Bob and Adele Levin’s I Will Keep You Alive: A Cardiovascular Romance is this husband and wife’s joint account of Bob’s heart attacks and recoveries. The Levins’ write-ups of their own emotional states, as well as their angles on vagaries of our country’s healthcare system, make their book a national resource – a map of the future for countless Americans fated to cope with hearts gone wrong. I Will Keep You Alive comes with an epigraph from Flannery O’Connor – “In a sense, sickness is a place more instructive than a long trip to Europe.” Its lessons from the land of the very sick reminded me of another instructive book: The Immoralist. Yet the Levins’ takeaways are sweeter and more sociable than Gide’s. Not that the Levins are pious types. (They are alive to dark humor in the horrors of their fearsome years.) It’s true, though, their testament hits hopeful notes that seem pretty far gone from the dailiness of hardcore modernists. Cue Ram Dass who’s praised I Will Keep You Alive as “an inspiring story of a journey through illness toward love, compassion and being.” The excerpt that follows starts with an upside as Adele Levin muses on her husband’s changes. Her entries to I Will Keep You Alive are italicized; Bob Levin’s are in plain text.
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The week before the operation, Bob’s review of William Boyd’s Nat Tate: An American Artist was published on-line. The book had been released and responded to as an actual biography; but Boyd had made everything up, not only the life, but the supporting journal entries, letter extracts, and recollections of friends.
Bob had worked on his piece the preceding month. I didn’t know how he could remain so focused or, conversely, why I had so little control in similar situations. Some years before, when a huge, longstanding melanoma, hidden under bushels of my hair, had me facing surgeries and, depending on its stage of development, radiation or chemo or, even, death, I’d had visions worth describing but couldn’t bring myself to write a word. (I’d had the surgery and surprised the doctors – and myself – with the best possible lab results: Stage One.) Perhaps, I thought, writing took Bob’s mind off his operation by filling him with other thoughts. What worked for me was watching thriller movies on cable, where the fears experienced by anonymous people were greater than my own.
Reading Bob’s review, I wondered, too, if the subject matter, or his analysis of the situation, related to what was going on in his life. His recent medical events must have felt like they were happening to a person he hadn’t expected to be, a fictional Bob, not the real Bob. The most striking thing about his reaction to the shocks he had survived was the positive way he had changed in order to manage them. He still felt like Bob to me, but there was more of him than previously. New parts were apparent. He was friendlier to himself and others, more empathic; and when he wrote, his mind reached for more than in the past. This was all good.
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Dr. Fleur ordered an angiogram for me at Alta Bates [hospital] to make sure the echo- had not registered a false positive. It seemed I was having a test a day and awaiting results and next steps in-between. That was probably always the case before surgeries and a good thing that doctors macro- and micro- focused to assure best outcomes, but it was nerve racking.
“I’m hoping,” Adele said. “I need endorphins. I haven’t had an indorphin in days. I’m only having outdorphins.”
It took two tranquilizers to put me to sleep the night before the test. A nurses’ strike was threatened, and it was unclear if a tech would be available for me. If there wasn’t, Dr. Volpe would have to postpone the operation. Even if there was, I would have to wait for the results. And, now that we knew there was an upside, they mattered greatly.
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[Due to a] strike, Alta Bates seemed staffed by temps from another planet, where all motion was slowed down, and even the simplest tasks, like finding an extra blanket, was bewildering. It was not long before their hesitations and fumblings left us giggling each time they left our room.
It took six hours, but the test was done. And since the clock in our room worked, we knew exactly when we would return home.
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The echo- had been right. The wall lived. And the doctors found a place they hadn’t known about which would benefit from additional blood flow as well.
I felt almost insanely good.
Before I had resented people who were heart-problem free, when I, who had lived right wasn’t, and they, who hadn’t, were. Now I saw myself as having an “opportunity.” I would have an experience that they had not. I would be better physically than I had been. I would emerge deeper, wiser, stronger.
Adele said she had similar hopes but had been scared to express them. “Like your Arizona friend said about faith. Love and desire are stronger than fear.”
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Over our long weekend, we enjoyed our café time and workouts, and added a restaurant outing. At home, we ate our favorite meals, scallops and pasta, egg-white omelets, and hamburgers with olive oil home fries. We watched the always enchanting Bringing Up Baby and the pricey same-day-as-in-theaters Moneyball. Family and friends called with best wishes. Marilyn and I worked out our plans for the day of the operation. Bob and I held hands and cuddled on the way to sleep.
By Wednesday, it felt safe to jump into what I had dubbed “The-day-before-the-operation-will-be-over.” I was pleased with how my mind had framed it. I find it hard to absorb both good news and bad news and come out with the positive, but it had been wonderful to hear Bob’s thoughts about getting this done and having an improved life. I still had bad patches, but this second-hand smoke of good feelings prevailed most of the time.
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Robert drove us to California Pacific. Since the ‘89 earthquake, I had been nervous crossing the Bay Bridge. I can’t wait for Angel Island. Then I can’t wait for the city. I was more nervous now.
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We stopped at the [hotel] Kabuki first. My room was lovely, but in hopes of staying overnight with Bob, I took a change of clothes and my pill box and tablet to the hospital in my backpack.
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Once we were inside California Pacific, it was BANG! BANG! BANG! Personal questions, temperature, pulse, blood pressure. Blood sample, urine. Physical exam, history, X-rays. It kept my mind off what was about to happen.
There were two beds in my room, and Adele was allowed to stay, which was reassuring to us both. The ward doctor, who was the last to visit me, apologized for being late. He had wanted to read my substantial file before meeting with us. He was astounded at how well I looked, after all I’d been through. He discussed the operation and recovery time, leaving Adele and I feeling reassured.
We said our now-customary good nights, which end with “I feel loved.”
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The only bad omen was that, the next morning, the nurse shaving Bob, pre-op, nicked one of his testicles, and he bled and bled.
I held a towel and applied pressure to the spot. The amount of blood and the time it took to stop terrified me. After the bleeding stopped, Bob and I sat in the hall and people-watched. The call to surgery came shortly after noon, three hours later than expected. We were taken downstairs, where we met the anesthesiologist. We warned him about Bob’s throat sensitivity, and he gave Bob something to relax him. I wished he’d medicate me too.
Bob and I parted with a kiss. It was not as hard to separate as after the second heart attack, when he felt and looked like he might not make it.
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I am joyful. I have faith. I will be healed I am loved.
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HAPPY OPERATION!
A grandmotherly woman, with short white hair and a nice smile, had me add my name, Bob’s, his surgeon’s, and my cell phone number to the list at the front desk. She showed me the board where I could see when Bob’s surgery began, when it concluded, when he arrived in recovery, and when he was ready for his overnight in the ICU. His surgeon, she said, would visit me after completion. Marilyn [Adele’s close friend] was on her way. I felt safe, protected; my tranquilizer was kicking in.
Many people were already waiting, some reading newspapers, others on computers, a lone woman staring at a TV on the far wall, several sitting, eyes closed, perhaps asleep. I took two seats together for me and Marilyn, with a view outdoors and a small hassock we could share or use as a table. Then I returned to the desk for help with connecting to Wi-Fi. A young man fiddled with set-up and succeeded. Marilyn called from the garage, and I gave her directions to where I waited.
It was wonderful to see her and feel her loving warmth. Everyone should be so lucky as to have a friend like her. Scrabble gave way to gin rummy, then to go-fish, as my attention span shortened.
At 1:30, a full hour before the expected finish, Dr. Volpe sat down with us. “A happy operation,” he said. He had repaired Bob’s mitral valve; a replacement hadn’t been necessary. He’d only done one bypass. His assistant, Dr. Ivanov, and his team were closing. He suggested I go back to the hotel, relax, nap, eat something. I could see Bob in two hours in the ICU. I gave him a big hug and “Thank you.”
I hugged Marilyn. I was shivering. I hugged myself. In two hours I could hug Bob. “Happy operation!” I said, trying out the words. “It’s over. I’m so relieved.”
Marilyn and I took the shuttle to the Kabuki. The clouds had cleared, the fog dispersed, the sea of terror calmed. I didn’t want a nap or food, but I did want a shower and change of clothes. I’d never enjoyed a shower so thoroughly. I called my sister and brother and Bob’s brother to tell them the good news. I convinced a reluctant-to-leave-me-alone Marilyn to cross the bay before the traffic built up. I walked her to her car in the hospital garage and promised to call after I saw Bob. I took a leisurely walk around the block and arrived back at the time Dr. Volpe had suggested.
The board said Bob was still in surgery.
“Why?” I asked the grandmotherly woman.
She called the surgical nurse.
All she said was that they were working on Bob.
I called Dr. Volpe, but he was unreachable, in surgery at another hospital.
I was left to imagine the worst.
For the next four hours, I received periodic updates from the desk, each with the same, non-specific information.
I alternated pacing, sitting, and, eventually, curling in a fetal position, propped upon my backpack, on a bench. I kept my eye on the desk, having told them to wake me if I fell asleep and there was news. Joey, my niece in L.A., had received the “All clear” from her Dad and called me to rejoice. I told her what was going on, and we stayed in touch while I waited. That was a comfort, as was talking to Marilyn.
I was furious at Dr. Volpe’s unavailability. His “Happy Operation” mockingly echoed in my ears. I told myself it might still be okay, but the possibility that it wouldn’t rang full force. I worried that Bob had had a stroke or heart attack or was bleeding to death. I felt intolerable pain, psychic and physical, which alternated with numbness. I prayed I would not lose Bob. That was the abandonment I feared.
Finally, the call came. Bob had been moved to recovery. A doctor who had worked on him would speak with me.
I took a seat by the window in the room where I had started this long, now interminable-seeming day. I watched other doctors arrive to talk with other wives, husbands, and families and awaited whomever had been with Bob. I called Joey and Marilyn. I was guardedly relieved, climbing slowly out of the tangle of fears. I knew Bob was alive.
Dr. Ivanov, a tall, forty-something man, with a dark stubble, arrived with an even younger anesthesiologist, whose smiling face was framed by red curls. They seemed exhausted. Dr. Ivanov said Bob was “Fine,” then excused himself. The anesthesiologist stayed long enough to explain they had been unable to close Bob because of heavy, uncontrollable internal bleeding. He said I could wait upstairs, where Bob was now. Once he was in the ICU, I could see him.
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Here is what we learned later from Dr. Volpe’s Operative Note.
Because of scarring, he could not tell whether one or two of my vessels were closed. He proceeded with the by-pass, though he was “not sure whether this will do any good.” I was connected to a pump, which kept my blood circulating. My heart was “lifted out,” the scarred areas excised, and segments of veins, which had been taken from each of my ankles, were grafted in to establish a new channel of flow.
My “formerly beautiful” mitral valve, while “grossly dilated” and scarred, was “not completely dead.” It retained “excellent quality” tissue. He need not replace the valve; ringing it would do. This repair was so successful there was “absolutely no regurgitation.” But I was “extremely bloody” and clotted so poorly, he suspected I had not stopped my Effient as instructed.
I was, he summed up, “very, very difficult to make clot… so much so that… we spent several hours in the operating room watching him and trying to get him to clot and this will be the big problem with this man postop. Of course I have no experience with Effient and the experience I have had with Plavix has not been good, so it remains to be seen what will happen with this nice man, but the operation he received, the technical aspects of it, were perfectly satisfactory.”
(Reading this for the first time, more than four years after it was written, still made me shiver. This “nice man” lying there. This technically “perfectly satisfactory” operation. This perfection and niceness resulting in this remaining unknown.)
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I introduced myself at the nurse’s station in the ICU. Bob’s nurse was summoned and took me to him. He was sleeping, she explained, and wouldn’t awake until morning. It was close to 8:00 p.m.
Seeing Bob was wonderful. He had good color and was breathing easily. The requisite tubes ran in and out of him, but in comparison to how he had looked after the second heart attack, it all seemed good. I asked if I could sleep in a chair beside him, but the nurse thought he’d be better served if I went to the hotel, had a decent night’s rest and had fresh energy for tomorrow, when he’d be awake. She was doing a double-shift and assured me she would take excellent care of him. She gave me the number to call, should I want an update at any point.
I sat with Bob a little longer, said our good night prayers solo, holding his hand, and kissed him. I was the only passenger on the last shuttle to the hotel. I called Marilyn, but, having already taken my sleeping pill, was too sleepy to talk. I fell asleep almost immediately. When I woke at 2:00 a.m., I called the hospital. Bob had woken briefly around midnight. The nurse had removed his breathing tube, and he was sleeping comfortably. He probably would not remember having awakened, but he was doing well.
I woke early, showered – and found a voicemail from Bob. I called back. It was thrilling to hear his voice. Again, I marveled at how much better he was doing than after his second M.I. I was on the first shuttle to the hospital. I felt so much better, I stopped at the cafeteria to pick up a few hard-boiled eggs, a fresh fruit salad, Greek yogurt, and a cup of Peet’s French roast to take with me. I hadn’t eaten one entire meal the day before.
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SQUIRRELS DO BETTER
Effient had been the problem. Being Plavix-resistant, I was fortunate it existed – but I was unfortunate its existence had been too brief for doctors to understand its workings. Patients came off Plavix a week before surgery. I had come off Effient – Dr. Volpe’s suspicions to the contrary – ten days before mine. But even this had proved insufficient. I had bled so badly that they had coded me.
Adele and I learned this from the nurse who had assisted Dr. Ivanov, following Dr. Volpe’s departure. We saw her my second day in the ICU, following my transfer from a dismal room, where I had to share a TV with another patient, to a room in which I had my own. She was a trim, no-nonsense brunette, who looked like she knocked down triathalons like pints of beer.
“You mean, like Code Blue?” I said. Maybe she had meant Code Grey. But that summons security when a patient attacks a doctor, and I had been in no condition for that. Maybe she had meant Code Pink. But that is when someone swipes an infant from Pediatrics, for which I had no inclination.
“Dr. Ivanov saved your life,” she said.
We had been disappointed to learn that he would be attending me for the rest of my stay. Dr. Ivanov, frankly, had a bedside manner which seemed gloomier than Dr. Caligari’s. He had already informed us, “It will be six months before we know if the surgery did any good. Only one-third of patients improve. One-third remain the same, and one-third worsen.” We had welcomed that information as would a birthday balloon a porcupine.
But now we were all thanks and gratitude.
I had a twelve-inch scar down the middle of my chest and, below that, what looked like a second belly button, where a tube had pierced me. I had a five-inch scar on the inner aspect of each lower leg, where the veins had been harvested for the bypass. My right shoulder ached from a muscle pulled when I had been spread apart for better viewing. The breathing tube had re-scratched my throat and re-started my coughing. (All this would hurt less than the bed sore I developed on my butt from being forced to lie in one position.)
My biggest problem was being forbidden to put pressure on the wires that knit my chest together. I could not use my arms to boost or steady myself while getting in or out of bed. I could not use them when I sat on or rose from a chair. I could not reach behind myself to pull a t-shirt on or off or to wash or dry my back. I could not lift anything heavier than a newspaper.
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On the third day, we moved upstairs from the ICU to Recovery. Bob’s room held one bed and one chair. Its view was of a slice of park. Its TV’s possibilities were unexpanded by cable. The first morning there, I overheard a doctor discuss Bob’s heart with residents he was leading on rounds. Everything he said about the consequences of Bob’s damaged heart being unable to deliver an adequate blood supply, worried me. I had forgotten that the doctor’s job was to teach his residents everything he could. If we had the recovery we hoped for, what he said made no difference.
But I was doing fine at the Kabuki. I found it easier to sleep there than when I had been running back and forth between home and Sutter. I became used to the shuttle. I discovered an organic grocery where I could get food for the day, which the nurses let me stash in their refrigerator. The neighborhood was rich with restaurants and cafes and bookstores. Sometimes I talked to my sister as I walked. Other times I went to a nearby park, atop a hill, from which I could see the city spread out before me. It was a familiar and also foreign country. I had almost hour-by-hour recall of Bob’s time in Sutter, but now the days blurred together. It wasn’t better or worse, just different.
Sutter had become almost a second home, but California Pacific remained a place apart. It brought back the 1960s though, and my early days in San Francisco. Every block evoked people I had known and experiences I’d had. On my walks, I contemplated the familiar street names and buildings and compared them to the now-different context. Although “then” had excited, with endless possibilities and dreams and a feeling of invulnerability, as a person, with Bob, I was much more solid “now.” In the ‘60s I had been searching for everything, a profession, writing success, the life I would live, and the person I would live it with. Now I had that person and that life and had lived it, fully, for forty-plus years.
Fillmore Street resonated most deeply. Most of my various haunts, like the Royal Café, no longer existed. There, in 1965, for 99-cents-to-$1.99, you could feast on soup, salad, fries or mashed, broccoli or green beans, liver, steak or veal, ice cream, and beverage. The sign, “Superior Food,” in the window had been an exaggerated misnomer, but it was good and affordable and suited me and my then-boyfriend, a troubled and brilliant revolutionary. He was trying to free me from my capitalist family and repressed sexuality, while I was trying to coax him back to college, which he’d left, freshman year, after his mother had killed his siblings and left his father and him for dead before killing herself.
From the park, I could see across San Francisco, to Buena Vista Park, where I’d played tennis, stoned, and to the Panhandle, where I’d danced to the Grateful Dead. I ran through the city in my head, connecting all the roads I’d driven and walked and made memories before Bob arrived. It had only been a few year digression before I was back on track with him, but remembering how far those times were from now gave me an unexpected boost. I had needed those experiences, but what I had found, a man I could love and a life that suited me was even better than I had hoped.
One Saturday, in the mid-‘70s, when I was a therapist, I’d sat on a bench with a view like the one I had now. Beside me was a woman I was treating. She had been bent on killing herself then but had gone on to live a couple good decades, in a good relationship, with good work, before dying of natural causes. As I stood up to return to Cal Pacific, I thought of all the progress she had made in those decades and that Bob had made in the last week and felt a bounce in my step, knowing we would soon be going home.
As Bob gained strength, we took longer and longer slow walks, out of the pocket of like-rooms and their nurses’ station, to the straightaway hall that connected other clusters of rooms. One day we found where Bob had slept the night before surgery. I was glad we had gotten past that. Another day we heard, then saw a hospital-gowned patient practically sprint past us. We joked about what he might be chasing but later found out he was the successful recipient of a second heart transplant. The first had gone bad, but his dash was a positive visual of the possible.
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Again, nurses, techs and therapists bled, X-rayed and scanned me. Again, my blood pressure, temperature and pulse were measured, day and night. I came off the drip I had been receiving to stimulate my blood flow. I came off my pacer wires. But the ICU’s restrictions held. To do more, I would have to hoist the Mack truck Dr. Volpe had warned of from my chest.
But cardio-rehab had strengthened my legs, making my “no hands” maneuvers easier. I rose and sat and rose and sat. I walked halls and climbed stairs. I did the assigned exercises and requested more. If my blood pressure registered too low for me to be allowed out of bed, I exercised while lying down and had it re-taken.
Dr. Volpe visited for the first – and only – time, five days after the operation. When he entered, I was exercising my lungs by drawing air through a tube, every inhalation an attempt to force a marker to the top of a plastic cylinder. “Squirrels do better,” he said, smiling at my best effort. He snatched the device and rang its gong. I was prepared to hear that, in his spare time, he sang tenor for the San Francisco Opera. Instead, he announced my recovery had progressed so well I would be discharged a day earlier than expected.
But Adele’s and my elation did not survive the afternoon. An echo-cardiogram, whose results Dr. Volpe had not seen, showed that my heart’s left ventricular’s function, with an ejection fraction of 30, was too weak to expel the fluid sluiced into me during surgery. Dr. Ivanov ordered me returned to the ICU for monitoring while IVs fed me medication to strengthen my heart and help me void. It was frightening to be back in ICU. It was frightening not to know how long I would be there.
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It felt terrible to see Bob’s spirits crushed.
I felt duped again by Dr. Volpe’s unwarranted high spirits and overly optimistic assessment. I had been in the room when the echo was done, and its audio now seemed as foreboding as the turbulence of approaching rapid waters. My strongest upset stemmed from the words “not strong enough to void.” I knew that was imperative for recovery. Again, a doctor with medical students-in-tow paid an annoying visit. Again, I caught a discouraging sentence. Bob’s heart might be too damaged to ever properly oxygenate his heart and limbs. We had to hope the drugs would turn the tide. We hoped to have a fighting chance for Bob’s body to do the rest.
Meanwhile, a minor problem reared. I had only booked one week at the Kabuki, and when I said I would need a room for a second, they said they didn’t have one. A psychologist/basketball buddy of Bob’s offered me a couch in his house across town, but just before I was to decamp, the hotel came up with an entire suite in its basement. It had no interior walls, just curtained-off compartments. A gigantic mirror hung over the bed. Neither the shower nor the TV worked. Its strangeness seemed to reflect the world into which Bob and I had been forced. But its nearness to him overrode its discontents, and the following day the Kabuki came up with something more normal.
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The ICU medication worked so well I twice wet my bed.
The next day I returned to Recovery. I was weak. I coughed. I went on and off different medications. No one mentioned discharge, but the whispers of doom vanished too.
I continued to walk and exercise. If confidence and macho daring pushed me to over test my arms, I re-trenched once Adele caught me. My appetite was good. I tried nearly everything the daily menus offered, but only the Italian dinner warranted a second chance. I watched snippets of ballgames. Adele snuck me a double espresso, which lifted my spirits further – but set my left leg jiggling uncontrollably. She proudly presented me a used copy of Kate Atkinson’s newly published Left Early Took the Dog. (Later she confessed that, since she knew I would have objected if I had known she had bought it new, she had the clerk mark it as if it was used and scuff it, so I would not suspect her duplicity.)
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Bob’s second weekend in Cal Pacific, Dr. Fleur visited.
Returning from vacation, she’d found Dr. Volpe’s message that he’d discharged him. Only after not be able to reach us at home had she inquired further. She’d tried to come earlier, but emergencies had intervened. It was good for us to think she was coming and then, when she couldn’t, to look forward to her again. When she got there, her blonde hair loose, lovely in skin-fit jeans and gorgeous sweater, we were not disappointed. She bubbled over with positive feelings…
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Dr. Fleur was reassuring. She said nothing suggested the surgery had failed. It was natural that its shock would traumatize my heart; recovery was equally likely. Even if I became no better than I had been, options remained. She found one clear positive. “Everyone agrees you’ve proved yourself a good candidate for a transplant.”
Which, while welcome news, was not exactly “I’ll see you again in five years.”
I came up with a second. For six months I’d teetered along the high wire of not knowing if I would need surgery. Now I had the stability of putting that behind me.
Two days later, – my ejection fraction up to 34 – nine medications in tow – I was home.