Timm's heart trouble (2)

As promised, here is post that accounts more carefully for Timm's heart condition in his final months. (You can read the first part of the post here.)

We haven't any medical records of Timm's earlier than August of 2007 when he switched to Dr. Paul Weaver.

Dr. Weaver's medical degree is in osteophathy. (The training of osteophathic physicians is almost identical to that of MD physicians; they use all conventional methods of diagnosis and treatment but are trained to place additional emphasis on the achievement of normal body mechanics as central to good health.)

The whole time Timm visited Dr. Weaver, from August 2007 up to his death on April 18, his blood pressure was never checked, nor was there any attempt to look at Timm's difficulties from a cardiac perspective. Dr. Weaver focused mostly on Timm's physical aches and pains. Had Timm also seen a regular M.D., his condition might have been diagnosed. But whether anything could have prevented Timm's cardiac arrest, we just can't know.

A Dr. Auerbach is on a prescription for Ritalin filled in August 2007, so he may have been Timm's former doctor for some time.

The medical records faxed over by Dr. Weaver's office after Timm's death may or may not be complete, but his records indicate that Timm was taking Tramterene for blood pressure.

Timm's friend Ken says that blood pressure was an issue with Timm over the past two years. "I went on meds but he thought he could address it with exercise. He was younger, too."

Timm was probably prescribed blood pressure medicine by Dr. Auerbach last year. He was concerned enough about his pressure to track it in two different Excel files last year.

From late May to mid-July 2007 he took morning and evening blood pressure readings on eight occasions. His highest blood pressure was recorded at 10 p.m. on May 27, 159/99. The lowest was recorded on the morning of July 11, 134/84.

Between November 10 and December 3, 2007, he took 16 morning, afternoon and evening readings, with a high of 155/100 at 9 a.m. November 16. There are notations for "before" and "after" a run and before taking Ritalin. On November 30 he indicates, "Low Sodium begins," which must mean he tried to lower his sodium intake.

Timm was referred to Dr. Weaver by Jan Roach, MT -- I'm guessing a massage therapist. Timm came to Dr. Weaver to deal with chronic pain in his right foot. In Dr. Weaver's notes Timm said the pain went back to an old tennis injury. He had given up running and was finding it difficult to ride his bicycle. (He also suffers from pain in the knee, wrists and neck, the result of other sports injuries. Timm was hard on his body.) Dr. Weaver applies a number of physical treatments (similar, I'm guessing, to what a chiropractor would do). Timm's blood pressure condition is noted but those vitals aren't recorded anywhere.

Timm saw Dr. Weaver on two follow-ups for the foot condition August and September and returns to running. On a visit in November Timm says his foot is better but then goes into another round of pains. His upper back and left shoulder get sore from cycling, his left thumb is so sore that he can't play his guitar. Dr. Weaver applies more physical treatments.

On a follwup visit in December Timm says he's running well but is suffering from the flu. A followup visit in January has Timm complaining a recurrent bout of the bug. He also complains of neck pain and shooting pains down from his shoulder.

Later in January, Timm's back again seeing Dr. Weaver with the third occurrence of the flu. "Chronic sinus problems" is added to the list of Timm's chronic woes.

According to Christie, in early February 2008 Timm came back from a run and complained of difficulty breathing. (He told her that he might have inhaled something while running and it caught in his lung; it was also the most flat-out run he'd attempted in long time.) He went to see Dr. Weaver that day; an X-ray was done on his lungs and a small hole was discovered which Dr. Weaver thought would heal. An antibiotic patch was prescribed but there was no evaluation of Timm's heart function at that time.

The first week after the appointment, Timm was moving slowly. He slept sitting up. Once or twice a week, Christie said, he "felt like something was stuck in his lung."

The second week Timm was feeling better but still felt something in his chest, so he went for a followup appointment.

In mid-March he went for a run. Afterwards he told Christie that he couldn't do as many miles and that his chest felt heavy.

Ken and Timm has been discussing his difficulties but Timm was offhand about it and didn't indicate Dr. Weaver had any concern, either. "I thought that was weird," Ken says, " because his trouble breathing was exactly the same as my wife Dana, who had suffered those symptoms after chemo for breast cancer and received extensive cardiac tests. The doctor read this apparently as an allergy problem only."

According to Ken, Timm blamed his flagging stamina on damage to his lungs from smoking in the past.

Ken says he encouraged Timm to go back to the doctor after 2 weeks because of his difficulty breathing. He got an inhaler and the meds.

Timm suffered from allergies which caused throat pain, congestion and headaches. He took a Sinus Cleanse powder containing sodium bicarbonate and sodium chloride (could these counteracted with the dyazide??)

He also had occasional migraines.

In early April Timm went back to Dr. Weaver saying he just didn't feel right. At that time Dr. Weaver renewed Timm's prescriptions for methylphenidatre (Ritalin), Singulair (an asthma medication) and triamterene (dyazide - a blood pressure medication). Dr. Weaver thought the symptoms Timm was suffering might have been due to side effects of the Singulair.

Although the Ritalin seemed to help Timm focus on the job, Ken didn't like Timm taking the drug. "He wasn't the same Timm when he took it; he became visibly more nervous, his movements tapping and jumping." There was also recent negative press against the drug, with the American Heart Association warning doctors to screen children for heart problems before prescribing the drug (due to an increasing number of sudden heart deaths).

Ken didn't like Timm taking the Singulair, either, because of the side effects (it was in the news for making people suicidal).

Dr. Weaver scheduled Timm for a chest CT scan to check pulmonary (lung) function on April 7 but Timm cancelled the appointment, saying he "felt better."

On the Sunday before his heart attack, Christie says they were in the park. It was a beautiful, warm, springlike day. At one point they lay on the ground and Christie lay her head on Timm's chest. He didn't complain of any pain, Christie said.

Ken says he spoke with Timm on the phone the night of April 17. Timm rang off at some point saying he needed to save the cell phone minutes. Nothing in his manner seemed unusual, Ken said.

According to the report filed Rural Metro Ambulance on April 18, parameds were dispatched to Timm's apartment between 9:30 and 10 p.m., following up on a 911 call from Timm complaining of chest pains and difficulty breathing.

According to their report, Timm told the paramedics that the chest pains had begun about four hours earlier that night following a run. He felt a sharp pain that was similar to the one he had felt four months earlier when he'd gone on a run and went to see his primary care physician (who diagnosed the problem as "a hole one of his lungs that would heal.").

Timm appeared in no immediate distress and his vitals at the time were not terribly amiss (140 over 80). However, en route to the hospital Timm went into cardiac arrest, lost consciousness and had to have defibrillation paddles applied twice. By the time the reached the hospital (3.4 miles away), Timm had somewhat regained consciousness and could talk in incomplete sentences. In the ER he told attending doctor Amy L. Dourgarian, MD, that he had no previous cardiac disease.

A chest x-ray ordered by Dr. Dourgarian at 10:30 p.m. did show "relatively dense upper lobe infiltrates" which "suggest the possibility of aspiration pneumonia," so Dr. Weaver's prognosis may not have been wholly off. It may be, also that the pulmonary problems masked the cardiac ones.

I’ve written the following before, but I include it in this post to properly conclude this chain of events: Still in the emergency room, x-rays showed that a thrombosis (clot) had massed in his anterior descending artery, the result of a lesion in the artery wall after built-up plaque had torn loose. Artery-reopening stents were injected into his femoral artery and the clot was largely dispelled, but there was damage to the anterior wall of Timm's heart that couldn't be repaired. Timm's vitals kept failing and twice he went into Code Blue. There was an attempt to insert an angioplasty balloon to reinforce the stents in the anterior descending artery, but by them his vitals were so low that no further attempts were made to revive him. Timm was declared dead at 2:55 a.m.

Timm took this photo on Saturday, April 12. Something about the dome these kids are playing on reminds me of Timm's heart.

No autopsy was performed on Timm, and without extensive past medical records, we will never know all of the reasons for Timm's heart attack.

I chose not to ask Dr. Weaver any questions after Timm's death because I wanted, more than anything, to get his medical records in as pristine shape as possible. (My uncle, a retired neurosurgeon, says it isn't unsual for medical records to be "doctored" to prevent malpractice litigation.) However, these questions I would now ask:

- Why wasn't Timm's heart condition explored deeper, given that Dr. Weaver knew that Timm was on blood pressure medication and that he was having difficulty breathing? Did a real condition in Timm's lungs (a "pneumothorax") mask the worsening condition of his heart?

- If Timm's heart attack was caused by plaque tearing loose in his anterior descending artery, how could it has built up as much as it had by age 44?

- How long had Timm been on Ritalin? Had he been screened with an EKG when the Ritalin was first prescribed? Could it have caused his heart attack.

- Could there be possible adverse reactions for Timm taking all three medications?

- Could there have been adverse reactions if Timm took supplements, vitamins or other herbal remedies? (I'm thinking here of the sinus cleanse powders, and exercise supplements like creatine.)

- When was Timm's last labwork?

These questions for Salem Hospital and Dr. Stiles:

- According to Dr. Weaver's notes, Timm was allergic to penicillin, iodine and opiates including codeine (he probably noted the last as part of his AA recovery). None of his allergies (or medications) were known when he was admitted to Salem Hospital; could he have been given any medications there which worsened further his condition?

- Could Timm have had a better chance of being saved had there not been a delay in getting Timm into the catherization lab around midnight? The ER had to continually supply life support (including 12 applications of defrib paddles) during the wait.

***

From all this I’d have to conclude that Timm's heart attack on April 17 was caused by the run he’d been on earlier that night – a fact that I missed until yesterday when I re-read the ambulance driver’s report. Timm felt the same symptoms of chest tightness and difficulty breathing after that run which he had felt in early February and in March. Behind that, high blood pressure and plaque buildup were certainly waiting for a stressful enough event to cause the plaque tearoff and lesion in his anterior descending artery which summoned the thrombosis (blood clot) which in turn caused the myocardial infraction which killed him.

I wonder if Timm was aware of the danger. It’s astonishing to hear the litany of physical hurts which dogged Timm in his attempts to get healthy – the injuries to his head and neck and shoulder, his back and knees and wrist, his fingers, his ankles and feet, his ribs. Were all of those injuries the result of a terrible compulsion to push too hard, to run, to break free

Surely Timm loved the feeling of an all-out run, heart pumping, exhilarated from the runner's high, to be in fine health, still young, still able to wallop the pavement with his shoes ... The great irony might be that that very impulse is what killed him in the end.

In remembering Timm, perhaps this whole post today just shows how much heart Timm had. How much he gave it his best shot.