Not Having a Heart Attack

At about 5AM on Tuesday the 27th of October, I got up to go to the loo.

As I got back into bed, I realised I had a slight pain in my back, a bit above and in from my left elbow.  I stretched to try to shift it, and snuggled down to go back to sleep.

But the pain didn't go.  I fidgeted to try to get comfortable, but to no avail.  And then it started getting worse, like someone was poking me in the back with their finger.  Firmly at first, and then quite hard.

I've had pretty severe pain from a "locked" joint in my back before, so I wasn't too surprised, and just tried to get comfortable and relax.  But the pain kept getting worse: no longer like being poked with a finger, more like with a knitting needle. 

No matter how I moved about, it wouldn't go.  I could feel the muscles in my back contracting hard, and the guy with the knitting needle was joined by a friend pushing a nail down into the top of my left shoulder.

And as the guy began wiggling the knitting needle about, I began to think that it wasn't just a problem with a joint in my back.  The muscles in my side were in spasm now, and it was painful to breathe deeply.

What could it be?  Could I be having a heart attack?  Could I actually be dying?  I vividly remember considering that as a real possibility.

But I could feel my heart beating slowly and regularly -- which was not what I'd expect to feel during a heart attack.  And didn't heart attacks have pain spreading across your chest?  I didn't have any of that...

But clearly something was wrong.  I had to do something... but what?  Phone Danny downstairs to come up?  Phone 999?

I hauled myself upright, which hurt a lot, and sat on the bed to regain my composure while I decided what to do.

And I noticed that as I sat there, the pain more-or-less went away, so that  after a few moments I found myself sitting calmly, breathing normally, heart beating slowly and steadily, and only the feeling of someone poking me in the back with their finger...   Which didn't at all match my understanding of a heart attack. So maybe it was just a really nasty back problem after all...

I tried lying down again.  But within a few seconds, the guys with the sharp implements were at it again. Sit up: fine.  Walk around the room: fine. Lie down: sharp pain, rising quickly in intensity.  Nothing I'd heard about heart attacks (or that I read when I searched the internet -- yes, at 5:30 in the morning, I really did search the Internet for the symptoms of heart attacks) suggested that the pain went away if you got up and walked about. So, I decided, it wasn't a heart attack.  Which meant it must be something to do with my back after all.

I remembered that lying on a firm surface was meant to be good for your back, so I tried lying on the floor.  But I couldn't do it: before I could even get nearly flat, the guys with the sharp implements were at it with a vengeance and the muscles in my back and across my belly were in spasm.

Yet as soon as I stood up, and walked around, everything went back to normal...

I really didn't know what to do: dialling 999 -- or even waking Danny -- just for a back ache seemed absurd.  So I propped myself up in bed with pillows, and  turned on the radio while I considered my options

I was actually due to see a physiotherapist that afternoon, in connection with a problem I'd had with my knee, and so I decided that the right thing to do was to  "re-purpose" that appointment to see if she could sort out my back...  But would the let me do that?  Ambush her with a completely unrelated complaint?  I wasn't sure, so I decided it would do no harm to go and see the doctor, just in case...

For the next couple of hours, until it was time to get up, I sat and listened to the Today programme, and dozed.  Then I had a shower and got dressed, with only the kind of problem I'd expect from a back problem, and set off for the  9 o'clock open surgery at the University Health Centre.  As I was walking there, I found myself worrying that the doctor would feel I was making a fuss about nothing.  After all, the only symptom I had while I was upright was that if I tried to take a really deep breath, it triggered a sharp pain just in from my left elbow.  But the memory of lying in my bed a few hours before, literally wondering whether or not I was dying, convinced me that whatever had happened deserved at least some reassuring noises from Someone Who Knows.  So on that basis, I decided to risk the charge of hypochondria, and see a doctor anyway.

At about 9:40 or so, my turn came round, and Dr. Millar -- one of the doctors at the health centre -- called me in to his office and listened while I explained what had happened, emphasising that, although I was obviously fine now, I really had felt pretty awful a few hours before. He put a rubbery gizmo on the end of my finger, and a cuff around my arm, and we watched while red and green numbers displayed that my heart rate, blood pressure and oxygen levels were all entirely normal.  Then he asked me if I'd been on any long journeys recently (only one car trip to London, almost two months before), or had any surgery (I hadn't), or whether anyone in my family had ever had Deep Vein Thrombosis.  "Yes", I said.  My dad had suffered badly with DVT -- it had forced him to retire early from the Post Office, because he found it painful to stand up for long periods.   And in fact, he had died of a pulmonary embolism while recovering from straightforward stomach surgery.

A few more questions then led into one of the most unexpected experience I've ever had, certainly in a medical context.  Dr. Millar produced a tape measure, carefully measured a distance down my right shin, and then measured the circumference of my leg.  And then did the same thing on my left leg.  I've since realised that he was checking for signs of swelling in my legs, but at the time it seemed like something out of Alice in Wonderland.

After a few more questions about my dad, he said he was "fairly sure" that my problem had just been muscular, but he thought it was worth me having a few tests "just in case".   I waited in the waiting room while he made the necessary phone calls.  At first he couldn't get through, but at around 10:30 he came out and gave me a letter to take to an appointment at the Acute Receiving Unit (the what?) at the Western General at 11 o'clock.   Getting an appointment in just thirty minutes' time, and being told it would be better if I didn't drive there, made me realise that, far from thinking I was wasting his time, Dr. Millar clearly thought there was something seriously wrong.  At which point, the penny dropped, and I realised the significance of the questions about my dad's problems...

Hailing a passing taxi got me there with a few minutes to spare.  I handed in my letter, then found a seat in the waiting area with about half a dozen other people, and prepared for a long wait.

But within just a couple of minutes, a nurse appeared and called me in.  I sat on a trolley/bed while she took several blood samples and checked my heart rate and blood pressure, and then I gingerly sat back while she attached wires to my arms, legs and body and plugged them into a machine that printed a ECG, which she took with her in search of a doctor.

Within two of three minutes, she led me into the next room where, something like 10 minutes after I'd walked into the building, a doctor explained to me that my GP had asked them to check whether I had had a heart attack or blood clot.   Based on the ECG, he was pretty sure that I hadn't had a heart attack, but he couldn't say anything about the blood clot until he got the results of the blood tests, which would be back in about an hour.  So I should go and have a cup of tea, and return to the general waiting area by about 12 o'clock.

After a long half hour trying nervously sipping at a cup of tea and nibbling a panini, I returned to the waiting area just before 12.   The doctor re-appeared, and led me back to the office.  The blood tests had confirmed that I had not had a heart attack, but the test that should have ruled out a blood clot on my lung had not done so.  My result was inconclusive, and the doctor felt I should have a CT scan.  Unfortunately, he couldn't say when that would happen: although the scanner was invariably busy, they tried to keep some slots free for acute referrals, so I'd just have to wait for one of those slots-- and it could be a long time.

The nurse put a cannula in my arm, so they could inject stuff that would make the blood flow more easier to see on the scan, and I went back to the waiting area to, well, wait.

There was a television, high up on the wall at one end of the room, but since the sound was turned right down, the procession of talking heads and adverts was not really very engaging.  Until, that is, I saw my name on the screen.  I did a double take, but saw only adverts.  Then, briefly, my name was back: the caption introduced the next section of the program as "Judge R Inder".  It seemed pretty surreal, and I found myself thinking of the television series "Life on Mars", where the main action took place in the lead character's dream, and reality only impinged through what he sometimes saw on the television.   The opposite seemed to be happening to me!  That was fiction.  But what was this?  Why was I seeing my name on national television?

The TV show (the one in the waiting room, not "Life on Mars") was in a court room setting, where two women were standing in front of a guy dressed in legal gear, who was asking them questions.   Hence, I guessed, the "Judge" part.  But my name?

It was only at the next break for adverts that I realised what was happening: the caption actually said "Judge Rinder".  But it was set in all capitals -- as "JUDGE RINDER" -- using a font in which the "R" had a particularly long/wide sloping leg, so that there was a noticeable gap between it and the rest of the word.  So it appeared, at first glance, to be "JUDGE R INDER".

Once I'd refuted the evidence that suggested I might be in some kind of dream, I still had a long, nervous wait. Eventually, though, the doctor re-appeared, albeit with disappointing news.  It seemed the scanner was particularly busy that day, so they weren't going to be able to fit my scan into their schedule.  So they would be sending me home, and I should come back the next morning, and expect to be there all morning.  Oh, and they gave me an injection of Dalteparin, an anti-coagulant, in my belly, Just In Case.

I went home in a bit of a daze, mooched about the house until about 10:00, and then went to bed. My attempts to lie down quickly summoned the guy with the knitting needle, so I propped myself up with pillows and dozed the night away.

The next morning, armed with several magazines, I returned to the Western General, where a different doctor put a cannula in my other arm, and again sent me to the waiting room.  But not that long after a nurse appeared and led me upstairs to be scanned.

Someone had warned me that because you had to go in to a small tunnel within the machine, getting scanned was a pretty claustrophobic experience.  But actually, the machine at the Western General stands like a wall across in the middle of the room, and you just have to pass through a hole in a cabinet.  So it wasn't claustrophobic at all. 

Nevertheless, the scan was an horrendous experience.  I had to lie on my back, which I could just about manage, but doing so induced gradually mounting pain.  I did my best to lie still, and told the radiographer that I was in considerable pain.  Her reply -- that that was why I was having a scan, and she would have me out of there in less than 3 minutes -- did little to make the activities of the guy with the knitting needle any easier to bear.

But then it was over, and I was back to the  waiting room, where I again had the chance to watch Judge Rinder in action. Eventually, the doctor came to fetch me, and led me to the office.  The scan had confirmed that I did indeed have a "moderate" blood clot on my left lung - an "unprovoked pulmonary embolism".  "Unprovoked" because none of the usual causes of these things were present in my case -- it had, apparently, turned up out of the blue.

But regardless of its origin, the treatment was to put me on drugs that would make my blood less likely to clot.  That would prevent the clots getting any bigger, which in turn would allow them to be broken down in the normal way.  So I could look forward to 3 to 9 months on a daily dose of Warfarin.

Getting the right dose, though, was critical, and  so I'd have to come to the hospital so they could take a sample of my blood, measure the INR and then tell me how much Warfarin I should take that night.  And I'd have to do this every day until my INR was in the target range for two days. After that, my GP would take over the blood testing, and it could be less frequent... Oh, and until they did get the dose right, they'd be giving me a daily dose of Dalteparin at the same time.  Starting right then, with another injection in my belly.

On the bus home, I tried to piece things together.  The way the pain went away when I was upright, but started building up over several seconds when I was lying down, seemed to fit with a blood clot that was only partially blocking an artery.  When I was upright, at least some blood could get past it, and so the symptoms faded and all was well.  But when I lay down, things moved so that it cut off the blood supply to part of my lung.  Which started getting more and more painful...

So I got into a routine of sleeping propped up in bed, going down to the hospital to have needles stuck in me each morning, and then getting a phone call to tell me how much Warfarin to take each evening.   For the first few days, I saw a different nurse each day, but quite quickly I worked my way through the entire staff of the Ambulatory Care department, and soon new them all by name.

I got quite excited at the weekend, when my blood test was in the right range for two days in a row, which the doctor had said would be the cue for handing me over to the GP.  But it was actually more complicated than that, explained the Woman With the Needles: before they would discharge me, they wanted to see a stable, satisfactory INR reading from a stable daily dose of Warfarin.  And at that stage my dose was still varying, which meant I'd have to come back the following day for another blood test which, sure enough, was outside the target range.  In the end, I had another full week of daily blood tests and injections in my belly while they slowly increased my daily Warfarin dose to the point where my INR was in the middle of their target range.

Each night during the first week, I found I could lie a little closer to horizontal without pain, so that by the end of the week I could get a reasonable night's sleep.  But only on one side, mind: lying on my back soon attracted the attention of the guy with the knitting needle, and I could not even contemplate lying on the other side.   But aside from that, the real only symptom I had was the short, sharp pain when I took a really deep breath.   I say "real" symptom, because I was incredibly aware of every little twinge or ache -- "was that pins and needles in my leg?", "did that brief, sharp pain inside my hip when I first moved signify anything?".

Then, as I was coming down stairs a couple of days ago -- a bit over two weeks after my Nasty Night -- I noticed that I felt different.  My arms felt "loose", and moving was easy.   And, indeed, I could take a deep breath with only the slightest hint of pain right at the very last moment.  At which point I realised that for the previous two weeks, I'd been subconsciously tensing the muscles in my trunk.

So now, I think I am on the road to recovery.

However, I've clearly got quite a way to go.  I tried going to table tennis practice on Friday, and although I didn't experience any pain, I did have to sit down for a rest after maybe ten minutes of gentle knocking up, and after doing that twice, I was pretty shattered, and very grateful for the offer of a lift home!

I must say the medical treatment I received was really excellent.  The GP took my complaint seriously, the hospital saw me within minutes of arriving there, and everyone I encountered on my numerous subsequent visits did a grand job.

At one stage, I definitely felt that they could have raised my Warfarin does more quickly, and thus saved me the time and discomfort of several trips to the hospital to have needles stuck in me. That, of course, is only natural for the one who has to spend the time and endure the discomfort without any knowledge of the problems that could be caused by getting things wrong.  But it also highlighted what I believe is one of the most important features of the NHS.

If the hospital had been a commercial organisation, they would no doubt be charging (either me, or my insurance company) hundreds of pounds for each blood test and Dalteparin injection.  They would, therefore, have a strong financial incentive to take their time over getting the dose right.   But within the NHS, I could be confident that there were no such factor in play, and that those who were cautiously inching my dose upwards were acting purely in what they judged to be  my best interest. And I think that is very, very important.