Back to the Land of the Living and Results

Well, I went back to work this week. I made it. I did it. Even though I felt incredibly guilty about being on leave, I needed that rest and intervention. I wasn’t going to make it much longer and definitely not to the end of the semester. Going back to work, I felt embarrassed and awkward. With teaching, it’s important to maintain momentum and the connection with students. I was worried I was going to have to start from scratch. I even thought I’d jokingly suggest we all reintroduce ourselves when I walked back into my classes, but as I walked in one of my students shouted “Hey! You exceeded the maximum number of allowed absences on the syllabus and we were going to drop you from the course.” I told him luckily they don’t have that power. We all laughed. It was brilliant and put my fears to rest. I am still struggling with the constant exhaustion and weakness. Over these last few months my energy level has plummeted and I just feel worse overall. I really hope this isn’t a new normal. I'm also dealing with some intense family issues, but my plan is to get some rest and recover this summer and be bright, shiny, and new for fall.  But I’m doing better. My spirit is renewed. I’m ready to keep up the fight and finish the semester with my students.  I’m ready to start enjoying life again. Snuggle my cats, laugh with my husband, do some cartwheels when no one is looking.

A colleague asked me today if I was on leave because of “stress.” I had to hold my tongue and politely inform her that she was mistaken. Sometimes I have to remember to be patient with people because I don’t look sick so they can’t know that even though I show up to work most days,  I’ve spent the last 4 months suffering and being periodically bedridden and needing to go to the ER.  I’ll take it as a compliment that I make chronic illness look good. 

I just wanted to mention the results my neurologist’s nurse practitioner gave me at Stanford for the autonomic testing I did in December. Autonomic testing can confirm autonomic dysfunction, and it is one test that was actually created to diagnose dysautonomia. I was scared out of my mind to do these tests and put it off for over a year, mainly because I did not ever ever ever want to do another Tilt Table Test again. It’s enhanced interrogation, straight up torture. I finally relented. There are three parts to the test: the TTT, the QSART sweat test, and Valsalva Manuever breathing test. This video explains them and you get to watch someone be subjected to them: http://www.jove.com/video/2502/quantitative-autonomic-testing Try to stay awake through it. 

I walked into the testing room on the verge tears and told the neurologist and nurse I refused to do the TTT. The first TTT I did in 2012 was before I was diagnosed with POTS, and I had no expectation for the test. When they lifted the table up, my heart rate, which was attached to a monitor that beeped loudly, went from 72 to 147. I thought some alarm was going off as my heart rate was beeping wildly. The sensation of slowly being lifted to vertical made me want to vomit and pass out. I will never forget that awful sensation. Then, my cardiologist injected me with a medication to make it go higher to see if I would faint. The test proved my days of partaking in the joys of rollercoasters and tilt-a-whirls are over.

Luckily for this second one, they were kind, patient, and nice and they cut me a deal. Instead of the table lifting all the way up to 90 degrees for 30 minutes, they let me just do 60 degrees for 6 minutes. My heart rate wasn’t attached to a monitor and I wasn’t injected with anything. It was a breeze. A neurology TTT is much easier than a cardiology TTT. My heart rate still went from 72 to 147. At least I am consistent. The breathing test was the most difficult but they told me it was normal, which I wasn’t expecting because breathing is a struggle. They told me my sweat test was abnormal and explained that there is some nerve damage so my body doesn’t sweat properly. That’s great for living in an area where it is over 100 degrees for four months a year. They told me I should do more testing for this. I’m not sure what other information that would provide besides confirming I am a weird sweater. I guess I could just put “weird sweater” on my resume and call it a day.

Not the Bill Cosby kind of weird sweater

I also did a nerve conductivity EMG (http://en.wikipedia.org/wiki/Electromyography)to see if the new mystery of my weird walking problem is nerve damage. The test showed no nerve damage. The saga continues and will likely include more testing to figure this one out. I have heard these words mentioned in relation to this new mystery: MS, ALS, Parkinson’s. I’ve learned it isn’t worth panicking about any new possibility until it is a reality.

I’m not sure what the autonomic testing really provided and I don’t really understand the results, so I failed at explaining them to my other doctors. This is the problem with having a rare chronic illness: I often have to be the expert and the line of communication between doctors. I'm not sure what my degrees in literature really prepared me for, but they definitely didn't prepare me for that. I see my neurologist at Stanford at the end of May and I hope he can tell me more about why those tests were useful besides confirming I have POTS. 

I worried about doing those tests for over a year and it wasn’t nearly as bad as I expected. I should have learned a lesson there, but I still panic and stress about every test I have to do. There will be more tests in the future, but I will face them in my battle gear.

The Past, The Present, and What the Hell is Dysautonomia?

Last weekend, I was at my parent’s house not watching the super bowl, and my mom brought out a pile of pictures she was going through. She handed me a picture that gave me a punch in the gut. This is a picture from when my parents took my husband, my sister, and I to Hawai’i a few years ago:

I looked at this picture in shock and not recognizing this pre-sick version of myself. It made me sad. I showed it to my husband and it made him sad too. I don’t accept wallowing, but I do have moments of “whose reality am I living in because this isn’t mine.” Like stepping through the looking glass or that horrific awakening after being disconnected from the Matrix. This picture is like looking at memories from that sleek, spectacular world where everyone wears pleather and badass sunglasses while dodging bullets. Pre-sick is a stunning alternate universe. Looking at this picture was another “WTF happened to my life” moment. It does not do to dwell on the past, so I had that sad moment and then moved on. I laughed and told my husband “I looked so weird and fleshy then.” And damn, I miss that hair. 

What It Is:

This is the present. I was diagnosed with dysautonomia and POTS (Postural Orthostatic Tachycardia Syndrome) in May 2012 when I did my first Tilt Table Test. Dysautonomia and POTS are very rare conditions and are very rarely diagnosed.  It’s estimated that 500,000 people are diagnosed with POTS. There is no pamphlet or brochure for this condition and most of the doctors and specialists out there have never heard of it. There are no specific medications for dysautonomia. Many with the condition will hear from doctors that your symptoms are "all in your head." It's an almost universal experience. This is why it took me over a year to get diagnosed. It’s been almost 3 years and I’m still trying to get a more complete diagnosis. Once you get a diagnosis, a cardiologist and a neurologist are the first lines of defense in the battle.

I am no medical professional (though I would argue I may deserve an honorary medical degree at some point), but as far as I know a Tilt Table Test (TTT) is the only way to get a definitive diagnosis for POTS. The test sounds simple: you are strapped to a table while lying horizontally. Your blood pressure and heart rate are monitored continually and they lift you slowly up to vertical while still strapped to the table. My heart rate immediately increased almost 80 beats. 72 at horizontal to 145 at vertical. It was unpleasant. If your heart rate increases by 30 beats, you have a definitive diagnosis of POTS. I was earning extra credit with the 80 beats. POTS is subset of dysautonomia, which means a dysfunction of the Autonomic Nervous System. Not everyone with dysautonomia has POTS. There are a variety of subsets. Dysautonomia is is referred to as an "umbrella term." It is important to find out which subset you have to get more focused treatment.

The ANS controls all of the functions your body preforms automatically: breathing, heart rate, blood pressure, digestion, body temperature, sweating, etc. "Autonomic Dysfunction" means the body is no longer able to self-regulate these functions. Normally, when you stand your body is able to adapt to gravity and maintain blood flow to your essential organs. The words “postural orthostatic” and “tachycardia” mean that upon standing the blood pools in the legs, your blood pressure drops, and your body goes into overdrive to maintain blood flow to your brain. This is why fainting (syncope) is often associated with dysautonomia and POTS. This condition can be result of nerve damage so the nerves (your direct line of communication in the body)  are no longer working as the connection between the brain and the body. It’s like the body just suddenly forgot how to be a body (you had ONE job!). I explain to people that it’s like my “wi fi” was turned off and I swear I paid my internet bill. 

Symptoms typically related to dysautonomia include dizzinesss, excessive fatigue, GI problems (including gastroparesis and dumping syndrome), blood pooling, syncope, brain fog, difficulty sweating and maintaining body temperature regulation, tachycardia, bladder problems, hypovolemia, etc. Symptoms manifest uniquely for each individual, which makes diagnosis that much more challenging. 

Dysautonomia is not a disease; it is a symptom and a condition. The real struggle is not getting the diagnosis. It’s finding the cause. The Elusive Cause is more difficult to track down than Sasquatch and for most people The Cause is never confirmed. My doctor at Stanford believes The Cause for me is likely a conglomeration of genetic predisposition, multiple neck injuries (in gymnastics and a car accident), and other factors. The Cause is still elusive for me because my doctors couldn’t tell me why I had sudden onset of the condition. Most of the time people acquire dysautonomia after a major illness, often a viral illness. Recent research shows that dysautonomia also has an autoimmune component. It seems most dysautomoniacs (if not all) have a variety of other illnesses and conditions. As one of my doctors said to me with much appreciated empathy “Some people are just lucky.” Dysautonomia is incredibly unique for each individual and presents differently. It can be severely disabling to the point that some are unable to work. I was unable to work the first year and I work now but with varying levels of success.

There are very few physicians who have heard about this condition and only a handful in the world who are experts on the subject. If you get a diagnosis, I recommend seeking one of these individuals out at a specialty, research hospital. That was the best thing I ever did. I am now treated by an expert at Stanford University. There is autonomic testing which can help narrow a diagnosis but only a few places in the US that I am aware of have the facilities to perform these tests. Many of these tests were created at the Mayo Clinic. I’ve heard that’s one of the best places to go for autonomic dysfunction. 

There are no replacement surgeries for the nervous system. It can’t be grown on a rat and transplanted into your body. You’re stuck with that lemon. And here’s the kicker: there is no cure either. The only option at this point for dysautonomiacs is treatment of symptoms. But there is hope. Sometimes the condition improves on its own and sometimes it doesn’t. There is medication used off-label to treat dysautonomia/POTS and there are non-pharmaceutical options (my favorite kind) to manage the symptoms as well. Treatment for dysautonomia often involves medication that raises blood pressure such as Midodrine or Florinef, an increase in salt intake, exercise to build strength and avoid deconditioning, and other medications to manage the wide range of symptoms patients have related to the condition. I take a calcium channel blocker (Verapamil) to lower my heart rate, Florinef to help my body hold on to salt and raise my blood pressure, and salt pills. It seems that more people and medical professionals are becoming aware of this condition. 

There are a few great websites that explain POTS and dysautonomia that are indispensable to understanding the condition and finding treatment:

Dinet.org

The Wikipedia page on POTS

Dysautonomia International 

Mayo Clinic's page on autonomic neuropathy

The most important thing to remember is that there is hope and dysautonomia may be part your life but it cannot take away your humanity, your values, and your spirit. There are resources to manage the condition so that you can live the best life possible. 

Arming yourself with information is essential in the battle because you will often have to be the expert when talking to doctors, and taking ownership of your health is imperative. I stepped through the looking glass, but I came out the other side a warrior.