A Match to the Heart

by Gretel Ehrlich

“No, I just hate facing pain. When I’m at the dentist I always ask for double Novocain.”

  When he finished the exam, he sat down in a chair. He had a sensual handsomeness and a farmer’s big hands and feet.

  “My friends always teased me at medical school about being too happy. I made it a rule never to study on weekends. What good does it do to worry?” I asked if he got “As” anyway, and he said, “Oh, I guess so.”

  Med school was Cornell with a residency at New York Hospital, a stint at an army hospital in Albuquerque during the Vietnam War, a rotation on the Navajo reservation, and a fellowship in cardiology with Norman Shumway at Stanford University, where Blaine helped perform the first heart transplant.

  “It was a very exciting time. In the sixties, cardiology was really taking off. We were learning so much, and the technology was improving so rapidly. Every week there was something new. We were suddenly able to save lives that could not have been saved a few months earlier.”

  Listening, I sat on the edge of the bed, dangling my feet in the foggy air flowing in through the window.

  “I’m in medicine as a practitioner—not a researcher—because I love people. I’d always wanted to be a doctor, but my parents didn’t have the resources to send me through med school. I thought of enrolling in engineering school instead, which would have been a disaster. Everything I built would have fallen down. At the last moment I was offered a generous scholarship to Swarthmore College that allowed me to use my savings for medical school, and I never looked back.”

  He stood to go, then told me he had already read one of my books and had begun another. “I’ll never get any reading done if I sit here all day,” he said, grinning. “Catch you later.”

  Later a nurse came in and encouraged me to get up and walk around (good for low blood pressure). She said, “Just tell us where you’re going so we can keep track of you.” One loop through the unit was all I could manage before retreating to bed. During the night I had another “sinking spell,” as my mother called them. Even lying flat I could not stay conscious. When my heart rate fell to thirty, the buzzer went off and nurses appeared.

  But the center did not hold. Each room was a composite flower’s petal exploded out, propelled by fire.... I was dying. Hummingbirds circled my head, separating oxygen from blood with their beaks. I gulped the rich dessert of air. Sandhill cranes flew through the room, way up near the ceiling, their cries growing fainter. I was going the other way.... Then I heard a nurse say to me: “Don’t worry, we won’t let you die.”

  How long have I been wandering? It was night when I started remembering again and I had been skating. In some places the ice was black, in others checkerboarded translucent and white. But the blades would not grip. I tried to glide but my knees faltered. Then I saw down into the ice: miles and miles of transparency.

  It was the dogs, not the nurses, who brought me back. They had done this so many times, the images of their rescue had become abbreviated: their sleek coats, both dark and blond, sideswiping my face; the sudden tug of the harness; then, bright air. The hospital room was quiet and I was inhaling oxygen. Between darkness and light, death and life, one breath and the next, there are these gaps. Even the lightning stroke is an opening, a vein in the heart of a storm, a passageway carved in the ivory of cloud. The open window behind my bed let mist in the room. I could hear the foghorn’s warning drone: BEWARE!

  In the Bardo Thödol, known as the Tibetan Book of the Dead, bar means “between”; and do, “a landmark that stands between two things”; joined together, bardo means “gap.” It refers to that wandering state between life and death, confusion and enlightenment, neurosis and sanity. The past has just occurred, and the future has not yet happened. In the bardo of the human realm we experience the body as illusory. Our relationship to our own existence and nonexistence is lukewarm. The whole world is a hiatus; the gap is not just a widening in the road before the next bend, it is where the road falls off the cliff.

  The bardo has also been described as a vast and desolate plain littered with corpses and bleached bones and feral animals feeding on remnant flesh, a plain that is crowded and empty at the same time where animals copulate wildly, fall away from each other, and move on. Then it’s a gray ocean again with no surface and no bottom, no reference points, no lighthouse, no breakwater guarding the harbor, no guiding light to lead me home. The bardo state occurs not only at the moment of death or the moment before death, but all during our lives; the bardo is the uncertainty and groundlessness we often feel.

  Chogyam Trungpa Rinpoche, who made the first translation of the Tibetan Book of the Dead for English-speaking Westerners, was born in a cattle shed to very poor parents. Trungpa was “discovered” as the incarnation of the tenth Trungpa Tulku when he was thirteen months old and taken to the Surmang monastery, where he was installed as abbot. Years later, when the Chinese Communists were invading Tibet and pursuing the tulkus, such as the Dalai Lama, and Trungpa and his entourage rode and walked across Tibet in the hope of reaching India. They had no maps—none existed. They began the dangerous crossing of the Himalayas in mid-winter, on December 15, 1959, under a full moon, and when they ran out of food, they boiled saddle leathers to make broth, since they were not allowed to take the life of any sentient being. Many of the great monasteries and most of the ancient Tibetan culture was being destroyed behind him. He would never see Tibet again. Yet he referred to his journey as “his trip to freedom.” In fact it was exile.

  Trungpa said the Book of the Dead is not only an instruction on how to die or help the dying but should rightly be called the Book of Space, the Book of Life, or the Book of Liberation—a primer in the physical aspects of death that arise as soon as we are born, as well as psychological styles of living and dying. A greater familiarity with death emboldens our love of life. The bewilderment and desolation we experience in the bardo—“I wander in the bardo state alone ...” one of the prayers says—translates into a sense of delight with the play of opposites, the way solidity and attachment breaks down, with what Trungpa called “the indestructibility of impermanence.”

  How far have I wandered? At dawn Blaine burst into the room, yanked the oxygen tube out of my nose, and smiled. “You don’t need that now.” He sat on the bed and told me about four migrant workers in the Salinas Valley who were hit by lightning the day before—but he couldn’t find out anything about their condition. They had been released, as I had been, with no follow-up or monitoring. Blaine’s visit pulled me back into life, into the world of newspapers and human problems; his curiosity and enthusiasm made me want to be alive. As he was leaving he told me he had called in another cardiologist, whose specialty is cardiac electrophysiology, to help figure out what was wrong with me. “We’re treating the results of your problems, but we don’t know the root causes. We don’t know very much about how electricity affects the brain and heart.” An unpleasant test was scheduled for the next day.

  Suzanne, the nurse, checked the pulse in my ankles, groin, neck, wrists. “If you go outside to sit this morning, don’t mind the underwear,” she said, pointing to some clothes draped over a chair on the patio. “A homeless person came into emergency and he was dirty, so I washed his underwear for him before I went on duty. He had been walking for days, he told me. Just walking.”

  I couldn’t believe I was in a physical state that prevented me from walking. Walking had long been my liberation. Every summer on pack trips I tied my saddle horse into my husband’s pack string and walked fifty or sixty miles through the mountains at ten thousand feet. And alone at the ranch while my husband was in the high country in another part of the state, I often ran crouching, over hundreds of acres. Now, to think of walking was absurd. I could barely lift an arm; to think of not walking was even more absurd.

  All my senses, perception, energies were telescoped down into that tiny room: a “hospitalscape” with no horizon. Each time a nurse entered, I could sense immediately his or her state of mind. She didn’t need to speak,
her presence told all: how preoccupied she was with her own concerns, the degree to which she could give herself over to any patient, how deeply she lived in the moment, her nose in death and her elbows in the messiness of living.

  Trungpa’s Book of Space is also a book about charnel ground, which is the full aspect of emptiness and desolation. This hospital unit for the acute care of cardiac patients was a piece of the Tibetan Book of the Dead.

  Once the bewilderment is gone, the Book of the Dead tells us, the gap is an expanding universe in which space is sharply defined, where there is “radiance with no radiator, accommodation with no territory, fulfillment with no motivation, communication with no receiver.”

  At sunset I made my pathetic loop around the unit, then ventured out onto the patio. The entire western sky was red. “It’s from the ash,” the nurse who came to check on me said. Today’s volcano is Mount Pinatubo, which erupted in the Philippines in June 1991, and whose ash still circles the globe. Lightning often occurs close to volcanic eruptions, and “flashing arcs,” fly out of craters and spread in all directions with the velocity of sound.

  I sat down in front of the wall of flame. The homeless man’s long underwear flapped in the breeze. He was somewhere in this hospital, lying in a bed, no longer walking. Nor was I. Lightning had entered me twice and now I was a burnt shell with nothing in me that could attract fire. The curtain of red was unmoving. Then darkness came down.

  I returned to my nest. As fog moved into the room, the illusion of place disintegrated. Already the end of the bed was gone, my legs, the nurses’ station. The heart monitor’s red numbers flashed backwards on glass doors, as if I had been turned inside out, life turned into death like a piece of suede, smooth inner skin exposed.

  When you are sick, days lie together haphazardly, like empty containers: each one counts because it means you are still alive, but the details of the greater world are unclear. Sickness entails a hiatus, a gap in habitual activity, an interval during which one is suspended motionless.

  From my all-interior-view room I could read the names of patients handwritten in bright colors on the chalkboard behind the nurses’ station. Every day the list changed—people either died or were discharged. My name was still there but it meant nothing. There was no longer a narrative to follow. Even the character of death had dropped out of my tale.

  chapter 7

  Joseph Ilvento, the young cardiac electrophysiologist called in by Dr. Braniff, specializes in the effects of electrical impulses on the heart. He spends his days sleuthing the electrical clues that might explain why a heart has gone into arrhythmia, tachycardia (rapid heart rate), or bradycardia (which is what I have, a slowed-down heartbeat), as well as “conduction disturbances” (electrical messages that have misfired). Much like an astronomer who can never see with the naked eye the galactic events he has devoted his life to studying, Ilvento deals with the consequences of electrical events—those secret journeys of impulses from synapses, down nerve fibers, through ganglia into the heart—which he can never touch with his fingers or see.

  Cardiac muscle is absolutely unique. Unlike skeletal or smooth muscle, the cells that make up this tissue have as their main purpose regular, periodic constriction. They are designed to drive the pump, to make the heart contract and release, not as a response to a voluntary impulse but spontaneously. Even the design of the fibers along which cells are clustered is different. While skeletal muscle fibers are long and stretchy and can contract at will to variable lengths, compliments of the central nervous system, cardiac muscle consists of crosshatched, branching filaments whose interconnections place cells so closely together that electrical impulses are conducted with terrific speed and accuracy.

  Myocardial cells have bulbous heads that, once activated, move in oarlike motions, rowing and rowing, bending the filaments in the direction of contraction, then disconnecting them as each rowing motion comes full circle, only to begin again. Under a microscope, normal cardiac muscles are dendritic and branching, and their fibers are arranged in patterns that look like lightning. When cardiac arrest is reversed, the tiny myocardial cells row through the frozen sea of tissue, pushing the pump into action again.

  I found Dr. Ilvento rather serious, but, according to Blaine, always the optimist, Ilvento is likable, “because he makes great pizza.” But pizza, which I rarely eat, was farthest from my mind when the head-up tilt-table test was described to me. “We have to find out why you’re passing out all the time, why your heart rate suddenly plummets. What we’ll be evaluating is your ‘unexplained syncope.’ ” “It’s going to be unpleasant,” Ilvento said, though he might have said horrific.

  I was strapped down—wrists, waist, ankles—to a table. Dave Wallace, a nurse assigned to Ilvento’s patients, velcroed blood-pressure cuffs and attached leads to an EKG machine. I asked if they were going to torture me, told them that even if they did I wouldn’t talk. Dave smiled. “It’s not exactly torture ...”

  The idea was this: I was to lie flat on the table for twenty or thirty minutes while blood pressure and heart rate were continuously recorded, then the table would be tilted straight up and I would hang, suspended in the standing position, for as long as it took—up to sixty minutes—to see if I lost consciousness.

  That morning I learned the meaning of panic—just in case I had missed that experience in my life. Before the position of the table was changed, Dave, the nurse, jiggled the straps. “Don’t worry, you won’t fall. Just relax.” Then they tilted the table straight up. It’s normal for blood pressure to drop eight or ten points when a person moves from a sitting to a standing position but mine slid. I had been crucified in my coming-back-to-life dream; now I was not dead in gray water but hung ridiculously to a table in a bright room surrounded by people who were trying to keep me alive by examining the mechanisms that were making me die.

  Drooping from my gallows, I was asked repeatedly by Dave and Ilvento how I felt. But it was the same old story: the room was black. Clamminess turned to a drenching sweat; my breathing came fast and the terrible, elephantine heaviness invaded my body again. The nurses were vague forms as they checked the monitors: heart rate and blood pressure dove.

  It’s not true that I wouldn’t talk if tortured. As the black hood dropped over my thinking, I began to plead for a reprieve: “Please put me down, please ...” The instinct to lie flat was indomitable. It’s the life-saving desire of the body to get more blood to the head. Quickly it became apparent to Ilvento that the “conductor disturbances” occurring in my body had to do with “vasovagal syncope”—the failure of the blood vessels to constrict. Blood and oxygen had drained into my feet and legs, and though I begged repeatedly and vehemently to be laid flat, they refused, simply watching my body go limp. I tried hard to hold out, to hang on to light and form and discursive thought, but the balloon burst and I was gone.

  What is the architecture of a blank, and how long can it last? What happens to memory when one becomes unconscious, does the synaptic gap go dark? Do the neurotransmitters drift aimlessly?

  Ahead of me it was dark but I could see the dogs’ glistening fur. We were sledding in moonlight. A needle was slipped into my vein. Atropine. I slid from one black puddle to another on a road made of limitless gravity. The needle in the vein was like a needle in a haystack, a needle flying between galaxies. Blackness prevailed. The dogs who rescued me had dark fur. I foundered in a dream about horses whose back legs—hips, hocks, cannon bones, pasterns, hooves—were cut up and laid at odd angles in a wheelbarrow, to be carted away. The dogsled carried me back into the day.

  I felt Dave’s hand on mine. He was saying something to me but I couldn’t answer. Ilvento was on the phone reporting to Blaine: “We got a positive result. She was out in fourteen minutes so this answers our questions. I think we can safely rule out most everything else. It’s vasovagal.”

  My face was gray and the back of my hospital gown dripped sweat. Almost unbelievably, they repeated the test after I had rested. “We won
’t let you go all the way out this time,” Ilvento promised, but I was skeptical. I felt like telling him I hated pizza. They tilted me up and quickly I felt faint. The black tunnel tightened around me—a noose—as if I had been sent to the gallows. Or was I being crucified again?

  When they laid me down, atropine was started. It wasn’t that I had suffered any pain, it was only discomforting. Later, dazed and unsteady, the nurses led me back to bed, like torturors leading the tortured.

  You don’t have to experience everything life can throw at you—torture or ecstasy—to fuel empathy; just a taste is enough. I vowed to send money to Amnesty International for victims of torture. When Blaine came by that afternoon his jauntiness rubbed me the wrong way for a moment. He sat on the bed and looked at me. My face was gray. It wasn’t necessary to ask how I was feeling, but he did anyway.

  “Everything is still dark,” I said. “I feel washed out... like I’m swimming and there’s nothing to hang on to.”

  “Here,” he said and held both my hands in his.

  At the end of rounds he returned to my room. I was slightly more bright-eyed. He sat down and explained the findings of the tilt-table test. “You’ve suffered an electrical insult to your brain stem and have lost the ability to vasoconstrict. You have no vascular tone in the smooth muscles of your blood vessels. You’ve also lost the ability to increase your heart rate. The sympathetic and parasympathetic nervous systems usually counterbalance each other. When the heart and blood pressure get too high, a message goes through the parasympathetic nerves to the brain, which secretes an inhibitory chemical that slows the heart down. The sympathetic system does the opposite: it speeds things up. I think your sympathetic system was burned by the lightning, allowing the parasympathetic vagus nerve to take over and have its way. It keeps telling your heart to slow down, because no excitatory chemicals are being released.”