Winnie was accompanied by her daughter during that first office visit for a cardiac consultation. The primary doctor was concerned that Winnie's symptoms of progressive fatigue, together with her ejection heart murmur, suggested aortic valve stenosis. Winnie was 95 years old and a widow. She had reluctantly moved from Maine to Boston to be near her only child. Winnie had been living alone on her small farm in Maine, and she now wished to remain independent in her compact apartment.
“. . . for the secret of the care of the patient is in caring for the patient.”
Over time, I learned that Winnie had been born, was raised, and had remained on a patch of land in Maine that she called home. She had married her high-school sweetheart, Norman, on her 20th birthday. They had a lovely baby daughter who later left the homestead to attend an out-of-state college. The daughter ultimately settled in Boston, where she married and had a son.
Norman died suddenly of a heart attack at age 42. In spite of that huge loss, Winnie continued tending to the farm. She was resilient, and over the years had learned to fix a tractor, perform varied home repairs, enjoy several crafts, and self-direct her education by avidly reading books and newspapers.
During that first office visit, while she was seated on the other side of my desk, I intently watched and listened to her responses during the history-taking. I noted that her thyroid gland was symmetrically enlarged and sensed that this alert lady with thinning gray hair and a weather-beaten, wrinkled face was a salt-of-the-earth citizen.
Her chief complaint was “feeling old.”
I asked, “When did you first get that feeling?”
“Oh, about 6 months ago,” Winnie replied in all sincerity.
The examination revealed an enlarged thyroid gland, sluggish knee and ankle jerks, and signs of noncritical aortic stenosis. Results of blood studies confirmed a hypothyroid state. An electrocardiogram revealed modest left ventricular hypertrophy, as well as prolonged atrioventricular (AV) conduction. A chest radiograph showed a slightly dilated aorta and striking aortic valve calcification that was the most likely cause of the AV prolongation.
I dutifully called the primary doctor with my recommendations and mailed a copy of the consultation to him, as well as to Winnie. The primary doctor agreed to institute a thyroid-medication regimen and requested that I again consult on an annual basis to monitor the aortic stenosis.
For the next couple of years, Winnie's condition remained stable, with slight progression of her aortic stenosis and prolongation of her AV conduction delay. She had abundant energy and arrived unaccompanied for her visits, which were highlighted by this feisty patient's telling me about local or worldwide problems and their solutions, and my telling her, with a wink, that she was “far wiser than her years.”
At age 97, Winnie suffered a crisis after ignoring a dizzy spell; this was followed the next day by a witnessed fainting spell. The diagnosis was intermittent heart block. The treatment was a dual-chamber pacemaker.
Winnie availed herself of my office-based pacemaker-monitoring service. Through more frequent visits and transtelephonic pacemaker transmissions, we developed a close bond.
When Winnie was nearing 100 years of age, she resisted her daughter's wish to plan a 100th-birthday celebration. She never expected to live so long and confessed to me that she was fated to die before her 100th year. I tried, without success, to reassure her that there was no obvious barrier to achieving that goal.
I was awakened one night at 4 am by the ring of my bedside telephone. It was Winnie, announcing that “my time has finally come,” because she had heard a loud, continuous, repetitive oscillating sound that seemed to be coming from her heart or chest. She was certain that doomsday was upon her. “I will place my phone on my chest and you will be able to hear it, too,” she said. Actually, I could hear the sound without her offer.
Before calling me, while anxious and frightened, Winnie had paced the apartment from room to room and was convinced that the strange sound had stayed with her. After some questioning, I ascertained that she physically felt well, and that she believed the sound emanated from her chest and her death was imminent.
Pacemakers do not trigger an alarm when their batteries are low, as can be the case with some models of implanted cardioverter-defibrillators. I had no explanation for this strange circumstance, so I advised Winnie to go to the emergency department of the hospital where I would meet her. The staff was alerted to expect her arrival. While driving to the hospital with a clear mind, I realized that the loud, frightful sound that I had heard on the telephone had a familiar quality—perhaps that of a common alarm clock. Might that be the case, I wondered? If so, the sound should have changed intensity when Winnie moved about the apartment and should have ceased when she left to go to the hospital.
Upon my arrival at the emergency department, Winnie greeted me with a frown and told me that it was her bad luck that the sound had disappeared. “Now,” she exclaimed, “we might never know the cause—especially if it was my heart!”
After ascertaining that the pacemaker was in perfect order, I inquired whether Winnie had a bedside alarm clock. “Come to think of it, I do,” she replied, “a brand-new one that my grandson got me. Very complicated with a radio and other gadgets. I couldn't set it up, so he came over yesterday and got it going.”
With that information, I assured Winnie that this incident was a false alarm, that it wasn't her time to go, and that she would have a joyous 100th-birthday celebration. And that she did.
From: Harvard Medical School and the Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts 02215