“The medical record does not describe what happened next.”
This sounds narcissistic, but every few months, when I have a quiet moment, I like to take out my electrocardiogram and look at it. Oh, it is entirely normal, and maybe that is the point. I marvel at the tall narrow QRS complexes marching regularly across the page at 66 beats per minute, each followed by a languid undulant T wave. You probably don’t know that 85 percent of the heart’s electrical energy does not appear on the electrocardiogram but is canceled out because of electrical forces moving in opposite directions. Don’t read anything metaphorical into that. I am just describing what happens.
My name is Layla Moradi. I am a 46-year-old cardiac electrophysiologist and a woman of Iranian descent. I don’t know anyone else who can tick all four of those boxes. Perhaps I could extrapolate from my electrocardiogram and claim that my heart is normal.
My parents met when they were engineering students at MIT, and I got an engineering degree, too, before veering off into medical school. My normal heart led me to cardiology, then I became enchanted by the beauty and precision of electrophysiology. We can place catheters in the heart and precisely measure electrical wavefronts as they move through cardiac tissue. We can localize abnormal foci and pathways and wipe them out. We can place a device in your heart that will track its every beat and shock it back to normal if it strays. In affairs of the heart, I imagine many people would like to have that power over their partner. I have teased Keaton about that, but he doesn’t share my passion for the heart.
Let me tell you an electrophysiology story.
Diane was a rising star in a major bank headquartered in Dallas. She was visiting San Francisco for a business meeting also attended by Jacob, who was local. They were mutually attracted to each other and managed to sit together at the group dinner on the final night of the meeting. Everyone eventually drifted away, but they stayed and talked, engrossed in each other. When the waiters finally kicked them out, they went to Jacob’s room. This is a story of cardiac vulnerability. This is also a love story.
The medical record does not describe what happened next; most of life’s key moments never make it into one’s medical record. Based upon subsequent events, my normal heart tells me that by the time they fell asleep, probably intertwined, they had forged a remarkably strong bond for such a short time.
The medical record states that Jacob was jolted awake at 4 AM because Diane was vomiting and exhibiting seizure-like activity. He later told me that his only medical knowledge came from watching hospital shows on television. She was unresponsive and turning blue. I have no idea how he managed to call the front desk and simultaneously start rudimentary cardiopulmonary resuscitation. After what must have seemed to him like forever, paramedics poured into the room and took over. They shocked her heart back to a normal rhythm. I assume Jacob must have grabbed a hotel bathrobe before accompanying them in the ambulance.
I met Jacob an hour later at Diane’s bedside in the ICU. He was cute, maybe 30 to 35 years old, with blue eyes and a mop of curly black hair. He still wore the hotel bathrobe, but the nurses had given him a set of blue hospital scrubs to wear underneath, booties for his bare feet, and a cup of bad coffee. He needed more than coffee. He looked shell-shocked, almost catatonic. He was squeezing Diane’s hand as if it were the only thing he had left in the world.
Diane was wrapped in cooling blankets to reduce her core temperature and improve her chances for neurological recovery. She was unresponsive and intubated. A residual smudge of red lipstick looked sad and incongruous against the endotracheal tube held in place by a strip of surgical tape randomly plastered across her face. Her blonde hair was mussed and matted. Her eyes were closed. She had an IV in each arm and a central venous catheter inserted under her right clavicle. Her ECG beeped across the monitor as a green line. As if to mock us, it was now normal.
I introduced myself to Jacob and offered a brief explanation, even though I didn’t expect much of it to stick.
“Diane has long QT syndrome. It can be caused by certain medications, but I believe it is hereditary in her case.”
I saw a question forming on Jacob’s face, so I explained: “Long QT syndrome just means that it takes longer for the heart to repolarize, or go back to normal, after it depolarizes. Depolarization is what causes it to beat. So, she has a longer period where her heart is vulnerable. And during that interval, she developed ventricular fibrillation.”
While Jacob was processing that, I showed him the very long QT interval on her ECG and a normal ECG so that he could see the difference. Despite his distress, Jacob nodded and I could see that he understood.
“So, it wasn’t anything we did?”
“No, absolutely not, it could have happened any time. In fact, she’s lucky that you were there. You saved her life.” This was true, and I was hoping it would make him feel at least a bit heroic.
But he started to cry. I found him some tissues. He cried harder, tears streaming down his face. He coughed and spluttered. I hugged him. I squeezed him hard. He hung on like a little boy hanging on to his mother.
Let me tell you that I am not someone who normally hugs patients or their families. I am reserved by nature, a serious Iranian woman, and I think that the doctor-patient relationship should be slightly formal. Yet I was making an exception. Jacob needed someone to cling to, and I was glad that it was me. And, to be honest, it worked both ways, clinging to Jacob did something for me, too.
“Jacob, Diane is stable now. You could go back to your hotel and get some rest. Maybe come back around five and I could give you an update before I leave for the day?”
Jacob edged closer to Diane and didn’t let go of her hand. “I’d rather stay it it’s OK” was all he said.
Our plan for Diane included induced hypothermia, keeping her cold for 24 hours to limit any damage to her brain. We would then allow her body temperature to rise to normal over the next 12 hours, and if her neurological function recovered, we would withdraw anesthesia and extubate her.
Over the years I have treated many patients with out-of-hospital cardiac arrest. Their chances for a full neurological recovery are not good, and, to be honest, to avoid disappointment I have stopped cheering for them. Don’t get me wrong, I will do everything in my power to save them, but I make no emotional investment.
Diane’s prognosis was better than usual due to her young age and other factors, and I found myself really rooting for her. I hadn’t even spoken to her yet. I knew it was because of Jacob. He stood there all day clutching her hand oblivious to how silly he looked wearing that hotel bathrobe. She was still completely knocked out, so he wasn’t getting any feedback from her. He could have left in the morning, after she was safely delivered to the ICU, or later, he could have gone home to change and come back. That man made me want to cry.
I live in the top half of a Victorian duplex in Cole Valley, close to the medical center. The disadvantage of this proximity is that my workday still clings to me when I get home. That evening I asked Siri to turn on all the lights, I slipped the shoes off my aching feet, got a glass of white wine, some of my homemade hummus, and baba ghanoush from the fridge and assessed whether the stale barbari, the bread I baked last weekend, was edible despite a few small green spots.
I plopped onto the sofa and put my feet up. One of my simple pleasures is just relaxing here, observing my space. I collect contemporary Iranian art, paintings by women. I drew comfort that evening looking at Tehrani Girl a portrait by Maryam Hashemi. As always, she returned my gaze, seated, erect, wearing a light-colored Western dress, a blue-and-white headscarf, and a large green and blue pendant around her neck. She nursed a black coffee on the small orange table in front of her and held a cigarette in her right hand. A small surgical strip across the bridge of her nose served as a symbol that Iranian women had the highest rate of nose jobs in the world.
“Who exactly are you, Layla?” she intoned.
“At least I still have my original nose,” I replied. But Tehrani Girl had a point. I felt unmoored and lonely. I couldn’t keep Jacob out of my head. I thought of the symmetry. Diane had a potentially lethal cardiac vulnerability, but Jacob’s heart was vulnerable, too. Aren’t you a romantic idiot, I thought, one is not the same as the other. I knew that I could never commit to someone as quickly as Jacob had done. I envied him.
I called Keaton to check on our weekend plans. My parents call Keaton my boyfriend, which is a bit of an old-fashioned term. He is tall, good-looking, quirky, of Korean heritage, works as a lawyer for the Sierra Club, and is eminently sensible. You might not consider pairing an Iranian with a Korean, but we both grew up as single children with immigrant parents who had high expectations for us. In a way, we are frozen in the same place; we did what was expected of us, so now what? Our relationship is placid. He is a stabilizing factor in my hectic life. That’s good I guess, but I’m beginning to feel that I could use more tachycardia and less placid. I told him about Jacob and Diane.
“Keaton, would you stand at my bedside in the ICU all day in a Holiday Inn bathrobe?”
“Maybe a Ritz-Carleton robe with a big crest that everyone could see,” he joked.
I knew he wouldn’t.
“Keaton, I wish I could be like Jacob, fall crazy recklessly in love, poof, just like that!”
“Layla, you’re just not like that. Me neither. We’re normal.”
In the morning, I met Diane’s family at the door to the ICU. Her father, Billy Denton, was a large florid man, with a brush cut, watery blue eyes, and a potbelly. His wife Lynn was shorter, thin, and pinched-looking, with worry clouding her eyes. Diane’s younger sister Meghan had a cheerleader face, a long ponytail, and wore a college sweatshirt with a mustang galloping across the front.
Right away, Mr. Denton asked, “Where are you from, Doctor?”
Ah, the question. I don’t get that as much now. And he managed to infuse the word doctor with a slight rising intonation, as if questioning how it could even be possible.
“I was born in Boston and grew up there. I’ve been here at the university hospital for 20 years now.”
I was half expecting the “But where are you really from?” question but it didn’t come. I gave them a quick summary of Diane’s situation. The women listened intently while Mr. Denton looked impatient. We went to Diane’s bedside. She looked the same as when I saw her last, but not so for her family. It is a shock to see your loved one intubated in an ICU, unconscious, with tubes everywhere and the monitor insistently pinging. Lynn brushed Diane’s cheek with her hand and began to whimper quietly.
Jacob was standing at the other side of the bed, fully dressed today and looking more composed.
“Who are you?” Billy demanded.
“Jacob Stein. I am Diane’s, ah, friend. I was with her when she had her cardiac arrest.”
“At 4 AM?” Billy spluttered and reddened as he more fully understood. “Get out of here!”
Jacob paused for a moment, stricken, then turned and walked out of the ICU. I resisted the urge to intervene. My responsibility is to my patient, Diane, and what role Jacob would play in her life would be her decision, assuming she recovered.
I took a deep breath and launched into a simplified explanation of long QT syndrome. I told them that Diane had completed the cooling protocol and was rewarming, that we were lightening the anesthesia and that she should begin to regain consciousness in a few hours. That we were treating her aspiration pneumonia with antibiotics and that she would need an implantable defibrillator to protect her from possible future cardiac arrests.
Billy interrupted: “God in his righteousness struck her down for her sinful acts.” Lynn pulled at his arm and tried to interrupt, but Billy pressed on: “Why else would this happen when it’s never happened before?”
Lynn tried again to shush him but Billy had launched his tirade and had momentum:
“As soon as Diane is well enough to travel we will take her back to Texas. We’ll get a second opinion from our own doctor. We’ll hear what our pastor has to say. We need to pray on this!”
“Shut up, Billy!” Now Lynn was angry. And Billy did shut up. Maybe he had said his piece, but I got the feeling that there was a line there that he was afraid to cross.
Meghan followed up: “Dad, Google says this is the best hospital in the country for cardiac electrophysiology.” They seemed to have forgotten that I was standing right there.
“Dr. Moradi has published more than 200 papers and won all kinds of awards.” She paused and then added with conviction: “We are lucky to be here.”
I took that as my cue to tell them more. I explained that long QT syndrome was probably hereditary in Diane’s case, and that they should each have at least an electrocardiogram. Lynn and Meghan looked appreciative for this bit of information and Billy looked skeptical, not yet ready to abandon his thunderbolt from God theory.
Diane was extubated late in the afternoon. Considering that the last thing she remembered was sleeping with Jacob, and now she was awakening in an ICU, her brain seemed in good shape. The nurses asked the family to leave for a few minutes while they cleaned her up and I asked the head nurse not to let them back in until I had finished talking with her. I explained to her who I was, what had happened to her, and how she was doing. She listened attentively and appeared to understand.
“How are you feeling?”
“OK, I guess. My throat is raw from the tube.” Diane rasped. She looked around the ICU, taking it all in, the bustle, the flashing lights, the beeps, the voices, the random noise. As physicians we easily forget how menacing and terrifying this place can feel from a patient’s perspective.
“You’ll be out of here pretty quickly,” I reassured her, squeezing her hand.
“I had weird, vivid dreams. I dreamed that I had died and that God or some tall angel in a white linen robe was squeezing my hand. Why are you laughing?”
“Are you sure it was linen and not terrycloth?” I explained to her how Jacob had accompanied her in the ambulance and stood there all day in his hotel bathrobe squeezing her hand. I never cease to wonder at what people bring back from near-death episodes or deep anesthesia.
“He was here again this morning until...” I hadn’t meant to go there.
“Until my father sent him away?”
“I bet my mother told Dad to shut up at some point.”
I nodded again. My concerns about Diane’s neurological recovery had dissipated. I explained to her that she needed an internal defibrillator. It would reduce her risk of dying within 15 years from 50% to about 1%. I answered all her questions. I let her family back in and soon after left for the day.
At home I filled my glass with the rest of the bottle of white wine from the fridge. I preheated the oven and put in two chicken kabobs that I had marinated in yogurt, onion and saffron earlier in the week. I do my serious cooking on weekends. I bake barbari the traditional way, with crushed nigella seeds. It’s so much better than pita bread. For me cooking is a way to relax and a connection to my parents and my culture.
I slouched on the sofa with my feet up and called Keaton. We caught up on what we had done that day, and when there was a lull in the conversation, he said solemnly, “Layla, I had a dream last night that reminded me of something that happened when I was eight years old. I had forgotten it.”
“Was it after you family had moved to New York?”
“Yes, my father got posted to the UN in the winter and I started school in February. My first day was Valentine’s Day.”
“Did you know what that was?”
“Yes, and I had changed schools before, so I was used to that. As much as any kid could be.”
Telling his story was upsetting Keaton, which was unusual, but he went on, “Mom was prepared. She gave me valentines to give to the other kids. She must have talked to the teacher ahead of time. And the teacher was very nice, she gave me a valentine and welcomed me.”
“But none of the other children did?”
“No, how could they be expected to?” Keaton paused for a few seconds and I waited for him to go on.
“I remembered the feeling I had that day. I felt empty . . . and alone . . . and frightened . . . like there was a wall between me and everyone else and no one loved me.”
“But your parents loved you!”
“Yes, of course, but I wasn’t thinking of that, or it wasn’t enough.”
After another pause Keaton laughed it off with a weak joke and changed the subject. I did not remember hearing him talk like that before. Being an outsider as a kid was something we shared.
After our conversation I silently studied Tehrani Girl and thought about heart damage. Then I wondered who would be at Diane’s bedside tomorrow.
“Billy had to go back to Dallas for business” Lynn explained with a trace of a sly smile.
Jacob was on the other side of Diane’s bed from Lynn and Meghan. Diane was coughing up green gunk but was wearing make-up and looked healthier. I explained to her family what I had told Diane the day before about her need for an internal defibrillator to prevent recurrences. No one has any idea what an internal defibrillator looks like or how it works, but I pulled a well-worn model from the pocket of my lab coat and explained its function.
“When can we get this done?” asked Diane.
It was Friday. I said that we could probably get it scheduled for Monday or Tuesday and she could be discharged a day or two after that if all went well.
“I’m going to stay with Jacob for a few days. How soon before I can fly back to Dallas?”
I noticed that Lynn looked displeased with this arrangement.
And then I heard myself lying outrageously: “Probably you should wait a couple of weeks before you fly, just to be safe. That will also give you time to come back and get your stitches taken out.” I neglected to mention that the dumbest physician in Dallas with the dullest surgical scissors could take out her stitches.
Friday evening, back in my favorite spot on the sofa, finishing my second glass of wine, half a Bambino’s pizza with extra black olives and anchovies eaten, half on the coffee table in front of me, under the watchful eyes of my Irani portrait women.
“Hey, Tehrani Girl,” yes, talking to my paintings again, “I’m 46 years old, and I’m washed out, and I need somebody, something.”
I paused for a second, and she continued: “It’s been brewing for a while, Layla. Maybe it’s time for a big change.”
“Tehrani Girl, maybe I need someone different. Maybe Keaton is too much like me.”
She looked to her left, then to her right, then she tapped her cigarette in the blue ashtray in front of her. She looked down at me and smiled, “You’re the heart specialist girl, you figure it out.”
I spent the rest of the evening online researching vacation possibilities in Tuscany. I had an urge to escape.
On Saturday morning I prepared a favorite recipe, lamb shanks with roasted garlic and onions. It was ready for the oven, and I had already made the saffron and rosewater ice cream that Keaton likes. Cooking usually calms me, but I felt a mixture of uncertainty and anticipation.
Keaton showed up on time and pecked my cheek.
“Hey, Layla, we’re going for a walk first, right, what street should we walk along?”
“Maybe Sacramento? We haven’t been there for a while.”
“Great, I’ve had a stressful week and just want to chill out.”
“We could walk over there,” I added, “Should only take about half an hour.”
We set off around noon. A pleasant breeze had rolled back the morning fog. Even though the sidewalks were crowded, we managed to mostly hold hands as we walked. Sacramento was one of my favorite shopping streets, but we weren’t looking to buy anything.
“Layla, look at the platter with the big heart on it!”
Keaton was pointing at the window of a second-hand furniture store. The platter was oval, about a foot across, a large red heart in the middle surrounded by cherubs and clouds. It looked antique and whimsical.
“You always say you need a serving platter, and you’re a cardiologist,” Keaton laughed.
The price was only $48. Keaton bought it for me. It was heavy, so we left it there to pick up on the way home. We meandered along Sacramento Street and looked in a few shops. I persuaded Keaton to try on a Japanese sweater, by Junya Watanabe, but he said it was too flashy for him and too expensive. We stopped for coffee and tea at Café Luna, a hole-in-the-wall, and took our drinks to a sunny sidewalk table.
I had rehearsed what I wanted to say, and now it all spilled out in one breath:
“Keaton, I have an idea. Let’s go to Italy for a month, two weeks in Rome and two weeks in Tuscany. I found a small farmhouse on-line we could rent there. Just the two of us. Good food and wine. We could cook together. Long walks and maybe some biking. We could rent a little Fiat, check out the hill towns. Maybe we’ll find a store with Iranian spices. What do you say?”
Keaton seemed taken aback, “Sure, Layla, that sounds great. When do you want to do this? Next month I’ll be tied up writing our amicus brief for the big water utilization lawsuit, so it would have to be after that.” He obviously did not share my enthusiasm. An image of Tehrani Girl giving him a thumbs down flashed through my mind.
“Oh, never mind Keaton, it was just a crazy idea. Are they giving you any help with the water brief or is it all up to you?”
Keaton had finished his tea and I took the last sip of my cappuccino. “Layla, I think we should do it. Maybe not for a whole month, maybe just a week or two. We can plan around my work.”
“I’d just like to go somewhere nice where we could focus on us. Build our relationship. Don’t you?”
Maybe Keaton didn’t hear my question. We wandered back down Sacramento Street, then towards home, not forgetting to pick up the heart platter. At home I gave Keaton a bottle of wine to open and put the lamb shanks in the oven. Soon the smell the turmeric and cinnamon began to waft through the kitchen. We took off our shoes, sat side-by-side on the sofa with our feet on the coffee table, sipped our wine, and talked about our week. Maybe everything would work out fine.
Three hours later darkness had fallen, and the only light in my small dining room came from the cluster of candles. Keaton pushed back his chair, discretely stifled a burp, and proclaimed that dinner was excellent. He started to help me clean up, but within moments we were standing in the kitchen kissing each other hungrily. I was trying to unbutton Keaton’s shirt, and the tip of his tongue was probing my ear. That excites me a lot. Maybe it was partly the wine, but my face felt hot and my knees felt weak. I reached behind me to steady myself on the kitchen counter, and accidentally pushed something over the edge onto the floor.
The heart platter clattered loudly and shattered into a dozen pieces. Keaton let go of me, knelt, and began to collect the shards. He sat on the floor, his knees and elbows sticking out in all directions, and started to fit them together, like a child working on a jigsaw puzzle.
“Keaton don’t worry about that now. Come back here and kiss me!”
I don’t think he heard me. As if in a dream or a third-rate film, I saw my heart, broken on the floor, and Keaton messing with it. I was shaken.
Tehrani Girl chimed in, “It’s all just symbolism, Layla, and maybe you’ve had too much to drink.”
Maybe so, but in retrospect that was the end of our relationship. Keaton and I are still friends, but we don’t see each other very often. I don’t love him now and wonder if I ever did.
The heart of an adult cannot grow by adding new cells, but the cells that are already there can grow by hypertrophy. Hypertrophy is how heart cells respond to stress, but hypertrophied hearts are vulnerable. That’s just basic cardiology. Sure, that’s not relevant to real life, but I don’t look at my electrocardiogram anymore.
Keaton glued the platter back together, but I don’t use it. Its fracture lines and excess glue are reminders of a flawed relationship. It is not a healthy platter, yet I keep it in my kitchen as a memento. It’s a symbol too, now I know that my heart is vulnerable, and I am fine with that.
David Waters is a retired cardiologist who lives in San Francisco and publishes a regular series of essays in the Canadian Journal of Cardiology entitled “Notes From Cardiology Clinic,” describing poignant patients and the social conditions contributing to their illness.
Marc Phillip’s first novel, The Legend of Sander Grant, was released by Telegram in 2009. He has published short stories, articles/essays, photographs and poems in the US and abroad. Marc is currently at work on his next novel as well as several short stories and at least one poem.