AGILE AGING GOES TO THE HOSPITAL (November 30, 2022)

Out of the blue

            The story started with a routine consultation with our family doctor. I’d asked her help with nagging fatigue. She’d prescribed a sedative, but it wasn’t working. An office measurement of my blood pressure and heart rate led to an EKG. My heart rate was racing and fluttering. The next day, when Nancy and the charge nurse at our retirement community duplicated these findings, we opted to get me into the Emergency Room at Stanford University Hospital. The nurse dialed 911. The summoned ambulance made a 10-minute dash to the ER, with Nancy following in her little red Fiat.

            More tests and measurements. The preliminary diagnosis was atrial fibrillation, but the ER team also detected more serious complications. What made my case unusual was that I was experiencing no symptoms or sensations: no pain, shortness of breath, chest tightness or light-headedness. In response to the team’s concerned questions, I kept repeating, “I feel fine.” After five hours of ER observation, they shifted me to the hospital’s Heart Failure Clinic. Since visiting hours were over, Nancy was politely requested to go home and return the next morning.

By my first evening in the hospital, already I was beginning to glimpse some Agile-Aging lessons about how I could be an effective patient:

1. 1. 1. Trust data more than sensations. Both at home and in the hospital, I’d been hesitant to accept the fact that I was having a serious medical problem. I wasn’t feeling discomfort, much less stereotypical “heart-attack” agony. The ER team had to explain to me that, in A-Fib cases, an absence of pain or other warning signs was not unique. (As it turned out, I never did sense symptoms during my entire time in the hospital. While this kept me comfortable, I was not an informative reporter to caregivers.) 

1. 1. 2. Don’t be afraid to call 911. In heart-failure cases, minutes could save a life. Another incentive: arriving ambulances jump ahead of private cars and walk-ins in the ER queue.)

The Heart Failure Clinic

            It was nearly midnight when my gurney arrived at this seventh-floor ward. In stark contrast to the bustling Emergency Room, this unit was dark and silent. Three nurses shifted me onto a high-tech bed, connected me to lines monitoring oxygen and heart rate, and encouraged me to try to get some sleep. The next morning I met the cardiologist in charge of my care and learned they were putting me on the favored cocktail of medications. Some of the names were familiar from TV ads, but the number was a bit intimidating. Altogether they performed a variety of healing functions: treating heart failure, lowering blood pressure, slowing my heart rate, thinning my blood to avoid clots, and draining my body of fluid to relieve pressure on heart and lungs.

1. 1. 3. Accepting dependency. Like many elders, I cherish my physical independence and resist any symbols of diminishing mobility. Now, overnight, I was confined to a hospital bed. I needed to press a call button to ask help with everything: moving five steps to my bathroom (though I was thankfully left alone with the portable urinal); changing my hospital gown and taking a sponge bath in the bed, since they didn’t trust my balance when standing; raising the head of my bed for eating or reading.
         
         For me, nights were the worst: being awakened twice to take my vital signs, twice more at different times to swallow medications, three or four times for diuretic-commanded bathroom breaks, then once again for a pre-dawn blood draw.

         I learned to accept that surrendered independence was a trade-off for safe, 24/7 care-giving. Soon, twice-daily corridor walks, with a walker and chaperoning nurse’s aide, became liberating excursions. 

Who’s who and what’s what?

            Steadily, I met the platoon of medical professionals taking care of me. In this hierarchical pyramid, my supervising (“attending”) cardiologist and my case-managing cardiologist ranked at the top. Since this was a teaching hospital, they were often accompanied by a silent entourage of residents and interns. The doctors mostly visited on morning rounds, briefing Nancy and me with progress reports. Nurses and nurses’ aides were my principal caregivers. One of each per day on a rotating roster, plus “floaters” shunted around the clinic for as-needed troubleshooting. Blood-drawing lab technicians came twice a day. Staff from housekeeping, food delivery and patient transport were frequent arrivals. Downstairs, I soon began meeting x-ray technicians, imaging specialists and specialized teams for electrical and surgical procedures. With almost no exceptions, all these professionals were competent and caring. Soon I realized this pervasive personnel courtesy was deliberately promoted by the institution’s selective recruitment and patient-centered staff training.

1. 1. 4. Learning staff roles and availability. Since I was bed-ridden for my first few days in the clinic, staff members were my lifelines. I had to quickly figure out the color-coding of different staff uniforms. Ditto which category to ask for which assistance. These professionals were working their tails off; many nurses served 12-hour shifts, three days each week. And since my face-time with doctors would be limited to five or ten minutes per day, it was essential to limit my questions and have them well-prepared.
         
         
      5. Building personal relationships. Common courtesy as well as self-interest encouraged me to get to know each individual caregiver. (After we became acquainted, several staffers confided that “common courtesy” from patients was not so common.) A majority of the folks working in this clinic were either immigrants or the children of immigrants: from doctors to housekeepers. For me, this was a blessing: not merely because these talented workers came from all over the world; but also because my familiarity with their home countries from my international-development career gave us common ground for connecting. Confined for long days to my bed in one room, I welcomed my interactions with this gracious crew.
         
         
      6. A partner’s multiple roles. Nancy stayed with me every day for 17 days, from mid-morning through late afternoon. I realize that other elder patients might not have a partner available to sustain such marathon commitments. But her presence repeatedly buoyed my spirits and made long stretches of inaction comfortable. We strategized together over how to make best use of the doctors’ brief visits. During conversations with hospital professionals, she added factual details to my recollections and asked questions I had neglected to raise. Nancy’s loyalty, judgment and mere presence immeasurably advanced my recovery.

Echocardiograms

            During my first 24 hours in the hospital, my doctors had been focusing on monitoring my atrial fibrillation and lowering my heart rate with medications. A chest x-ray confirmed an absence of blood clots. Now they sent me downstairs for an echocardiogram, an ultrasound of the heart measuring its pumping efficiency or “ejection fraction.” By good luck, I’d had the same test performed in the same hospital in July, when the measurement had shown a healthy heart (65% in the normal range of 55-75%.) That recent precedent served as a baseline. This time, to the doctors’ serious concern, my pumping efficiency had plummeted to only 17%, a life-threatening indication of heart failure. The consolation was that, within three days, the medications promptly improved that performance to 39%. Since the lower threshold of the “safety zone” was 35%, I’d climbed out of immediate danger.

1. 1. 7. Moving goalposts. These widely fluctuating test results – dangerous low score followed by swift rebound – were a reminder that I shouldn’t seize upon any single result, high or low, as final. To avoid destabilizing elation and despair, I needed to go with the flow and allow my doctors to react to new data with a modified treatment plan. 

Cardioversion

            The extremely low ejection-fraction score convinced my doctors that atrial fibrillation had probably persisted undetected for some time, cumulatively damaging my heart. They therefore recommended that, rather than rely solely on medications and my slowly climbing ejection fraction, we should accelerate this recovery with cardioversion. This electrical shock to my heart would slow its racing rate and restore normal pumping rhythm. I accepted this proposal and descended to lower levels again for this quick but general-anesthetic procedure. Although my doctors assured me that cardioversion was extremely low-risk, it sounded a tad unnerving. (Nephew Thom flew in from Southern California for a couple of days, completing a family trio to face this challenge.) The jolt did its job. Nancy and I now settled into a brief period of additional monitoring by the medical team, in preparation for my hospital discharge.

1. 1. 8. On again, off again. Most of my time in the hospital, I was relaxed with the rate of treatment progress. Between sleeping, interacting with Nancy, reading, and being poked and prodded by nurses, the hours and days didn’t chafe. That said, I soon learned that announced schedules for procedures regularly slipped. (For example, my appointment for cardioversion was postponed three times over two days.) My nurses confided that many, especially senior, patients found comparable delays extremely irritating. My managing doctor and I had a candid chat about this pattern. He explained that, in all the hospitals where he had worked, procedure schedules were planning targets, compiled at the start of each working day. Not fixed deadlines or contractual commitments. Unexpected emergencies, COVID-provoked staff shortages and multiple departments competing for shared scanning, lab and surgical services all conspired to keep schedules fluid. If patients can accept this, they will spare themselves aggravation which can even impair their healing. A more realistic response is to focus on forward progress, not delayed appointments. (I did not follow up with an obvious question: why didn’t hospital doctors and nurses make this scheduling fluidity clear to their patients? My guess is that my doctor and his colleagues knew this admission would not be welcome to bedridden patients.)

Mayday! Mayday!

            My only drama during the two-week hospital stay occurred at the exact moment of my initial discharge. My supervising doctor had been satisfied with my recovery but wanted “an insurance policy” for me and for the hospital before sending me home. He recommended an external monitoring device called a Life Vest. This was actually a four-component electronic system comprising a vest, a monitor, a data-recording unit and a battery recharger. Its functions were to monitor my heart rate and shock me back to normalcy if my rate surged dangerously high or low. He wanted me to wear the vest and stay connected to the monitor 24/7 for one or two months. Nancy and I were both unenthusiastic about this prospect but the supervising doctor intimated he wouldn’t be comfortable discharging me unless I agreed to wear it. We relented, a device vendor’s representative stopped by to give us an equipment briefing, and, after a parallel pharmacist’s briefing and the signing of legal discharge documents, we were ready to leave.

            One nurse removed the chest leads connecting me to the hospital’s monitoring system, replacing them with leads to the device monitor. She and Nancy then helped me put on the vest – more like a canvas bra. Next, they assisted me to change into street clothes and shoes. My current nurse took an IV port out of my forearm. I hefted the heavy monitor and greeted the transport staffer waiting outside my room with a wheelchair. Three or four other nurses and aides came in to say goodbye.

            All of a sudden, the monitor erupted, emitting pulsing alarms plus an ominous voice: “STAND BACK! STAND BACK!” Even though none of us had prior experience with the Life Vest, Nancy and I figured out from the briefing that the monitor was warning all around to stay out of range as it prepared to shock me. Since I’d felt no symptoms or sensations and the device wasn’t supposed to shift into shock mode unless there was a serious heart incident, we thought it must be malfunctioning. (We couldn’t check what was happening to my heart since I’d just been disconnected from the hospital’s monitoring system.) A summoned doctor rushed in and instructed my current nurse to take the vendor’s troubleshooting phone number off the equipment box and dial the Philadelphia support number on his hospital cellphone. Nancy and another nurse thumbed through the printed owner’s manual, searching for shutdown instructions. Meanwhile, I kept pressing two buttons on the monitor, triggering a recycling “Don’t-shock!” signal every 45 seconds, as I’d been trained in the briefing.

            From what I could hear of the troubleshooting conversation, it didn’t inspire confidence. The vendor’s rep seemed more interested in defending the manufacturer’s device design that in telling us what to do. “I’m sure our device is all right.” The whole scene was quiet but scary. I was especially concerned that if my urgent button-pressing lost control of the monitor, I’d be slammed with a major shock.

            The chaos probably lasted only five minutes but it felt like forever. Suddenly, the device shut itself off, without administering any jolt. We opened my shirt to take off the vest and found my torso bathed in royal-blue gel, a medium released to improve conductivity. The doctor directed the nurse still on the phone to have the vendor promptly fax a printout of the monitoring data recorded by their portable system. His concern was to find out ASAP what had caused the activation: a device malfunction or a heart malfunction. I was readmitted for another overnight stay in my room, until we could determine what had happened. The vendor’s data didn’t arrive until the next afternoon. The printout indicated I’d in fact had a ventricular tachycardia, a potentially life-threatening heart failure. My supervising doctor was visibly relieved that the device he’d insisted on had not misfired. He promised to get a substitute vest delivered to the hospital so I could get on home. But Nancy and I had had time to talk privately before receiving this recommendation. I was convinced, with her concurrence, that I could not successfully manage another erupting-vest emergency on my own at the retirement community. The doctor listened with empathy and quickly understood that a vest was not going to be a feasible insurance policy for me. He said he’d go back to the drawing board with the cardio-electronics team and come up with alternative protection.

            The team’s proposed solution, which I promptly accepted, was to install in my chest a two-component miniature device with the imposing name of an Implanted Cardioverter Defibrillator (ICD). The Pacemaker component would focus on my heart’s upper chambers, watching for signs of atrial fibrillation. It would send electrical signals to restore normal rhythm if my heart rate fell below 50 beats per minute.  The defibrillator component would do the same for the lower chambers. But since any ventricular tachycardia was life-threatening, this component would administer a severe shock if necessary to restore normal rhythm. The entire device was the size of a small cigarette pack, with two leads into my heart. Battery life is 10-12 years. The procedure to install the device lasted 90 minutes. Interestingly, they used only a local anesthetic, and I was able to hear and speak with the surgeons throughout.

1. 1. 9. Respectful self-advocacy. When my parents were approaching the end of their lives, I sometimes accompanied them to their doctors’ appointments. I remember being amazed by Mom and Dad’s deferential passivity in those consultations. Although both were successful entrepreneurs and civic leaders in their personal lives, my parents clammed up in doctors’ offices like petitioners before the Oracle of Delphi. I made a silent promise to myself to strive for shared decision-making in my own medical interactions.
         
         In the gel-spewing Life-Vest scenario, this objective was a bit delicate to implement. In the hospital setting, the doctors had overwhelming authority. They stood at the top of the professional pyramid and the decisions involved concerned medical science and practice. That said, the consequences of those decisions would be long-term. And it was my body and my life that those decisions most affected.
         
         Having decided I definitely could not manage this equipment back home, my challenge was how to respectfully but resolutely convey that decision to the device’s proponent, my supervising doctor. My solution was to attribute my decision to my own lack of confidence as a vest user, without criticizing the doctor’s recommendation or the device’s capabilities. This formulation opened the door to a win/win alternative. The doctor could feel secure that the ICD device would give his patient post-discharge protection; while I could feel secure that my back-home healing would not be dependent on lugging around a cumbersome external system. Lesson for elder patients: make it easy for your caregivers to do what you need.
         
          

On the Mend

            Writing this at home in late November, I’m feeling stronger every day. This week, my latest echocardiogram confirmed that my heart-pumping efficiency has climbed back into the normal range. With Nancy’s help and the use of an ingenious, color-coded medications organizer, I’m sorting and swallowing 10 pills a day. My implanted device has been double-checked and is performing as designed. I’m walking 30 minutes a day and working weekly with a physical therapist to start rebuilding muscle strength. Nancy and I are learning to adapt to a low-sodium diet. My post-discharge supervising cardiologist says it’s probable that I can reach full recovery by the end of December. All in all, I’m very glad to be back.

1. 1. 10. An important caveat tempering this account is that it would be foolish to extrapolate excessively from a single individual’s hospital experience. Every case is different. Two of my friends with heart problems felt their recent experiences at Stanford Hospital were negative. One fundamental difference was that they each had to share rooms with other patients. I was in the Heart Failure Clinic where every patient had a private room.
          
          
      11. I believe that adopting an Agile Aging perspective to hospitalization can have practical value for us elders as patients: reducing discouragement and irritation, empowering us to participate effectively in treatment decisions. I’d love to learn blog readers’ comparable experiences and insights. Drop me a line: rbs@agileaging.net.