Atrial flutter ablation: Personal experiences.

     The year of 2018 has been a medically challenging one for this retired internal medicine physician. When people ask me how I am feeling, I always just say that I am experiencing medicine from the other side of the check in desk. I have been retired for over 10 years and no longer proceed through those secret corridors where all the mysteries of our medical care take place. At now almost 75 years of age, I guess it is not unusual to need the help of my former colleagues in medical care.

     My most recent encounters have centered around new onset atrial flutter. On August 14, I was just relaxing on a Wednesday afternoon, looking at my emails, sitting in my upholstered chair in our living room. My husband was contentedly watching the afternoon news. Suddenly I felt some flip flopping in my chest. At first I thought it was just some early atrial beats which I tend to get quite often. But in a moment I knew this was different. I quickly found my carotid pulse and it was very rapid. I tried to count it and came up with a heart rate in the 140s. I tried a cough, and also held my breath and bore down (the Valsalva maneuver) but this did nothing. It didn't take me long to realize that I would have to go to the emergency room. I was tolerating this rapid rate OK. I was not short of breath or dizzy, no chest pain, but it certainly was not comfortable to have the heart pounding in my chest as it was. I told Amos he would have to take me to the ER at the Grafton hospital where I usually get my care. It was now about 4:30 in the afternoon. After check in, assessment by nurse and doctor and an EKG, I was diagnosed with typical atrial flutter with a rate of about 125.  Blood work showed no evidence of electrolyte abnormalities, thyroid hyperactivity, or acute coronary occlusion or myocardial infarction. In other words, no obvious serious cause. Apparently intravenous diltiazem which is used to convert this abnormal rhythm to normal sinus rhythm had been in short supply and none was to be had in the pharmacy, so I was treated with an alternative calcium channel blocker, verapamil, and in about an hour and a half I converted to normal rhythm. The ER doc consulted the electrophysiologist on call and I was discharged home on oral diltiazem to try to prevent this from happening again. I was told to follow up with the electrophysiologist for an outpatient cardiac workup.

 
  Here you deserve a little explanation about what atrial flutter is. Many people have probably heard of atrial fibrillation, one of the most common heart electrical rhythm disturbances. Well, atrial flutter is a little different. As opposed to atrial fibrillation which is totally irregular with aberrant electrical impulses coming from mostly the left atrium but also some from the right atrium, originating like fireworks through out those two upper chambers of the heart, atrial flutter is a rapid regular heart beat which usually occurs in the right atrium only and consists of a circular electrical impulse that occurs at such a rate that it can keep restimulating the same tissue over and over again in what is called a reentrant rhythm. By the time the impulse gets back to its origin, that electrical tissue of the heart has repolarized and is set off again in a repeating pattern. Usually the rate is from 250 to 300 atrial beats per minute. Not all these beats are able to get through to make the ventricles of the heart contract. There is usually a 2 to 1, a 3 to 1, or a 4 to 1 block so that the ventricular rate is half, 1/3, or 1/4 the rate of the atria. In my case, with a rate of 125, I had a 2 to 1 block at the time the EKG was taken. Atrial flutter is usually not a life threatening rhythm immediately, but there are two risks that develop if allowed to continue. When the atria are not beating properly either irregularly or too rapidly blood clots tend to form within the heart and can break off and go elsewhere in the body, most damaging to the brain causing a stroke, or to the heart itself causing a heart attack. Secondly if the rhythm is too rapid for long periods of time, the heart tires and begins to go into heart failure. Therefore ideally flutter needs to be converted to a normal slower rhythm or at the very least to a slower flutter rate and blood thinners need to be used to prevent those blood clots from forming.

     Two weeks later, I was having a lot of irregularity in my pulse. I was not having the regular rapid pulse of flutter, but instead normal rate but very irregular beats. The concern with flutter is that it can be mixed with episodes of atrial fibrillation which carries a higher risk of complicating stroke. I called my primary care doctor's office to get an appointment and couldn't get in with her but another previous partner of mine agreed to see me. Well, of course, on the way driving to the appointment, the irregularities stopped and taking my pulse, I knew I was in sinus rhythm again. My former partner correctly ordered a Holter monitor to be set up to see if we could catch these episodes of irregularities and further diagnose what they were. This was a 48 hour monitoring and I was able to drive right over to Grafton hospital and get hooked up with this monitor. 

 

    The Holter monitor showed many PVCs, premature ventricular beats this time. I noticed these while being on the Holter monitor, mostly when my pulse slowed below 60. I even jogged in place while on the Holter to see if the elevated pulse of exercise would suppress the PVCs and that is exactly what happened. My elcectrophysiologist agreed with my thought to reduce the dose of diltiazem slightly because that does slow the heart rate. I was having a resting heart rate sometimes of 50. I did OK for a while but then I had a second episode of atrial flutter and again had to go to the ER. IV meds again stopped the episode but now a decision would have to be made. I could just always go to the ER when this happened, but my electrophysiologist suggested a cardiac ablation. This is a procedure done with a catheter placed in the femoral vein in the groin which is then fed upwards to the right atrium where a quite complicated computer mapping system pinpoints where this flutter electric impulse starts. In the case of typical flutter, there are very few variations in this site. Then electrical burns are placed in a circle around this area to prevent these impulses from propagating to the rest of the atrium and triggering that rapid rentry flutter pattern. I must say that as a doctor entering that ablation laboratory, I was amazed at the equipment, at a whole wall of computer screens and about 7 people monitoring, serving as operative assistants, imaging and ultrasound technicians, anesthesiolgist,  computer screen technicians, and personal nursing caregivers. Wow! A wonderful example of where medicine has arrived. Everything went well, and after about 6 hours of rest to let the femoral vein site close more securely, I was released to go home. All over. No further atrial flutter. The only thing I object to is the fact that the electrophysiologist still thinks I am high risk for atrial fibrillation since there was a 20 beat run of it on my Holter monitor. Also my left atrium is slightly to moderately dilated and this enlargement is one of the preceding hallmarks of atrial fibrillation risk. This means I am on blood thinning medications chronically to prevent stroke. The medications used for thinning the blood to prevent clots is better than that used in the past, which was actually rat poison, or warfarin. That med required weekly to monthly blood monitoring and even a special diet. Eliquis is better, doesn't require either of these. So a new med to my list and I am on about my business. No other losses of function or activities. Yey! 

 

 

 

     

     I mentioned in a recent post that my life has been rather complicated in the last 3 years or so. That is, indeed, a true statement. There is a list called the "Life Event Stress Ratings". In this list are about 25 things that can cause stress in your life. They are rated according to the significance or stress in your life that these might cause. But checking through this list and checking some of these events and then adding up the points you have accumulated, you then are given somewhat of a broad risk percentage of some sort of illness or mental anxiety state might occur. Below is this list and my rating. 

The Holmes-Rahe Life Stress Inventory 

The Social Readjustment Rating Scale INSTRUCTIONS: Mark down the point value of each of these life events that has happened to you during the previous year. Total these associated pointed. Life Event 1. Death of spouse 100 2. Divorce 73 3. Marital Separation from mate 65 4. Detention in jail or other institution 63 5. Death of a close family member 63 6. Major personal injury or illness 53 7. Marriage 50 8. Being fired at work 47 9. Marital reconciliation with mate 45 10. Retirement from work 45 11. Major change in the health or behavior of a family member 44 12. Pregnancy 40 13. Sexual Difficulties 39 14. Gaining a new family member (i.e. birth, adoption, older adult moving in, etc.) 39 15. Major business adjustment 39 16. Major change in financial state (i.e. a lot worse or better than usual) 38 17. Death of a close friend 37 18. Changing to a different line of work 36 19. Major change in number of arguments with spouse (i.e. a lot more or less) 35 20. Taking on a mortgage (for home, business, etc.) 31 21. Foreclosure on a mortgage or loan 30 22. Major change in responsibilities at work (i.e. promotion, demotion, etc.) 29 23. Son or daughter leaving home (marriage, college, military, etc.) 29 24. In-law troubles 29 25. Outstanding personal achievement 28 26. Spouse beginning or ceasing work outside the home 26 27. Beginning or ceasing formal schooling 26 28. Major change in living condition (i.e. new home, remodeling, deterioration, etc.) 25 29. Revision of personal habits (i.e. dress, associations, quit smoking, etc.) 24 30. Troubles with the boss 23 31. Major changes in working hours or conditions 20 32. Changes in residence 20 33. Changing to a new school 20 34. Major change in usual type and/or amount of recreation 19 35. Major change in church activity (i.e. a lot more or less) 19 36. Major change in social activities (i.e. clubs, movies, visiting, etc.) 18 37. Taking on a loan (i.e. car, tv, freezer, etc.) 17 38. Major change in sleeping habits (i.e. a lot more or less) 16 39. Major change in number of family get-togethers (i.e. a lot more or less) 15 40. Major change in eating habits (i.e. a lot more or less, eating hours, surroundings, etc) 15 41. Vacation 13 42. Major holidays 12 43. Minor violations of the law (i.e. traffic tickets, jaywalking, etc.) 11 Now, add up al the points you have to find your score. 150pts or less means a relatively low amount of life change and a low susceptibility to stress-induce health problems. 150 to 300pts implies about a 50% chance of a major stress-induced health problem in the next 2 years. 300pts or more raises the odds to about 80%, according to the Holmes-Rahe prediction model. Sources: Adapted from Thomas Holmes and Richard Rahe. Holmes-Rahe Social Readjustment Rating Scale, Journal of Psychosomatic Research. Vol II, 1967. 

    About 2 years ago, I achieved enough points to raise my risk of stress induced illness. I sold my large home that my husband and I built, and moved to a smaller condo. During the beginning of that year, I placed my husband in a Memory Unit, and we underwent the Covid 19 epidemic, during which I had Covid 19 twice though I kept up with every new vaccine offered. Neither of these episodes were severe, but the fear of them was at times severe. The my husband passed away. I joined a new church and sought and joined and started to participate in two new social organizations. (Note: Some of these life events are not bad; indeed they are usually associated with joy, but they are big changes in one's life.)

    Looking at all this info, and adding up my experiences, I accumulated over 150 points for two years in a row. Thankfully, the past 1 year has been much more settled and I do feel that I have adjusted to my new settings and life circumstances. So far no severe illness. 

    What can we do to alter the bad effects of large scores on this list. Well, reducing stress for each or any of these events that occur, would be good. Balanced diet, enough sleep, medical care and monitoring, meditation, prayer or whatever spiritual tradition with which one is comfortable, and of course, support of loved ones and friends. These are all the things we usually read about. Also, can we plan our lives to some extent to avoid compiling too many of these changes in one year. Perhaps. I do regard my life for the most part as having been remarkable and very positive. Perhaps that has given me the resilience necessary to weave my way through all thee changes. May such changes for you be gentle and well tolerated. My blessing to you!

Mystery Photo Explained.

        I am preparing a Powerpoint talk on Buddhism at the request of a book club that I attend at my current church in my home community. I do not claim to really know or practice Buddhism to an adequate degree, but I have also attended weekly meetings to a meditative and spiritually seeking group of folks of various religious backgrounds and traditions which does have some Buddhist leanings and which meets in a local Mindfulness center which is Buddhist. I therefore know enough that I want to try to give at least an idea of the basics belief system of Buddhism. Some of the more esoteric ideas about non-self and the lack of a belief in an actual personified deity seem quite alien to our Western patterns of religious thought. Yet Buddhism and at least one of its regular practices, that is various forms of meditation, have gained a foothold in Western practices. Meditation indeed has a multitude of benefits both for mental health, and even for physical health. Such a practice is easy to establish but perhaps somewhat difficult to stick to. The group I am giving this talk to is strongly Christian, actually the local equivalent of the Church I grew up in located in a small town in northern Illinois. The congregation of my new church is fairly intellectual and well educated and some of them are curious about Buddhist traditions. As I say, I don't know much, but I think I know more than my audience.

         Buddhism is older than Christianity, with the Buddha's life occurring at about 500 B.C.E. For 400 years, his teachings were not even written down because the Buddha himself discouraged recording them. For several centuries the sutras, ie the teachings, were memorized and orally transferred by monks dedicated to such an occupation. However, once their written recording occurred, another 2 millenium's passage has led to multiple lists of beliefs, many interpretations, and blosoming of numerous different sects of practice. It may take a lifetime of study to fully understand all these variations. Still there are some very basic beliefs mostly in numbered lists that pertain to all Buddhist beliefs. My plan in my talk is to present some of those basic belief systems.

         A significant resource for me has been Thich Nhat Hanh's book: "The Heart of the Buddha's Teaching: Transforming Suffering into Peace, Joy, and Liberation." Thich Nhat Hanh, affectionately called Thai or Thay, was a Vietnamese monk since age 16 who is credited with bringing what he called "Engaging Buddhism" to the West. He had to leave Vietnam during the 1970s due to the Vietnamese War and its aftermath. He established a retreat center in France called "Plum Village." He finally had a very disabling stroke, but was able to return to his home city of Hue, Vietnam and died there in 2022. He has written many books and his style of teaching is very approachable and very easy to read.

         Of course, during my many world travels, my husband and I visited several countries in East Asia where Buddhism is a significant if not the dominant religion. We visited several places in India important in the Buddha's life and saw the monuments there. In China, after supression of significant Buddhist presence during the Revolution, Buddhism is being allowed to return, though it is still heavily monitored and controlled by the Comunist Party. Buddhism has been historically and still is a strong presence in both Cambodia and in Thailand. And of course, Tibet is the source of one very large and prominent variety of Buddhist thought. I have a multitude of photos of all these places. Therefore, I plan to intersperse these photos amongst the lists of the Buddhist belief system numbered bullet points.

         Hence I came upon some photos of the Potala Palace in Lhasa, Tibet. This imposing structure on a hilltop in the middle of the capitol city of Tibet. It was the home of the Dalai Llama before he was exiled from Tibet to Dharamsala, India, by the Chinese takeover. It also was home to multiple monks, with multiple shrines and memorils and relics of many boddhisatvas throughout Tibetan Buddhist history. I have always said that after visiting Tibet, I understood the strong presence of spirituality there of whatever kind. At the altitude of Lhasa, oxygen is scarce. The landscape is harchnd austere. And it is so very different a culture from what we know in the West. Yet the people are so friendly and outgoing, that one can't help but feel an opening of the heart, and a sense of peace and wonder.

         So here is a photo, your Mystery Photo, of the Potala Palace in the center of Lhasa, Tibet.

Mystery Photo Reinstated

In my past as the author of this blog, I occasionally tried to stump you with a photo from somewhere in my husband's and my world travels. Well I am no longer making such long jaunts, and my husband has moved to another realm, but here is one of my husband's photos from a very famous city in the world. I really think that this one should be pretty easy. Watch for an upcoming blog with more photos from this great city.

Censorship in 2023: I am angry!

I am very disappointed, offended, insulted, angry. Well, I have gotten some of those feelings out into these words and feel very slightly better. As a physician I know that bottling up and burying feelings of anger and frustration are not good for our physical health. But I never thought I would be faced with such a cause for all this frustration in 2023 in the United States of America. I have been a user of Facebook for many many years. Most of my blogs here are informational and sometimes personal, but I like to think usually examples of fairly OK writing and my hope was always that they would provide some value to others by representing both educational topics and just topics about living life during the last 13 years of my postings. I wrote a blog here, the one previous to this one, dated May 2023, entitled Delinquency. In it I apologized for not having posted in a long while. I also like to use these blogs aa an oral history of a time that was very trying for our world with Covid 19 and the results of this epidemic and also justaposting these historical times with my own personal trials of the last several years. I tried to post a link to the blog of May 2023 just now and it was censored by Facebook. I invite you to read this previous blog. It is the one just prior to this one that I am writing right now. I don't feel that it was exceptionally political. In fact I think it was rather factual. I would suspect that at least 2/3 of our current population in the United States if not more would agree with my concerns. It was not judgmental, it was not derogatory. It was as far as I can tell not racist, or homophobic or any other type of ...phobic. But Facebook judged it not fit for public consumption and censored me. Until I erased it, I was not allowed to post anything further on Facebook. Any way that I tried to get the link into a post on Facebook as I had done in the past, was censored. Finally I entered an incomplete link asking readers to guess the rest of the link so that some might find their way to my blog. Just as an aside, in the past I have done this many times, and there has been no problem Also in the past when I posted very frequently on the blog, you could find that blog just by googling "Renaissance Woman Retired" and the link would come up. Now since I have not been posting very much, that is no longer the case. More importantly, I would like my current readers here to read that former post at blogspot, and tell me what needed censoring there. I am just curious what my readers think. What did the current AI of Facebook identify that was unfit for general consumption? Yes there is a fairly dismal look at some of the current affairs around the world. So are we not allowed to look at bad situations, or negative outcomes? Are we expected as writers to only state "apple pie in the sky" pollyannaish views now? Is it a fact that human beings can't take a critical look at what is happening around our country, in our cities, at our border, and indeed in the world? If that is so, I feel we all have a lot to worry about. This post is critical and negative and so I am sure that Facebook will not allow it to be posted, so I will not even try. Therefore, I am resorting to my old standby, blogspot, to allow me to vent my frustrations. I think we have a lot to worry about here.

Delinquency is My Middle Name.

What can I write here? An apology to any of my readers that are still out there? Some excuses. Annoying affirmations. I don't know. I guess I will just stick to the facts: I have not posted here in over 3 years. So I will just deal in hard on facts! The fact is that we are now beginning the 4th year in Covid. Certainly things have improved a great deal. We are not only no longer in a lock down. We are no longer wearing masks. And most of us are now not consciously trying to avoid people, or trying to stay six feet away from others when out and about. I just returned from a trip from my home in Wisconsin to visit my younger son's family in San Clemente, CA. Flights are very crowded now, ie full planes on almost every route. Rarely do you see someone wearing a mask in the airport and I saw no one else on my flight wearing a mask of any kind, regular cheap around the ear kinds, or N 95 masks. There just are none. I did wear a mask on the way out because I didn't want to get there for my several day visit and then start to get sick. The one time that I got Covid in August of 2022, I came down with symptoms 24 hours after the known exposure so I knew it could happen rapidly. And I wore the mask on the return trip from CA just because it wasn't a significant discomfort on the way out so why change on the way back. And getting Covid is still an annoying discomfort. You need to isolate still. I as a physician do not feel I can go out to public places and be close to others unless I have turned from positive on the home testing devices to negative. The one time I got Covid, I just had maybe 4 days of significant symptoms but it took 11 days for me to turn negative. That is very annoying because I just felt I had to stay home. Covid is still around. Every few days one hears of someone we know that has been ill. Yet when I ask my surgeon son about the situation in the hospital, he answers that it is normal. Everything is running as smoothly as before Covid, though there are still some precautions being taken. Elective surgery is still precluded in the presence of Covid positivity in the patient. And there are still some cases of severe SARS (Severe Acute Respiratory Syndrome) in the ICU, but mostly in patients with other compromising illnesses. Visitors to outpatient care now often see a posted notice that wearing a mask is optional and there is no longer a greeter asking every person entering the clinic a group of questions about recent possible symptoms of any Covid like illness. Our society as a whole still shows signs of what we have gone through. Many businesses and restaurants in particular have closed. People now have discovered multiple different ways to go shopping, to do business online, even to seek medical consultation online, and certainly there is evidence that the long shutdown of schools have left our young people at least a year behind in their schooling if not more. We still do not know the social scars that the absence from school has caused. Our society seems still somehow anxious, fearful, angry, lacking civility, and common decency, and crime rates have skyrocketed. There is dramatic inflation that is slowing the economy. In person retail has been irreparably damaged in many ways. Small colleges are closing because of multiple effects: smaller enrollment, inflation of costs, and who knows what else. There have been a tiny number of bank closings, but these have been explained away as caused by poor management, and the government has extended FDIC coverage to all patrons of those couple banks. Our country is engaged in a proxy war in Ukraine and our enemies around the world seem emboldened. The causes of all of these crises and others are multifactorial and can not be entirely blamed on Covid though it no doubt has had some effect everywhere. How do we individually and societally deal with all of these changes and our current collective malaise? There is no easy answer. But I think that we need to return to some of our former values. Church attendance is reduced. Small kindnesses and politeness, and deeper compassion seem hard to practice. There are occurrances of road rage, of airline passengers just totally losing control of their emotions and striking out at others, of course, the crime waves in cities, and other examples demonstrate our collective anxiety and even despair. So we need to return to what could be called "Church" practices, no matter what the exact spiritual tradition or belief system. Almost all world religions have practices and rituals that reach beyond the individual and express caring, compassion and concern for others. We need to start practicing those traditions again. After 50 years of my life, while educating myself, raising a family, maintaining a household while working fulltime as a physician, I had ceased going to church. I always had an active spiritual practice but it was irregular and not based in collective society. I meditated, attending a spiritual seeking group weekly, and read a lot. But I was not a participating member of a large traditionally practicing religion. Within the last year I have returned to a church similar to the one in which I grew up...a Protestant sect, called Congregationalists, which is mostly baed on Calvinistic thought, but has not succumbed to mergers with other Protestant denominations. I have found a very accepting and welcoming community in that church and have become significantly more involved in the activities there. I think that has helped me with some of my pessimism about the current state of affairs around the world. It is good to have at least weekly attempts to find goodness in people and to find hope that the current cycle is a passing phase of humanity's existance and to return to acts of kindness and good deeds for our fellows that hopefully will turn us all around. For me at least, this has helped. I don't have any other magic ideas. I think everyone has to find their own best pathway but I think that many of the traditional ones used in the past would work for each of us. We must remember that the causes of our current societal malaise is multifactorial and very complex. No single solution will work to solve the ills but I think that small steps that are familiar to each of us individually, especially those with which we grew up, will help us cross the bridge to some sort of world change that is better. We must hope and build faith that this will happen. I myself plan to continue to update this old fashioned blog with some new posts that hopefully will be worth reading. A lot has changed in my life in the past 3 years and maybe just reading about some of my experiences and how I handled them will be of some help to my readers. I hope so.

Synchronicity

           As I wrote in a previous post, Covid 19 isolation has me cleaning out closets. I found a clipped article from Shambhala Sun, a Buddhist magazine, from November, 2000, written by Rachel Naomi Remen, MD, who in the 2000 magazine is listed as a clinical professor at UCSF School of Medicine and medical director of the Commonweal Cancer Help Program. She has written a very entertaining book called "My Grandfather's Blessings: Stories of Strength, Refuge and Belonging, published by Riverhead. In this article she talks about the strange coincidences that occur in our lives that seem as though they have some outside guiding hand and often serve to awaken us or guide us in some fashion. In this time of great travail, I was moved again by rereading this article. I especially found her opening moving and reproduce it here for your edification.

     "Glimpse of a Deeper Order:  According to the Buddhist understanding of auspicious coincidence, all circumstances can be brought to the spiritual path.  Everything that happens in our lives, whether positive or negative, can serve to awaken us to the nature of the world. But occasionally, events cluster in particular ways that give us a glimpse of the deeper structures of reality, and suggest that time and linear causality may not be the ultimate way in which the world is ordered..

     "There are many possible responses to such happenings, which Jung called synchronicity. Some people give them a highly individualized meaning, finding guidance in a personal decision they are facing or confirmation of a direction they have already chosen. But perhaps the real meaning of synchronicity is more universal than personal, with every instance simply pointing to the possibility of a hidden pattern underlying the events of this world. 

     "Either way, these events offer us a certain reassurance, and they also have the power to awaken us. A common response to such an acausal happening is a sharpening of attention, a sense of the closeness of something unseen. Startled awake, we may listen for the direction in which the universe is moving, and discover a wish to participate in it.

     "Synchronicity often takes us unaware and may restore us to ourselves."

     The author goes on to tell about an experience during the Christmas season when she was so busy with her work that she had no time to prepare for the holiday and especially to do one thing she always did which was add an angel to her many years of collecting angels to honor those who had died that year in her medical practice. She dealt with End of Life care and thus was often placed inside another human being's crossing into whatever lies beyond. She met a lady on an airplane who sensed her troubled state of mind and gave her an angel which that fellow traveler's grandmother had just given to her. What a coincidence or was this occurance the definition of a synchronicity?

     Dr. Remen writes further "I suppose one might call this coincidence and perhaps it is. But it felt as if whatever it is that we really serve when we serve others had reached out and shaken me awake, saying 'You get on with the work...I'l take care of the small stuff.'

     "This is the sort of event which Jung meant by synchronicity, a meaningful coincidence which thumbs its nose at linear causality. At a certain level, synchronicity suggests there is more to life than we realize, and that we and all others may not be alone, I regard such a happening as a blessing. Such things may happen at any time, but in the years I have worked with people facing death and those who survive them I have heard many such stories. Perhaps such things are either more frequent at these times, or perhaps in some way every death is a bridge between worlds, and allows us to see things differently for a little while.

     "Synchronicity is always an experience of the unknown. Events such as these do not really prove anything. They are simply a reminder to wake up and pay attention because the mystery at the heart of life can speak to you at any time."

     When I reread this little article, I felt a few moments of expansiveness which some people of the Buddhist bent have called "kensho."  As a physician, I have certainly experienced what Dr. Remen is talking about and these episodes certainly do seem to occur around death. Many of my patients have told me stories of "coincidences" or "synchronicity" that happened around the time of a death in their family. Some of these stories also seem to involve a "ghost" or "seeing" the deceased again in a very life like way. I will tell a little story about just such an experience in a later post.

 Curious about synchronicity. Here's a starting reference:

 https://lonerwolf.com/synchronicity/https://lonerwolf.com/synchronicity/