Heart attack for two--lessons for everyone: few people are aware that minor symptoms they may put down to indigestion may presage the onset of a heart attack. Greater awareness may go some way to reducing the high mortality rates from this disease.

Days of the week are not necessarily significant, but sometimes a day or a time will hold a special place in your memory because of a significant event.

One Friday, I happened to make a chance purchase--a small, ornamental glass volkswagen. My big sister Lynn had a "pet" volkswagen; she had had it for over 30 years, wrapping it up every night after driving it into the garage out of the weather. Lynn was proud of her antique friend that had transported her everywhere, especially during her nursing career.

That night I mulled over whether to give the ornament to her straight away or hold on to it for Christmas. I decided I would give it to her that weekend and enjoy the pleasure she would get from it.

On Sunday night I spent time with Lynn, had a cup of tea, and giggled over various things, including the glass volkswagen. At 10.30pm, I said my usual goodbyes and went home, planning to see her again on Tuesday. Somewhere in the early hours of Monday morning, my sister died in her sleep. How I wish she would come back. Lynn was 54, a good person, slender, vegetarian due to her love of animals, someone who exercised daily. She had a strong, but sensitive personality, and she had such plans for the future--plans she will never fulfil.

Lynn died of a heart attack. The Coroner's report showed ischaemic heart disease. Dad died of a heart attack at 65. When he was 42, he stopped smoking following the death of a dose friend. Dad was afraid he would get cancer too. Both Lynn, aged 10, and Dad had had rheumatic fever. In Lynn's case there was no record of residual damage to the heart, but neither of us knew of any investigation into her recovery back in the late 1950s. Lynn remembered taking asprin for a while. Lynn was a smoker, a second risk factor for a heart attack.

Forty years on, she had complained of indigestion. If she had something to eat, the discomfort would go away. I had told her that if this discomfort persisted she needed to have it investigated. I was concerned about her vegetarian diet and thin figure. We spoke of her rheumatic fever. We discussed her symptoms, history and the possibility her symptoms could indicate heart problems. And then it was too late. I was angry I had not been more forceful and she had been so stubborn. I miss my sister.

Nine months after my sister's death, I got out of bed one morning, said my usual hello to "Lynnie" (my children and I were then living in the house she had lived in), and cursed the annoying indigestion I was feeling. I was looking forward to the All Blacks' test that evening. I started making beds, picking up clothing and kids' debris as I went. The discomfort persisted, so I had a drink of milk, but still it persisted. I stopped, went to the kitchen, sat at the table and had another drink of milk.

My intellectually disabled son was also sitting at the table. As he watched me pounding my chest, I am sure he must have thought I had regressed to our former ape state. I stood up, thinking I could continue with my housework, and was suddenly overcome with a sense of inexplicable urgency, an overwhelming feeling of doom and gloom. I yelled at my other son to turn off the radio and TV. He responded instantly but anxiously, asking why. He soon realised I was in no mood to be questioned.

I stumbled up the hall, thinking I must wash my hair and put on a bra in preparation for going out. I went to the bathroom and Looked at my grossly pate and unwell reflection. I walked out and collapsed on the floor. I crawled to my daughter's bedroom and tent on the bed. I told my 13-year-old son to call an ambulance. When he asked me if I was alright I could only say, "I don't know': When he asked me if I was going to die, I said, "I don't know." He was terrified.

My body was drained of energy, my arms felt like Limp flags. I felt a sudden urgency to go to the toilet. "Not on your nelly! I'm not going to the toilet. My life depends on it," I told myself firmly. We could hear the ambulance coming--my son was ecstatic. In came the paramedics who hooked me up to the electrocardiogram (ECG) machine. I could tell they weren't pleased with the rhythm strip results. There was a slight improvement in my blood pressure when lying down. I happily took the asprin they gave me and was stretchered to the ambulance. I noticed all the neighbours seemed compelled to do their gardening all of a sudden. No matter, in this state they won't recognise me, I thought. Fortunately, Tauranga Hospital is near my house. Accident and emergency (A & E) were expecting me and I was received promptly. The team was efficient and effective. How I wished I wasn't a nurse, that I was stone deaf and temporarily blind. I could close my eyes and eliminate the visual aspect of my dilemma, but I couldn't fine tune the audio system.

With cardiac enzymes elevated, it was clear I had had a myocardial infarction. So lightening can strike in the same place twice. Now I ask myself: would I have been quite so alert if it hadn't been for Lynn and did my nursing experience contribute to my seeking attention quickly and recognising the symptomatic events?

My thoughts were all over the place as I tried not to pay attention to the activities+ around me. But I could not avoid them--S T elevation, tomb stones on ECG, hypotensive, hypovolaemic, intravenous Lines--a plumber's nightmare.

Coming to terms with mortality

I had always assumed I was going to live "forever" or at least Longer than those 20-30 years my senior. I had planned to be involved with grandchildren, to spot-colour my grey hair, become wrinkly like a prune, even sport the Latest walking stick or drag off pedestrians on my mobile scooter. Coming to terms with my own mortality meant realising we are fragile human beings; we are not bullet proof. Most of us take it for granted that the events from birth to old age will follow a fairly set process. When this is interrupted, we are shocked. After this experience, I don't think I will have any problem observing the gradual changes of ageing any more. I felt a sudden need to petition the Almighty. I was too young to die, I told him, and I had a family who needed me. You already have "Lynnie", so please spare me, I begged. Next it was up to the intensive therapy unit (ITU). Discussions were going on between the team and the cardiologist. Streptokinanse was on the agenda. Twenty minutes had now elapsed since the journey from A & E to ITU. I had a good view of the ceiling and fully investigated a lonely piece of sticking plaster stuck to a tile above me. I refused to acknowledge my companion the Defib machine--no jump start for me, I thought.

After 20 minutes of monitoring, my ECG returned to normal. I suspect the Streptokinase was far more effective in improving the odds for me than the atypical precordial thump I gave myself at the kitchen table. As for the All Blacks, they carried on without me, but I'm here to watch future games. They won that night and, so, some might say, did I.

Trying to define pain

People ask me to describe the pain I experienced that morning. As a nurse I realise how difficult it is to offer anything other than a clinical definition. There was no elephant sitting on my chest or tight band around it, as I have heard some male heart attack patients describe. It wasn't sharp or notably identifiable as pain. Our bodies experience all kinds of pain and the degree varies from person to person. I could only describe indigestion, which was no different to what I would expect to experience if it was simply indigestion. This discomfort was centred directly below my diaphragm. How could someone spot the difference or significance? After experiencing a heart attack, chest pain is monitored. I'm so conscious of my circumstances that the search for symptoms totally consumes me. I recall the many times I've thought with alarm, "What's that?" Was I short of breath? I was still breathing and I wasn't cyanosed. Hyperventilation doesn't count when you're scared. Does our clinical terminology need to be adjusted? Asking what a person feels throughout the day may result in a more accurate picture. Perhaps we should check with people whether they are conscious of anything different happening to their bodies. The angiogram identified a 90 percent blockage in my mid right coronary artery. I was transferred to Waikato Hospital for angioplasty and stenting. I was frightened throughout this procedure too. I now understand the origins of the term "scared to death".

My perspective on nursing has changed because of this experience. I now have much greater insight into the effect and subsequent impact of trauma and illness on the patient and his/her family. I use this new knowledge in my clinical practice. One year on from my heart attack, I am still trying to put my Life back together, and above all, regain my confidence so I can Live without fear and settle to sleep at night. I think of my sister I am unable to protect and feel sad.

A new focus in life

I have re-evaluated my priorities, having discovered that, over this time, my only concern was for the precious people I nearly left behind. I have put my order in for a Long Life and targeted 105 as a suitable Long-term goat. The only conditions I stipulate are that I have all my marbles and can still chase them when they spill out of the bag. Sunny days are more brilliant now, rainy days clear the air, music soothes the soul, and I have a need to reach out for life's purpose.

Perhaps the key to our true cardiac profile, one that fits into a familiar clinical frame, is to respectfully visualise an essential blood-pumping, self-lubricating mechanism with many moving parts and occasional design faults--a relentlessly beating instrument of Life, nurtured on a healthy diet of hope and expectation, seasoned with a genetic salad mix and sprinkled with an assortment of risk factors.

Lifestyle and genetic risks contribute to cardiac disease. People are exposed to many environmental and personal risks. Over the years, we no doubt encounter risk factors we are not even aware of. In my case, I can think of many.

Failing to recognise symptoms

The mortality rate for heart attack is high, around 5D percent. In hindsight, my sister and I both failed to recognise our symptoms as cardiac because the symptoms were not severe enough. As far as our health status was concerned, we didn't think we were particularly tough, just a Little grittier than average perhaps. We'd both known hardship and struggle. We were relatively young, both slim, hard working, and took more than sufficient exercise. We did not indulge in too much of anything, except work. Our medical histories were good. Outside of childbirth, neither of us had ever been in hospital. On the pain scale of 1-10, childbirth would be at 10. Our cardiac "pain" did not compare, maybe only 3-4. Why shouldn't we have considered ourselves to be relatively healthy?

While we can all identify the risk factors, and we know we are exposed to risks every day, cardiac symptoms etude us, so much so that half of all sufferers die. Like Lynn and me, people obviously tolerate unrecognised symptoms for far too long. Perhaps people are disadvantaged because it is expected a heart attack will always be preceded by recognisable symptoms or illness. But you can't feet cholesterol slowly depositing itself in your arteries and the pain is not necessarily significant or identifiable, especially for women whose tolerance for pain may be higher than men's.

Over a lifespan, pain is experienced in all parts of our bodies, from skinned knees and bloodied noses, to occasional infections, tooth ache, sore backs and joints from working too hard or having children. When another pain comes along we wait for it to go away, or until its severity makes us react. This tolerance dearly has a price. Since my heart attack, my perception of pain/ discomfort has changed dramatically. If we lowered the pain threshold measurement and broadened our understanding of symptoms, perhaps people would gain knowledge of the range of possible symptoms, and subsequently we could make a dent in that 50 percent mortality rate. People should also remember that cardiac treatment does not necessarily mean major surgery. Caught early, cardiac disease may require relatively minor intervention.

The care and expertise I experienced throughout this ordeal--from the ambulance staff, the two cardiologists, registrars and house surgeons, to vigilant nursing staff at A & E, ITU, the cardiac care unit (CCU), Ward 7 and transfer escorts--were exemplary. I thank each person involved in my treatment and recovery at Tauranga Hospital. I would also like to acknowledge the auxiliary staff and the team at Waikato Hospital.

I thank my sister Lynn. I hope I am worthy of the love she gave me and the Lessons she taught me.

Gene Hill, RN, works as a community nurse for the Nga Kakano Foundation at the Waitangi Family Practice in Te Puke.