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Being human Reflections on Life, Being Human, and Medicine Updates on my health

Life Lessons from an Old Diesel Engine (or How to Live a Wise and Sustainable Life)

Our sailboat has a 3-cylinder Universal M25 diesel engine. The engine is the same engine that is used in Kubota tractors. It is rugged and reliable. It is designed to run for hours and hours and just work. It is what you would expect from a farm tractor. It is like a mule or a work horse. It is not intended to be a racehorse. 

We use the engine to get in and out of the marina. We commonly will motor our way around Lake Macatawa and down the channel to Lake Michigan before we raise the sails and turn the engine off. Other times if the wind is too weak or in an unfavorable direction we will opt to just motor, or do a combination (motor/sail) to get where we want to go.

If I push the throttle all the way to its stop, I can get the boat to do about 7.3 miles per hour (about 6.3 knots). If your goal is to get somewhere quickly, a sailboat is not generally your best way to do so. That is not really the point when you go sailing. You go for the experience more than the destination. It is the joy of being there (on the water with the wind, the waves, and the quiet) and the people that you are with, more than where you end up. 

Sailors sometimes talk about how hard you should push the engine when you are motoring. Some have noticed that the difference between full throttle (at 2400 rpms) is not that much greater than partial throttle (at 2000 or 2200 rpms). You end up going about ½ to 1 mile per hour slower. The engine runs cooler. You burn a lot less fuel. 

I have taken to doing this on our boat. I pull the throttle back a little bit. The engine runs a little bit quieter. It is easier for people to talk. We go a little bit slower. It is not really very much of a difference. We may get to the end of the channel 2-3 minutes later than we would have otherwise. That really doesn’t matter so much.

The idea is that maybe you shouldn’t just peg the throttle the entire time. Instead perhaps you should count on the trip taking a bit longer and settling in with some margin on what your engine (and boat) are capable of.

That concept might make sense in the context of motoring on a sailboat. When it comes to our own lives, however, it seems we have a lot harder time doing this. 

I have had times in my life when I was just crazy busy. I deprived myself of sleep and heaped stress upon stress on top of myself. I can remember feeling overwhelmed at times. I would get up in the early morning feeling the weight of the things undone and the coming day. I would step into the shower and try to have the hot water wash away the fatigue. As I did so I would wonder if I was approaching my breaking point. I thought that if I did, then I would be forced to stop and rest, and back off in the intensity in my life.

Everyone has a limit. That is obvious. You are human. There is only so much you can achieve. 

So let’s just say that you could quantify your breaking point. Let’s say that your breaking point is at a level 100. You can operate at a level 99 but feel very stressed and be dangerously close to your breaking point and personal tragedy. Someone else might have a breaking point of level 80. Perhaps they too are getting pressured (either internally or externally) to deliver their most. So they push themselves to a level 78 or 79 all the time. The funny thing is that no one really knows what everyone else’s breaking point is. To be honest, most of us don’t really know what our own breaking point is. But the important thing is that we accept the level 78 or 79 from the second person as giving their all. But what would life be like if you (a person with a breaking point around level 100) lived your life with limits set at 78? I suspect you would be happier. It clearly would be safer. Your life would be much more sustainable. Some research data suggests you might actually achieve more by being less stressed and more focused. You would also have reserve. When a real crisis hits, you will have a reserve that you can draw upon to counter the crisis.

A wise sailor doesn’t feel the need to push the throttle to the max. He knows it is okay to set the engine at a nice sustainable level and leave a little bit of margin left. He can use the extra throttle if or when there truly is a crisis. The majority of the time crisis mode is not needed. The engine is happy doing what it was designed to do. The sailor is happy living with reasonable expectations for the journey.

A wise person sets limits in their life that allow for margin. While everyone around them might push them or insist that they give their all, they choose to instead set their limits wisely. While their internal drive may tell them to say “yes”, “yes” and “yes” they know that they do ultimately have a limit to what they can do. They choose to define that limit carefully. They look to having a sustainable life.  

It doesn’t mean that they are lazy or neglect what is important. It does mean that they seek to avoid overcommitting and burning their reserve. They resist the urge to try to overdeliver.

There is always a limit. Everyone has a limit. That is not a question. The question is where the limit is set. Is your limit set wisely? Or do you live your life forever in crisis mode?

This is for me easier said than done. 

I have been an optimist. Whenever I would see something to do, I would really want to do it. But at times I really pushed my limits. On top of being a husband and father, a cardiologist, and building and growing a transplant program I would commit to research, writing textbook chapters, speaking events, and a host of other things. I wanted to do them all. In the end I mostly pulled them all off. But I am not sure that I should have.

Now my world has changed. Cancer, surgery, radiation, mitotane and recovery were definite limits. Persistent adrenal insufficiency was not a limit I counted on but one which has become a reality for me. A level 100 person has become a level 50 person. 

What do I give up? How do I set limits? I routinely hit the limit now. Navigating this has been a much bigger challenge for me than it was to just work really hard and really long hours. I am not good at setting priorities. I don’t know how to set limits on myself. I am struggling to learn. It feels like it would be easier to just run away from everything than to figure out how to prioritize and set more reasonable limits.

We pull out of the marina with the engine running at a slow speed. I push the throttle all the way to its stop. The engine pulls hard and the boat picks up speed. I intentionally pull back on the throttle a little bit. The engine quiets down. We make a reasonable speed. All is good.

Can we be wise? If you have pushed the throttle to the max, can you pull it back a little bit? Can you let your engine settle in at a reasonable and sustainable level? Your boat may not move as quickly. You will have to change your expectations. But maybe that is okay. If people ask, “Is this as fast as we can go to get there?” You can answer, “This is the exactly the speed that we should go to get there. It’s all good. I am doing my best.”

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Being human Medicine Reflections on Life, Being Human, and Medicine

Mysteries – In Medicine and In Life – And How to Navigate Them

He died. We could see his heart on the echocardiogram. It looked normal. And yet he still died of heart failure. There wasn’t anything I or anyone could do to have stopped that.  It was a tragedy. It was also a mystery. What was wrong with him? Why was he going into such bad heart failure?

Let’s roll the timeline back to a couple of other stories.

Story number 1: Headaches. 

Disabling awful headaches in a woman who had never had problems with headaches. She was a highly functional working wife and mother. Her life was busy. And then her life ground to a halt. The usual migraine preventive treatments and therapies didn’t work. Local experts didn’t help. The major university center didn’t help. The highly specialized headache institute didn’t help. In desperation she went to the Mayo Clinic. There I found some wisdom. The doctor at the Mayo Clinic called me. 

“Mike, I don’t know what she has. Clearly something has happened to her. There is something wrong. We do not know what it is or what to do to help her. In my experience, we usually figure this out eventually. Sometimes it is a new or unusual presentation of something we know about. Sometimes it is a new disease. It might not help you much, but we need to just support her and continue to wait and keep looking.”

I left primary care for cardiology. A few years later I ran into her. 

Me: “How are you? How are your headaches?”

Her: “I am better now. It took a lot of time but eventually I got better.”

Me: “Did anyone ever figure out what was wrong with you?”

Her: “I was the first case in West Michigan of the West Nile Virus!”

Mystery. Solved.

Story Number 2: Shortness of breath

She was short of breath. It was a sudden change. Her life was being trimmed back by the new and progressive thing that was pulling her back. It was like a belt restraining her from the busy life that she had always enjoyed. Her brain was busy, active and young. Something in her body kept her from living what she had taken for granted in the past. 

EKG: normal. Chest x-ray: normal. Echo: normal. PFTs: normal. Stress nuclear study: normal. Cardiopulmonary exercise test: Reduced exercise tolerance but no clear cause.

I couldn’t find anything to help her. Eventually we talked about doing the best she could to learn to live with it. We talked about gradually progressive exercise and rehab. 

This patient I also left to my colleagues when I left primary care for cardiology fellowship.

Fast forward again about 5 years. I was rounding in the hospital. I walked into a patient room and there she was sitting in the chair in my patient’s room. She jumped up and came over and hugged me. I was there to see her husband but for a moment we talked about her.

Her: “Thank you so much for pushing for answers! I am cured!”

Me: “That is wonderful. What was wrong? What did they figure out?”

Her: “I got even worse. When I did they saw my heart rate going really low. They put in a pacemaker and it brought me back to my old self. I can do everything again now.”

Mystery. Solved.

Maybe the doctor from Mayo was right. 

Maybe there are times in life when no matter how hard you try you can’t solve the mystery. 

  • It doesn’t mean that there isn’t something wrong.
  • It doesn’t mean that there is no mystery.
  • It just means that you may not be able to solve it in the moment.
  • Sometimes, you have to just keep asking the questions and looking for answers.
  • Sometimes you will get the answers later.

Soon after I finished fellowship I saw a patient with severe shortness of breath. The echocardiogram showed normal ejection fraction (squeeze of the heart). The heart walls were a little thick. I did a right heart catheterization and an endomyocardial biopsy. When we do an endomyocardial biopsy, we take a few tiny pieces of the heart muscle and send them to the pathologist to look at under the microscope. The biopsy showed green birefringence with congo red staining. It was cardiac amyloid. Further testing confirmed that it was ATTR (transthyretin) amyloid. This is a progressive condition where the body makes an abnormal form of a common protein. This protein then essentially gets “stuck” in the tissues. In this case the protein was getting stuck and filling up his heart muscle slowly over time. As it did so it made the heart thick and stiff. In order to pump, the heart has to be able to relax and fill with blood. If the heart cannot fill with the usual amount of blood, it cannot pump enough blood. The heart’s squeeze can look completely normal on an echocardiogram. The walls might look a little bit thickened but overall the appearance on echo can often be of a normally functioning heart.

Eventually I diagnosed more and more patients with ATTR amyloid. I called a friend from fellowship. He was seeing the same thing. He had started a “cardiac amyloid” center. Eventually we decided that ATTR amyloid was likely much more common than anyone thought. We in medicine had just not been recognizing it.

Since that time physicians in the heart failure world have become well aware of ATTR amyloid. We diagnose a lot of patients with it. We now have treatments for it. We also see that what we diagnose is likely the “tip of the iceberg”. There are likely a lot more patients with mysterious heart failure that might have amyloid. We don’t really yet know how many of these patients there are. One survey of patients over 60 with heart failure and a normal appearing echo suggested that amyloid was the cause 13% of the time. Another study found that of patients presenting for transcatheter aortic valve replacement (TAVR), one out of every 7 patients had amyloid.

Mystery. Solved (partly.)

My patient at the start of this blog died with bad heart failure but he had a normal ejection fraction. In retrospect I suspect that his poor heart performance was likely ATTR amyloid. 

What does this mean beyond the bounds of the practice of medicine?

There are times when the world does not make sense. You know that something is wrong. You do not know what is wrong. As hard as you try to understand, in the moment you are unable to figure it out. You do not know what to do about it. 

What do you do?

It is important to know that just because you can’t explain what is wrong, it doesn’t mean that nothing is wrong.  Sometimes it means that you are just not able to figure it out in the moment. It could be a variation on some theme that you know well. It could be a new problem that you have not faced before. Time can be your friend. Sometimes in the future you will come up with answers. Sometimes time will bring healing on its own. Sometimes time will bring you an effective solution to the problem. 

  • Step 1: Admit that there is something wrong.
  • Step 2: Do your best to try to figure it out. Seek expert advice and input. 
  • Step 3: Supportive care. Do the best you can to try to figure out how to live within the limitations of the problem.
  • Step 4: Acknowledge that just because you don’t get an answer, it doesn’t mean that nothing is wrong. Retain hope that time will bring answers and resolution.

This clearly applies in medical practice. 

It often applies in life too. 

It amazes me how things that used to puzzle me, now, with age, make sense. 

Sarah (my wife) has noted how with age certain passages of Scripture that used to be confusing, now make perfect sense. I agree. No one could have explained them to us at the time. We needed to live it. Time brought wisdom and understanding. Many times the answers didn’t come in an abrupt or blinding way. Often the answers came slowly and then in retrospect, made perfect sense. 

Why couldn’t Glenda have just had Dorothy tap her heels at the start of the journey? 

Mysteries. 

Sometimes – with time – Solved.