Posey was able to follow all of the simple directions I was giving him. As we were bathing, I’d ask him to lift his chin, or turn his head a little, just to see if he could do it. As the bath progressed, I asked him to move most of the parts I thought he still commanded. He moved everything for me, at least a little, but then, I'd set the bar pretty low. I was checking to see that the parts all worked, and that he could follow commands. Until he did it, I wasn’t sure he could.
He was answering my open-ended questions with yes or no grunts; he was becoming non-verbal. It was as if the things of speech had become an extra demand on him; that speaking had become a heavy labor; that forming words and then finding enough air to expel them was a vanity he could live without.
His respirations were becoming more labored. Instead of allowing his breaths to come to him naturally, he was fighting them, using the muscles of his upper chest to try to force the air into him.
Normally, you don’t take a breath of air, the breath takes you and comes into you when you stop trying – when you relax the muscles of the diaphram and allow the air to simply fall in. The body isn’t set up to make you work to breath air in – it’s designed to make all the work in the breathing out. The natural vacuum that’s produced with exhalation functions to draw the next breathe in without you even trying. High to low, goes the saying; it’s the universal law, and usually on the final exams of most science classes.
Listening to his chest, I heard crackles of fluid that sounded like carbonated soda. The noise of bubbles started low and ran about a third of the way up his chest. The heart rub I had heard the day before was also more noticeable, I could now hear it with every breath in, as well as out.
Posey’s abdomen was white, tight and distended. I could have bounced a quarter off it and poked my eye out with it if I tried. I listened with my stethoscope and heard none of the normal tinkles and gurgles coming out of it – the belly was hypo active – again, as if the body had better things to do with the energy available to it than to waste it in digestion.
Urine still collected in the bag hanging from the side of the bed – but it was dark and cloudy, and not much of it.
Posey’s legs and feet continued to be swollen, a bit worse than the day before, and they were icy cold when I lifted them up to bath the backs of them. I felt for pulses, checking each ankle for a minute. I pretended to feel pulses coming from each side, but it might have been a wish on my part, and I would not have bet much money that they were actually there.
Posey’s body was compensating for the damage done in his heart the day before, and it was clear that his body was not functioning within the normal rules and expectations of equilibrium.
The body lives to be in balance. Most of its functional activities are set up to do whatever they have to do, and then return everything back as quickly as possible to a steady type of baseline. The body is both conservative and boring, it wants things to stay the same – balanced and stable. The body is the sort of living thing that if it had not been programmed to do stuff, it would be happy to come back in its next life as a lump of coal.
There is a name for what it does – homeostasis -- not too much and not too little. The body is a nervous Nelly of a structure, unfortunate in having to do the functional job of herding cats in this life.
“Just get them in the bag Leonard,” the body says, “I’ll take it from there.”
When the body gets out of whack, it tries to get back to normal by compensating. Compensation takes different forms. The body shuts down the parts of it that it feels it can lose without dying – complex thought, eating, pooping and comedy. It shuts blood away from what it decides are non-critical organs, and then cuts down what it gives to the rest -- these legs are just extra weight, do I really need both kidneys? How smart do I really need to be? Decisions get made, slowdowns and shutdowns occur. The body compensates for damage in this way until it doesn’t --until it decompensates.
Compensating is like climbing up a ladder to the top of a diving platform at a local pool. It’s slow, one rung at a time, with pauses to look at the changing scenery and to enjoy the new perspectives that the increase in height allows for.
Decompensation is what happens when you get to the platform and jump into the pool. It’s fast, but the view on the way down doesn’t look anything like the view on the way up.
Posey was making the climb – his body was giving up the things of life – eating, talking and passing gas. He was getting ready to jump.
As I finished all my bathing and evaluating, the monitor above Posey’s bed bonged in alarm. I looked up and saw that his heart rate had increased to 140 beats a minute, and that the rhythm of it was now irregularly irregular. He was now in atrial fibrillation.
The mechanical part of the heart is flashy part, it’s in your face and obvious. But the heart is also wired to conduct electricity and this is the part of it that actually animates the show off meaty part.
The heart is a group of individual muscles that meet, connect and then agree to do the same thing at the same time. It’s a true dictatorship of the proletariat. On TV shows you hear the expression “bag of worms” to describe a dying heart. The worms they describe are the individual cells of heart muscles that, in the process of dying, start working independent from each other.
It’s like bad capitalism, when each individual muscle of enlightened self interest gets greedy and runs amuck. It leads to the general anarchy of grab as grab can, and every muscle becomes all for itself. Without the structure of common purpose, the cells stop work together --they all begin to die alone – individuals and small groups of cells now wiggle alone in a bag, squirming for the sweet release from the bondage of self.
The electrical control panel in the heart, the main switch box, is usually located around the top of the right ventricle, or lower Right atrium. From this area, an electrical pulse is generated and travels to the atriums (so they contract first,) then it conducts its way down the path to the ventricles, causing them to contract a few parts of a second later. This is a single heartbeat.
The switch area is called the sino-atrial node. It consists of bundles of specialized heart cells that are connected to pathways of conducting fiber. The pathways spread out, and in their spreading, hardwire the heart with pathways for electricity. When the specialized bundles fire a chemical pulse, that’s converted into electricity, the hardwire connection carries the pulse to all of the heart muscle, making the individual cells beat together in one large contraction. It’s not always this straight forward, but this is, in a general way, the primary way the heart is structured to function.
The sino-atrial node may misfire if the area around it dies or becomes swollen, but with a massive heart attack, it’s usually the irritability that causes the heart to misfire. Dead tissue is full of acids and chunky minerals that have been released by the death of heart cells—it’s irritating, and when the juices leak away and touch the damaged areas next to it, it can cause them to misfire. If you think of the sino-atrial node as the command center and all the individual muscles soldiers -- they may all be planning to “wait until you see the whites of their eyes” to fire, but just one muscle firing too soon or too late can start a cavalcade of contractions. Heart muscles not working together can also be thought of as death.
Atrial fibrillation is less a problem that the ventricular kind. Ventricular fibrillation is when the muscles in the thick bottom, primary part of the heart begin to contract randomly. When this happens, the pump fails and the random individual parts that are firing randomly eventually give up their individual battles, and the heart stops. Ventricular fibrillation, if not corrected, is a fancy word for death. This is the thing that people who play doctors on TV get the paddles out for. It’s the one thing that you can shock people out of successfully. It’s the reason large companies and airports keep portable defibrillators available in their buildings.
It’s like the slap in the face you give a person acting crazy under stress to get them back on the right page, only with electricity and not an open hand.
Atrial fibrillation, though a problem, is something that can be lived with, but is not a thing to be desired.
The sino-atrial node is located between the atria and the ventricle. When the pathways to the atria are blocked, the atria lose the metronome that controls their rate of firing. They begin to beat randomly, and at their intrinsic, programmed rate of fire – usually more than 60 times a minute, but up to 200, if they feel the urge. The atria do not provide the major part of the hearts contraction, but do add a substantial kick when working correctly (10-20%.) When they fire randomly, they lose the kick and the heart loses a measured amount of its efficiency.
Posey did not need to lose efficiency; he was on the edge and ready to slide down it already. The treatments for atrial fibrillation were Digoxin and cardioversion. Since he was already on Digoxin, I started getting the equipment together for cardioversion, and called Dr. Q.
To cardiovert someone from a bad heart rhythm to a good one, you carefully applied a judicious amount of electricity to them and hoped the jolt would change things. The shock stopped the heart and allowed it to reorganize for a second, to depolarize then repolarize -- and to then start again fresh and all of the same mind and habit
Cardioversions were usually done electively, with an anesthesiologist standing by to give sedation, a signed consent form, and a psychologically prepared patient.
I talked to Dr, Q. We decided to go old school and do it ourselves, just the two of us.
I brought in the defibrillator from the hall and plugged it in. I managed to catch Mrs. Posey on her way back to the room, and got her to sign a consent form for the procedure. I asked her to wait in the waiting room until the procedure was over – because some things are uglier than they look, and a cardioversion was one of those things.
When Dr. Q arrived, I lowered the bed and removed Posey’s gown. I spread a salty conducting gel on the top, right side of his chest and then applied the gel to the lower left side as well.
After giving Posey 5mg. of Valium intravenously, Dr. Q. picked up the paddles from the cart, placed them on Posey’s chest, and shocked him with 100jewels of electricity from the defibrillator. Posey screamed like a little girl and jumped up in the air while thrashing his arms. Dr. Q. put the paddles down and looked at the monitor.
Posey was back in a regular rhythm, but the rhythm was still fast and ugly looking.
Valium was given to relax Posey for the procedure, though he was fairly obtunded at the time anyway. It was also given for its hypnotic effects -- Posey would not remember the cardioversion when he woke up, though I imagine it might come back to him late at nights when alone with his own thoughts.
I elevated Mr. Posey’s bed, and checked to see if he was still breathing. I cleaned up the empty wrappers, scattered pads and other pieces of disposable equipment and supplies, and then dumped them in the trash bag hanging by the door.
As I took the defibrillator out of the room and back to its place in the hallway, I noticed Linda L. standing by the door, watching the monitor. As she turned and walked away she said to me, “Better, but still ominous.”