Estelle’s Broken Heart

Wild Onions, 2003

Their daughter, as usual, brought them to clinic today. Robert and Estelle are both in their 80’s, still living together, both still working in the nursery they hadstarted forty years ago. He supervises the planting of new seeds, she still drags a hose about as she waters, knowing just how much water is needed to nurture each bed. Both have hearts hat have been broken and repaired—he a bypass of clogged arteries, she the replacement of a narrowed aortic valve. Although I suspect most patients do not look forward to visiting their physician, I always anticipate seeing this couple.

My first question to a patient is often, “Are you here today for a routine return appointment, or are you here because you are having problems?” Each of them nods yes to the first option. It’s simpler to see them both in the same room, for the to-be-examined spouse or the has-been-examined spouse will add commentary about the one being examined. Between the “No, I’m not having chest pain” and “Yes, I’m still able to do my daily chores” I hear a complaint about how bad the traffic was today (it took 12 minutes to drive the 6 miles to clinic instead of the usual 10 minutes), concern about the wholesale market for impatiens plants this ear and a story about their granddaughter, the newly-graduated veterinarian, who diagnosed a rare illness in a prize horse. Before she leaves, Estelle hands me a card with a heart on the front. It is the bleeding heart of Jesus. Estelle tells me that it was prayers to this Jesus of the bleeding heart that brought about her recovery.

Today our interactions are halfway between doctor-patient interactions and interactions between casual friends. But that has not always been the case. The card Estelle brings me today takes my mind back to another time.

I met Estelle five years ago when she was hospitalized with congestive heart failure. The strong diuretic rid her of excess lung water that was causing her shortness of breath, but the sonogram of the heart showed that it was beating less vigorously than normal and that her aortic valve was not opening as widely as it should. She’d had a malignancy some years before. Perhaps the chemotherapy used to treat it had damaged her heart muscle. Because of a concern about the malignancy (would it come back?), because she was already past her mid 70’s, but most importantly because she herself so wished, we decided together not to pursue the search for any remedy that would involve more than medicines.

For the next three years she was able to continue watering her plants, and the maladies common to one of her age were more bothersome than complaints caused by an ailing heart. But then one day she came to clinic, “earlier than usual”.  My exam confirmed that the heart was again the problem, despite the medicine she was taking. The sonogram showed that the aortic valve, between the heart and the aorta, had become much more narrowed and was now quite definitely the cause of her symptoms.

In three years the plot had changed. Yes, she was three years older, now 80. But the malignancy had not returned and there was now an operation that might cure the problem. I laid out the plan to her: a heart catheterization and then an operation to replace the badly damaged aortic valve with a pig valve.

There was no hesitation in her reply: “At my age? Never!” It was not my duty to talk her into such a major ordeal, so we agreed to increase the medications. This plan worked, but only for two months. She was admitted once, then again, for heart failure. Each time she refused any further testing that might lead to surgery. And then she came to the Emergency room one night, coughing up frothy pink fluid and gasping for breath, in extremis. The strenuous breathing rapidly tired her out. We quickly intubated her and connected her to a ventilator. It was necessary to give intravenous medications to strengthen her weakening heart muscle and to monitor her heart pressure with a catheter through a vein in her neck, but she finally was able to breath relatively normally, the intravenous stimulants were tapered off and replaced with medications she could take by mouth, and the plastic tube connecting her to the breathing machine was removed.

I was sitting in the intensive care unit writing a note in another patient’s chart the night before she took this unexpected right turn. It was February 14, a day when for most people broken hearts, although a cause of distress, are objects that time or a new love can repair. I watched Estelle’s daughter wheel Robert into her room. I could see, but not hear, the interaction between the two octogenarians. Robert seemed unaware of the medicine bottles, the beeps of the device monitoring her heart rate and blood pressure and the hisses of the breathing machine. He handed her an envelop. She was obviously not able to open it—was she even aware of what he had given her? The daughter opened the card. I could see it was a valentine. She read the lines to Estelle, and then tacked it to the corkboard on the wall, careful to prick the three thumbtacks through the border of the card and not the heart itself.

It was three days later, now out of the intensive care unit, that Estelle decided to “at least go with the catheterization.” Three days later a new pig valve was in her heart, opening and closing 80 times a minutes. The heart, now able to pump more easily, soon returned to near normal function. Seven days later I saw the daughter wheeling Estelle out to a waiting car. She was anxious to get home to Robert and her plants.

This is the story that Estelle’s card, commemorating the bleeding heart of Jesus, brought to my mind today in clinic. She gives credit for her recovery to the prayers to the Jesus pictured on the card. I wonder if another card with another heart was not just as important.