Marie Conti was lonely, painfully lonely. Michael and Laura had been living in Toledo for more than a year. Michael’s job consumed his time, including weekends, and opportunities to visit his parents in Detroit were limited. As usual, Carlo was obsessed with work, struggling to keep his business afloat as the industry changed from carburetion to fuel injection. He and Marie rarely socialized. Marie was alone, unhappy and apprehensive about her future. She worried about everything. The more free time she had the more anxious she was. She worried about Michael and Laura and she worried about her health.

Throughout her life, Marie had been blessed with good health; now, at the age of seventy-two, a few months younger than her husband, she had a problem. She recently suffered from inexplicable fatigue and weakness brought on by the least exertion. She hadn't mentioned it to anyone, most notably, Carlo. She knew he would minimize her symptoms, blow her off  and tell her to not think about it. He would never allow her to seek medical attention--never.

For Carlo, doctors were out of the question. He despised physicians. For decades he had blamed greedy, incompetent doctors for Cassandra’s death. His daughter's death left a gigantic hole in his heart—a hole that never mended. He would never forgive the medical community for taking her from him.

When Michael was a baby, Carlo reluctantly permitted Marie to take him to a pediatrician for immunization shots and nothing more--that was it. Neither he, Marie, nor Michael had been to a doctor since. 

In secret, Marie tried vitamins and over the counter remedies, an unsuccessful attempt to alleviate her symptoms. Her fatigue improved briefly after taking such pills, but soon returned, worse than before. She was short of breath when walking, especially climbing stairs. Her concern grew to desperation. She had to see a physician, regardless of her husband's wishes. If she asked to see a physician,  he would react with anger, she was certain of that. She decided to keep it from him. Marie deeply loved Carlo, and felt ashamed for going behind his back but there was no alternative. 

Her plan to see a doctor posed another problem. She had no health insurance. Years past, she had pleaded with her husband to buy a health policy. He reluctantly agreed to major medical coverage only—no insurance for routine care. He was convinced his family would never be seeing a physician for office care; so there was no point in having full insurance coverage. If Marie went to a doctor she would have to pay cash, being careful to not generate any statements--any evidence of her visit to a doctor. Carlo kept tight control of the family’s finances, personally paying all bills. He would find out. 

Marie didn’t know a single doctor and decided to sek help from a friend, a retired nurse who had worked in hospitals for years. 

“Hello”

“Helen, it’s Marie.”

“Hi, Marie. Nice to hear from you. How things goin’?”

“Helen, I need your help--your advice on finding a good family doctor. 

“Sure, I’ll be glad to help.”

“Could we meet tomorrow for lunch? I’d like to discuss my dilemma.”

“Of course. I‘d like that.”

The pair arranged to meet the following day at a local coffee shop in Birmingham.

“Marie, it’s great to see you. So what’s this all about? You seemed a little sullen on the phone. Is everything okay?”

“Oh, sure. I’m okay. I just need a little advice. Let’s take a seat and have some coffee.” 

Marie and Helen, one of her few friends, sat at a corner table in the shop.

“Helen, I’ve been feeling lousy for months. I’m really beat, tired and worried. I think I should see a doctor.”

“Of course you should. Who’s your family doctor?”

“I don’t have one.”

“Your kidding?”

“No, I’m not.”

“Marie, you must have a gynecologist? He could refer you to someone.”

“I’ve never seen a gynecologist. I’ve never seen any doctor, Helen.”

“Never?  What about when you were pregnant with Michael?”

“Well, yeah. I saw an O.B. at the end of my pregnancy. Carlo refused to let me go for prenatal visits.”

“You can’t be serious! Why would he do that?”

“It’s a long story. Carlo doesn’t trust doctors. He got that way years ago when Cassie died. I’d rather not get into that.”

“That’s okay. If you’re sick, why don’t you just tell Carlo you have a problem and you have to see a physician?”

“I wish I could. Carlo’s a wonderful man, but when it comes to doctors he loses it. He’s irrational. He doesn’t know a single physician. He thinks they’re all incompetent crooks. Helen, I can’t tell him I’m going to see a doctor. I know it sounds crazy, but that’s how it is."

“So, how can I help?”

“I was wondering if I could go to your doctor or one you know from the hospital.”

"I’d be glad to refer you to someone.”

“Helen, I’ll have to pay cash for my visit. That’s not a problem for me, but I need a doctor who’s willing to take patients with no insurance.”

“Marie, my doctor, Dr. Pierce, is a good man, very thorough, but not real personable. I don’t think he’d be a good choice. I’d recommend Dr. Kawalski. I know him from the hospital. He’s a great guy. I’d be happy to talk to him about your situation, if you'd like.”

“That would really be helpful. I feel so foolish about this. The whole thing--no insurance, going behind Carlo’s back--you know.“

“It’s no problem. Kawalski’s a nice guy, an internist with a good reputation. I’m sure he’ll be willing to help you.” 

“What should I do? Will you call me after you clear things with Dr. Ka-wal. . . .”

“Mark Kawalski”

“Yes, Mark Kawalski.”

“I’ll call him this afternoon, and try to get you in tomorrow.”

“Thanks, Helen. You’re a good friend. I appreciate it. I feel better already.”

“Come on, Marie. What I’m doing is no big deal. I’m glad to do it. I just want you to find out what’s wrong and take care of it. Marie, this thing with Carlo is crazy. I can’t believe you don’t have a doctor.”

“I realize how it sounds. I just don’t want to talk about it now.”

“That’s fine. We’ll get you taken care of, regardless of your kooky husband.”

Marie wasn’t offended by the comment. She laughed. “He is a nut sometimes, but I couldn’t live without him.”

“Listen, honey, he couldn’t live without you, remember that. He should be glad you’re taking care of yourself.”

The couple made small talk before leaving the shop. Helen promised to call that evening.

Dr. K, as he was known, saw Marie as an added patient on Saturday morning. As Helen had said, he was very personable with a wonderful sense of humor combined with a professional approach.

Marie felt sheepish—embarrassed as she explained her situation: no documented medical history, no prior physicians, no health insurance, not even a medical exam for the past forty years. Kawalski reassured her that the cost of her evaluation would be minimal. He agreed to perform tests without charge whenever possible. Marie thanked him profusely. 

The doctor listened intentlyas she described her symptoms of fatigue. He did a complete physical examination, which he reported as entirely normal: normal blood pressure and pulse, unremarkable ear, eye, nose and throat exam, clear lungs, normal heart exam, no abdominal or pelvic masses, normal neurological and vascular status and no lymph node enlargement.

“Mrs. Conti, your physical examination is fine. I find nothing abnormal. However, your symptoms do concern me. My initial impression is that you may have a problem with your heart or lungs. We also need to make sure you're not anemic. A low blood count can cause exhaustion as you’ve described.”

“Doctor, what could be wrong with my heart or lungs?”

“Well, you may have coronary artery disease. Lung problems are less likely.”

“Coronary artery disease! You mean a heart attack?”

“No, I don’t think you’ve had a heart attack. Your EKG will give us more information on that. But I suspect you could have some narrowing in your arteries causing your fatigue.  Prior to having a heart attack, a lot of people simply feel tired with exertion, as you’ve described.”

“But I don’t have chest pain."

“Mrs. Conti, that’s a common misunderstanding. Many people with coronary atherosclerosis, hardening of the arteries, don’t have chest pain. Everyone knows about chest tightness and left arm pain from heart disease. Unfortunately, some heart patients simply feel tired, exhausted or short of breath. Since they don’t have chest pressure or pain they may delay medical attention. That can be disastrous. It’s good that you’ve come in today. If it is your heart we can diagnose the problem early and avoid a heart attack. Current treatments for such a problem are magnificent. But first we have to make a diagnosis. I doubt that this is a pulmonary problem. You have no evidence of emphysema, bronchitis or asthma. And you’ve told me you’ve never smoked, correct?”

“That’s right. I don’t think a cigarette has ever touched my lips.”

“Good. Let’s concentrate on your heart first. I’ll also do some blood work to check your hemoglobin to make sure you’re not anemic. And we'll check your cholesterol and thyroid levels."

Marie was silent. Her face drooped with concern.

“I can see that you’re upset Mrs.Conti, but believe me, it’s better to have a coronary blockage than some of the other possibilities I’ve thought of. As I've said, treatment for coronary disease has advanced tremendously over the past few years. You’re actually better off having heart disease than something like emphysema, lung cancer or leukemia. Those conditions could cause your symptoms as well. It may sound strange, but I hope you have a heart problem because it can be treated, and it’s the most treatable condition you could have in view of your complaints of fatigue. You’re gonna be okay, Mrs. Conti.”

“Thanks for the reassurance, Doctor. What do we do now? “

“For starters, we need to do a cardiac stress--a treadmill exercise test. I’m sure you know people who’ve had that done. My technician happens to be here this morning. I think we could squeeze you in the schedule and get the stress test done today if you want. It' ll give us a lot of information about your heart, and possibly, a definite diagnosis. Is that okay with you, Mrs. Conti?”

“Is the test expensive?”

“Please don’t worry about the cost. I can make adjustments. In fact, I’m quite willing to do the test free of charge. I will ask that you pay the fifty dollar charge for the nuclear tracer."

Marie was grateful and wanted to proceed right away. She was directed to the cardiac stress lab. The technician, a young woman, prepared her for the test. After removing her blouse and bra, she had EKG electrodes placed on each arm, across her chest and on her lower abdomen. She was wearing a skirt and high heels. The skirt was no problem, but she wouldn't be able to walk on the treadmill in heels. She removed her shoes and put on a pair of cloth hospital slippers. The technician explained the procedure. 

                                                                    . . . 
 

The purpose of a stress test is to see how the heart reacts to exercise. If a coronary artery narrowing is present, and is severe enough to cause symptoms such as chest pain or shortness of breath, it will nearly always cause changes on the electrocardiogram when the heart muscle is stressed by exercise. Exertion forces the heart to pump more blood and consume more oxygen. If a narrowing, generally greater than an eighty percent reduction in the artery diameter, is present, it will restrict blood flow and oxygen delivery to the point that the patient feels symptoms and the electrocardiogram shows changes of ischemia, the medical term for oxygen starved tissue.

The test is designed to produce a graduated increase in exercise load. The study is broken down into three stages with the speed of the treadmill and degree of incline increasing every three minutes. The study is stopped when the patient becomes exhausted or the electrocardiogram shows evidence of a problem. 

Dr. K was there to observe the EKG monitor and watch Marie’s response to exercise. Her resting electrocardiogram was normal. However, this was of no reassurance. A normal resting EKG can only give evidence as to what has happened to the heart in the past—a previous myocardial infarction, for example. It is not useful in predicting future events, or in determining whether or not underlying coronary disease is present. This explains the unfortunate, but frequent phenomenon of a man or woman who suddenly drops dead from a heart attack after being given “a clean bill of health” with a normal, resting EKG.  Likewise, a cardiac examination with a stethoscope is of no value in detecting coronary blockages or narrowings.

At rest, a tight narrowing in a coronary vessel can allow passage of enough blood to maintain adequate oxygenation of the relaxed heart muscle. However, during exertion, this same narrowing will often result in inadequate oxygen supply to meet the demand from the exercised, stressed myocardium. Once the threshold of reduced oxygen supply is reached, the continous EKG strip on the stress monitor will show dynamic changes of ischemia. At this point, the patient often experiences typical symptoms of chest pressure, left arm ache, shortness of breath and fatique.     

                                                                   . . .
 

The technician started the treadmill and Marie walked at the slow pace of stage one exercise. She felt fine. Her electrocardiogram remained normal for the first three minute stage. The pace picked up and the ramp incline increased as the test entered the second stage. Marie told Dr. Kawalski she was getting winded. He reassured her that her electrocardiogram looked fine and encouraged her to continue. As expected, her heart rate gradually increased. The technician took a blood pressure: one-hundred-fifty over eighty. That was no problem. Blood pressure normally increases with exertion.

As she approached the end of stage two, Marie's legs became weak and she was noticeably short of breath. She told Dr. K she couldn’t go much further. 

The doctor approached the monitor for a closer look. The  EKG strip was showing  subtle changes of ischemia. 

“Mrs. Conti, I’d like you to hang on for another minute.”

“Okay, I’ll do my best.”

The test entered stage three. Marie’s heart rate was one-hundred-sixty and her blood pressure had increased to one-eighty over ninety. She was puffing hard.

“Mrs. Conti, do you have any chest discomfort? Any pressure or pain?”

Marie gasped, “No, Doctor. I just can’t catch my breath. I have to stop!”

Kawalski instructed his technician to administer the IV nuclear tracer. “Alright, Mrs. Conti, just hang in there for another thirty seconds."

“Thank goodness!”

“Bring her down, Cindy.  We’re stopping now, Mrs. Conti.”