I ignored the first signs something was wrong, early on Wednesday morning — a sharp but minor pain on my left side, just under my heart. Since it only flared when I leaned forward, or moved quickly, I’d assumed I’d tweaked a muscle, or a tendon, or something fiber-y, in my rib cage near my lung, but what was around there I wasn’t exactly sure — my knowledge of anatomy is remedial, by design. A friend of mine came out of her “Conquer your fear of Flying!” course even more nervous, saying “They spent hours explaining how an airplane works. Great, now I have hundreds of different details to worry about. All I wanted was for them to tell me ‘It’s magic’ and move on.” That’s me, but with the body.
As the pain persisted throughout the day I tried to remember what I’d done to strain whatever it was, but couldn’t come up with anything, which bothered me, although only in a background nagging way. I soon incorporated it into my routine, avoiding certain moves, and when I went on my daily walk, I added a “side-muscle” stretch to my routine. That worked for a few minutes, enough to convince me it was something that could be managed.
By nighttime the pain had worsened, although it was still relatively minor, and I’d figured it probably had to do with the lung — worsening when I breathed in deeply, coughed, sneezed — and so my hypochondria, a substantial inner demon I’d subdued decades before, stirred, and I thought of my brother who’d died a few years prior from lung cancer.
Was that what I had? No. No. Don’t go down that road, Chris, don’t let the mind loops begin, it’s a muscle thing, and it will go away in a day, you will see. But you did nothing to injure a muscle, no awkward move, no new repetitive movement. Muscles don’t irritate themselves out of the blue like that. So the debate began, but it didn’t get too far because I was exhausted, since I’d been sleeping badly since returning from Australia, and so I fell asleep quickly.
The next morning the pain was a little worse, but I was too focused on writing for the mind games to begin again. By the time I went for my walk I’d actually forgotten about it, but by mile five it flared up1, more intense, the pain spreading into the shoulder, underarm, and down the back, and I began to genuinely worry, and while climbing a hill at mile seven, I had a brief panic — wait, wasn’t this the sign of a heart attack? No. I wasn’t short of breath, and the pain was on my side, not my chest, and it wasn’t a tightness, but rather sharp. So began round two of the battle in my brain.
But that’s the thing about hypochondria, it’s an extreme position, and so the opposition to it is also extreme, and a moderate rational debate is impossible, and conquering hypochondria produces its own problem — denial — and that's where I was when my “don’t worry, be happy” side won and so I changed how I sat, watched football, and then went to sleep only a tad concerned.
The denial survived the next morning, despite the pain now being constant, and I even went out for a walk, but by mile three, as my lung burned with each breath, pain rippling up my side, into my shoulder, down my back, clarity finally won and I realized I’d made a huge mistake, and then I panicked. This was something serious and I needed to get to an ER, but that was fifteen miles away, and my car was three miles away, and anyways my wife’s car was broken, so she couldn’t come pick me up. Thankfully I saw a car approach that I knew from past walks, a driver I’d chatted with before as they stopped at the mailbox, and I waved to them and asked for a ride to the parking lot, claiming an ankle injury, because I didn’t want to freak them out, as well as me.
But I was freaked out, although measured, because despite my hypochondria, once the internal debate is finished and I make a decision, a calm overcomes me, which is part focus (solve this problem), part fatalism (if I die I die, so be it).
I drove home, picked up my wife, and we went to the ER. The drive was comically slow, punctuated with delays of every possible type (construction, accident, police activity, garbage truck, etc.), and I found myself laughing because why not, and even began to root for more absurd delays, to complete the quest of “collecting road obstructions.” To break the tension I pivoted to a jocular, but semi-serious, conversation about my funeral, telling my wife that I wanted my friend Jon to DJ the wake, but then I realized he would probably choose music he thought I should like, not music I actually liked, and that I really needed to put together an “After I die” instruction sheet, and while I was OK dying, I hadn’t properly prepared for it. The idea of my friends standing around eating Big Macs, sipping Modelo, thinking I actually liked some obscure punk song, rather than John Prine, Merle Haggard, and Bob Dylan annoyed me way more than it should have.
I was doing everything to distract myself from the searing pain in my chest (no, my side, not my chest, be precise, it matters), and the anxiety of going to an ER, something I’d not done in thirteen years, and only three times before.
The ER was new, empty, and ordered — about as different from the one in Brooklyn I’d gone to twice before, and where I’d once waited overnight, sitting on a gurney with a gash on my scalp, listening to my Walkman, while handcuffed gunshot victims wheeled by, police monitors squawked, and a slight Latino custodian came by, also listening to his Walkman, feather-dusted the vent above my head sending a shower of dust into my open wound.
As an older male with chest pains (side!), I would have jumped the queue but there was none, and within a minute I was on a bed, and in another tethered to the machines by wires, tubes, and cords — a reverse umbilicus — my body feeding an orchestra of squawks, beeps, and pings.
As the nurse, a hard, perfunctory woman, connected me, she went through a checklist of mandatory questions, ending with “Is anyone in your home trying to harm you?” which made me laugh, at the incongruity of it and nerves2, which got me a scolding, “You do know domestic violence is a serious issue,” to which I laughed again, covering it up with a cough, while doing all I could do to suppress my inner smart-ass and tell her, “Well, if you consider the financial obligation of a family as a form of harm…”
After ten minutes of intense focus I was largely left alone for the next four hours, which I took as a good sign. I lay on my bed in the corner, constrained by the wire jumble, only summoning a frustrated nurse when I emitted the wrong beep (“Stop moving your arm when the monitor inflates”).
I did get mistaken for another patient — a man apparently in for detox — despite passing the rote greeting (“Name, birthday”). The doctor’s assistant handed me medicine for alcohol withdrawal.
“I’m not an alcoholic,” I said.
“I never called you an alcoholic,” he responded, defensively.
“No — as in I haven’t had a drink in ten days, and I’m here for my side pain.”
In the fourth hour I was told they wanted to check for a pulmonary embolism (PE), via a CAT scan, and everything fell into place. Of course, why hadn’t I thought of that. I’ve long known about clotting risk in my family — my cousin died young of a PE a decade before, and one of my brothers two decades before — and I’d developed clots in my leg following ankle surgery.
I also know about the risk of clots from flying, and I’d only returned ten days before from Australia. That is why I always book an aisle seat, why I get up at least once every two hours and walk to the back of the plane and do a set of stretches — focused on circulation in the legs3.
Why in the world didn’t I realize that is what was going on? That the pain was in my lung, and it was from a clot, and I needed to go immediately to an ER and get on anticoagulants before the clot could expand, or additional clots form. I can try to rationalize it now — I suppose I believed I would spot the clots in my calves before they moved up to my lung (wrong) — but I have to chalk it up to reckless ignorance. I’d been too cured of my prior hypochondria.
After the clot was found, I was eventually checked into the hospital where I spent the next evening, and placed on a heparin drip. I had about as nice of a room as one could expect, quiet and with a view, and the staff was fantastic, but it was a miserable sleepless painful night and I went home the first chance I was given, the next afternoon, but with a lot of questions — I’d only gotten a short opportunity to ask the doctor, who was affable, but overworked.
Why had the clot formed, was it because of my fifteen hour flight ten days before?
Possibly, even probably.4
Why hadn’t it immediately killed me as it sometimes does, like with my cousin?
Immediately dangerous PEs are generally large clots that severely obstruct pulmonary circulation, straining the right side of the heart, until the circulatory system collapses. Your clot was smaller.
What percentage of clots do that?
I don’t know off the top of my head, although the longer one lets it go untreated the higher the risk.
Given how often I fly, is this a condition I need to be medicated for?
Yes, probably, but you need to make an appointment with a hematologist to see precisely what medicine, and for how long, and what other lifestyle choices you might need to make.
Should I cancel my upcoming October trip?
I can’t answer that for you, but if you were my father, I wouldn’t let you go.
Since I’ve left the hospital I’ve been sleeping, going to the McDonald’s to read/write, and scheduling doctors' visits. Not only for the PE, because they found another medical issue that needs following up — nothing currently serious but requiring specialist attention.
My mood is fine, even relaxed, but the pain is still there, although decreasing each day, and I’m more listless than sore.
Given how central traveling is to me I’ve been using the downtime to try and be more clear-sighted about what risks come with my lifestyle — something I can’t properly answer without more doctors' visits, which are unlikely to happen soon.
Even when I get that information there will still be a lot of uncertainty, so for someone like myself, who likes quantifiable answers, there isn't really one to hang my hat on.
While the link to airplane travel and clots is genuine, how strong a connection is unclear. Given my family history, the literature suggests for long-haul flights (which I almost exclusively do), it can be as high as one in five hundred, although for most it’s about one in five thousand5. It is a risk that can be reduced, at least somewhat, by wearing graduated compression (15–30 mmHg) socks, although estimates of how much they help vary considerably. Still, it is something I will do from now on, and everyone else should.
How often a clot ends up being deadly is also hard to pin down, given all the variables, but the literature suggests a treated PE carries roughly a five percent mortality rate. Untreated, that can rise to around thirty percent.
Which means, with a lot of assumptions and hand-waving, I came up with the back-of-the-envelope number of a one percent chance I die from a clot per decade of travel. Not really that bad of odds, but the thing about odds is they are just that — it’s not really a consolation to be lying on the floor of a bus in Mongolia, my vision going dark, thinking, “You know, this is a pretty rare event! How unlucky of me!”
Then there is the question of what if I become ill in Indonesia, or Myanmar, or Uganda6? This week I kept thinking about what if this had happened to me while in Alice Springs. As much as I’ve come to love that city, and as much as it would have made for a great “experience,” I’m not sure a month alone there would have boosted my spirits.
The real issue here though is my family history, which takes precedence over all the other statistics. Sure, you are unlikely to find gold randomly walking around, but if you grow up right next to a gold mine…
So whatever the numbers, I’m grounded for a while, which is fine. A health break, as long as it’s truly about physically and mentally mending, is necessary every so often.
That will change the tenor of this newsletter, and that might require a pause, but I’ll cross that bridge when I come to it.
The bigger lesson is I need to be more of a hypochondriac. Worrying about your health is actually a good thing, as long as it doesn’t become compulsive, obsessive, and destructive. That requires more trips to doctors, and that might be the most dangerous part of my lifestyle — not having a regular enough routine to see specialists when necessary. That’s hard enough to do in the US, with such long waiting times, but even more so when your schedule is so complicated.
One last thing I’ve been thinking about this week. There was a doctor at the DC meetup I held earlier this year who told me, rather bluntly, that I needed to be more careful about blood clots given my family history and how much I fly, which I politely ignored. I’ve forgotten your name (sorry), but if you’re reading this — you were right, I was wrong, so thank you.
PS: Thanks to everyone who has reached out to me. I appreciate all the kind words. In the grand scheme of things, given how reckless I was, I got off lucky, and if the worst that comes out of it is six months at home, with a lot of doctor visits, then I will consider that a big win.
PSS: I’ve received a lot of feedback and comments on last weeks piece on aboriginal Australia. I’m sorry I’ve not responded given the last week, but I hope to eventually getting around to reading all of them.
Look, I get what she is doing, and why she is doing it, but I do find the checklist rules, which have to be applied to everyone because how dare you profile, a bit funny, independent of my anxiety at the time.
Another listed risk factor is alcohol. I have a pretty hard rule about not drinking the day before flying, or when in the air. This flight back from Sydney was the emptiest I’d been on in the last five years, and I, like everyone else, had my own entire row, and when dinner came I thought, hey, why not, and had three beers. I regretted the decision later in the flight, not a lot, but enough to remember why I don’t drink on flights. Well, now I have even more of a reason!
According to the literature, travel-associated clots occur within the first one to two weeks after a flight, with risk returning toward normal by about eight weeks.
There is a lot of data out there, but here is the summary I got,
- For flights over four hours, estimates put the risk of clots at roughly 1 in 4,600–6,000 flights.
- It is basically zero for flights under four hours.
- The real issue is having another risk factor — previous clot, family history, cancer, recent surgery, obesity, older age, clotting disorder, etc.
There is also a chance I get ill in Korea or Japan, where the health care is as good, if not better. And while that might almost have a romantic feel to it (great hospital food!), the worst thing about being ill during travel is being all alone.