Ischaemic Affairs of the Heart

The heart attack

One imagines a heart attack would involve sharp stabbing chest pain, confusion and dizziness, followed by collapsing onto the ground and gasping for air.

In my case… not at all.

I was walking to my local railway station along a 800m route I had done hundreds of times before. The chest-pressure started about half-way. It was a hot day and — frankly — I'm almost 60 and getting out of shape, so didn't think much of it.

But the chest pressure intensified while I kept walking. I remember reading a few years ago that a heart attack was like an elephant was sitting on your chest, but here it didn't feel like that at all. It was actually more like something the size of a hand continuously pressing down onto my breastplate — hard. Otherwise the rest of my torso or legs were fine. Could even keep walking as strangely there was no pain, just some really serious pushing onto the central part of my chest.

My arms did feel heavy though. Not sore or fatigued, but like I was carrying 10 kg weights. The left arm actually did feel a little heavier, but not by much. My shoulders and neck were also stiff, but I've had a rickety neck since playing rugby as a teenager, so nothing unusual there.

The chest pressure was continuous, not throbbing. On a scale of 1-10, maybe only “7”. I kept telling myself that it couldn't be a heart attack as I would not be able to keep walking if it was.

And that's it. Have had worse toothaches or indigestion. So I continued walking to the corner, caught my breath, wiped the sweat off my forehead, and then crossed the road to the station to catch the Penrith bus.

Early warnings

It wasn't the first time this had happened.

The first occasion was ten days earlier during one of my twice-weekly 1000m freestyle laps. The chest-pressure this time was so mild that I assumed it was from having swallowed too much air while swimming. Sure enough, when completing the laps I stood up and did a large burp, and by the time I got out of the pool I was fine. Likewise the next swim four days later. Laps, pressure, burp, fine.

During the following swim on Saturday, three days before the station-walk, things were more intense. This time the chest-pressure started early during the second lap, with it becoming painful by the 300m mark. Also noticed that my arms and shoulders were weirdly “heavy”. So I reluctantly stopped and got out. It took about five minutes this time before I felt normal again.

The next morning I took the dog for its customary walk before breakfast, along a hilly 2km route. Again there was chest-pressure and heavy arms, but not as intense as during the swim the day before. Figured I was just out of shape and hungry, and maybe all I needed was to take things easy for a couple of days. So Monday morning did some light gardening and cleaning — no problem. Tuesday morning, again no problem, but later during the walk to the station before lunchtime… bam.

When I recounted to a hospital on-call cardiologist later that evening, she remarked that the Saturday swim would have been my first significant heart-attack, the Sunday morning dog-walk a milder second, with the station-walk being the biggest and third. In her opinion I was lucky I didn't drown during the Saturday swim.

Ambulance

When I got home I phoned for an ambulance, which arrived within five minutes (!)

This would be impressive in more connected parts of Sydney, but where I live in the Blue Mountains it is almost unbelievable. By way of comparison: an ambulance I called for my mother on 2020-11-10 took 40 minutes to arrive, a subsequent call on 2020-12-18 took just under 4 hours.

So it was reasonable to assume I would have at least 30 minutes to prepare. Plenty of time to pack an overnight bag plus leave notes for the neighbours on how to feed the pets. But the knock on the door came early, so everything had to be slapped together in a rush. Managed to pack and lock up okay, but forgot to include two of the most important things: a toothbrush & toothpaste!

The two paramedics were small young women in their late 20s. Very professional and friendly. I was lucky they had been driving down the highway a couple of kilometres away when they got the call. Their ambulance looked brand new, although it was narrow and cramped inside — how would you fit a really overweight person in here, and how would these slight women ever manoeuvrer them? Because COVID-19 was still a thing, we all had to wear surgical masks, although they told me I could remove mine when I got a hospital bed.

They asked which hospital I wanted to go to. I jokingly replied RNS, Westmead or POW, fully aware they could only take me to the closest available facility. In my case that was either Katoomba or Nepean Hospital. As they had just come from Katoomba, they warned me things were seriously backed up there, and since their facilities were also very limited (would they even have a cardiologist?), we chose Nepean.

During the unhurried drive — no sirens or swerving or running red lights — one of the paras took down my details, emergency contacts, inserted a cannula in my right arm, stuck silicone electrode-tabs onto my torso, recorded an ECG and measured my blood pressure. She asked me to describe what had happened, what medication I was taking, how old, tall and heavy I was, whether I smoked or drank alcohol and was there any history of cardiac illness in my family?

Was there ever! Nearly every adult on my father's side has Type II Diabetes. My mother had hypertension for the last 50 years of her life. Most importantly, my father died of pericarditis when he was 52, his brother due to thrombosis at 47 and the brother's son at 41 of a heart attack. All suddenly without warning.

That raised an eyebrow.

Nepean Emergency Department (ED)

Upon arrival we noticed there were already eight ambulances parked around the ED entrance. As by now I felt fully recovered, I offered to spare the ladies the bother of fiddling around with the gurney by walking instead. One of them wisely told me to stay where I was, as I might end up sitting on a floor for hours if I wasn't wheeled in.

As we went in through the entrance, I noticed a crudely hand-drawn Code Amber poster stuck to the window. Once inside, the waiting room was stacked with people and trolleys, with only a few patients on triage beds or chairs. The rest, like me, were on gurneys. As these were parked everywhere, my paras had to wheel me deep inside the building to a relatively uncluttered corridor. I asked one of the paras if it was always like this. She laughed and said she had seen it much worse.

Because I had a suspected heart-attack, I was triaged for priority attention. Blood samples were taken within minutes, likewise another ECG and blood pressure reading. I felt absolutely fine by now, so had relaxed conversations with one of my paras about her job (the other had gone to do paperwork). Meanwhile, random patients attempted to use the toilet opposite us and kept banging on the door because someone had locked themselves inside. I asked my para whether she and her colleague should leave to attend other cases, but she replied they had to stay with me until I had been allocated a bed. If it took hours then so be it, the downtime was appreciated.

While still in the corridor on the gurney, an on-call cardiologist came to tell me that irregularities in my ECG and elevated levels of blood troponin confirmed that I had a heart attack this morning (!) I told her that I felt completely fine by now, she smiled behind her mask and said I was lucky.

Within an hour of arriving I was allocated an ED bed. The paras wheeled me into the ward and we bid farewell. They also remarked how lucky I was to get a bed so quickly, as one of their colleagues had been stuck in the waiting room all afternoon.

There were six beds in my ward. Everything had a 1990s vibe, clean but surprisingly antiquated. What was once white plastic had yellowed years ago. No sunshine. No view outside. No fresh air, although the air conditioning worked quite well and it was pleasantly cool. Was given RAT nasal swab to test for COVID-19 — negative. Was asked again if I smoked — no. Then more blood samples, another ECG and blood pressure measurement. My shirt and undershirt were changed for a white cotton hospital smock, which was closed at the front but completely open at the back. This turned out to be a nuisance as sensor tabs were stuck all over the front of my torso, so it required major shuffling and squirming to get the smock above my shoulders to provide access.

My nurse was another slight young woman in her late 20s, this time covered in tattoos. She told me she was near the end of a double-shift and was feeling light-headed, so was being ultra-careful to avoid making mistakes. Behind us I noticed two of the six beds were occupied by mental health patients, one by a bloke who insisted on getting up and wandering around to argue with everyone. The other by an elderly lady who lay in her bed and ranted loudly about how her family were out to get her. The bloke was eventually escorted away to the mental health unit, while the lady was calmed by an injection of haloperidol. I asked the nurse about this and she replied that people like them come to hospital because they have nowhere else to go.

The cardiologist came back and stayed a while so I could tell her my whole “chest pressure” story. This is where she remarked how lucky I was that I hadn't drowned on Saturday. I didn't say anything, but at the time it didn't make sense — I just stopped swimming after six laps and got out, what's the big deal? She told me I had to stay in the ED until a bed became available in the cardiology unit upstairs, hopefully soon. Tomorrow I would get an angiogram, probably at midday or in the afternoon.

A little later a couple of administration people then came along with clipboards and pages of admission paperwork to be signed. I pointed out that I had private health insurance, so they told me to tick a box on the form. Was later given dinner — a small roast beef sandwich — accompanied by a couple of tiny “blood medication” tablets.

It took 4½ hours before a cardio bed was found, but I didn't mind as I felt fine. Even SMS'ed one my friends that I was a fraud here lying among genuinely sick people. Eventually an orderly came and as I got out of bed he told get back in as they would wheel the entire apparatus to the cardio ward. It turned out later that, again, I was very lucky to get the cardio unit transfer so quickly. Another heart-attack patient I spoke with the next morning told me she had spent 16 hours in the ED before they found her a bed.

Cardiology Ward

It was already night outside. While being wheeled along the corridors, I asked the orderly if I was being transferred to the new 14-storey clinical services building which opened in April 2022. He said no — the current plan was that both ED and Cardiology would move together to the new building in February 2023. They had intended to move a few months earlier, then delayed it to December, and it had been put off yet again [i].

We caught the lift to the 5th floor (W5B) and I was wheeled into a 4-bed ward, with each patient screened by movable blue curtains. My bed was placed at “Bed 26” near the door, and it quickly became apparent that the room was warm and unusually stuffy. There was no airflow at the head of my bed, so I started to sweat a lot.

The bed to my right was completely screened off, but as the curtains were not soundproof, you could hear repeated and loud moaning from an elderly gentleman with every breath: Oooh God … Argh … Ooooooh …. In the bed opposite was a young man in his 30s with his wife lying beside him on top of the cover, both quietly arguing with the head nurse that the wife wanted to stay overnight with her husband because going home was “unsafe”. The nurse said no. The wife said she wouldn't move. The husband emphasised it wasn't safe. The nurse said she would call security. And on and on until the stand-off concluded with the wife agreeing to sleep on a couch somewhere outside.

Meanwhile more ECGs were recorded and the dozen silicon tab probes on my torso were connected by wires to a blue-tooth box hanging from a cloth pouch around my neck. Eventually managed to bed down for the night at 22PM, but it was so stuffy that falling asleep was difficult. Was then woken by a nurse every 30 minutes to reattach silicon tabs which kept slipping loose due to my sweating and moving around. At 1AM we went out into the corridor and I asked her to tape the things down, as the half-hour interruptions were really annoying. She got some hospital tape and then each tab was terminally affixed with a cross of 10cm lengths — making me look a bit like the trinity test device. Went back to bed and finally managed to get some sleep by moving the pillows to the foot of the bed, where there was at least a tiny amount of air-low.

Morning Prep

The next morning I went out in the corridor to phone my Private Health Insurance and ask a few pertinent questions: Why was I with non-insured public patients? Was there a problem with my insurance? Why was I paying thousands of dollars a year in fees to get exactly the same treatment as those who were uninsured?… The matter was cleared up quickly — my policy was valid and, among other things, it enabled access to treatment in a Private Hospital. If I wanted a transfer then I needed to discuss it with my cardiologist. On top of this, insurance also let me avoid the 1-2 year waiting-lists for so-called “elective” surgery.

Went back to the ward and was told, after my incredibly slight breakfast, that I was now Nil By Mouth until the angiography was done this afternoon. Consequently was hooked up to an infusion to keep me hydrated and help flush the Metformin from my blood, as apparently it didn't play well with the angiogram dye.

At 9AM a different on-call cardiologist came by on his rounds. Despite some confusion earlier in the morning, I was definitely booked for an angiogram after midday. In his opinion there was no point in transferring to a Private Hospital as I should be discharged from hospital by tomorrow afternoon. Also, he told me, there wouldn't be any specialists available in the private sector anyway, as they were all still on summer holidays. (I confirmed this a week later when I phoned Nepean Private Hospital.)

A little later I received a visit from a young doctor who said he was once my Y11 Chemistry student. He recognised my surname on the admissions whiteboard and guessed it must be me. A little later a nurse recognised me as her Y10 science teacher (!) Then another nurse appeared with a toothbrush (easy) and toothpaste (hard — he had rummage through a storage cupboard in a ward downstairs). Even he remarked how hot and stuffy it was in my ward.

A nurse then came by with a weighing chair to measure me: 110kg! I had gained 12kg in the last two years =/

Spent the rest of the morning in a chair beside my bed, reading a book on my phone while trying to ignore the sequential moaning from my screened neighbour. At one stage I got up and went for a short walk in the corridor outside to cool off, and then came back to have a conversation with a patient diagonally opposite my bed. She told me about her heart attack while watching television a couple of days earlier, the long delay she experienced while stuck in ED, and how the angiogram she had this morning was over before she even thought it began.

The young man in the bed opposite wasn't so lucky. An angiogram typically requires a thin tube inserted into the artery in your right wrist and is then pushed towards the arteries near your heart. If that doesn't work, then they try your left wrist. If that also doesn't work, then they go in through the femur artery in your groin. Which is what happened to him, and even though he wasn't in any pain, he now had to lie absolutely still for a number of hours to prevent the incision in his groin from reopening. Alternatively, those whose wrists are accessed can move quite freely after the procedure.

Mid-morning I was prep'ed by shaving my wrists and also, with some confusion, my groin. They handed me an electric shaver and the wrists were easy enough, but there was considerable ambiguity in the instructions for the groin: how much do I shave and were? The sides. The sides of what? Your groin. Where do I shave again? The sides.

Midday. An orderly appeared to wheel me and my bed across to the ward where the angiogram was done. Finally got to be to in a ward with air-conditioning… bliss. Am given a local anaesthetic and lay there for 20 minutes before being wheeled into the diagnosis theatre, just before 13PM.

Angiogram, Stents & Sonogram

The theatre mostly continued the antiquated 1990s vibe, although there was a brand new and quite large LCD monitor mounted onto a swinging arm on the right-hand wall. There were metal rails criss-crossing the ceiling and I was surprised how dim the lighting was. There were about four medical personnel in the room, all wearing light blue surgical gowns and masks. The cardiovascular surgeon, however, was in light green.

I got up out of my bed and was asked to lie on a specific point on what was essentially a waist high rectangular table. No one explained what the procedure entailed, but I mostly knew anyway. A tube would be inserted up an artery (arm or groin) and then pushed close to my heart. Then a dye would be injected into my blood which is opaque to x-rays. The purpose of the dye is to make the arteries around my heart visible and thus make any issues obvious.

I was asked to shuffle around a bit on the table to properly align myself with the continuous x-ray source (which I assumed was coming from beneath). A large detector box was then positioned over my chest and my right arm was clamped to the table. Use of the word “clamp” here is not exaggerated, as I could not move my arm at all and still had a bruise from it a fortnight later. The surgeon then did his thing.

I was conscious throughout the entire procedure, although couldn't see much because of the large off-white box hovering above my chest. I didn't feel the tube going up my arm, and was considerably relieved that they could use my right wrist and didn't have to resort to jabbing my inexpertly shaved groin. As my fellow cardiac patient remarked this morning, there was no pain or discomfort.

Once the dye was in, the surgeon exclaimed: Jesus! Look at that! He made a few verbal notes into a Dictaphone and then swung the huge LCD monitor around so I could see a faint grey 5× larger-than-life outline of my pumping heart, with the coronary arteries visible as thick black wiggly lines. He pointed to a part of a thick artery that obviously looked pinched, similar to the neck of an hour-glass. He told me You have a 95% blockage here, did you ever feel fatigued for no reason? Told him that I didn't, and even after the heart attack I was fine when resting. He then pointed out another blockage further downstream, which he said was “≈80%”, along with a couple of others in minor arteries which were “< 70%”.

A decision was immediately made to insert two metal mesh stents (Balloon angioplasty) to clear the “95” and “80” blockages. The other ones they made a note of, but would leave for now.

Here unfortunately things did get painful. As the surgeon went about his work, a strong dull pressure built up in my chest to a level where it became quite uncomfortable. He reassured me: Just a bit more, almost done… Yeah well, I replied — so was I. He paused for a moment… and then resumed. Another couple of minutes and he was finished.

While working he told me he had a stent himself, while his brother had actually died because he neglected to seek treatment for chest soreness he had experienced on and off for a year. So my attendance here today was very timely…

I was told the process of inserting the stents would push plaque from my main artery into some of the smaller side tributaries, but I would be given medication to help break them down. The surgeon used an analogy of a snow-plough pushing snow off the street, but blocking a few driveways in the process.

A bed was wheeled in, the arm-clamp was released and I climbed off the table and into the bed. Was then wheeled into the ward outside, a few metres opposite the theatre entrance. Within minutes a lady sonographer appeared at my left side and told me who she was and why she was there.

Her role was to use ultrasound equipment to measure the blood flow through my heart, and also check for any heart muscle scaring. This sounded reasonable, but she then spent 20 minutes painfully pushing a probe into my chest and ribs. While she went about forcefully prodding my sides, a couple of cardiologists and the green-gowned surgeon appeared around my bed. They all had crinkly eyes from broad smiles behind their surgical masks. You have no idea how lucky you are!

I shook the surgeon's hand and thanked him. He took off his mask and we spoke for a couple of minutes. He looked exhausted and must have been near the end of a very long shift, similar to my ED nurse yesterday.

The sonographer finally completed her extreme prodding and told me the blood flow through my heart was normal and, most importantly, there didn't appear to be any scar tissue. She contrasted this with a man in his 30s she scanned yesterday, who had 30% scaring because he kept putting off getting his chest pains examined.

Critical Care Unit (CCU)

Was wheeled back to the Cardiology Ward CCU room “No. 5”, which had a single bed with dedicated vital-monitors plus an en suite. It also had a west-facing balcony with floor to ceiling glass windows and door. The balcony exterior was covered in thin steel wire mesh and unfortunately the door was locked, but at least the windows let in natural light. Noticed immediately that the air-conditioning worked, although not as well as the recovery ward I had just come from.

I was then plugged in to a 1200ml Tirofiban infusion to help prevent platelet formation and flush the angiography dye from my system. The flow rate was adjusted to last 12 hours.

Was comfortable enough lying in bed, although my right arm was hooked up to the infusion tube, while my left bicep had a blood-pressure cuff on it which was programmed to automatically do measurements every 30 minutes. Most of the time the reading was 130/85, which under the circumstances was normal.

With the monitor wires on my torso connected to the vitals-monitor above my left head, plus the BP cuff, plus the right arm infusion tube — I effectively found myself immobilised. Had to ask permission from the nurse to unhook so I could use the en suite, although I had to carry the infusion apparatus with me (its wheels were stuck).

Was given a small hot dinner at 18PM, the first food I had eaten since the light breakfast at 6:30AM. Noticed after eating that the pressure in my chest increased remarkably. Buzzed for the nurse and she responded immediately. She then paged a doctor, who showed up within 10 minutes. Blood samples were taken for enzyme and sugar analysis, he checked my vitals, did another ECG and after a while came back to let me know that all the data indicated that everything was okay. By then the chest pressure had abated significantly, so there was nothing to worry about.

I had been advised that after the stent insertion there would be a bit of temporary chest discomfort as my heart and organs got used to the new mesh intruders. Nothing overwhelming, but definitely noticeable.

Overnight Observation

After dinner I tried to watch TV, but found all the channels were locked and could only listen to various smooth-music radio stations — was told you have to pay extra if you want to watch TV. Fair enough, but discovered later that full TV access was included because I had private insurance — all I had to do was ask.

With all the day's excitement, found it very difficult to fall asleep. Finally managed to do so, but was awoken almost immediately by aggressive beeping from the vitals-monitor above my head. Apparently my resting pulse-rate, already low, triggered an alarm when it dropped to less than 50 BPM, which was whenever I started drifting off to sleep. After a few more false alarms, followed by protracted negotiations with the nurse, we agreed to reset the warning limit to 46 BPM. This finally silenced the thing.

Eventually and with great difficulty, went to sleep. Was having a complicated dream about walking through a crowd in a park and was then seated on a knee-high brick wall, talking to someone beside me. Someone else came along and tapped my left arm, indicating they wanted to interrupt. I told them to wait a minute, but they forcefully grabbed my left elbow and started squeezing hard. What the hell!? I suddenly awoke to find the BP cuff had fully inflated and was doing an automated BP measurement. Buzz the nurse, who laughed when I told her. We started negotiating again, this time about the frequency of BP measurements — finally agreeing to lower the frequency to every 2 hours, as my BP values had been consistent since arriving at the CCU.

Discharge

CCU final morning

First thing next morning I asked the nurse if it was okay to unhook myself so I could walk around. As the infusion expired at 3AM, she told me it was — provided I came back within 15 minutes. Used the time to visit the patient in my previous ward, with whom I had the angiogram conversation yesterday morning. She looked surprised to see me and was relieved that I was still alive. She told me that orderlies had quietly come in the afternoon to gather my effects and then vanished, so she had assumed the worse.

I went back to my CCU room and was re-hooked. While lying in bed, another nurse came in to ask if I wanted stay another day — I said no thank you.

After 9AM received a quickie visit from the on-call cardiologist. He did a review and said it should be okay to go home at midday. During discharge I will be given more information about medication and what happens next.

Half an hour later a nurse came to confirm I was being discharged before midday. She then removed the monitor tabs stuck to my torso — pulling out a lot of hair with each strip of tape. I then had time to have a quick shower, and walked out of the CCU at 10:45AM.

While waiting at reception, the Head Nurse told me to find a cardiologist through my GP as the one who inserted the stents yesterday didn't work in private practice.

A small woman orderly then came with a wheeled chair and rolled me down to the “Transit Lounge” (sic) on the ground floor. The detailed conversation we had on the way down was fascinating: apparently she was a fully qualified specialist nurse in her home country, but as her qualifications were not recognised in Australia, she had to completely re-do a Nursing degree, of which she still had a year to go.

Transit Lounge

The “Transit Lounge” we went to was actually where patients are processed before being discharged. While waiting in a lounge-chair, another senior Cardiology Nurse came along to give me detailed briefing:

• I needed to see my GP within 3 days
• No driving for 2 weeks
• Very gentle daily exercise at first, increasing to more as the weeks go by
• No lifting more than 2kg with my right arm for a week, to prevent the cannula and wrist incisions from opening
• Use the small bottle of Glyceryl Trinitrate spray provided to temporary relieve any angina (chest pain)
• Always take the blood thinner medication to prevent the stents from getting blocked

She then provided a detailed breakdown of what had happened. With the aid of a heart diagram from one of her brochures, she showed where my blockages were located: the 95% was almost the entrance to the Left Anterior Descending (LAD) Coronary Artery, with another 80% blockage a little further down. She told me I also had a few other less significant blockages, one at 70%, but they were in sub-arteries much further along, which at the moment didn't warrant intervention.

I then waited for my exit materials for an hour until midday. Was given three copies of discharge papers, containing a medical summary of what happened, treatment, and medication I needed to take. Was also given a bag of prescription medicines which looked like they would be sufficient for a week.

Finally at midday a mate arrived to give me a lift home. The Transit Lounge admin then escorted me to the main hospital entrance. I made sure of letting him know how impressed and happy I was with the treatment I had received.

I had arrived at Nepean at 15:30 PM on Tuesday and left at midday on Thursday — less than 48 hours later.

Silent Ischaemic Heart Disease

Victor Chang Cardiac Institute information page (Retrieved: 2023-01-27)

The Cardiac Nurse told me my condition was known as Silent Ischaemic Heart Disease, where typically it is only diagnosed after death. It is a common condition for men of my age, especially with my risk factors (see below). Plaque builds up inside the cardiac arteries (atherosclerosis) until they become sufficiently blocked to starve the heart muscle of oxygen and nutrients. The heart then stops. As I didn't experience any symptoms until the exertions a few days earlier, hence the qualification of “silent”.

It used to be known as a Widow Maker heart attack, but the term has fallen out of favour in the last twenty years because women can also be affected. Despite this, a Google Search for the term reveals it is still used regularly in the USA.

The big question is, how come I survived? There were a number of reasons. The 95% blockage was close, but still wasn't the fatal 100%. Secondly, I had never smoked and spent years swimming and walking, so my heart muscle was unusually strong and could still function adequately with lower than normal arterial blood-flow. Another plus was that I have an unusually low resting pulse-rate of 55 BPM, so there was less lifetime stress on the heart muscle. Most crucially, I have always had normal cholesterol levels. And I was lucky.

The remark by the ED cardiologist about drowning during the first attack suddenly made sense. My heart muscle stops because it is starved of blood-flow. As I'm already face down in water… game over. Similar thing when walking to the station a few days later, except here I fade out and die on the footpath.

According to the ABS (2022) Causes of Death, Australia (Retrieved: 2023-01-27), the leading cause of death in Australia is Ischaemic heart disease, with it being responsible for 20 100 deaths in 2021. Then add another 3 400 for Heart failure and complications and ill-defined heart disease. Furthermore, according to a SMH (2023) Fatal heart attacks surged in Australia. Here's Why article (Retrieved: 2023-01-27), monthly deaths in 2022 have increased by 17% due to the impact of COVID-19.

The Nepean experience

Nepean Hospital has a reputation which is far from ideal (Retrieved: 2023-01-27).

I had already seen how they “treated” my mother when she became sick towards the end of 2020, with things being so dysfunctional that I lodged a complaint with the Health Care Complaints Commission a few weeks after her death (Submission ID 20961, Outcome File No. 21/00195).

So I was expecting the worst. Yet this time, to be honest, my experience was overwhelmingly positive.

Despite the “Code Amber” alert and overcrowded waiting room, I secured an ED bed within an hour. An on-call cardiologist attended within 30 minutes and again later in the ED. I was transferred to a bed in the Cardiology Unit within five hours. The angiogram and stents were done 18 hours later. Was given a solo CCU room with attentive nurses and doctors and was even offered an extra day if I wished. Staff were always helpful, polite and professional. The discharge admin even walked me to the front entrance and wished me well.

When I departed from Nepean Hospital I felt relieved, elated and even a little confused. Why had everything gone so well for me and yet so appallingly for my mother in 2020?

The following is purely conjecture, but it may help explain:

• I was 59 years old, otherwise healthy and worth saving (my mother was 86, frail, with terminal cancer)
• Heart attacks are treated as top-priority (as opposed to the ill-defined stomach cramps my mother had) and treatment has to be given immediately to prevent cardiac muscle damage
• The Cardiology Unit would be among the busiest in the hospital due to Western Sydney's demographic issues (Retrieved: 2023-01-27), meaning it is staffed 24/7 and they really know what they are doing
• I had private health insurance and “ticked the box” on the admission form. Which meant the hospital received payment from the insurance company in addition to their usual government operating budget (my mother was Medicare only)
• Maybe they recognised my name from the HCCC complaint?…

Dr EFF

Not his real name.

Upon release from hospital, you are given a few days medication with an expectation you will visit your GP to obtain prescriptions for longer term use.

I called my GP practice first thing the day after release, a Friday. Was informed by the receptionist that my GP had left the practice a couple of months earlier. In that case I told her any GP would do as all I needed was prescriptions and a referral. She did a bit of typing and the first available GP booking was Monday 10:50AM — in three days time. As there was no hurry I agreed.

Received an SMS from the surgery a couple of hours later confirming the appointment and warning me: […] Private billing fees apply for all appointments. Masks are still MANDATORY in our Centre. The fee was $70 up front, with Medicare refunding $39.75 a few hours later via direct bank deposit.

Arrived at the surgery at the allotted day & time. Was told by the receptionist to sit in the corridor outside the doctor's consulting room. Forty minutes later I was beginning to get restless. The doctor then appeared and noticed me sitting there. I looked at my watch and then at him. He fired back I'm running a little late. You're not dying are you? I quietly replied Well, I did have a heart attack last week.

Ten minutes later he ushered me into this room to start the consultation.

He was fiddling with his computer: This stupid @$%ing thing! Can never @$%ing find the page you're looking for! Then he read my discharge report from the hospital: @$% me! Jeez, you're @$%ing lucky!

What really got him riled though was hearing that I had not once been offered a Heart Stress Test in the last decade. You're @$%ing kidding me! These @$%ing idiots! With your risk factors it should have been the first @$%ing thing any doctor does!

When I related how impressed I was by the care I received at Nepean, he was more sanguine: Well, we shouldn't have a hospital where you have to #@$%ing praise them just for doing their #@$%ing jobs.

I was beginning to like this guy.

We talked about how my heart attack was known in the 1980s as the “Widow Maker”. We also talked about former NSW Attorney General Paul Landa (1941-84), who died suddenly while playing social tennis in Vaucluse. This despite being perfectly fit and definitely not socio-economically disadvantaged.

Got the prescriptions I needed and then asked for a referral to a local cardiologist. Doc wrote one out, but warned it might take six months to see one. He suggested I should keep calling practices until I found one who was available. They're all the @$%ing same mate.

The next day, with luck still on my side, I found a local cardiologist who had a cancelled booking, and was thus able to set up an appointment for mid February, in five weeks time.

Cardiovascular Risk Factors

The following is from Hajar R. (2017) Risk Factors for Coronary Artery Disease: Historical Perspectives (Retrieved: 2023-01-27)

There are many risk factors for CAD and some can be controlled but not others.

The risk factors that can be controlled (modifiable) are: High BP; high blood cholesterol levels; smoking; diabetes; overweight or obesity; lack of physical activity; unhealthy diet and stress.

Those that cannot be controlled (conventional) are: Age (simply getting older increases risk); sex (men are generally at greater risk of coronary artery disease); family history; and race.

The following were pertinent for me:

• High blood pressure
• Diabetes
• Overweight
• Stress (12 years as a selective high school science teacher)
• Age
• Male
• Family History
• Race (Eastern European)
• Creased ear lobe

Looking at that list, I was guaranteed to develop this disease. Had I taken a Heart Stress Test, say 10 years ago, then the blockages would have been detected far earlier before they became life threatening.

Meds

Am currently taking the following medication:

• Metformin 3×500mg (diabetes II)
• Telmisartan “Micardis” 80mg (blood pressure)
• Candesartan 4mg (heart attack recovery & blood pressure)
• Aspirin 100mg (blood thinning)
• Ticagrelor 2×90mg (antiplatelet & prevent blood clots)
• Atorvastatin 80mg 40mg 20mg (cholesterol)

The Metformin and Telmisartan I was already taking before hospital [ii].

The Aspirin and Ticagrelor are only for 12 months. Will have to discuss with the cardiologist the need for Atorvastatin, as my blood cholesterol levels have always been normal [iv].

Slow Recovery

Ambulance Bill Shock

The $568.34 bill for the ambulance arrived almost three weeks after the trip, although I am exempt due to my private health insurance.

It would of course be much cheaper to catch a taxi, but if you land in an ED waiting room as crowded as the one I experienced, then you won't have paras to attend or a gurney to lie on while waiting for a bed.

Weight loss & Exercise

At the time of writing (2023-01-27) I have lost 6kg since leaving hospital. I plan to lose another 9kg to get me well below 100kg. It should be achievable, as I lost 30kg over eight months in 2009.

The weight loss was done by reducing portion sizes, eating mainly vegetables, reducing dairy, red-meat and carbohydrates (bread, pasta) and eliminating treats & snacks. The hospital portion sizes I received were a wake-up call that I had been massively overdoing things for years.

Despite always being active, I was warned to go easy on the exercise. Start with 5 minutes a day gentle, then 10, then 15, then 20 etc. As at the date of writing I am walking 2km each morning before breakfast at a moderate pace (≈ 25 minutes). Intend to increase it to 3km in a month's time. The rest of the day I'm moving around as normal, although taking things slowly on up-hill stretches.

My current (ambitious!) plan is to be fit enough to do the 26km Otford-Bundeena hike in July or August, and then resume swimming laps in October [v].

Recurring Angina

Angina is chest pain from your heart. From what I have read it is very common after stent surgery, simply because you now have foreign objects in your cardiac arteries stretching them open.

Luckily for me the “pain” was intermittent and more like discomfort (barely 1/10). I was given Glyceryl Trinitrate pump spray to squirt onto my tongue if things got too bad, but I only felt the need to use it a couple of times since leaving hospital.

A quick Google search shows others are not so lucky, with some reporting the occasional “stabbing pain”. This has not been the case for me (fingers crossed).

Sleep Interrupted

This is the hardest part of life after hospital. After I relinquished my full-time teaching position in March 2021, I used to get a solid 7 hours sleep a night. After hospital haven't had that kind of sleep for weeks.

If I'm lucky I will get a total of maybe 6 hours, but that will be in 60-90 minute chunks with big gaps in between. On bad nights it will be four hours, or less.

Dr EFF confirmed my guess that it's a mixture of my body getting used to the new medication, along with my subconscious chewing on the capriciousness of coming within a whisker of dying. Being mid-summer with 20°C overnight minimums doesn't help either. Time will tell if the sleep returns to normal [iii].

Pre-packed overnight bag

Having learned from my mother's example — where she was misdiagnosed and prematurely discharged from hospital only to return a few days later — I have set aside an overnight bag just in case.

These are the things I have packed:

• Toothbrush, toothpaste & small bar of soap
• Spare medication (see above)
• 2× underwear briefs
• 2× boxer-shorts to use as pyjama bottoms
• 2× spare socks
• Small towel
• 204V phone charger with a 2m cable

There is no need to pack a top or t-shirt for bed-wear as the hospital will issue you with a smock/ gown.

If you need to call an ambulance, it's a good idea to wear a short sleeve top as it provides easy access to your arms for blood samples/ BP measurement etc. It's also a good idea to wear secure footwear that you can easily step into and out of, as you will be doing this a lot in hospital (in my case I used loosely tied trainers).

#1

The first time I accidentally almost killed myself was in 1979 when I was 15 years old. I was making napalm on the apartment kitchen stove — as you do. A small batch I had made earlier in the morning worked fine, but deciding to go industrial with 2L of petrol was my undoing. This time the vapours exploded in a yellow-orange whoomf and then everything suddenly went black. I remember thinking Oh crap, I'm dead.

Clearly I wasn't. A few seconds (minutes?) later I awoke on the other side of the kitchen staring at a raging petrol fire on the stove. Triple-zero, fire-fighters, hospital, a stern lecture from the fire-station chief, a friendly insurance assessor who laughed while writing up the claim as a cooking oil fire. Boys will be pyromaniacs.

#2

A couple of years later I was with my HSC high-school friends on a weekend away at Palm Jungle. We had gone far off the main track and were setting up camp in the jungle, near the edge of ocean cliffs which run the length of the National Park. Having set up our hooches, a friend and I decided it would be fun to chop down a tree and throw it over the cliff's edge — as you do.

We found a small tree that was about 8m tall, but with a trunk thin enough to be easily hacked through by our machetes. Did I mention my mate was wearing army-surplus fatigues, while I was in blue overalls with a tweed pork-pie hat? “Deliverance” eat your heart out.

So we cut down the tree and dragged it, with great difficulty, through the jungle to the edge of the cliff. Except it turned out it wasn't a sheer edge, but rather a 20m rubble slope at 45° to the top of the actual edge, which then had a 50m drop to rocks and the ocean below. We had to cautiously venture out onto the top of the slope, dragging the tree behind us, hoping its weight would cause it to slide down and over. Except it just sat there. So we dragged it a bit more, and then a bit more, until it suddenly started to move.

To our surprise we found ourselves caught up in its canopy as it slid past. The laughter stopped, and we were on our hands and knees scrambling desperately to get a hand/ foot hold on a slope filled with moving branches and leaves and loose rocks, while rapidly sliding with the tree toward the cliff's edge. I remember thinking Not yet! Not yet! I don't want to die!

Again, clearly we didn't. A few metres short of the edge we managed to dig in enough that the tree plunged over without us. After a suitable pause in the bright morning sunshine, we looked at each other and climbed back to safety.

#3

I was 35 when diagnosed with Cutaneous T-Cell Lymphoma — Mycosis Fungoides. When the biopsies came back my dermatologist told me I appeared to be early Stage I, and indications were that the disease may have two years to run (loved the imprecise language). He helpfully showed me full-page colour photos of what the disease looked like in Stages III & IV… it was the stuff of nightmares.

I was referred to a leading oncologist at a major Sydney teaching hospital. He was very keen to meet me, because it allowed his team to study the progression of the disease from its earliest stages. Consequently I was measured and studied and photographed and treated at irregular intervals for two years. Except the disease didn't progress and some of the red/purple skin lesions actually cleared up (!)

About this time a leading non-Hodgkins lymphoma specialist was visiting from London, and wanted to see me. He had a look at the small patches on my arms and feet and said: That's not Mycosis Fungoides. Looks more like some kind of eczema. So more biopsies, which all came back negative this time. Sorry about that.

#4

24 years later, cheating death for a fourth time was the most sobering. It's obvious things can get out of control with home-made napalm or cowboy specialists or doing perilous things on a cliff's edge. But just walking to the station on a warm summer morning?…

Once again the stars had aligned. With all the good fortune I had experienced, many told me I should buy a lottery ticket. What the hell… I bought two tickets.

Of course I didn't win. But then again, you can only stretch your luck so far.