Part III: Causes and Risk Factors

Earlier this year, I experienced a sudden pulmonary embolism (PE), from which I am still recovering.  Having been extremely healthy all my life and a very active person, I was not prepared for becoming a temporary semi-invalid.  Part of my journey to recovery has been to learn all I can about the condition, so that I can have the best recovery possible and also educate other people about my own experiences.

My Story

The excellent health I have always experienced was the proverbial blessing and curse in my experience with having a pulmonary embolism (PE).  According to my doctors (and friends who are wanna be doctors and perhaps everything I’ve managed to find on the WWW), the fact that I was in physically good shape certainly aided in my survival, and I trust it continues to aid in my overall recovery.  However, my history of having great health and being physically fit lulled me into a state of denial about the very real medical crisis that was unfolding in my own body.  Because I was not very familiar with the symptoms of pulmonary embolism, I continued to attribute my growing problems to everything from stress to exhaustion – until my body sent me signals that couldn’t be denied.

When I say excellent health, it’s no exaggeration.  I had never been hospitalized since my birth 48 years ago. I strove to keep myself in good shape, working out at the gym 6-7 days each week (if you’re there chances are I’ve seen you), taking stairs instead of elevators, walking instead of driving and keeping physically active.  I never smoked, used drugs, or drank (except for the more than occasional Diet Coke – although tye attending ER physicians didn’t believe me — almost had to call friends to verify this fact), and used almost no medication in my lifetime.  I even obtained an MPH and an MBA with a focus on Health Administration, so I certainly knew the general do’s and don’ts of promoting good health.

In retrospect, the one risk factor that stands out for me is related to my work in the travel industry.  I spend hundreds of hours per year in overseas flights.  The so-called “economy class syndrome” of cramped seating quarters is a major culprit in clot formation (see below).  But I estimated that I upgraded at least 80% of my flights this past year with frequent flier miles, in order to take care of myself.  (I’ve idly pondered the chances of finding an attorney who could get my miles back from the airlines!)

Lesson learned:  Just because your health is good, it doesn’t mean that you’re not at risk for a PE.  Understanding your own risk factors can help you better recognize your own degree of risk.

Causes of Pulmonary Embolism

The large majority of pulmonary embolisms are caused by a blood clot or as in my case a series of clots creating a sudden blockage of an artery in the lung.  In most cases, the blood clot originated in the veins of the legs, broke loose, and traveled through the circulatory system to lodge in the lung.   Individuals who form blood clots in the deep veins of their legs may have a condition known as deep vein thrombosis or DVT.  Therefore, the single greatest cause of a PE is the presence of DVT.

However, a pulmonary embolism can be caused by a blockage created by something other than a blood clot, such as: fat from the marrow of a broken bone, tumors, air bubbles, and even amniotic fluid.

Risk Factors

Because the overwhelming majority of PE incidents are related to blood clots, particularly those in the deep veins of the legs, a look at risk factors should focus most on those elements most associated with such clots.  Avariety of factors can influence one’s risk, ranging from ones that are completely outside an individual’s control to those associated with lifestyle choices.

The most significant risk factors associated with both DVT and pulmonary embolisms are:

• Prolonged immobility – Blood clots are more likely to form in the legs during periods of greater inactivity.  If you have recently experienced extended bed rest or travel, you may be at greater risk.  Many PE episodes occur during recuperation from illness or injury or after a long plane or car trip.
• Medications – Taking birth control pills or hormone replacement therapy medications increase the risk of clotting.
• Diseases or disorders – Cancer, heart failure, stroke, and severe infections are all associated with increased risks of abnormal clotting.  Certain cancers, for example, can increase levels of substances in the blood stream that increase clotting, and chemotherapy itself can increase the risk.
• Surgery – Recent surgery involving the legs, hips, brain, or abdomen are associated with increased risk.  Hip and knee replacement surgeries are particular culprits, as they may release tissue debris into the bloodstream during bone prepping.
• Family history/genetics – Some individuals inherit a tendency to form clots too quickly.  Your family’s medical history is a significant factor in determining your own risk.
• History of recent pregnancy and childbirth—A baby’s weight pressing down in the pelvic veins can create pooling of the mother’s blood return and increase the incidence of clotting.
• Age–Older adults are at greater risk of forming blood clots, particularly above the age of 70.  Valve malfunctions, dehydration, and age-related medical conditions are all  contributing problems.
• Lifestyle issues – Individuals who smoke, are sedentary, or are obese have increased risk of pulmonary embolisms.  High blood pressure is an associated risk factor.

In another upcoming article, we’ll take a look at how some of these risk factors can be reduced or even prevented, but for now, it’s important to know your risk factors as a predictive or diagnostic tool.  The more you know your own risks, the more likely you’ll be to take appropriate action.

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Part II: Signs and Symptoms

Earlier this year, I experienced a sudden pulmonary embolism (PE), from which I am still recovering.  Having been extremely healthy all my life and a very active person, I was not prepared for becoming a temporary semi-invalid.  Part of my journey to recovery has been to learn all I can about the condition, so that I can have the best recovery possible and also educate other people about my own experiences.

My Story

In my own case, I began experiencing pain and difficulty breathing almost a week before I was diagnosed.  At a Bat Mitzvah party given by friends, I noticed that I wasn’t able to dance the way I normally could.  I chalked this fact up to the fact that it was my birthday.  At the ripe old age of 48, I was either having psychological twinges or age was truly catching up with me.  I continued on with my usual schedule throughout the week, making excuses for the fact that I wasn’t feeling great at all; e.g., I was just stressed because summer is the busiest time of my year for work and knew that in 3 weeks time the pressure would let up. I traveled to New York with Dafna on Monday night and somehow managed to work despite the continual (and increasing) pain. Later in the week I made a presentation at my former synagogue in North Woodmere (NY), and when done I honestly couldn’t remember a word I had said – but somehow I got through.

By Saturday night I was feeling even worse, but attributed it to exhaustion due to missing my Shabbatafternoon nap, which helps compensate for getting only 4-5 hours sleep per night otherwise.I told Gilad that I really needed to get a good night’s sleep as I was wiped. On Sunday morning I continued to feel queasy and weak but went to the gym for my normal workout.  (I’m a pro at denial, apparently!)  But I was only able to complete about a third of what I normally do.  All day – while seeing groups off for the summer at the airport –  I felt weak and “out of it,” and found myself sitting down frequently to rest – something I never do.

That evening I went to dinner with my father-in-law and company along with Ilan and Dafna.  About an hour after we arrived, the pain became unbearable and un-ignorable.  It was truly like no other pain I’d ever experienced before.  Ilan insisted on taking me to the hospital, and by this time I was unable to argue (although I did try).  I had an obligation to “Roast” a friend (at was called the “2^nd Annual Stuart Katz Memorial Roast – did someone know something I didn’t?) and said after that was done I’d go to bed early – but my body (and Ilan – who proceed to Carol for consultation) knew better.

The fact that I tried to soldier on for a week while my body was telling me something was going seriously wrong put me in greater danger.  I was later told by the attending Emergency Room staff that I was literally within hours of death by the time I arrived at the ER.

Lesson learned:  Being able to recognize the signs and symptoms of a pulmonary embolism is critical, as timing can be everything in preventing serious damage or death.  Many people ignore symptoms until they are too late.  The death rate from a PE is still significantly high, largely because of delays in obtaining treatment.  Personally and most importantly – listen to your children and loved ones when you yourself won’t listen to your body.

Primary Symptoms

Depending upon the size of the clot, how much of your lung has been compromised, and your overall general health, your PE symptoms may vary significantly.  Obviously, individuals who have an underlying heart or lung disease are likely to experience more intense symptoms and be more at risk for severe lung or heart tissue damage or even death.

For most people, the most common symptoms are:

• Shortness of breath.  Regardless of whether you’re sitting quietly or being normally active, a sudden, unexplained feeling of breathlessness is a hallmark sign of pulmonary embolism.
• Cough.  In the absence of related symptoms, the onset of coughing is another common sign.  The coughing may produce sputum or mucus that is foamy and pink due to the presence of blood.
• Chest pain.  This symptom often causes an individual to feel that he or she is having a heart attack.  The pain is sudden and sharp, and usually worsens if one tries to cough, bend, breathe deeply, or eat.

Any of these symptoms is cause for alarm, but the presence of all three is a major indication that you are experiencing a pulmonary embolism.  If so, seek medical help immediately!

Associated Symptoms

In addition to the classic triad of primary symptoms listed above, there are other symptoms commonly associated with a pulmonary embolism that are frequently described as being similar to the sensation of a panic attack.  They may include the following:

• Rapid or irregular heartbeat
• Excessive sweating
• Feeling of being about to faint or being lightheaded
• Increased heart rate or palpitations
• Feelings of anxiety

If you have not been diagnosed as having panic attacks and you have any of the other acute symptoms such as shortness of breath, coughing, or chest pains, you shouldn’t attribute symptoms to “nerves.”  Get an expert opinion to rule out something much more serious.

Some individual also experience other unusual symptoms such as:

• Wheezing
• Bluish-tinged skin
• Weak pulse
• Swelling in the legs

Remember that pulmonary embolisms can occur in people who are otherwise quite healthy, so don’t ignore these symptoms, particularly if you experience primary symptoms and/or a cluster of several other symptoms.

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Part I: Introduction

What do tennis star Serena Williams, news broadcaster David Bloom, and TV pitchman Billy Mays all have in common?  They were all victims of a pulmonary embolism, and the latter two individuals died from it.  Pulmonary embolisms strike individuals of every age, health condition, and livelihood.  No one is immune from this often silent killer, to which about 15% of all sudden deaths are attributed.

Pulmonary Embolism Defined

A pulmonary embolism (PE) occurs when an artery in a lung becomes blocked by some material, usually a blood clot.  The most common cause of a pulmonary embolism is the movement into the bloodstream of a blood clot that has formed in the deep veins of the legs.  The tendency to form blood clots there is known as deep vein thrombosis (DVT).

The effects of a pulmonary embolism vary considerably, depending upon the size of the blockage and the length of time in which blood supply was restricted.  A large clot that completely stops blood flow to the lung can be quite deadly.  But even among survivors, no one escapes completely unscathed.

Small clots may have lesser residual effects, but recovery can take anywhere from weeks to months or years.  Lasting damage to both the lungs and heart may occur.  Lung tissue that is served by any blocked artery is damaged or destroyed, reducing overall lung capacity.  Pulmonary embolism can also cause a condition known as pulmonary hypertension.  Because the blood pressure in the lungs may become too high due to obstructions, it can “wear out” a portion of the heart.

Each year approximately 300,000 Americans are diagnosed with the condition, and an estimated 3-4 times as many individuals have the condition without receiving a diagnosis.  Worldwide estimates are difficult to assess, as diagnosis can only be definitive with the right diagnostic tools.  A death from pulmonary embolism is commonly reflected as a broader cardio-pulmonary problem.

And why are these facts and figures so important to me?  Because I quite unexpectedly joined the ranks of Williams, Bloom and Mays, and countless thousands of other individuals.  On June 26, 2011, when I should have been “roasting” my good friend Ben Rosenberg, I was diagnosed with pulmonary embolism, and almost became a sudden death statistic.

My Story

My profile is not the typical one for someone who just suffered a major health crisis – and perhaps that’s the whole point.  Judge for yourself:

Having just turned 48 (I know some thought I was older and others I was younger – but this is the age on my driver’s license), I had never had a major medical problem in my entire life.  My only trips to hospitals were to visit ailing friends or relatives.  I worked out rigorously and religiously 6 days per week, and enjoyed a full and happy life.  My career in the travel field, presiding over several travel companies has afforded  me the opportunity to fly frequently to countries all around the world, explore new cultures, and meet interesting people.  With one foot in the United States and the other at home in Israel, I had far-flung family, friends, and business associates who daily enriched my life.

I’m also a family man, soon to be celebrating 25 years of marriage to Carol, and proud father to Adina, Gilad, Ilan, and Dafna. On the day I was hospitalized, one of my daughters, Adina, was just heading off to Canada to work in Camp Moshava, and I was feeling particularly proud.  Ilan, who literally saved my life by taking me (making me go) to the ER – was in New York enjoying his final day before heading to work at a camp for children with Special Needs.  Gilad was in New York working for the summer and on this very day volunteering for (US) Customs and Border Patrol – and was at my side each and every day while in the hospital and Dafna was taking a breather from an unbelievable academic school-year before returning home for her continued summer adventures.  Like Carol and myself, all of our children have been active in volunteer work. Our family also takes great pride inactive expression of our Jewish faith, enjoying everything from affiliation with our synagogue community to hosting kosher travel tours around the world and of course at home in Israel.

So that is me before the moment of crisis:  a healthy, happy man, content with his family, his work, and his faith – secure in the knowledge of his good health and a bright future.And then the pain comes.  The days of hospitalization.The weeks stretching into months of recuperation.

Lesson learned:  It CAN happen to me, or to anyone.

In the series of articles to follow, I’d like to walk you through some of my own experiences with pulmonary embolism, as I share with you some important facts about:

• Signs and symptoms;
• Causes and risk factors;
• Diagnosis and treatment;
• Recovery; and
• Prevention

From my own experiences, I know that my lack of knowledge about the condition, combined with my denial about the signs my body was giving me, brought me to a medical crisis that came all too close to being fatal.  While normally reticent about my personal life, I hope that by sharing my own experiences and feelings, I may help someone else to avoid becoming a statistic.

If you don’t believe it can happen to you, neither did I!  So I hope you’ll join me on this story of lessons learned, of a sudden loss of health, and a still gradual recovery.  The end of my story isn’t even written yet, but with my strong faith and incredible support system I believe it will end with my health fully restored.

I hope you will take this journey with me.

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At sundown on Tuesday, June 7th this year, the festival of Shavuot will be celebrated.  We will once again commemorate the time centuries ago when the first fruits of the harvest were carried to the holy Temple and presented as an offering to God.  Shavuot is the last Jewish festival in springtime, and it’s a great time to travel to another country and celebrate with individuals of another culture, joined in a common experience.  The world over, we light candles, decorate our rooms with greenery, eat delicious dairy foods, study the Torah, and read from the Book of Ruth.

I’m thinking about Romania as a possibility this year.  It’s certainly a country with a rich Jewish heritage, as well as a beautiful countryside to revisit.

Jewish History in Romania

The first Jewish settlers were believed to have arrived in Romania thousands of years ago, as part of Roman legions invading the region.  Then during the Middle Ages, immigrants settled in parts of Romania, followed by larger numbers from Spain after its expulsion of the Jews in 1492.  By the 16^th century, the Romanian Jewish community had evolved into a relatively large and prosperous group, and by the 1920s, almost 800,000 Jews lived in Romania.  After the later turmoil of the 20t h century, from the Holocaust to the Communist reign, the Jewish population decreased significantly  Only an estimated 9,000 – 15,000 Jews call Romania home today.  But in today’s Romania, you can still see traces of its proud Jewish heritage.  Nearly 100 well-maintained synagogues dot the countryside, along with more than 800 Jewish cemeteries.  I’d like to celebrate a Jewish festival day in a country which so tenaciously holds on to its heritage.

Today’s Jewish Community

Encouragingly, about half of the synagogues are in regular use.  Romanian anti-Semitism appears to be at an ebb, and the country’s relationship with Israel is stable.  Signs that the community is holding to its roots include Sunday morning programs on Jewish subjects, centers for historical studies, and Talmud Torah classes for youth.  Bucharest’s Jewish community is quite active, and there are outposts of Jewish culture scattered throughout the country.  As one measure of its stability, 10 different kosher canteens are in operation by various communities, and three ritual providers make kosher meat available.  The current resurgence in religious practice also is an encouragement to me as I consider a return visit to Romania.

Sightseeing in Romania

As a seasoned traveler, I would be less than honest if I didn’t admit that the pull of Romania is not just a religious one.  I always welcome any reason to spend time in a country with which I’m less familiar.  From my brief time there, I know what treasures Romania has to offer to a curious tourist.  Here are just a few of the sights on my must-see list:

• In Bucharest, the Choral Temple, built in 1857, features Moorish turrets and lavish interiors.  It’s the largest active synagogue in Bucharest today.  I’d also like to stop by the Museum of the History of the Jewish Community, which features books and artwork by Romanian Jews.
• In Islai, I plan to visit the National Theatre, decorated in French-eclectic style and featuring a renowned auditorium with excellent acoustics. I must re-visit the Great Synagogue of Iasi, the oldest surviving prayer house in Romania and second oldest synagogue in all of Europe.
• In Brasov, the Council Square is worth a stop.  Build by the Saxons with massive stone walls and bastions, it’s reputed to be the spot where the Pied Piper led away the children of Hamlin.  The Bran Castle, infamously known as Dracula’s Castle is also located in this Transylvanian mountain city.
• Piatra Neamt, situated in the Carpathian foothills, is home to the Ba’al Shem Tov Synagogue, a wooden structure built in 1766.

A Romanian Shavout Celebration

But the centerpiece of this trip must be an authentic Romanian celebration of Shavout.  I’m still learning about some of the rituals and customs. Somehow I’ve become most fixated on the foods!  I know that the typical palacsinta tortes (blintzes) are made in Romania with a mixture of mushrooms, lemon, dills, and cheese.  They also serve their mamaliga (polenta) with white cornmeal, to signify purity.  Given the diverse backgrounds of Romanian Jews, the cuisine is quite eclectic.

Most of all, I hope to attend prayer services at one of the historical Romanian synagogues.  And I’m practicing the Romanian version of the blessing that is said when the Shavuot candles are lit:

“Burikh Atu A-d-y-n-o-y E-l-o-y-h-a-y-n-I Melekh Hu-Oylum Asher Kiddshuni Be-Mitsvoysoyv Ve-Tsivuni Lehadlik Nayr Shel Yoym Toyv.

Burkh Atu A-d-o-y-n-o-y E-l-o-y-h-a-y-n-I Melekh Hu-Oylum She-Hekheyuni Ve-Kiyyemuni Ve-Higgiuni La-Zzman Ha-Zze.”

If you have any other suggestions for how I can enjoy Shavout in Romania, please let me know.

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Shabbat in Pushkar, India’s Hidden Gem;
I’ll be back in November for the Camel Festival.

Sure Shabbat anywhere in the world is special.  It is Shabbat, after all, isn’t it?  But, how about enjoying the Sabbath in an exotic locale like India’s Pushkar?

Yeah, I thought you’d like that idea.

Pushkar is not only sacred on Shabbat, but a sacred pilgrimage site (one of five) for devout Hindus.  It’s one of the oldest cities in the country, dating back more than 60,000 years.

Throughout Puskhar’s long history (and its designation as a holy site) many Hindu temples were built.  Too bad during Muslim conquests many of them were destroyed; but many were rebuilt in the subsequent years.  One of the most famous is the Brahma Temple, a 14^th century building.

A few other temples to see while you’re out in the area are the Sri Sawai Bhoj Temple, the Varaha Temple of Rangji, and the most visited Varah Temple–dedicated to the god Vishnu.

Stroll along Pushkar Lake, considered a holy lake when a lotus was dropped Brahma’s hand personally.

Yet, as exciting as Shabbat in Pushkar is, it gets better.  How?  The Pushkar Fair is a famous 5-day Camel Festival every November; which brings more than a quarter of a million of visitors a year to see it.  At first glance you might just think its one big camel market, where thousands of camels are sold (or traded).

But, it is the way they’re traded & sold that makes this out of the ordinary.  They’re all decked out wearing silver and beads, jingling and jangling while they walk.  Even the camels’ noses are pierced.

Mostly this festival takes place in November, but it’s possible for it to fall in October as it falls according to the moon calendar.  The festival kicks off with a camel race, with music and shopping going on throughout the entire festival.  Competitions (like who’s got the longest moustache) and art & sport exhibitions take place, also.

Alongside the sacred Pushkar Lake, women set up stalls selling their wares of jewelry, fabric, and other bric-a-brac; all the while, men are still off selling or trading the ornately decorated camels.

Come to think of it, with that many people coming to Pushkar is it really a hidden gem?  I don’t care, but I do know I’ll be there in November for the Camel Festival.  Won’t you?

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