“LOOK AT ME!” screamed the nurse. I had no idea why she was screaming, but I could not question her authority. I was helpless, lying on a gurney, groggy and exhausted. It was 30 November 2019, a day I will never forget. It was the day I started the second half of my life—one in which I see every experience, good or bad, as a gift, one in which I live every day with a sense of urgency, as if it could be my last. That day, it almost was.
I was in the second month of my tour as deputy commodore of Destroyer Squadron 23. We were in the middle of Composite Training Unit Exercise, arguably one of the most difficult training events for the strike group staff, and we were coming off a transition day. We conducted the morning huddle at 0730 with the oncoming watch team, discussing the plan for the day. Strike Group 15 was adjusting the scheme of maneuver, as a cold front was moving into the Southern Californian coast. It was one of those days I was happy to be embarked on the USS Theodore Roosevelt (CVN-71) instead of one of our guided-missile destroyers, which were being tossed around like corked bottles in the developing storm.
That’s when it started; the burning sensation down the middle of my chest, with sharp, piercing pain shooting toward my back. I shifted my stance and leaned on the chart table in an effort to minimize the pain, all while trying to keep a straight face. It would be uncool to let anyone know I was having discomfort. Besides, the brief was almost over, so I gritted my teeth and decided I would call the senior medical officer (SMO) after I returned to my stateroom.
The pain had resolved by the time I got there. I called the SMO and, based on my description and the fact that my symptoms resolved after a few minutes, he and I agreed it was likely nothing serious. Perhaps a bit of heartburn? We decided to meet at 1200 that day so he could perform a thorough evaluation.
As planned, I went to the 0900 morning update brief with the strike group staff. Two minutes into the brief, I knew something was wrong. The pain had intensified to an unbearable level. Without saying a word to anyone, I abruptly stood up and stumbled back to my stateroom. I left my door open, afraid I would not be able to open it again myself. I was sweating profusely and struggling to stand up, sit down, or lie down. I called the SMO on my radio and, in a strained voice, explained my situation and asked him to send someone to my stateroom quickly. Nothing I did relieved the pain.
One of the officers on my staff walked by my open door and saw me grimacing. I can’t remember the exact conversation, but he stayed with me until help arrived. It was reassuring having him with me, as I was afraid I might pass out. One of the ship’s nurses and a corpsman came to my stateroom, took my vital signs, and asked if they should call for a stretcher to carry me to Medical. The thought of being belayed on a stretcher, down four flights of ladders, and into Medical sobered me up fairly quickly. In my mind, the process would have taken an hour and resulted in me tumbling headfirst down the ladder. I reluctantly declined the stretcher and slowly walked down to Medical. Even though I was still in excruciating pain, I painted the face of the Warrior Captain: strong and defiant on the outside, but seriously injured and bruised on the inside. That’s what warriors do, right?
When I reached Medical, they opened my shirt, placed stickers on my chest, and performed an electrocardiogram. The tech left the room with the printout without saying a word. Soon, the SMO walked in and said, “Rob, we have to medevac you immediately. You’re having a heart attack.” The diagnosis was terrifying. A number of thoughts ran through my mind. This could be my last day on earth! What about my family? I might never get to see my kids grow up.
As the pain in my chest consumed me, the thoughts fled. All I wanted was relief. I pleaded with the corpsman, “Give me something for the pain!” I was given an aspirin, nitroglycerin, and some morphine, but nothing seemed to help. I continued squirming on the gurney, until I started feeling tired. I remember saying, “I don’t feel very well. I am going to lie down for a bit.” I said a quick prayer and blacked out.
I woke up to the nurse screaming, “Look at me! Look at me! Don’t go back to sleep!” I thought it was strange to see the room filled with people. I had only closed my eyes for a second—at least that’s what I thought. I had an oxygen mask over my face and a number of leads coming out of my chest. The pain I was feeling before blacking out was gone. I stared up at the lights and the nurse standing over me. That’s when I heard the doctors speaking: “Cardiac arrest requiring chest compressions and one shock.” I thought, Wow! I was dead and had to be resuscitated. Just that morning, I was focused on maneuvering the force to kill country Orange units and protect the carrier, then, in a flash, I was fighting for my life.
My first indication that something was wrong occurred some eight months prior. I remember lying down one night, and my heart started beating so fast I thought it was going to come out of my chest. My initial thought was that I was just amped from the day’s events. I got out of bed, got a drink of water, and my heartbeat returned to normal. I made a mental note to discuss it with the doctor the next day when I saw him on the ship.
The next morning the palpitations returned while I was on the ship sitting in a critique. I went to Medical and explained the symptoms to the ship’s doctor. He gave me an EKG and said he could find nothing wrong. I went back to work reassured because I had been cleared by Doc.
A few months later, while walking my dog up the hill in front of our home, I found myself huffing and puffing and had to stop on multiple occasions to catch my breath. Just a few months prior it would have been nothing for me to run up that hill. Now, my heart raced, I was sweating profusely, and I could not make it without stopping. I am getting old, I thought. If this is what 48 feels like, 50 is really going to be hell. I blamed myself for getting out of shape and committed to a new workout routine. Needless to say, my condition did not improve noticeably after three months. I continued to experience shortness of breath after a few reps of relatively light weights.
The week leading up to my cardiac arrest, the chest pain started. The first time I was sitting at my desk after dinner, so I assumed it was something I ate. After a few minutes, it went away. The same pain returned a few days later, but it was a bit more intense and lasted for 10–15 minutes before resolving. I had been attributing these symptoms to heartburn but was becoming concerned. Instead, I convinced myself that the medications I was taking at the time were somehow causing my symptoms. As it turns out, I was dead wrong.
Conditioned for failure
In the weeks leading up to my heart attack, I was seen by my primary care physician and subspecialty providers no fewer than 15 times for routine follow-up, an ailing knee, and stomach pain. On every visit, my vitals were taken, and everything was normal. I have no history of heart disease in my family, and while I was stationed at the Pentagon in 2012, I was given a full battery of tests before I was cleared for duty. How did this happen? Why did I have a heart attack? Why didn’t my doctors think I was at risk?
Cardiovascular diseases remain the leading cause of death worldwide.1 Traditional risk factors include age, male gender, high cholesterol, high blood pressure, diabetes, smoking, and family history.2 Primary care providers are able to use this information to estimate an individual’s ten-year risk of experiencing an adverse cardiovascular event, which in turn can be used to guide preventive therapies such as cholesterol-lowering medications and low-dose aspirin.3 These medications typically are used in conjunction with other therapies to reduce blood pressure, quit smoking, improve blood sugar control, maintain a healthy body weight, and improve physical fitness. Together, these interventions can significantly reduce the long-term risk of cardiovascular events.
Other factors also may enhance cardiovascular risk. These may include medical conditions such as chronic kidney disease, specific genetic factors, or chronic inflammatory conditions such as rheumatoid arthritis and HIV/AIDS. In some individuals, current population-based risk calculators may underestimate the true risk for cardiovascular events, leaving their disease unrecognized and undertreated. As a result, a heart attack may be the first indication that an individual has coronary artery disease.
Is it my heart?
Chest discomfort is a common complaint in emergency rooms and primary care clinics. While all chest symptoms should be taken seriously, many times they are attributable to processes unrelated to the heart, such as gastroesophageal reflux disease. Doctors use fundamental knowledge of anatomy and physiology, specific disease processes, and their own clinical experience to ask directed questions and elicit information necessary to make a diagnosis.
With respect to symptomatic heart disease, evaluation begins by asking patients about symptoms experienced during physical exertion. This can identify individuals with chronic ischemic heart disease; those with sufficient plaque within the coronary arteries to limit blood flow during exercise. In this case, the oxygen being delivered to the heart tissues via red blood cells is limited. Patients with this condition may experience typical cardiac chest discomfort, which intensifies with exertion and is relieved by rest.
However, some patients experience symptomatic variations, including shortness of breath, back or neck tightness, epigastric discomfort, arm discomfort (typically the left arm), or any combination thereof. Given differences in presentation, patients and providers may not recognize these symptoms as cardiac-related and may attribute them to other disorders such as heartburn, chronic obstructive pulmonary disease, or old age.
Researchers at Naval Medical Center San Diego are using an advanced cardiovascular imaging technique known as coronary computed tomography angiography (CCTA) to screen for coronary atherosclerosis in older active-duty service members.4 Prior studies suggest that a significant proportion of asymptomatic patients (40-60 percent) at intermediate risk for cardiac events by traditional risk calculators will have some degree of coronary atherosclerosis that is detectable by CCTA.5 In addition, recent data indicates a significant reduction in cardiovascular events may be observed in individuals who are started on guideline directed medical therapy as a result of their imaging findings.6 Current research aims to determine if cardiovascular screening and early implementation of appropriate medical therapies can minimize the risk of cardiovascular events in active-duty personnel, thereby enhancing force medical readiness, limiting operational costs, and ultimately saving lives.
Don’t become a statistic
Since the event, I have had a lot of time to reflect. I let my family down. Had I been educated on the facts and known what to look for, I would have made different decisions.
As surface warriors, we work in a high-stress environment. This is true for many military officers and enlisted personnel across services. But it is not uncommon to hear of a shipmate who refused to go to the doctor for fear of being descreened from sea, sub, or nuclear duty. From an early age, we are taught to grin and bear it or tough it out when our bodies start signaling that something is wrong. I’ve done it, and I am fortunate to be alive to tell my story.
As a junior officer, I had a first-class petty officer die at lunch after playing a basketball game. Then there’s the story of the triathlete who suffered a heart attack in the middle of a race and died. Or maybe it’s the chief who died from a heart attack two years after retiring to his first nine-to-five job. I was always quick to assume the victims did not take care of themselves. That could never happen to me. Yet, according to the World Health Organization, nearly 18 million people globally died from cardiovascular disease in 2016. I was almost one of them; a footnote in the annals of history and another victim of a pervasive and insidious disease that most sailors never think about.
My advice is simple: Don’t Be Like Rob. Pay attention to your body. Find a primary care provider you trust, and follow through on their testing and treatment recommendations. I always tell my sailors to take care of themselves, but I failed to take care of myself. Taking care of yourself is as important to the mission as it is to your family. You may not get a second chance.
1. World Health Organization, “Fact Sheets: Cardiovascular Diseases,” 17 May 2017.
2. I. Cho, S. J. Al’Aref, and A. Berger et al., “Prognostic Value of Coronary Computed Tomographic Angiography Findings in Asymptomatic Individuals: A 6-year Follow-up from the Prospective Multicentre International CONFIRM Study,” European Heart Journal 39, no. 11 (2018): 934–41.
3. D. K. Arnett, R. S. Blumenthal, and M. A. Albert et al., “2019 ACC/AHA Guideline on the Primary Prevention of Cardiovascular Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines,” Journal of the American College of Cardiology 75, no. 10 (2019): e177–e232; and E. Di Cesare, L. Patriarca, and L. Panebianco et al., “Coronary Computed Tomography Angiography in the Evaluation of Intermediate Risk Asymptomatic Individuals,” La Radiologia Medica 123, no. 9 (2018): 686–94.
4. TS-H Investigators, “Coronary CT Angiography and 5-Year Risk of Myocardial Infarction,” New England Journal of Medicine 379, no. 10 (2018): 924–33.
5. Cho et al., “Prognostic Value of Coronary Computed Tomographic Angiography Findings; and Di Cesare et al., “Coronary Computed Tomography Angiography.”
6. TS-H Investigators, “Coronary CT Angiography and 5-Year Risk of Myocardial Infarction.”