Donovan’s World

Slowly at first but inexorably increasing in speed, the black, moving platform insisted that I stride, faster and faster, to keep both my balance and my dignity. It went on… and on… and on. For the first time in six weeks my breath was forced through my mouth and I felt my heartbeat in my temples. This amazing physical effort was being monitored minutely and continuously. Although I was deeply disturbed by the output demand I trusted the doctor and his nurse utterly.

Finally, taking giant strides, puffed out and sweating, my legs shaking and my arms feeling stretched, I asked for it to stop.

‘I’m sorry’ I blurted, ‘I had simply had enough. Have I done badly?’

While I tried to control my heaving chest I was enthusiastically congratulated for my staying power. The test, I was told, would have stopped after fifteen minutes. I had done twelve. There were no sinister indications on the dials. I suffered no angina pain. My pulse rate declined quickly to a satisfactory level. The importance of the test was immediately apparent to me. I had discovered that I was capable of far, far more physical effort than I had suspected. It meant that from now on I could commit myself wholeheartedly to my daily exercise routine. It meant I could exercise to the point where I was short of breath - nature would tell me when to rest.

Shortly the period of primary recovery was ended and I was to go back into daily life and routine; a few more days at home then back to work.

My last instruction session featured a visitor from the YMCA Cardiac Club who pulled no punches. She looked solemnly around the room and warned us that to achieve any length or quality of life we must take exercise as a matter of priority. She made me realize that wherever I was and whatever I was doing, I must exercise; I must never let my disciplines slip.

But I knew that it would not be possible to make a commitment to organized group routines. While it might suit many others, I knew I could not keep up with the time demands of the Cardiac Club. So I worked out private routines which would fit my lifestyle - two sessions of exercise a day plus a half hour vigorous walk. In all the days of the half a year since

I flew solo, I have hardly missed a session. [And that continues to this day - 2008!]

And so, back to work, back to daily routines. At first the knowledge of my mortality and my heart attack went with me, sitting on my shoulder, reminding me. But as time passed the minutes of forgetting grew into hours and sometimes days.

The daily round brought with it confidence and reassurance but there was one more bogey to exorcise - the beta-blocker. While I was very active, physically, it was still impossible for me to get my pulse rate above 80 and walking was quite uncomfortable, my muscles aching constantly. I discussed this with my doctor and asked if we could try stopping the beta-blocker. My blood pressure readings were excellent and my resting pulse was getting slower and slower as I grew fitter. Taking my pulse first thing in the morning I was getting readings under 50 and my doctor felt that I was adding a ‘training effect’ to that of the beta-blocker.

But he was reluctant to let me off although we halved the dose. He wanted me to stay on Loten for a full six months after which period, he said, it had been found that Loten had done its job. So I continued for a little longer but after about four months I again asked to be taken off the drug. He agreed and blood pressure measurements over the days following proved that I no longer needed beta-blockers, my readings were good and low and have stayed that way since.

The results of ceasing Loten were dramatic. Over about four days my body came back to normal. My face, which had been grey and drawn-looking gradually coloured until I had a healthy pinkness. My feet, hands and nose-tip, which had been frozen, thawed. My working pulse rate rose, with exercise, to much higher levels but quickly sank back to a reasonable 70-ish at rest. For a while I did not allow it to rise above 100 but later I worked it up to 130-140 at top output -quite enough for a 56 year old.

My body, six months after ‘C-day’, looked better than it had for years. I weighed 79kg, having lost 14kg. I was much fitter. I looked good and I felt good. And the small fortune I spent on buying new clothes and having old ones altered didn’t matter one little bit.

I revelled in two comments made by my doctor. Having satisfied himself that I was suffering no disadvantages from discontinuing Loten he, an ex-Cambridge University rugby ‘blue’ looked at me and said: ‘I think your chances of having another heart attack are about the same as mine of having my first.’

Later, when I was to travel to Australia and wanted to take out some health insurance it was necessary for him to sign a declaration of my good health. There on the form, over his signature, were the wonderful words ‘He has completely recovered from coronary thrombosis.’.

Perhaps best of all, I found my life so much more to be treasured. Every moment is a gem to be used and enjoyed to the full. I have placed far greater value on my friends and those I love. Conversely I have little time for fools and avoid their company. Activity is the panacea for depression. Whenever the phantoms come crawling into my mind and try to undermine my spirits I displace them with activity. Even in the middle of the night (and it happens less often) if I awake and start to have fearsome thoughts I get up and do something; read, write, make a cup of tea; and soon there are no more shadows and sleep comes easily.

Hope was and is our good companion, an unstintingly generous friend, always there; and having a coronary is not the end of the world - for the majority of us, if we embrace Hope, it’s a beginning.

© DON DONOVAN

I was extremely nervous. I still had no real idea how seriously a heart attack can affect one. I had no idea how much my body could take, physically. I was leaving the controlled environment of the coronary care ward; starting to take the first risks. I was determined to comply, in every respect, with the advice and instructions given by the doctors and nursing staff.

I got the impression that whatever criticisms might currently be levelled at the hospital system, coronary care is well developed and working efficiently. This is hardly surprising considering the incidence of heart disease among New Zealanders, who seem to have been set up for it by the national diet, if nothing else! There was no shortage of advice, both written and verbal, and there was available a six weekly rehabilitative instruction course - two and a half hours every Tuesday afternoon.

Six weeks is a crucial period. As with an operation scar, the damage to the heart has to take time to heal. That small part of the heart which ceased to function when the clot blocked the coronary artery, thereby stopping blood from sustaining the heart tissue, hardens into scarring. In my case, I was told that it might be a small area about the size of a thumb nail.

Of course, that part doesn’t come back to life. But they say that a new network of collateral blood supply lines develops at the same time as healthy arteries become wider to bring blood to the surrounding heart muscle.

Over the six weeks my exercise regime slowly intensified, my emotional state settled, the activity periods lengthened and I began to realize that life after a coronary was not just a simple matter of survival, it was an opportunity to look forward to a far richer life ahead than I might have had had I not had the coronary.

The first of the instruction periods at North Shore Hospital was an eye opener. Husbands and wives were both encouraged to be present. In general, that group of what we, darkly, referred to as ‘victims’, was in pairs because, I guess, heart attacks mostly hit middle-aged people who tend to be part of that great, boring (but comfortable to live with) unsung crowd that does the old fashioned things like getting married and staying that way!

By far the majority of ‘victims’ were men. Which is perhaps fortunate because I’m sure women are better at looking after their men than the other way round. Each week from the start, the first thing we did was to weigh ourselves and enter the result in a book. The day I had the heart attack I weighed 93 kg. The first instruction day - about three weeks later - I weighed 91 kg and by the time I had finished the six week course my weight was 84 kg.

(At the time of writing, six months after ‘C-day’ [September 1989] my weight is 79 kg. So, by trauma, diet and exercise, I lost 14 kg which is over 30 pounds.)

The only thing we had in common was heart attacks. We were strangers pushed together by adversity. I hated being there. I don’t like meeting new people at the best of times, let alone being forced to meet them, and where some of them had obviously been there in previous weeks and so had developed transient acquaintanceships here was I, a new boy, not wishing to join in the bonhomie nor wishing to admit that I might be undistinguishable from the others - middle-aged, gaunt, haunted and scared!

As the weeks went by I came to know the group better and was interested in attitudes. There was an overseas visitor who had been taken ill while here on a holiday. He certainly didn’t have the build of an archetypal candidate for heart disease. He was a small man with a trim figure and maintained throughout that he had neither eaten the wrong things nor allowed his  body to become neglected. He seemed puzzled, angry and querulous and yet I felt that as I watched him over the weeks there was, inside, a ferment, a tension.

His wife made a comment in the early days that made me realize how difficult it is for loved ones - she said that she felt she had to keep watching her man for she was frightened that he might, while alone, have another heart attack. She said that there were times when she studied him intently while he was asleep to satisfy herself that he was still breathing!

Another man, grey, wispy, intelligent and resigned had been an air traffic controller. He made no secret of past stresses. It is almost a cliché, following Arthur Hailey’s ‘Airport’, that air traffic controllers are highly stressed and live at a constant point of hysteria. I doubt that the job is so very bad or that mandatory stress controls are that slack but my colleague could have stepped from the pages of ‘Airport’. I wondered whether his coronary might have been part of life’s script for him?

One younger man - probably in his thirties - railed against his hard luck. He seemed angry all the time, not only with fate, but also with the hospital, doctors, nursing staff, advisers and life in general. It was as if he felt that he had been falsely accused and unjustly condemned for a crime he had never committed. Stress radiated from him.

Another couple appeared almost amused by it all. They were calm and openly discussed the details of the coronary and their life style. Yes, he smoked - but not much; yes, he enjoyed a few beers - but not too many; his favourite meal was the weekly roast, and he loved his cheese. His father had had a heart attack. He played a bit of golf - wasn’t that exercise? The one contributory factor that appeared to be missing from his makeup was stress - but just about everything else was there!

And there was one old friend. I hadn’t seen him for years. I hardly recognized him for he, like me, had lost some girth. A lovely man; cheerful; good natured. He had headed a very large, international manufacturing company and had probably been subject to stresses and strains without showing it too much. He loved his cheese, too, and wondered whether he would ever be able to give it up! He gave me real Hope with one of those stories I am always happy to hear. He told me his mother had had a heart attack in her fifties but was now still alive in her late eighties and in very good health.

It was at the first of these six sessions that I had another shock. The cardiac nurse, as a matter of routine, took my blood pressure and found it to be elevated. I told her that I had never suffered from high blood pressure except under stress such as I had had after the kidney operation of the previous year. So we waited until the end of the session when she took another reading on a different gadget and found the same, high, reading. It was so high that she went immediately to the duty cardiac doctor who put me on beta blockers straight away.

Beta blockers (I was on Loten) are designed to control the heart’s rate of activity - a bit like a governor on an engine - so that the pulse rate cannot over rev. I was disappointed that this was necessary but accepted that my heart must not, in these early weeks, be put under unnecessary strain.

Apart from that set-back my progress was steady and encouraging, leading me to a point where, two months after ‘C-day’ I was ‘going solo’ so to speak, making my own way at my own speed without supervision or advice.

Each session had both specific topics and those that went on week to week. We were given exercise programmes starting with simple, easy actions that progressed by added repetitions and by the addition of more strenuous routines.

At first, five simple repetitions of swinging the arms from the sides to clapping hands overhead were demanding. It surprises me now to look back and see how weak I was.

Over four weeks we kept a record for the physiotherapist. Exercises were done twice a day, plus a walk, and we had to record the number of repetitions of the exercise routine, the length of time taken over a daily walk, and pulse rates before and after exercising.

Some indication of progress: On the first day of structured exercise, exactly ten days after the coronary, I achieved five repetitions per session of five simple movements. My pulse rate before starting was 60. After it was 68. I walked for ten minutes around the paddock at the side of the house.

Tewnty-eight days later, having moved to grade three of exercises that included modified press-ups and running on the spot, I recorded: ‘…15 repetitions with before and after pulse rates of 60 and 72.  The walk was 35 minutes - vigorous.’

Being on beta blockers meant that I could never over-exercise and my pulse rate was unable to rise much above 80 which was fine in the early days but later,  when I was well on in my recovery, I found the beta blocker effect frustrating - my muscles ached and effort was a struggle of the will to advance against the drug’s insistent brake-like retardation.

I found the physiotherapist’s sessions to be the most useful of all, and the woman who instructed us, Mary, was extremely good at it. She taught us not only how to do the most effective exercises but also how to relax properly in order to relieve the body of all unnecessary strain. She showed us numerous techniques, many of which I use today [and still use in 2008].

Diet was another important instruction and from ‘C-Day’ onwards mine would never be the same again. The National Heart Foundation of New Zealand has published a pyramid of foods, the top third of which shows foods to be eaten least - total fats (not just animal or saturated fats but all fats), sugars and salt.

The next third contains a list of foods which should be eaten in strict moderation; this includes milk, cheese, lean meat, poultry, fish, dried beans, nuts and eggs.

Then comes the base third of the pyramid - a whole wealth of cereals, breads, vegetables and fruits that may be eaten without concern.

Our diet henceforth revolved around that last category, supplemented by treats from the middle list; but the top of the pyramid was, to me, forbidden!

I have always been a tea lover. I was worried that I might find too much of it harmful. But I was pleased to hear from the dietician that I needn’t worry - I think it was her favourite drink, too!

We learned a little about the heart’s functions - enough to help us understand what had happened to us. We learned the difference between angina and a coronary, the first being insufficiency, the second cessation of coronary artery blood supply. We were given anginine, a drug that dilates the coronary arteries and so improves supply when the need is indicated by angina pain. We were told that if we should have heart pain we should try anginine and if, after three administrations over twenty minutes, the pain had not subsided, we should call the ambulance.

We finally learned about stress - the forms it takes and how to cope with it.

And we had one bizarre session which started with us all being given a sheet of newspaper from which, with our eyes closed, we had to tear out the shape of a cat. The session turned into a talk about sex after a heart attack. I never worked out the relationship between post-coronary sex and newspaper cats but it was a hilarious session given by a charming young woman who looked as if she’d had less sex than I’d had moon walks!

In essence, she comforted us with the knowledge that a middle-aged coupling probably uses about the same amount of energy as climbing two flights of stairs. It goes without saying that the satisfaction derived from both activities differs markedly!

The one outstanding topic missing from these instructional sessions was the psychological aspects both of the causes of a heart attack and the after effects. It seemed to me that there was a pragmatic emphasis. With the possible exception of stress as a causal element the factors under review were practical and physical - diet, overweight, exercise, hypertension, smoking, alcohol and heredity. The effects of the mind were hardly addressed.

Rightly or wrongly I have become convinced that I subconsciously talked myself into having a heart attack. I had certainly been under unresolved stress for a long period and my cries for help, both to others and myself, had gone unheard. A heart attack is such a shocking event that it demands attention and insists upon being taken seriously. By having a coronary I made myself heard. Those in my life who had inflicted stress upon me had to listen; and I, for survival’s sake, had to make myself heard.

If I am correct in my theory then it’s possible that other heart attack victims have also talked themselves into their situation in order to demand attention; but I never heard the possibility discussed by any of the doctors, nurses or patients I met. I am also certain that recovery requires as much understanding of the processes of the mind as of the body.

One becomes so aware of the fragility of life that any discomfort in the chest creates stabs of apprehension. I found that for weeks after ‘C-day’ the after shocks rumbled around my chest cavity like seismic tremors. At first, these ill-defined aches and pains were accompanied by depressions but - and here’s where Hope gains strength - the more times these episodes happened, and the more times I survived, the more I was able to shrug off the demons and dragons of the mind who would try to undermine my morale. I had not been prepared for the psychological struggle in any of the instruction sessions and yet I think it was a central problem in convalescence and restoration.

It’s also a problem that must be worse with greater severity of the heart condition. I thanked my lucky stars that my heart attack had been relatively uncomplicated. I neither had to experience angiographic examination (where a photographically opaque solution is passed through the arteries so that areas of damage may be seen while under X-ray) nor was surgery necessary; although had it been I should have gained Hope from knowing that an old colleague of mine, who had had a triple by-pass operation ten years ago, had just started a new business at well over sixty years of age!

The initial panic over, the teaching process began. It started with the questions ‘What happened to me?’ and ‘Why?’

This is my understanding of what I came to learn over the days and weeks of recovery:

The heart is a hollow organ that pumps oxygen enriched arterial blood from its left side to nourish the far flung ends of the body. The right side pumps the oxygen depleted blood to the lungs where it picks up new oxygen from the air we breathe in.

To keep the heart going it has its own, separate blood supply from the right and left coronary arteries. If this supply is impaired pain or discomfort are experienced. If it is stopped a heart attack (otherwise known as coronary thrombosis or myocardial infarct) occurs.

Commonly - and this is what happened to me - the arteries harden, narrow and lose their elasticity because of waxy cholesterol deposits. Blood flow being restricted, a clot forms in the artery, blocking supply of blood to part of the heart. That part which is denied blood ceases to function and in doing so it usually causes pain.

I suffered discomfort rather than pain but I have been told that some people experience acute pain, whereas it’s possible also to have a heart attack and feel no pain at all. The speed with which Pat got me into resuscitation was a major factor in my recovery for the sooner the clot reducing injection was administered and the sooner I was on oxygen and under observation, the sooner the condition was able to be stabilized.

Once having blocked the artery, the clot can go no farther. The artery narrows. There is nowhere for the clot to go. The good side of this is, of course, that it isn’t going to move on and jam up some other part of
the works!

Why did I have a heart attack? This is an infinitely more difficult question. Accepting that the state of medical art today [1989] will appear crude in fifty years’ time, current wisdom gives us a series of standard ‘risk factors’ which we have to accept:

• Living a ‘Western’ way of life
• Smoking
• High blood pressure
• Fats and cholesterol
• Diabetes
• Overweight
• The wrong parents
• Lack of exercise
• Stress

I said earlier that I believe that every one of us, if we can be honest with ourselves, knows if there’s something wrong with us and has a good idea why. We know when we smoke too much. We know if we over-indulge. We know when we’re not getting enough exercise; because we don’t feel too good. And we know that if we discipline ourselves to treat our bodies a little kindlier we feel fitter, brighter and happier.

Don’t we?

I know with absolute certainty the elements in my life that led to my heart attack - both the primary and secondary causes.

The principal cause was stress. There were two fundamental stresses in my life both of which involved other people who, if I were to describe the factors, would be hurtful to them. I therefore have no intention of elaborating. In any case, there is no need to.

Of these two stress causes, one was far more serious and on-going than the other. Every day of my life for more than three years before ‘C-day’ I lived in repressed fury. My friends never knew. Neither did my colleagues. In fact, it was remarked to me by a number of people, that I was the last person they’d have expected to have a coronary.

Anger, hurt, resentment, frustration accompanied me like bad companions whom I tried to ignore. In the end they mugged me. But, to be fair, I helped them. I was overweight; oh, I didn’t have a big beer belly but I had that evenly distributed layer of comfortable flesh, hidden behind well cut suits and nourished by executive food, that so many of my peers have. I knew I was overweight; that’s why you’d never have seen me in a T-shirt! But I was still capable of pulling in my tummy, briefly, when I observed my side view in the mirror (also briefly) and I kidded myself that I was ‘well-built’.

I did not eat wisely. Breakfast was often cooked - bacon and cheese on toast being a favourite. I didn’t spare the butter. I never ate lunch because I felt that by leaving out a whole meal I’d control my weight. The trouble was that I’d eat up handsomely in the evening!

While my general diet was sensible (Pat saw to that) transgression was regular. I was partial to ice cream. I was addicted to chocolate. I relished a weekly ‘Quarter-Pounder-With-Cheese’. I enjoyed a glass of whisky although I was never much of a drinker. And I smoked an occasional cigar, having given up a moderate cigarette habit some years before.

Consequently, my cholesterol levels were a little elevated. I had known this for some time but I was not fully aware of the implications. On the other hand, I had only suffered high blood pressure on rare and traumatic occasions. For example, in October 1988, while visiting the USA, I had had an emergency kidney stone operation and my blood pressure had been raised enough to keep me in hospital for half a day extra. On all the other occasions I can recall having it checked it was ‘normal’.

I was not and am not diabetic. While being a middle-aged male put me in the danger area, I had no complaint about my parents who both lived to a good age and neither suffered early or chronic heart disease.

As for exercise; I had taken the attitude of Oscar Wilde - or was it George Bernard Shaw - that whenever I felt exercise coming on I would lie down until the feeling passed over.

I had, in my youth, played rugby and squash but not lately. I objected to taking exercise not associated with an end. I was perfectly happy to work hard, physically, as an adjunct to other achievement - lawn mowing, scrub cutting our ten acres, fencing, tree felling and logging, gardening and so on - but the idea of, for example, jogging was abhorrent.

Thus, overall, I had some of the contributory factors to heart disease. In essence:

• Severe stress
• Overweight
• Raised cholesterol
• Lack of exercise

Over the next few weeks all of these, plus a subsequent complication, would be addressed.

I came back into the house and switched on the television set. I cannot now remember whether the match had re-started for I then became aware of an oddness of feeling, a heaviness high in my chest; not painful, just uncomfortable, a bit like indigestion; a condition I rarely suffered. I felt a strange electrical tingling inside my upper right arm.

I became aware, also, that I was not cooling down. I was sweating more than before. I had a strong desire to walk about, to stride up and down the room, to try to walk away from this unpleasantness - something alien that I had never before experienced.

Soon I began to think the unthinkable. Soon a shiver of fear touched me. Could this be a coronary? Was I, at 56, experiencing the classic scourge of the middle-aged businessman? Or was I, perhaps, cossetting myself, making a fuss that would prove unjustified?

Should I shrug it off and not say anything? Or was I now old enough and wise enough to make a fool of myself?

I chose the last option. I called out to Pat.

‘I don’t feel well. Something’s wrong. I think I’m having a heart attack. Will you drive me to Auckland Public Hospital?’

There was no fuss, no panic. She, as always, could divine the true seriousness of the situation. She drove me briskly, sensibly, the twenty minutes to the city and, at my insistence, dropped me at Emergency to report to the desk while she parked the car.

‘I think I’m having a heart attack’.

To which she asked: ‘Have you been here before?’

I have never, to this day, worked out the relevance of that question and had no need to answer it for somehow I was dropped into a wheel chair and carted into the casualty station - the M.A.S.H. unit - that is the start of hospital emergency.

The clock on the wall read 2.50 pm. I had first felt the discomfort less than an hour ago. It meant little then to know that but I later discovered that the speed of my presentation at hospital was an important factor in my subsequent recovery.

Efficient nurses readied me for examination. I was hooked up to gadgetry that I could neither see nor understand. I felt disorientated, small, vulnerable, out of control. The room was impersonal, functional. It had the practicality of the laboratory or the lube bay of a service station. For a while - it seemed an age - I was left alone.

I have never in my life felt so lonely; so uncertain.