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Thursday, January 2, 2014

Reflections on a near-death experience

Now that it has been nearly two months since my cardiac arrest and resuscitation, I have finally found the leisure and the motivation to put fingers to the keyboard to gather some thoughts and feelings about it. Of course these include at least in part the sort of changes in attitude and philosophy people are commonly supposed to experience, but for the most part, my own experience seems different.

In my particular case, the way it happened was not a bolt from the blue, but during a test specifically designed to provoke signs of cardiac ischemia. I knew I had mild coronary disease, but I was on lipid-lowering medication, had a good blood pressure, didn’t smoke, exercised regularly, wasn’t significantly overweight, and had passed two previous stress tests. On the other hand, I had just come to the emergency room with chest pain. But on the other hand, (I guess that’s the first hand), my EKG and cardiac enzymes had returned normal. So the event was a surprise, but not a huge surprise. Nonetheless, it’s a bit daunting to know that there but for fortune, the event could have occurred on the airplane I planned on boarding that evening.

First, let’s attend to all the questions, truisms, and philosophic platitudes.

No, there is no white light. At least not in my case. Perhaps I wasn’t out long enough. (Although long enough to have a seizure and need CPR until the paddles were charged and shock administered. ) Or maybe I’m not headed in the “white light” direction anyway. On hearing of my failure to see a white light, a friend asked, “Well, how about a red one?” Or maybe I just don’t believe in a benevolent God who watches over me. In any case, there was no white light and I did not witness the scene from above. I would love to have had that opportunity to watch it though. However, the experience was that one minute I was walking and talking on the treadmill and the next minute I was being rudely awakened from a sound sleep by a slap on the cheek and a bustle of frenetic activity. Nothing spiritual about it.

Next, that thing about “no longer sweating the small stuff,” “stopping to smell the flowers,” appreciating “the big picture,” etc. I wish I could say I have been changed by the experience but I really haven’t. I’m still compulsive. I’m still what they call “Type A.” I still sweat the details about patient care. I still worry about stupid stuff. The same minor irritations still annoy me; in fact, they annoy me even more sometimes because I feel I have less time to be bothered. Mind you, I do smell the flowers, but I don’t stop. Flowers are nice but I have other things I want to get done. And to illustrate how little I have changed, I will relate an incident that occurred walking our dog in a park where picking up after your pooch is the law. It took me only a minute to realize my foolishness, but I actually had the temerity to tell my wife she was going about picking up the dog poop the wrong way. (I won’t explain my logic, but I thought she should start with the small turds and work her way to the larger ones.) She reminded me that I was criticizing a woman with a bag of dog shit in her hand, standing within an easy hurling distance. So much for stopping to smell things.

Naturally, having turned 60 last year, I spent a lot of time contemplating my mortality for 6 months before and really ever since that birthday. I was even thinking, the day before my event as I was driving to work, how beautiful the nearly bare trees looked in a sunlit morning mist, and how I would miss that sort of beauty if I was told my life would be cut short.

But since the arrest, the notion of mortality has taken on a more immediate flavor. I have always had the sense that we spend our days skating on thin ice and not knowing it, never realizing how it all could fall apart without a moment’s warning. Lately, that sense is keener. I am reminded of a rented DVD that has skipped a few times, frozen, and been rescued by going back a scene. If you have had that happen, you know the feeling that it might freeze again and this time not allow you to finish it. So you watch every moment knowing it could be the last you see of the movie. I never really have been able to “live in the moment,” but I think I have gotten a bit better at it. The other observation I have come to is a firmer conviction that the thing we spend the most time worrying about is never the thing that gets us. It is always something from a completely unexpected angle.

The awareness that my span on this mortal coil is finite leaves me with less patience for people or things that waste my time. I am quicker to throw out some item on my desk that I would have previously contemplated making use of at a later date. I am less inclined to have my philanthropy dictated by letters with appeals from charities that happen to enter my mailbox or appeals to add a dollar that are made at the checkout counter; I am going to make my contribution how I want to, when I want to, and to whom I want to, of my own accord.

For better or worse, I am less inhibited about expressing my feelings, both benevolent or angry. On the streets of Manhattan, my wife and I were nearly struck by an aggressive driver in an SUV who was turning right onto a side street as we were crossing the same street with a walk sign in our favor. I turned and thrust an accusatory finger at him. He rolled down his window. I yelled, “I had the green, buddy! “ He yelled back, “So did I!” I responded, “Pedestrians have the right of way, mister!” My wife, seeing he was half my age and fearing he might get out of the car to continue the discussion, tugged at me to continue walking (but only after she chimed in, “Yeah, read the book!”). As we walked on, I turned my head to look back and saw a crowd of pedestrians gathered around his vehicle scolding the man. I am not sure that before two months ago I would have confronted the guy. I guess I felt like, “I’ve been DEAD before, buddy, and you think YOU scare me?”

By the same token, I am much more liberal with my praise, generous with my smile, and generally more understanding of other people’s limitations and frustrations. I am nicer to everyone I encounter, even if they are dunderheads or nincompoops. After all, they are probably doing the best they can. I don’t hesitate any longer to say what I think, but I am quicker to forgive. (Exception: None of this applies to those jerks on the Merritt Parkway who think they will get there faster by first tailgating me in the left lane and then going around me on the right to cut in front when traffic is doing 65 in the passing lane, 60 in the right lane, and everyone is 3 car-lengths apart as far as the eye can see.)

I still think a lot about what it will be like when death does finally catch up with me. Will it be sudden, or will I be given a fatal diagnosis? Will I find that I have been obsessing about a healthy diet and exercise, only to learn I have pancreatic cancer next year? Or will something take me from completely out of left field? I know this much: I was looking back on my life this morning, waiting for some minor surgery with propofol sedation, wondering what I would choose to look back on. I found myself looking back on all the good times and not the bad ones. There have been many bad times, perhaps as many as good, but they seem to recede in my recollection. It is the joyful ones that stand out. Some people have criticized the effect that digital photography has had, allowing us to so easily edit out the bad images, unflattering takes, and blinked eyes. But memory does that too, and maybe that’s a good thing.

After my bypass surgery, and hospital discharge, I had the most uncanny sensation as I was being wheeled through the hospital lobby out to the car. Traversing the lobby was a crowd of people there, walking in all directions, most of them not looking down at the man in the wheelchair, each seemingly preoccupied with his or her concerns or plans. I was overcome with an acute awareness of each of them as a thinking, feeling individual with all of these cares and concerns, each with a life that was infinitely complicated with circumstances I would never know. It was reminiscent of that movie where the protagonist hears everyone’s thoughts, but for me like a world where I now almost expected I might hear them but knew fully I was deaf. That sensation has faded with time, but I think it can only be described as a heightened sense of empathy.

I guess one of the most positive consequences of having survived my experience is the feeling of gratitude that I have for my return to life, health, work, family, and all the joys of living. I am grateful to everyone who worked so hard to bring me back to health, people who number in the hundreds in one way or another. I am grateful to my good fortune, if not to a God who I have serious doubts about. I find it easier to believe I am incredibly lucky than to think that a supreme being should concern him or herself with the fate of one person on a planet of 7 billion souls among a galaxy with hundreds or thousands of planets occupied by millions or billions of equally sentient beings. It’s enough for me to thank my lucky stars.

David M. Sack, MD, is a Fellow of the American College of Physicians. He attended Harvard and Johns Hopkins Medical School. He completed his residency at Lenox Hill Hospital in New York City and a gastroenterology fellowship at Beth Israel-Deaconess, which he completed in 1983. Since then he has practiced general gastroenterology at a small community hospital in Connecticut. This post originally appeared at his blog, Prescriptions, a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

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Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Iowa City, IA, with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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