Hustle and No Flow

Adapted from MWJ 2006.10.31

Getting MWJ out the door is basically a three-stage process. The first two stages involve making MDJ: first we read all the news and find the patterns and figure out what's going on, then we tell you. At the end of the week, we pick the most MWJ-like parts of MDJ, editing down the content to a suitable length, and publish an issue.

As the summer of 2006 advanced, I found that I was running out of energy way before we got to stage 2. In late June and early July, I started noticing what felt like a normal summer cold - sinus drainage, possibly exacerbated by allergies. This led to coughing as my lungs got congested.

This is nothing new for me - I had severe hay fever as a child, and I'm used to random congestion and drainage, periods of time where I go through Kleenex?-brand facial tissues (see the proper trademark use?) like sports spectators go through potato chips, and other respiratory inconveniences. I think I first noticed it really bothering me the week of 2006.07.17.

When it was still bothering me the next week, I called my doctor and talked to him about it, asking if I needed to take anything to shake it so I wasn't bothered by it during WWDC in San Francisco. (I knew I had to go to WWDC this year or else we'd never understand what's going on with Leopard. Missing WWDC 2002 where Jaguar debuted taught me that much.) My doctor prescribed a five-day antibiotic course that ended just before I left for San Francisco.

Unfortunately, it didn't solve anything. If you saw me at WWDC, you may have noticed that I looked tired. Walking just the three blocks from the hotel to the conference left me breathless, something I ascribed to my lungs being filled with crap from my sinuses. I'd also been gaining weight, because when I start getting sick, I tend not to eat very well, so it didn't seem like a mystery. I made it through the week, but it was exhausting.

Your body and mind do try to compensate for their failures - I knew I wouldn't have nearly enough energy to publish issues from WWDC, a task that, even in perfect health, is massively exhausting. That's why we started the subscribers-only WWDC 2006 Weblog, where John Welch and I posted live updates from the venue. Blog entries aren't as polished as normal MDJ articles, and there's not as much connecting of the dots, but it was a good way to get information out and spend less time doing so. My lack of energy left me less time, so it was a decent compromise.

When I got back home after WWDC, I called my doctor again, since the symptoms were at least unchanged and probably worse. That's when we got serious about it - he prescribed Cipro, one of the heavy-duty antibiotics, as well as renewing an antihistamine prescription and adding a new one for a narcotic cough syrup. That was good cough syrup. It worked really well - it tended to make me loopy for an hour or two, and I was to take it every four hours, but it really stopped the coughing. I treated this week or ten-day period as if I was actually on sick leave. I didn't try to do much work, especially since we'd just published the equivalent of 30 pages of live WWDC coverage. Being able to rest for a while felt good.

I kept up a normal schedule of activities, but I was just too exhausted every day to get to Stage 2 of publishing MDJ after completing Stage 1, which takes several hours per day on its own. By now, I'd been "sick" for over a month, and I wanted some answers. I found out that I felt "better" after being out of the office for a day or two, so I started wondering if there was some kind of "sick building syndrome" going on.

We mentioned on our news blog in July and August that the GCSF Production Studio has its own separate heating and cooling, and that the cooling simply was not keeping up with the many weeks of triple-digit temperatures we experienced this summer. At one point, we had two fans plus the heat pump going just to try to keep the indoor temperature to around 80°F.

After realizing I felt better outside the office than in it, we took another look inside the heat pump. At the same time I started the first antibiotic prescription, we had removed the heat pump from its housing and found a thick layer of algae and collected water, which we removed, sanitizing it before putting it back in place. Yet just days later, the sound of water collecting in it meant that it wasn't operating well. We tried removing the water by hand as best we could, but it was a stopgap measure. When we removed the collected water manually, the heat pump cooled more efficiently - for about four hours, and then water had collected again to the point of gurgling sounds.

On Labor Day weekend, after two days out of the office had left me feeling better than the previous two days in it, we took another look at the Production Studio's heat pump. Even though we'd cleaned and sanitized it less than four weeks earlier, it looked like it hadn't been cleaned in years. This time, we looked carefully and noticed that the heat pump was not draining the water at all. In fact, we couldn't figure out how or where it was supposed to drain the water it took from the air as part of "air conditioning."

This was not the original heat pump installed in the studio, but rather a replacement we obtained new in 2001. While it fit the original housing, it was apparently designed for a different case or to sit at a different angle. When it was installed in our studio's housing, it simply did not have any drainage apparatus in the bottom that would allow collected water to escape. The only way dehumidified water could have escaped would have been for it to be installed at about a 30° angle, and we can't even picture how that would work. In short, I have no idea how the water was ever supposed to get out of the thing, though clearly it did for the first three or four years it was in use.

Finding no way for water to escape, we chose to drill holes in the bottom of the unit to let the water drain. That solved it - lots of water drains every time the air conditioner is on, and even with some 95°F temperatures since Labor Day, we've kept cool without using even one extra fan. I also found signs of mold on the indoor ventilation parts - unsurprising since water had been collecting there. We got rid of all of that and sanitized it again, and since then, there's been absolutely no problem with cooling, mold, or (now) heating.

This is why I thought I had been suffering from "sick building syndrome" - I had respiratory problems all summer, and here was solid evidence that bad stuff was in the air. Even if there were few allergens, the studio was hot and humid, which makes it harder to breathe and stresses your circulatory system. What's worse was that all the time I had been in the Studio trying to get work done "in spite of" my cold or flu or whatever it was, I may have just been making myself more and more ill.

Nonetheless, by the end of that week after repairing the heat pump, I did not feel any better. I'd completed the Cipro treatment, and the narcotic cough syrup had run its course, and I felt just about like I did before I started those treatments. The cough syrup was not having as much effect as it did when I started it, and if I tried to not use it, I would cough like crazy but without "producing" anything. My doctor asked for a chest X-ray, but it looked clean, so he renewed the cough syrup and told me to call if it didn't help. I got out of the office that weekend, but I was clearly having more trouble breathing than ever.

I went to Norman for the University of Oklahoma football game that Saturday (2006.09.09), remembering that I had felt better outside the office, even though we'd now cleaned and sanitized the air systems here. When I go to games, I wind up walking about a mile across campus three times during the day. Each of those times, I had to stop and rest along the way five separate times. I'd never had to stop and rest on that walk before this year. Once I arrived somewhere and sat down, I was fine, but even the shortest walk exhausted me. It was like I could only take half a breath, and even that half a breath didn't have much effect.

The following night, I was coughing so hard that I actually bruised some rib muscles. I had to hold my hand over my ribs to cough without making that worse. I was trying to get back into the swing of things the next day, knowing there would be iPod announcements the following day, but that night I couldn't even sleep - I could barely lie down without engaging in a coughing fit. At 2AM on Tuesday, 2006.09.12, I decided that I would go to my doctor's office as soon as it opened and tell him the truth - I couldn't really breathe. I would ask for some oxygen, or a more intense respiratory treatment.

The doctor normally wasn't in the office at that hour, but he happened to stop in before making hospital rounds and he saw me. He listened to my chest, he noticed the weight gain, he saw swelling in my feet and ankles, and he told me that he wanted me in the local hospital immediately.

On the way to the hospital, I heard Macworld editorial director Jason Snell on NPR discussing Apple's announcements to come two hours later, predicting that Apple would announce something very much like what we now know as iTV. I had sat next to Jason during the "Time Machine" session at WWDC just a few weeks earlier, so hearing that while driving up to the emergency room door was a bit of a surreal moment.

What really happened

After a couple of days of diagnosis, the doctors found the answer: no later than late June or early July, probably a week or so before I noticed symptoms, my heart began to fail. I've been exhausted and out of energy because my heart is not pumping as much blood as my body would like to function properly. The term is congestive heart failure, or CHF, though some doctors are starting to call it just "heart failure."

As it was explained to me, the body is as unprepared for the idea that the heart might fail as most computer diagnostics are for the idea that the processor might fail. If a memory test writes specific values into memory and reads them back, it fails not only if the RAM is bad, but also if the processor doesn't get the values right. However, few diagnostic utilities imagine that it's the processor at fault - they tell you that your RAM is bad and that's that.

Similarly, if the body detects that there's not enough blood flowing from the heart, it presumes that the heart is fine, so the answer must be that you need more blood. The body then sends signals that you're dehydrated and starts retaining as much fluid as possible, believing that you'll make more blood from it. However, since you don't really need more blood, the fluid collects in the body instead - in extremities, in your tissues, and eventually in the lungs and around the heart. When the heart is surrounded by fluid pressing on it, it has to work even harder, reducing blood flow further, and starting the kind of downward spiral that leads to the blue screen of - well, for my sake, let's just say a "panic."

I'm no doctor, and honestly, I think I'm more of an impatient than a patient, so I probably still have some of the details wrong. There was no real warning sign for this - although there is a history of heart trouble in the family, it's not this kind, and it wouldn't show up for another two decades or so anyway. I've long been overweight because producing MDJ is not exactly aerobic activity, but there was no sign that I have blocked or congested arteries, a diagnosis that's since been confirmed. That leaves the "best guess" as that some kind of random virus struck me a while back and damaged the heart muscle, starting the cascading failures.

[Note: the full name for the cause of the CHF is idiopathic dilated cardiomyopathy, where idiopathic means "no known cause".]

It was not trivial to diagnose - even once I was in the hospital, the first thing they did was an EKG, and it was perfectly normal. It was the next day before an echocardiogram (an ultrasound of my chest and neck) revealed the problem - my heart was pumping less than half as much blood on each beat as it should have. For those of you who know about heart problems, they estimated my ejection fraction at 23, where normal is 50 to 65. If it gets down into the low teens, they start talking about "transplant lists."

Once they made the diagnosis of CHF, I was to be transferred to the Oklahoma Heart Hospital, but that didn't happen until the next morning because OHH had no beds. The real treatment began the night before in the local hospital - I was put on a diuretic to help me shed the retained fluids. It worked better than anyone might have imagined - I lost 22 pounds in 26 hours by shedding fluids, all via the way you're likely imagining right now.

I went through more X-rays and respiratory tests at OHH, but once the fluids had largely been eliminated, the associated pneumonia cleared up within about 18 hours. I was able to go home two days later, on 2006.09.18, getting home just in time to see the Sooners lose-but-not-lose to the Oregon Ducks. Two days later, a one-hour trip to the grocery store really exhausted me. I was worried, but that following Friday, just four days later, I got out and walked around the Oklahoma State Fair (on the annual GCSF Field Trip) and the latest OU football game - and I was able to make the cross-campus walk all three times without stopping to rest.

Yet a grocery shopping trip two days later exhausted me again, probably because unlike the other activities, I had to carry a lot of stuff around and push a cart for a while. It took a few weeks before grocery shopping didn't wipe me out. Also, for the first two weeks after discharge, it was really hard to sit up for long periods of time - I lost so much weight so fast that my back muscles were not used to the new distribution of mass. (That really hurt at the first post-discharge football game.) These problems made it hard to move on to Stage 2, despite having caught up on news and E-mail by then.

The October story

For those of you who read most of this in MDJ 2006.09.28, provided in the subscribers-only MWJ RSS feed, I should note that this section is new, since that was a month ago.

During the first week of October, I returned to OHH for a "left and right heart catheter lab." This is basically where they poke a hole in my femoral (leg) artery and snake a camera up to my heart to look around and check for arterial blockages or other impediments to blood flow. The procedure, on a Wednesday, was supposed to leave me loopy for an entire day and weak for a day after - my sister, who also happens to be a registered cardiac ICU charge nurse, told me that I'd have to lie flat on my back after the procedure for four to six hours, staying flat, to make sure the blood clotted to keep the femoral artery closed. I was told to expect that the anesthesia for the procedure, while only local, would leave me loopy for much of that time, too weak to drive home, and probably not able to remember the procedure itself. I was supposed to be weak the next day, too.

If they found serious arterial blockage, I was told they would put a stent in my arteries right then to improve the circulation, and would have to stay at the hospital overnight. If something went wrong implanting the stent, I would have emergency open-heart surgery right then and there so I didn't bleed to death. That, of course, would require months of recovery, but I was told it was unlikely. Understandably, I pretty much cleared the week for the procedure and its after-effects: we got MDJ 2006.09.28 out the door the week before, but I didn't think I could get caught up before going into the cath lab.

As it turned out, it was all unlikely - there were no complications and I have no arterial blockage, but my ejection fraction had not improved any over the preceding three weeks, either. At this point, we learned that it's more about preventing further damage to my heart. There is a small but significant chance that a certain medication can help me recover some EF over time, but it is far from guaranteed. The procedure was nothing like the fears, though - they inserted a medical device to close the artery that would dissolve slowly over the next two to three months, so no lying down for six hours waiting for clots. I never lost consciousness, I remember it all even today, I didn't feel loopy at all, and we left the hospital less than two hours after the procedure was done.

The three-hour cath lab procedure cost more than twice as much as two days of staying in the same hospital. Since then, my stamina has mostly recovered. I found out in a follow-up visit last week that I feel dizzy after arising from a seated position, but not from reclining or lying down, because my heart isn't pumping enough blood - some of it collects in my lower extremities. When I'm reclining or lying down, that's fairly evenly distributed over the length of my body.

When I'm sitting up - that is, working - it collects in my feet, and it takes a few seconds for enough to get all the way up to my brain once I stand up. I may have to find a way to keep my feet elevated more while working, even though my current (and expensive) office chair that keeps my back problem in line doesn't allow for it. That's not a problem for today, though.

What's next?

The summer makes a bit more sense now, even if only in hindsight. Reduced blood flow means reduced energy, explaining why no matter how hard I tried, I couldn't get back on a regular schedule after some building repairs in early July. I could sit down and read hundreds of articles and even write in short bursts, but long-term effort - even writing effort - just exhausted me. I thought it was because I had breathing problems, and while that was part of it, it wasn't the real story.

I've regained a lot of strength, and don't have to stop for naps as I did for most days in the first month or so, but that's not all there is to the recovery. To help keep my body from retaining fluids while my heart muscle tries to recover, I'm now on a low-sodium diet. Since the body retains fluids to keep sodium at a pre-set concentration, the more sodium you eat, the more fluids your system retains. By "low-sodium," the doctors mean 2000mg or less of sodium per day, just slightly below the USDA recommendation of 2400mg per day. (It's 1500mg per day for people aged 50 and over.)

This sounds easier than it is - most American adults eat somewhere between 3500mg and 4500mg of sodium per day, and perhaps more if it's in convenience foods, the kind that busy guys like me have relied upon. A single fast-food bean burrito typically has over 1100mg of sodium. A can of soup has nearly 2000mg. Almost every fast-food salad or sandwich tops 800mg by itself, and many of them top 1600mg.

I now have to spend several more hours per day than I did before thinking about and preparing my food so I won't eat too much sodium. It's not just salt - baking soda is sodium bicarbonate, and baking powder is largely baking soda, so even quick breads can have huge amounts of hidden sodium. That's not even mentioning the dreaded MSG that may mean no more visits to Chinese restaurants. I even had to get rid of my long-time over-the-counter favorite, Alka-Seltzer? Plus brand cold medicine. It effervesces because of sodium - nearly 1000mg in a two-tablet dosage. I can't drink half a day's sodium allowance in one glass.

I'm getting better at the new dietary restrictions, but it still takes time I'd rather spend getting issues out the door. Yet I know it's something I have to do. It gets easier as I get used to it - sandwiches are easy if I have low-sodium bread and fillings, soups are easy if I have very low sodium stocks (most commercial "low sodium" stocks are still about 500mg per cup, but I've found some with about half that much), and so on. It's a matter of getting into a new routine. Avoiding processed foods has also helped me lose another 22 pounds since being discharged, though I still have lots to go.

Now that the heart cath lab is over, I'll need a sleep study to determine if I need apparatus to help me breathe during sleeping hours, since sleep apnea can be very hard on a heart, especially one that's trying to heal. Even so, I have to say that getting rid of the extra fluids has made it so that I almost always sleep through the night after taking simple over-the-counter pain relief for my back with low-dose antihistamines (think "Tylenol PM" or "Nyquil").

That's been a double-edged sword. For the past year, I've wished I could sleep seven to eight hours straight through and haven't been able to. Now I do, but when I get tired, I conk out fast - it's very difficult for me to stay in the office to get an issue done, even if it's only an extra 90 minutes. One night, I got very tired in the early evening and slept for a few hours - but that long nap let me write until the early hours the next day and get an issue out.

There's still a long road ahead of me, and the past three months of almost silent running have been evidence of just how hard it's been. It's taking time, but I think I'm ready to resume an MWJ schedule that should deliver you at least three issues in November and four in December. We had considered a 2007-2008 MDJ Power 25 for January 2007, but since the last one happened right about the time my heart failed, that's now right out.

Trust me, I'm not leaving all this behind - give me broadband, a comfortable chair, a 23-inch display and a reasonably fast Mac, and I'm doing this until I can't do it anymore. If it hadn't been for MDJ and MWJ, and a decision about five years back to provide me with medical insurance, I might not be here right now. Keeping that insurance is now one of my highest personal priorities, and the way to do it is by providing the issues of MWJ that you and I have both wanted, but that my mysterious malady kept me from producing. The one-month period between 2006.09.12 and 2009.10.12 generated over US$25,000 in medical bills, and we all know they're going to try to make me pay as much of it as they can.

We'll also get the subscription database straightened out - I did something funky to the receipts code before I went to the hospital, so most of you have not received receipts for charges since about 2006.09.06. Sometime this weekend, we'll write new database code to send everyone a current status report - dates of charges, next renewal dates, RSS URL, usernames, passwords, and anything else we can think of that might be useful to you. We should have made that possible some time ago, but now we need it, so it'll happen.

It was supposed to happen after the heart cath lab, but I thought we'd have MWJ out by then. The original plan was to finish up the "MacBook Wi-Fi Hack" story that started in MDJ 2006.08.30, before I even knew what was wrong. I don't know why, but after the hospitalization, for a few weeks, the idea of a blank page in Word just knocked me out. I knew pretty much what we wanted to say, and in what order, but hours and hours of staring at the page and the source material didn't lead to any progress. It was the worst case of writer's block I'd ever had. When it was still going on by mid-October, I decided to put it on hold and go for the Q4 results instead, because we know how to do those.

Even those have taken longer than I expected, but more gets done each work day than the day before, and that's all I can ask. It's a new world for me. Adjusting takes time I'd rather not spend on adjusting. Still, I'm a lot happier knowing what's wrong and what to do about it. You never realize how much you miss taking a deep breath until you can't. I don't ever want to go through that again.

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