Rhythm Of The Night (#2): Sleepless in Suburban Philadelphia

In my last post, I wrote about the trials and tribulations of getting my resting pulse and blood pressure under control, and I wrote that in my initial annual physical (in March 2017), when those issues were uncovered, my doctor ordered a sleep study to be completed. 

(As a side note, I started using the hashtag #pokeandprod2017 for all of my doctors visits and tests that occurred last year...)

In May, I started with a consult appointment, where I filled out a quick survey that asked me questions about my current sleep environment. Did I wake up in the morning feeling tired, or feel tired throughout the day?  No. Did I take naps during the day, or did I feel tired while taking long drives? No. Did I wake up multiple times throughout the night? Once or twice, but not more than that. There were a few other questions that I can't remember what they were, but the end result is that my score wasn't very high, so that didn't indicate a high probability of Sleep Apnea. 

The sleep doctor then took a look inside my throat, and I realized what was coming next: as an adult, I've been told by dentists and doctors that I have a disproportionately large tongue, and also the largest tonsils they've seen. I'm not exaggerating that, either; I told the doctor that just before he was about to say it. I don't know why my tonsils weren't removed; they didn't cause any issues during my childhood. But I have also been told that my tongue is so large that over time, it has pushed against the roof of my mouth, so I have an abnormally high roof of my mouth. All of this is important to note for later...

So then I was told that I had a choice of taking an in-home sleep study, or I could have the study in their sleep lab; so naturally I chose in-home. I was able to pick the day I wanted to have that done, and then on that day, I would come in and pick up the monitor. They would give me instructions, then I would sleep that night, and drop off the monitor the next morning. I chose a weeknight in June.

The day of my study, I went in to pick up the monitor, and they gave me the instructions. The photo here is basically what the monitor looked like; a small plastic box strapped around my chest, with wires attached to my head and face and arm, and a tube that went under and just inside of my nose. The placement of the wires didn't have to be pinpoint accurate, and the instructions were printed on a piece of paper to follow. The monitor was connected wirelessly to the sleep lab so they could monitor the monitor and make sure data was recording properly. 

And with that, I was off to complete my day and ready for a good night's sleep...

...or as good as you could imagine possible with all that stuff attached to me in various places. I probably ended up getting four hours of somewhat good sleep, between 2AM and 6AM; the rest of the time, I lied there awake in the dark, afraid to move too much. I normally sleep on my side, so I didn't want to dislodge any wires, and it was hard to sleep with this box resting on my chest. But, I did get some sleep, and the next morning, I dropped off the monitor.

Two days later, I got a call from the sleep doctor, who stated that I definitely had Sleep Apnea, just a notch below the Severe category. My AHI score was 29.5, and a score of 30.0 would have put me in the Severe category. So, he asked me to come in for an appointment. I went in a week later. 

AHI = Apnea Hypopnea Index; an Apnea event is where my breathing has been blocked for more than ten seconds, and a Hypopnea event is where my breathing has been reduced but not blocked for more than ten seconds.  The score is the number of times on average that I had an Apnea or Hypopnea event in an hour; so basically, I had stopped or had reduced breathing 29.5 times per hour on average that night, or more than 200 times total. The doctor gave me a graph that showed each event over the 8 hours I was being monitored, and showed which sleep position I was in. That part I found interesting, because as I wrote above, I sleep on my sides...or so I thought. In reality, I may fall asleep and wake up on my side, but I spent half of my time that night sleeping on my stomach.  Some year ago, I realized that I was snoring from sleeping on my stomach, so I worked on changing my sleep position to sleep on my side, and it did make my snoring easier. Except that my sleep study showed that I spent a lot of the night sleeping on my stomach, and the rest of the time alternating one side or the other. I only spent five minutes actually sleeping on my back. The graph also showed that my Apneas and Hypopneas were all occurring on those times where I was sleeping on my stomach.

The sleep doctor then explained that his belief at what was causing my events were a combination of my weight and...my abnormally large tonsils...that at night, the muscles in people's throats relax, and that combined with my weight and tonsils, caused my throat to close much more often than a normal person. That interrupted breathing reduced the amount of oxygen in my system, which in turn does two things:  cause my heart to work harder to pump blood through my system, which in turn raises blood pressure over time (ding ding ding!), and also causes the body to react by slightly waking me up, in order to un-relax the throat muscles, in order to restore normal breathing.

I'll pause here, like I did that day, as that was a major revelation to me. That, and it's a little disconcerting to think that a couple hundred times a night, I was actually not breathing. The sleep doctor said that fact in and of itself sounds worse than it really is, but yes, it does cause issues, and if untreated, would get worse and more dangerous, not only in terms of heart health and blood pressure, but also increases the chances of longer-lasting events. 

Enter...a CPAP machine. What a CPAP machine does is to force a small stream of air into my
airways, which helps keep the throat open which then keeps breathing more normal, and relaxes the heart. Fortunately, I was given the option of choosing a mask that only goes under my nose (pictured by the cheesy-looking couple on the right), not a mask that covers my mouth. Fortunately, I normally sleep with a fan on for white noise, but I was told that the machine itself is very quiet (and in fact, it's quieter than a fan). I picked up my machine in late August, and I have to admit that it has made a difference in my sleep. For one, I don't think I realized how much I was tossing and turning at night, but I now definitely toss and turn much less. Second, it only took one night to get used to having a soft piece of rubber under my nose blowing air into my nose, but it is a very soft stream of air. I was told that I needed to make sure I slept with my mouth closed, and that was probably the hardest thing to get used to that first night, but that only took one night to get used to. 

Finally, the CPAP machine tracks my AHI score every night, and I can download statistics to my smartphone wirelessly (and yes, I know I sound a little bit like a commercial here). I can track my AHI score, how long I have the machine on, how many times I pause it (to get up to go to the bathroom, for example), and if there is any air leakage.  That first week, my AHI scores were between 4.0 and 5.0 - down from 29.5. Over time, my score has slowly dropped and is now pretty consistently between 1.0 and 2.0.  It tracks the difference between Apneas and Hypopneas, and I have many nights now where I don't have a single Apnea. And I have gotten very used to the machine...almost instantly. Most nights, I can't tell that I have a tube resting under my nose.  The entire concept is really kind of amazing to me.
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I don't have a deep insight to wrap this up; at least not one that is much different than the ones yesterday, except for this one point: there is a lot of "negative press" about CPAP machines; how hard they are to get used to, and how hard it is to sleep with. I remember thinking going into this that I was going to just go for broke and go into this positively, and try to ignore the many comments that are out there online and in conversations about CPAP machines. I felt that in this case, it was important for me to go into this with a much of a positive attitude as I could, and not create a negative self-fulfulling prophecy. I don't know how much that actually helped make the transition as easy as it was, but I'd like to pretend it did.

“The best cure for insomnia is to get a lot of sleep.” 

― W.C. Fields

Rhythm Of The NIght (In the ER): An A-Fib Story

Yesterday, I had my six-month follow up with my cardiologist; and I am glad to say that everything continues to check out well. I had a follow-up with a cardiologist, because of things that happened starting just shy of a  year ago...

Last March, I had my routine annual physical, and my blood pressure had been creeping up over the prior couple of years, so that was something that I wanted to ask about. The last time I had it checked, six months before that, it was 140/95. That day, it again was 140/95, but more importantly, my resting pulse was 118, which was something new. My doctor; who was a new doctor for me because I had just moved back to PA months before, asked me a few questions about whether I felt my heart racing, or if I ever felt short of breath, or tired, and I answered no to all of those things. When the rest of my physical was complete, she said she was going to order a sleep study to check for Sleep Apnea, a blood test to check for any thyroid issues, and to start me on a beta-blocker; specifically Metoprolol Succinate, mainly to lower my pulse but also to lower my blood pressure as a side benefit.

I went out and bought one of those automatic blood pressure monitors, and for the first two weeks, everything seemed fine.  My pulse dropped to 76 and my blood pressure dropped to 125/85 fairly consistently. But one night, on a Thursday night, as I was lying down to fall asleep, my heart started beating erratically; I could feel it inside of my chest beating without any kind of rhythm. It wasn't beating very hard, or pounding, and there wasn't any chest pain. I didn't feel any shortness of breath; just that my heart beating all over the place. So I sat and waited to see if it was going to go away. Fifteen minutes, then thirty, then forty-five, and no changes. After an hour, I finally decided that I should go to the ER; so I grabbed my keys, wallet, phone, and phone charger (priorities) since I lived only two blocks away, I drove over, walked in, and told the check-in desk that my heart was beating erratically.

The ER folks put my into a bed, hooked my up with an IV and a blood pressure monitor, and a finger pulse reader. The ER doctor walked away for a couple of minutes, and when he came back in and looked at the monitor, he said "yep, you're in A-Fib", which of course is Atrial Fibrillation. He then informed me that:  1) I wasn't going anywhere that night except to be admitted to a room, 2) he was going to add a heart rhythm medication to my IV bag, and 3) he was going to give me a shot in my stomach that was going to burn for a couple of hours.  The shot was a blood thinner, and he explained that it was necessary because, when the heart is in A-Fib, the heart doesn't pump blood as efficiently as normal, so it may sit and pool in different areas of my body; without the blood thinners, the pooling pool could form clots, and in his words, "we don't want this to turn into a stroke or anything like that."

So...I'm normally a calm and collected guy...and I tried to act like it at that moment...and maybe I did...but inside, that really kinda knocked me down a peg or two. I then debated whether I should call my parents then, or in the morning, and I (wisely) decided to call them then. My dad came over and ended up sticking around the entire time I was in the ER until I was admitted...which ended up being three hours, from 12:30AM until 3:30AM, to sit there and think about it, in the ER bed, with my heart flopping around all over the place.

At 3:30AM, I was finally wheeled up to a regular room. 

The hospital I went to is the same hospital where my mom was a Nurse for 35 years, where my dad was a Lab Tech for 20 years, and where I was a Radiology Dept Courier (wheels patients to and from the Radiology Dept) in the summer of '93. The Nurse assigned to my room was someone that worked with my mom. They reloaded my IV bag with additional heart rhythm meds (since my heart was still flopping) and I was still hooked up with the finger pulse reader. I was also given a blood pressure cuff that took my blood pressure every five or ten minutes, I think...I don't remember, and finally, a EKG monitor with all of those sticky electrode thingys (that's a technical term, of course). Somehow, with all of that, I was able to sleep from 4:30AM until 6:30AM.

At 8:00AM, the nurse came in to take my breakfast order - from the low sodium menu. At 8:10AM, the Cardiologist Physicians Assistant came in to ask me a few questions, and to inform me that I couldn't eat breakfast as they were still waiting for my heart to snap back into a normal rhythm. At 8:20AM, I had to call my boss to tell her that I was sitting in the hospital, and that I wouldn't be logging into work...which was a surprisingly hard phone call to make. It was hard because I hate to cause people to worry, but there was no avoiding it.

At 9:00AM, the PA came back in, and gave me a different heart rhythm medication, and a different blood thinner. At 9:10AM, the Cardiologist came in, and asked me a whole ton of questions to try to determine why this was happening. Had this happened before? No. Had I been feeling chest pains at any point overnight or before? No. Does my family have a history of heart disease? No. Did I have high cholesterol? No. The only thing that changed...was the recent addition of the beta-blocker. He then informed me that they were going to wait an hour to see if my heart snapped back into rhythm, and if it didn't, they were going to potentially perform an Electrical Cardioversion, in which they put me under and try to shock my heart back into rhythm.

So...then I started watching the clock...9:30...9:45...and then right after 10:00, the Nurse and the PA both walked in and said "you're back in rhythm." I hadn't realized that yes, in fact, my heart was no longer flopping around, and I was indeed back in rhythm. Not too long after, the Cardiologist came back and said he wanted to perform the normal gauntlet of heart tests just to see if there was any physical cause of this A-Fib episode. So...within an hour, it was off to...the Radiology Department...and several of my former co-workers who I hadn't seen in 25 years...which was a nice reunion with me wearing that drafty backless gown.  My reunion consisted of an Echocardiogram ("...we're going to turn down the lights and rub a soft warm jelly all over you and listen to the sweet music of your heart", which is exactly what the tech said), and then a Nuclear Stress Test ("we're going to dump some nuclear waste from Limerick (Nuclear Power Plant) into your blood, then we're going to have you pretend you're running for your life on a treadmill", which is exactly what that tech said), and then a chest X-Ray "for old times's sake." I was told that if all of the tests came back OK, then I could be discharged.

At 3:30PM, I was told that all of the tests came back just fine, so they were going to start the discharge process, but that could take a few hours, was there anything I wanted? I said I wanted my original breakfast order and to watch the rest to Maury to take my mind off of things.

So what caused it? The cardiologist said that sometimes, A-Fib episodes can be a one-time thing, and to take comfort in the fact that all of my tests came back showing that I had a very strong heart with no issues or abnormalities or anything like that. We scheduled a follow-up with him for two months, and a follow-up with my primary doctor in two weeks. I was given a prescription for the second heart rhythm medication I was given, with the instructions that if I entered another A-Fib episode again, as long as I wasn't having shortness of breath, or dizziness, or chest pains, I was to wait an hour to see if they went away on their own. If not, I was to take those four pills, and wait another hour. If my heart doesn't snap back into rhythm after that hour, I should then head to the nearest ER. And with that, I was discharged, on Friday evening at 5:30PM.

I had a pretty quick decision to make; on Sunday, I was scheduled to take my monthly week-long trip to Rochester for work. I had to decide whether I thought it was a good idea to do so or not. I wasn't given any restrictions, or any warnings, so I made a decision that if I didn't go, that would be a decision made out of fear, and I wasn't about to start living in fear of a what-if; and so I decided to take the trip as normal and keep it moving. 

That week worked out fine.
The week after worked out fine.
My primary doctor follow-up went fine, but she suggested increasing my dose of the beta blocker, thinking that my A-Fib episode was caused by my heart trying to get used to the meds and that the dose wasn't high enough. But in reading online about Metoprolol Succinate, one of the listed side effects is A-Fib. So to be honest, I wasn't too sure about increasing the dose versus maybe changing meds. But I filled the script anyway.

Before I took the increased dose; two days after that appointment, on a Sunday, my brother and I painted my parents' garage on a 90-degree day, and that evening, I started having steady light palpitations, but without chest pains, or shortness of breath, or dizziness. These were different from the A-Fib episode, as my heart was in a regular rhythm this time. So...online I go, and several articles pointed towards dehydration as a cause of palpitations, and after a couple of hours, they went away. But at that point, I was too freaked out to make any changes to my meds, so I called my primary doctor, and she agreed that I shouldn't increase the dose, or stop taking the meds, until I talked to my Cardiologist.  And I ended up being fine again for a couple of weeks. All that time, I had been walking once or twice a day, 30 to 45 minutes each time, and I never had any issues doing physical activity.

THEN (no, this isn't over, yet)...two weeks later on a Thursday, I was driving to Pittsburgh on my way to visit friends before heading up to Rochester for my normal monthly trip, and I ended up driving through a pretty intense thunderstorm in the mountains west of Somerset. As the storm ended, I started another round of palpitations, the same as the painting "episode". And same as before, these lasted about a couple of hours. I chalked those up to the stress of driving on the narrow PA Turnpike in a raging downpour.

That theory proved wrong when I had another round of palpitations again Friday night relaxing, Saturday night relaxing, Sunday afternoon driving on a sunny day to Rochester, and Monday, and finally in Tuesday, I called my primary doctor to mention all of this, and she referred me to my Cardiologist follow-up, which at that point was three weeks away. She reminded me of my test results, and asked me if at any time I had had chest pains or shortness of breath or dizziness, of which the answer to all of that was no...

...which left the next three weeks to be an exercise in blind faith. Faith that everything that I was being told was right, faith that if something more serious were to occur, that I would notice it soon enough, and react correctly, and that everything would end up being ok. Which...is VERY hard to do.  

And that pattern continued for the most part for those three weeks...fine in the morning, palpitations in the afternoon or evening lasting two or three hours, and then fine after that. It was so consistent that I actually started to get used to it. When I finally had my Cardiologist follow-up, he reiterated what my primary doctor said; he felt that it was my heart reacting to the meds and not having a high enough dose, so that I should increase my dose and see what that does; and if that didn't change anything positively, then we would re-evaluate and take different steps. I was told to keep in mind, again, the fact that all of my heart tests were fine, and that he wasn't seeing any issues that concerned him.

And so, finally, to end this story, I increased my dose, and within two days, I stopped getting palpitations, and everything has been fine ever since. I jokingly say that my heart liked moving fast and fought for two months to keep doing so. My pulse is still down around 76, and my blood pressure is at 118/65. I have had two cardiologist follow-ups since then (last August and yesterday), each time with EKGs, and all is well.

In my next post: the Sleep Apnea side of the story.
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In hindsight and moving forward:

First, there is something to be said in finding medical professionals that you trust, and who are willing to sit and listen and explain things. I didn't go into that aspect above in depth, but everyone that was part of my care that day in the hospital, and in the various appointments afterwards, have been truly wonderful even during the unknowns that occurred, and I realized something along those lines: the medical profession, in the end, really is all just guesswork; educated guesswork, even highly educated guesswork, but still guesswork, and I think that sometimes gets lost. The body is going to do what it's going to do, and the study of medicine and anatomy and diseases and disorders is all about following trends and probablilites and scientific theories...and there are always exceptions to those. In the end in my case, my doctors were following the trends and keeping a close eye to make sure that there weren't any extreme exceptions; and though it was a nerve-wracking two months, in the end, it was only two months, and I am better off now than I was at the beginning of this. I think sometimes people think that doctors should know what is occurring and what will occur, without exception. And to be sure, there are some doctors who come across that way, and that is dangerous indeed. In my case, my doctors never once gave me definitive statements; they explained several options, and they explained what their preferred options were, and why, and that to me is very important to look for out of your medical professionals.

But more than that: in looking back, I don't think my ER visit was life-and-death, but hearing the words "prevent a stroke or something else" really jolted me. It's another, but much more personal reminder, of how life does not come with a guarantee. You really never know when "your time is up" and none of us are even guaranteed a warning. Wasted time is lost time, time you can't get back. The whole "you never know" cliche is yes, a cliche, but it's real. And to me, nothing is worse than having regrets over wasted time.

I bolded above my conscious decision to not live in fear, and it's also related to the comment above that I made referring to blind faith. Even though that first decision I faced at that time was over something as meaningless as a business trip, I faced the same type of decision in mid-June. I had a planned a father-son trip to New York City for Father's Day; this was going to be our second overnight trip together, and it was only 3 weeks after my increased dose of meds. I did have a string of thoughts come across my mind as to whether it was a good idea for me to be travelling with just my 10-year old son; and what if I did have another palpitation episode, or another A-Fib episode, and what if I had to find an ER in NYC at 10 at night; what was he going to do? How traumatic would it be for him to have to ride in an ambulance with his father in this large city, alone? I hesitated in planning the trip, honestly, but in the end, I took the trip, and everything ended up fine; it turned out to be a fun and memorable trip for both of us. But sometimes, and probably more times than we do, you just have to push past the fear, whatever fear it is, and have faith that you are going to get through whatever it is you are wanting to accomplish, and that you are going to be able to handle any trial that comes your way; because there will be trials. And this isn't a commentary on doing anything reckless; for each decision I made in this area came with a lot of research and information gathering, but nothing is ever 100% guaranteed or predictable. There comes a time where all the preparations have been made, and it's time to take that next step.
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"You can spend minutes, hours, days, weeks, or even months over-analyzing a situation; trying to put the pieces together, justifying what could’ve, would’ve happened…or you can just leave the pieces on the floor and move the f--- on." - 2Pac

(Over) Simply Stated

In my last post, I wrote about society's trend towards hyperbole and extremism; but there's a third aspect to our conversations which is just as dangerous; over-simplification.

I wrote about this several years ago (linked below): our trend towards shorter and shorter "sound bites" or phrases, due to the limitations brought upon us by texting (160 characters per text), tweeting (originally 140 characters per tweet), and Facebook. We don't have conversations any more. We don't have discussions any more. We don't have debates any more. Instead, we seem to have these little competitions around who can get the biggest rise out of the smallest combination of words. We try to out-clever each other, or out-rhyme each other, or whatever other comparison points we wish to judge each other one, in an effort to either reduce our self-inferiority complex, or inflate our self-superiority complex. 

Here is a perfect example:

"Guns don't kill people, people kill people."

That's an over-simplified statement.
The correct statement is:  

People with guns kill people.

That might still be over-simplified for some people's tastes, so I'll expand:

People with guns kill people more quickly and more efficiently than almost any other method.

That is a statement that can drive some meaningful conversation, some debate, even if there is some disagreement, and maybe we as a society can work towards some kind of resolution. 

Or this example:

"This isn't a gun issue, it's a mental health issue."

That's an over-simplified statement.
The correct statement is:

"This is issue of both guns and mental health, combined, in this particular case and in several other cases as well."

And I find this over-simplification issue to be the case in most of the major topics of conflict in our society: race, economic status (welfare, taxation), human rights (LBGTQ issues, healthcare, immigration, womens' rights), etc. Our debates have devolved into a series of short, over-simplified, hyperbolic, extremist statements; and because of that, we as a society have been stuck in the same place for, in my opinion, quite some time.

Is this who we are? Are we really at a point where we just say the same little fragmented phrases over and over again, entrenched in our little self-defined worlds?

I'm going to keep this post pretty simple and end it right here...

Prior post: http://jemacedo9.blogspot.com/2011/03/conversations.html

The Hyperbole Generation

Is it me, or does it seem like hyperbole is the new official language of the United States? Or worse, it's close and more dangerous cousin, extremism?

I'm not sure when this trend started, and I don't think it's important to figure out when, but the problem with hyperbole and extremism is, it trends towards leaving us divided and worse yet, stagnant as a society - or even worse than that, going backwards.

It seems to be that just about every topic, every subject, every debate, quickly devolves into a childish back-and-forth arguing of two utterly ridiculous polar opposite viewpoints. And many times when that happens, people get offended, and then things get taken personally, and then the entire original point of the discussion gets lost into a battle of ego and emotions and then we've lost. 

Our extremist statements happen so often now that we've become numb to them, to some extent. We often make blanket statements without the words "all" or "always" or "never" without realizing it. Many times, we paint broad brush strokes over all kinds of topics without even thinking of the ramifications of doing that, and then worse, we then try to support or defend those blanket statements. And even worse than that, many times, we're just repeating a blanket statement that we've heard from someone or someplace else, without even attempting to put those statements into some kind of context.

For the most part, we've become lazy with our conversations.

It's generally making things worse.

Think about any discussion you've had over the last few years, where you may have disagreed with someone. Did that conversation enlighten you?  Was there a even exchange of ideas and points that, even though you may not have ended up agreeing with them, those points made you think a little? Did the conversation help frame a perspective around both your opinion and idea, and the other person's opinion and idea?  

Or instead, did you feel like you were in a competition? Did you try to be on the offensive, or did you feel you had to be defensive? Did you feel like it was a win-or-lose situation, instead of a teach-and-learn situation?

For a society to survive, it is imperative for everyone to try to find a common ground, a consensus, and a place to come together, and that can't happen if our discussions and conversations wind up in us vs them camps. We can't progress if all we're doing is entrenching ourselves into our isolationist views, unwilling to concede even the tiniest point in an effort of compromise. Past societies have collapsed because the division caused by extremism either caused the society to implode in revolution, or explode by invasion.

Meanwhile - time doesn't stop. Everything moves forward, whether we're united or divided. But there's strength in numbers and the truth generally lies somewhere in the middle, not near the outliers. To what end do we wish to travel towards - a peaceful unity, or a divided war? 

And more importantly...are we willing to look at ourselves? Or point the finger elsewhere instead?

LOVE.

So we have another school shooting. On Valentine's Day, no less. A day that is supposed to honor and cherish love; instead, we have to mix in utter sadness and despair.

You know what's missing? 

Love.

Not love of money, or power.
Not love of our accomplishments.
Not love of our egos.

Not love of only the people we hold close to us,
or only the people we identify with,
or only the people we judge to be worthy of our selfish definitions of love.

Love. Pure, simple love.
Love of all
Love of ALL.

Open love.
Accepting love.
Helping love.
Embracing love.
Uplifting love.
Understanding love.
Selfless love.
Hopeful love.
Unconditional love.
Non-judgmental love.

Stop putting up walls and boundaries,
and especially stop doing it in the name of protecting what we say we love.

Stop pushing others out.
Stop pushing others under.
Stop pushing others aside.
Stop pushing others away.

Stop dividing each other.
Stop separating each other.
Stop classifying each other.
Stop judging each other.

What the world needs now is love.
Love's in need of love today.
Love will find a way.
Love makes the world go 'round.
Love will save the day.

Send one your love.

Have I told you lately that I love you?