To Seattle with Heart

Carolyn carefully maneuvered our Toyota pickup across several lanes of busy traffic and then moved on into the commuter lane as we traveled south toward Seattle, on Interstate 5. This Friday morning I had two appointments in Seattle at the VA Medical Center on Beacon Hill. My first appointment was to have my lung function tested and then immediately following that test I would have a cardiac nuclear stress test. Both of these tests had been ordered due to previously measured low blood oxygen saturation of 89 coupled with chest pain and breathlessness on exertion. We were one among many cars speeding down the Interstate toward Seattle.  The view down the freeway was inspired by the hazy silhouette of Mount Rainier visible directly down the highway.  The mountain is a prominent icon of the area and was basking in the early morning sun as lines of cars roll toward the city of Seattle.

I do not drive much anymore due to a combination things. Primarily it is because my tremors are a difficult to manage distraction while I’m trying to drive.  There is also the more subtle issues that accompany many of us who have Parkinson’s such as: slow response time, difficulty processing multiple data input and increasing difficulty making decisions. Carolyn and I had been warned by my neurologist that my diagnosis could be used against me in court if I had an accident whether I was actually at fault or not. So, Carolyn now does most of the driving and fortunately she is very good driver and actually enjoys it.  When we go places I am now free to sit and watch the scenery and the traffic roll by my window and think of whatever I wish. I usually think that is a good thing but sometimes I withdraw quietly and think about life before PD.

Seattle is a special place for us and we look forward to returning whenever a reason of any kind presents itself.  Thirty six years ago I was working and living in Seattle when I first met Carolyn.  She was an active duty Army nurse stationed at Madigan Hospital at Fort Lewis which is a bit further down Interstate 5 near the city of Tacoma. In those days I ventured down there once a month to work in the hospital pharmacy on my reserve duty weekends.  On one of those weekends we were introduced by a coworker of hers. Things took off from there and Seattle was as romantic as Paris for two who would fall in love and pledge their lives to each other.

This morning Carolyn was driving her 64 year old man with Parkinson’s to the VA Medical Center in Seattle for tests to determine whether lung and heart disease were also part of the mix. I am thankful that I am not alone at this stage of life and that my wife of many years remains committed to our lives together. I reached across the cab and slipped my hand under her thigh for a little help calming my tremor and for a bit of a lift from the energy that still flows between us when we touch.

We passed through the center of Seattle and exited the freeway and began the climb up Beacon Hill where the VA Medical Center is located.  After finding a parking spot in a visitor’s lot placed well below the medical center, We gathered our things and started up the hill to the hospital. It was a short walk that felt long. My body responded to the uphill exertion with increased tremors and tightened muscles in my upper arms and across my chest.  This soon became breathlessness and chest tightness.  I had to pause occasionally to catch my breath and to wait for the discomfort to subside. Carolyn stopped with me and encouraged me to take deep breaths.

Once we entered the VA Medical Center we did a bit of wandering around looking for the pulmonary lab, my first appointment.  As had been our experience in the past, navigating the maze was not a problem. We found  helpful staff along the way and actually checked into the pulmonary function lab early.

The pulmonary(lung) test lab was tucked in a room somewhere deep in the medical center with no windows to the outer world. In spite of the windowless dreary surroundings the pulmonary tech was upbeat and proceeded to guide me through a variety of tests intended to determine the state of my lung function. By measuring the amount of breath I could breath out and how rapidly I could do it, it is possible to determine whether the major enemies of lungs are present: COPD, asthma or pulmonary fibrosis. I gave it everything I had and to my surprise I did very well.  Finishing up the technician clipped a pulse oximeter on my finger and read the results.  Ninety eight she said and then added, “just perfect.”  She pronounced my lungs to be in good shape.  I returned to the waiting area a bit puzzled since two previous measurements at routine appointments had been in the high 80's. Not good numbers. I gave Carolyn the current good news that my lungs were healthy and we moved on.

For the heart part we went to nuclear medicine for a cardiac nuclear stress test.  This test provides visual images of the heart both at rest and while under stress. It provides a picture of whether blood is flowing freely to vital areas of the heart when placed under maximum stress. For this I was taken to a test room with a medically wired treadmill designed to monitor EKG, heart rate and blood pressure during the stress part of things. In the same room there was also a large scanning device that produces images of the heart by sensing a radioactive dye injected intravenous and then taken up by the heart tissue.

The nuclear medicine technician placed an IV access in my right arm and then injected the radioactive dye. I went back to the waiting room to wait until the dye distributed in my cardiac tissue.  As I waited I tried to read but I was absorbed by the sights and sounds of the VA. The pain and suffering on display is sobering.  There is a steady stream of vets constantly moving throughout the facility to make their appointments for treatment or diagnosis.  Young vets and old vets. Often very disabled, they are aided by the help of people, wheelchairs, canes, walkers, artificial limbs and their own will power.

I was called back into the scanning room for the resting cardiac scan. The technician directed me to lay down on a narrow horizontal platform with a support for my head. He made me as comfortable as he could and then briefed me on the importance of remaining still.  He explained that the machine would move me into position and then would begin taking a series of cross sectional pictures that a computer would assemble into a 3 dimensional image. 

I was at rest and my heart was at rest as the machine transported me on my skinny bed into position for 30 minutes of cross-sectional heart scans. I had been instructed not to go to sleep since sudden awakening could allow me to jerk and spoil the results. Nonetheless I did fall asleep. I could feel that strange sensation of calm and diminishing tremors that precede sleep as I was transported into the machine. Fortunately I woke up without movement and after the scan’s completion and review by the technician the pictures were pronounced successful.

After a short delay I was introduced to two nurse practitioners who were going to carry out the next phase of things. One was learning by observing while the other was a veteran of such procedures. This part of the test consists of walking a treadmill while both the speed and the incline on the treadmill are systematically increased until you reach a predetermined maximum heart rate. At this point the heart releases a potent natural venous dilator, adenosine, which opens up the blood vessels to allow increased flow of blood to the heart. The nurse carefully questioned me to determine whether I was healthy enough to endure such a test. There is a back up for those who are not up to the test physically. For those patients one of several drugs is injected IV to simulate the natural response of a  heart under stress. I passed and was allowed to walk the walk.

Once I indicated that I was ready, the treadmill started moving and I started walking to keep up with the movement. At first it was easy. The nurse asked me if I was ready to pick up the pace and I responded, “yes.”  Things became progressively more difficult as the process was repeated.  The monitor allowed me to watch my heart rate as it moved upward: 100, 110, 120. One hundred thirty three was my target and as I approached that number I was really struggling with rapid breathing and tightness around my shoulders neck and chest. I pressed myself to keep walking and told myself, “I can make it.”  When I thought that I could go no further my heart rate shot past 133.  The nurse carefully slowed the treadmill while I kept walking.  I was now weak and hanging on to the support bars of the treadmill breathing deeply and thankfully recovering quickly.  Any delusions I had about still being young were swept away.

The nurse examined the EKG tracing generated on a paper strip and said that she could see no problems.  That was good news, my 64-year-old heart has still has solid wiring as indicated by no EKG abnormalities showing up even with high level physical stress.

The last scan is intended to identify areas of the heart that might not be getting the vital flow of needed blood when under stress and would be interpreted in light of the first. The procedure was a carbon copy of that used for the first scan.  After completion I returned to the waiting room to wait for preliminary results.  Little time passed so I was caught a bit off guard when the technician reappeared and announced to Carolyn and I that the initial results including the image of my heart under stress showed nothing major. "You are free to go home," he said.  A heart felt thank God entered my mind. The results will later be reviewed more fully by a cardiologist and if anything else is found I will be notified by my family doctor.

That was it. We packed up our things from around the chairs we had been sitting in and got ready to make the long trek home to Whidbey Island.

Now we traveled northbound on interstate 5 as we retraced our journey of the morning.  Mt. Rainier was at our back and my faithful driver was once again at her task.

I fully understood that doing well with these two tests now freed me to pursue as many physical activities as myself and my Parkinson’s would permit.  Still troubling me though is that I have no specific reason to explain the symptoms. The low blood oxygen values that had appeared at previous routine visits and the breathlessness and chest discomfort are very real.

It would seem reasonable that new symptoms of any variety might lead back to Parkinson's in one who has the disease. I wondered how could that be for cardiac and lung issues?  After some internet research I found that Parkinson's no stranger to these issues.  Respiratory difficulties have been specifically correlated with the wearing off periods of dopamine therapy.  The Parkinson's connection with respiratory difficulties is left until the more likely and sometimes more deadly issues of lung and heart disease are ruled out or dealt with.  I had once read that prior to dopamine therapy that Parkinson's was a sentence to early death due to respiratory failure.  If you have further information on this leave me a comment or contact me.

I have included excerpts and links to two sources that identify potential links to wearing off of drug therapy and shortness of breath.

Shaky in Coupeville

http://forums.webmd.com/3/parkinsons-disease-exchange/forum/535
"Respiratory symptoms in PD are not rare, and may sometimes be linked to medications. Some people report shortness of breath (SOB) and wheezing that occur with exertion more than while at rest. These type symptoms have been linked to dopamine agonists in the past, but the newer agents, pramipexole and ropinirole, do not seem to have these issues."

http://www.ncbi.nlm.nih.gov/pubmed/19715385
"Although levodopa is considered the gold standard for Parkinson's disease therapy, prolonged use of this drug can result in motor complications such as a 'wearing-off' phenomenon. This outcome is seen in a significant number of patients with Parkinson's disease taking levodopa and, in some cases, is observed only a few hours after intake of the last dose of levodopa. Patients experiencing the wearing-off period may present with sensory, autonomic, psychiatric and motor fluctuations. Although infrequent, shortness of breath is an important non-motor wearing-off symptom experienced by patients with Parkinson's disease. In addition to being a symptom induced by wearing off, other causes of shortness of breath include pulmonary diseases, coronary artery disease and anxiety. Thus, it is important to identify the cause of shortness of breath to ensure that the appropriate treatment is initiated."