Our center was equipped with supplies—oxygen tanks, crates of foodstuffs—that had been ferried down by ambulance. A fire ladder served as a scaffold for bags of fluid. Twenty or so doctors and nurses staffed the different “departments”: trauma, burns and injuries, wounds and fractures. I was in asthma and chest pain. We treated firefighters suffering from smoke inhalation, giving them oxygen to breathe and albuterol mist to help open their airways. But otherwise things were eerily quiet.
On my way downtown the previous afternoon with a caravan of doctors from Bellevue, I had braced myself to confront throngs of seriously injured people. But there was no one around except rescue workers. “Where are all the patients?” I blurted out when I arrived, thinking they might be at a different location.
“They’re all dead,” a colleague replied.
Now we sat in the haze, ash still falling like snow, trading stories. A physician told me he happened to be standing outside the first tower when it collapsed. “I ran under a bridge,” he said. “There was huge debris falling all around me. Every step I took, I kept saying to myself, ‘I can’t believe I’m not dead yet; I can’t believe I’m not dead yet.’” Then he began hearing strange thuds. Those, a firefighter told him, were people jumping off buildings.
We sat for hours, waiting for something to happen. Then, in the early afternoon, word came that a victim, a young woman, had been found alive in the rubble. An American flag was hoisted at the site, and rescue workers began the painstaking work of extricating her. By late afternoon, about fifty doctors and other volunteers had formed a human chain from the street to the top of the rubble, several stories high, and were passing down the debris, piece by piece. Two large cranes with huge jaws then took the shrapnel and transferred it to waiting trucks.
I stayed until evening, hoping to help in some way, but I’d spent the better part of two days at the site, away from my worried wife, and I was exhausted. They were still working when I left.
For weeks after I returned to work that fall, the smell of dead bodies wafted from the morgue tents set up at First and Twenty-Ninth, outside Bellevue. I had been cutting through the street to get to conferences at the main hospital, but no more. Then, one day, I heard that the victim who’d been saved at Ground Zero was on the cardiac arrhythmia service, and not because of her broken leg. After her rescue, recurrent ventricular arrhythmias inexplicably set in, causing her to keep passing out. Medications couldn’t suppress the arrhythmias, psychological counseling hadn’t helped, and surgical options, including an implantable defibrillator, were being considered. By the late fall, she was on the catheterization table as electrophysiologists at Bellevue tried to figure out what had gone wrong inside her heart.
* * *
Heart rhythms are strongly influenced by emotional states. But how do emotions trigger rhythm disturbances? How does psychological injury disrupt the heart of a traumatized young woman that has beaten a billion times without fail? Bernard Lown, co-recipient of the Nobel Peace Prize for his work with International Physicians for the Prevention of Nuclear War, performed some of the seminal studies exploring such questions. As a high school student, Lown was fascinated by psychiatry, but in medical school he quickly became disenchanted by the subjective nature of the discipline. However, his fundamental interest in mind-body interactions persisted throughout his career. As a cardiologist in the 1960s, he decided to investigate whether psychological stress could trigger sudden cardiac death. In his earliest experiments, he studied ventricular fibrillation in anesthetized mice. To predispose the animals to fibrillation, Lown experimentally blocked a coronary artery, causing a small heart attack. He found that 6 percent of his animals developed ventricular fibrillation because of the coronary occlusion. However, Lown discovered that fibrillation occurred ten times more frequently when regions in the brain that mediate anxiety were electrically stimulated at the same time the coronary artery was occluded. Lown and his colleagues later found that they did not have to stimulate the brain to produce a fatal arrhythmia. Stimulating autonomic nerves that mediate blood pressure and heartbeat largely did the same thing.
But what Lown really wanted to show was that psychological stress by itself could trigger dangerous arrhythmias. He decided to study premature ventricular contractions (PVCs) in dogs. These extra heartbeats are often a precursor of fatal arrhythmias because they can strike during the vulnerable period of the cardiac cycle. PVCs indicate that the heart is in an excited and, therefore, vulnerable state. For the psychological stress, Lown put each dog in two different environments: a cage, in which the animals were essentially left undisturbed; and a sling, in which they were suspended, paws just off the ground, and received a single small electrical shock on three consecutive days. When the dogs were later returned to these two environments, Lown observed a remarkable difference. Animals placed in the cage appeared normal and relaxed. However, when they were transferred to the sling, they became restless, and their heartbeat and blood pressure went up. The rate of PVCs rose dramatically, too. Even months later, the memory of the minor sling trauma was deeply embedded in the dogs’ brains and profoundly affected cardiac reactivity. These findings, Lown writes in his book The Lost Art of Healing, demonstrated that psychological stress, already known to be a risk factor for coronary artery disease, can substantially increase susceptibility to malignant arrhythmias, too.
Later, working with psychiatrists at the Brigham and Women’s Hospital in Boston, Lown’s team found that survivors of sudden arrhythmias often experience acute psychological stress preceding their cardiac arrest. Nearly 1 in 5 of a group of 117 patients suffered public humiliation, marital separation, bereavement, or business failure in the twenty-four hours prior to their attacks. Moreover, Lown and his colleagues showed that medications that block sympathetic nervous system activity, such as beta-blockers, protected patients from those arrhythmias. Meditation largely did the same thing.
Lown’s research confirmed for the first time that emotional stress can initiate life-threatening arrhythmias. This conclusion is now widely accepted in medicine. We all agreed, for example, that post-traumatic stress was exacerbating the arrhythmias in the young woman rescued at Ground Zero. But in the months after 9/11, I learned a remarkable corollary to Lown’s observations: not only are arrhythmias triggered by psychological trauma but they (or at least their treatment) can cause it as well. Such stress can then feed back onto the heart, creating a malignantly vicious cycle. The mind-heart link, in other words, goes both ways. One night in November, two months after the attacks, I got to see this up close.
* * *
I met Lorraine Flood on a rainy evening in the faculty dining room at NYU Medical Center, where about twenty patients with implantable cardiac defibrillators had assembled for a support-group meeting. In June 1998, eight years after her first heart attack on the eve of her son’s wedding, Flood underwent an hour-long operation to implant a pager-sized defibrillator under the skin of her left chest. Like most patients, she was told that the device would monitor her heartbeat and apply a shock if the rhythm degenerated into something dangerous. “I was so relieved,” Flood told me that night. “I used to worry, ‘If something happens, I may not survive it.’” But then her defibrillator started working.
Flood was sitting with her husband, Al, with whom she had driven out from Colonia, New Jersey, where he was a bank executive and she owned a travel agency. She was a tall seventy-one-year-old woman with a regal bearing and salon-done blondish hair. I asked her why she had come to the meeting. “I’ve had a horrible time,” she replied. “I still wake up every morning and pray to God and say, ‘Lord, please, no shocks today. Please, no shocks today.’”
They started a few weeks after her implant, when she began to have arrhythmias that caused her defibrillator to fire. “I used to see this bluish-white light, and that was my warning I was going to get shocked,” she said. She would quickly sit down and then feel the device discharge into her chest. “Nobody told me what it would be like
. Oh, they said you’d feel a little something, but they never told me it was like a donkey rearing his hind legs and just with all the power he has hitting you right in the chest with full force—bang!”
Once, she was shocked sixteen times in nine days. “I was sitting on the couch when I started to get the shocks. I screamed like a banshee. My poor housekeeper didn’t know what to do. She ran upstairs and got me a bathrobe and slippers to go to the hospital. I said, ‘Catherine, I can wear clothes!’”
On the phone with her doctor, she was jolted by another intense shock. “I have always had a high threshold for pain—I never take Novocain at the dentist’s—but I just couldn’t handle it.”
One afternoon, she was at her grandson’s preschool when she saw the bluish-white light. “I felt it was warning me that I better get out of the room so I don’t frighten the children,” she recalled. She went into a bathroom, where she got what she described as a “mild shock.” Later, when her doctors checked, they said the defibrillator hadn’t fired. “They said it was a phantom shock,” Flood said.1 “But no one can tell me it wasn’t related to the defibrillator. I’ve been shocked enough times to know what it was.” Flood’s defibrillator was adjusted to make it less sensitive to arrhythmias, but she continued to feel nervous, increasing the likelihood of future shocks.
She stopped going to work and hired a full-time driver. She stopped going out with friends or singing in the church choir and eventually resigned from the school board. She had tickets to The Lion King on Broadway but didn’t use them because she was afraid of getting shocked during the performance. “Dr. Shapiro said to me, ‘So what if you scream in the middle of the play? You’ll scream, and then you’ll watch the rest of the play.’ But I couldn’t do it.”
Flood soon developed a Pavlovian fear of places where she had been shocked. One was her shower stall. “It once threw me against the wall of the shower,” she said. “Well, you never saw anyone leave that shower so fast. I had shampoo in my hair, suds all over my body, and I ran into my bedroom screaming, and Al came running in. It was terrible.” She started using her husband’s bathtub. “I couldn’t even look at the shower; that’s how frightened I was,” she said. “Then I decided, ‘Lorraine, this is ridiculous.’ One day I opened the shower door and put the water on. But I couldn’t go in. I just watched the water.”
Her constant fretfulness put a strain on her family. “I think my husband considered me a little cuckoo,” Flood said. I asked her husband, a tall man with white hair and a patrician face, about this. He chose his words carefully. “It is a little hard for me to understand how paranoid she is with it,” he admitted.
At a neighboring table, Mohammed Siddiqui, a well-dressed man in his late fifties, was sitting quietly with his wife, Anjali, waiting for the meeting to get started. Siddiqui said he had joined the support group three years prior, after his defibrillator was implanted, but it wasn’t until the previous March that he had gotten shocked for the first time, in the passenger seat of his Nissan while his wife was driving. “It lifted up his whole body,” his wife said. “He jumped in front of me. He was looking at me so strange I thought I must be going the wrong way.”
That shock was followed by two others over the next ten days, including one while he was sleeping. When doctors checked, they said his defibrillator was responding appropriately to irregularities in his heartbeat and that he shouldn’t worry. But instead of feeling reassured, he found himself constantly worrying about the next shock. Once an executive at a land-development company, he stopped driving because he was afraid of getting shocked on the road and having an accident. He avoided leaving his home and indefinitely postponed a visit to his family abroad. He lost ten pounds and started to feel chronically weak. He had what appeared to be classic post-traumatic stress disorder, with nightmares and recurrent thoughts about the event. His palpitations, his wife said, had only increased since the 9/11 attacks.
I walked over to the buffet table, where Dr. Shapiro, who had invited me to the meeting, was chewing on a chicken skewer. He had just gotten out of a procedure and was still wearing blue scrubs. “I see you’ve met Mr. Siddiqui,” he said with a smirk. I told him what Siddiqui had said. Shapiro shrugged, seemingly at a loss for words. “I can’t explain it,” he said. “How can a shock make you weak for nine months?”
The meeting, Shapiro explained, was intended for people to open up about their defibrillators. Since the 9/11 attacks, he said, patients were reporting more defibrillator shocks than ever, probably because of increased psychological stress. The rate of ventricular arrhythmias in patients with implantable defibrillators had more than doubled. One patient of his, he said, was so disturbed after getting repeatedly shocked that she held a séance at her home to rid it of “evil spirits.” Another had actually made Shapiro turn off his defibrillator. “He said he’d rather allow his life to end than deal with the pain and frequency of those shocks.” Shapiro mentioned the young woman who was rescued at Ground Zero. No treatment for her arrhythmias had worked. The next step was probably a complex radio-frequency ablative procedure in her right ventricle.
Shapiro told me that his own father had gotten a defibrillator after a series of heart attacks. After the implant, his father’s heart inexplicably went into incessant arrhythmias, an “electrical storm,” and he was shocked eighty-five times in three hours. Traumatized, he couldn’t sleep for weeks. “But I kept telling him the defibrillator was a good thing, that it was doing what it was supposed to,” Shapiro said. “It was allowing him to see his grandchildren.”
* * *
In the annals of dying, sudden arrhythmic death is something of a paradox: it is at once the most desirable way to die and the most feared. Sudden fatal arrhythmias are the leading cause of cardiovascular mortality across the world. Millions die of them every year, and most victims, like both my grandfathers, never even make it to the hospital. Most sudden cardiac deaths will leave loved ones bereft. But some will leave only gratitude for a merciful end.
Even as recently as thirty years ago, sudden arrhythmic death used to be greeted with almost total helplessness. Remember old movies in which a businessman slumps at his desk and a co-worker puts two fingers on his carotids and then pronounces him dead? The camera treated these deaths with an almost comical dispassion, as if they were fated, and this reflected society’s powerlessness in the face of this killer. But things have changed since Michel Mirowski invented the implantable defibrillator. In 2016, about 160,000 defibrillators were implanted in the United States, more than double from a decade ago. The population of eligible patients has expanded, too—from actual survivors of cardiac arrest to patients like Jack, my magnetic patient, who are only at an increased risk of it.
Today Mirowski’s invention is tiny (nine defibrillators would fit on this page), nearly foolproof, and highly effective. The batteries last almost a decade and can be surgically replaced. Though it costs approximately $40,000 to implant one, considering that defibrillators often extend patients’ lives by three years or more, the procedure in many cases is a bargain.
But all medical technology carries a different price. Artificial hearts cause blood clots and disabling strokes. Dialysis saves lives but often results in painful, even life-threatening, infections. For implantable defibrillators, designed to deliver peace of mind, one of the biggest downsides, paradoxically, is fear.
A few weeks before the support-group meeting, a senior cardiology fellow and I were called to the bedside of a twenty-four-year-old man, a professional basketball player in Europe, who had just been shocked for the first time by a defibrillator implanted earlier that day. He had been admitted to Bellevue a few days prior after passing out in practice; his doctors had identified a genetic heart abnormality. He was a muscular, intimidating man who was whimpering in pain when we arrived. His girlfriend wanted to know why the defibrillator had fired. My colleague and I “interrogated” the device with a special computer and found that it had delivered an “inappropriate” shock—m
eaning that it thought his heart was fibrillating when it was not. We made some adjustments. “Try not to worry,” I said to the patient, who looked shell-shocked, as we were getting ready to leave. “If you get shocked in the future, you will have needed it.” His girlfriend wanted to know if he could still play basketball. Would the defibrillator fire if a pass hit him in the chest or if his heart rate sped up during a game? It was unlikely, the senior fellow replied, but he conceded that it wasn’t impossible. The patient thanked us, and we left. Somehow I knew he was never going to step on the court again.
* * *
A few months after her implant, Lorraine Flood went to her first support-group meeting. “I thought perhaps the stories I would hear from other people would help me,” she said. She was surprised at how well the other patients were coping: going to their jobs, going on vacations, getting on with their lives. It was inspirational but a bit dispiriting, too, because she thought some people at the meeting were in denial. “Sometimes I had the impression that people weren’t opening up,” Flood told me, “that they weren’t 100 percent honest about how painful a shock can be. One lady I befriended got shocked for the first time in a bank. She said, ‘It was nothing.’ Well, it’s not nothing.”
While the support group made Flood determined to get on with her life, her anxiety continued. Pretty soon, she was having full-blown panic attacks, which only worsened her arrhythmias. One evening when she was home alone, she suddenly experienced an overwhelming fear that her defibrillator was about to go off. She started sweating. She went to her neighbor’s house; in his driveway there was a motion sensor wired to a lamp. When it went off, so did Flood. “I was screaming, crying uncontrollably, pounding on the door, tearing at my hair,” she said. “I’m the type who needs everything to be in place, and I looked like something the cat dragged in.”
Heart--A History Page 19
