. I passed out while getting out of bed on the way to the restroom. My cardiologist initially was not concerned. However, after consulting with colleagues, he suggested I might need a pacemaker. No way! I was not going to have a foreign object implanted in my body. It would be a problem going through security at airports and I could never have an MRI. Magnets would inactivate the pacemaker. With all my orthopedic problems, I always needed the option of an MRI. I refused to become bionic. I would rather die.

“I would rather die.”  That was my mantra when discussing it with friends or my doctors. They all smiled and humored me but secretly probably thought I was nuts. My wife definitely did. It all changed when I was on a heart monitor during a tooth implant. My heart rate dipped to 33. It got everyone’s attention including mine.  I wore a Zio patch for another two weeks and saw a new electrophysiologist.

“Well Rudy, your average heart rate is 42. You can probably survive for another few years without a pacemaker. You have sick sinus syndrome and eventually your heart rate will get slower and slower. You’ll have more syncopal (fainting) episodes and become unable to maintain your exercise level.”

The doctor had just said the magic words.  I could tolerate anything but the loss of my headbanging lifestyle.  It didn’t matter that I was aging, I still needed to be able to exercise at a certain level. My favorite adage over the last few years had been, I no longer compete, I complete. That’s all I wanted.

“Will I be able to continue all my activities with a pacemaker?”

“Yes, you will have a an on-demand pacemaker that will adjust your heart rate according to your exercise level.”

***

A month later, I was lying on gurney, plugged into a heart monitor, waiting with Leanne to be rolled into the surgical suite. Just before the anesthesiologist arrived, Leanne pointed at the monitor. My heart rate had dropped to 29. I was finally convinced. It was pacemaker or die. I chose the former. A few hours later, I was bionic. My heart rate could never fall below 55 and with the right activity, it could reach 140. I soon discovered that 140 was not adequate for me and only deep breathing or impact activities would increase my heart rate. Shallow breathing while cycling or swimming would not trigger my pacemaker to increase my heart rate adequately. I would struggle. The high impact of running did but not enough. My pacemaker needed to be adjusted to my needs. I was on a learning curve.

The pacemaker specialists had me running in a parking lot while they monitored my heart rate on an I-pad. They would adjust the settings according to my response. Initially, it responded eighty percent to impact and twenty percent deep breathing. It made cycling and swimming difficult. After several visits and parking lot runs, they found the perfect balance between impact and deep breathing response. They also adjusted my maximum heart rate to 160. I was good to go. I learned to take deeper breaths and increase my motion and impact when hiking, walking or running.

I feel far from perfect and hate knowing that I am bionic and have a ten-year warranty until I need a new battery. Still, I am alive and still headbanging. I guess I owe a measure of gratitude to the little box protruding from the left side of my chest.