When the Dam Leaks
The new heart was beating. The surgery was done. By any external measure, the crisis had passed.
What nobody tells you—what the discharge packet does not cover, what the follow-up schedule does not account for—is that the emotional accounting hasn’t even begun.
Before the Transplant: The Exposure Starts Early
The prednisone didn’t begin post-transplant. It began weeks earlier, during the treatment for amiodarone-induced thyrotoxicosis—the event documented in Out of the Frying Pan that set everything in motion. High-dose corticosteroids were the preferred treatment for a thyroid gone haywire, prescribed before the transplant listing, before the surgery, before any of what followed. The emotional exposure had already started by the time the heart came out.
This matters because the timeline most people assume—transplant happens, then the emotional aftermath—is not quite right. The dam had been taking on pressure for weeks before the surgery. By the time the transplant added its own considerable weight, the structure was already stressed.
What Prednisone Actually Does
Prednisone is not a mood drug. It is an immunosuppressant and an anti-inflammatory, prescribed for reasons that have nothing to do with how a person feels. What it does to the emotional architecture is a side effect—documented, significant, and almost never explained in the detail it deserves.
The range of psychiatric effects is wide: aggression, depression, emotional lability, anxiety, disrupted sleep, a nervous system running without its usual dampening. The mechanism is not that it creates emotions that weren’t there. It strips the filters. The containment mechanisms—the ones that had always kept the emotional at a manageable distance from the rational—are chemically dissolved. What remains is the raw material, uninsulated, exposed.
A raw nerve. That is the right image. Not broken—exposed.
Different people respond differently to that exposure. Some with rage. Some with depression. Some with a flatness that is its own kind of loss. My response was contemplation—forced reckoning with things that had been filed rather than felt, surfacing without invitation, demanding engagement. Not chosen. Not welcomed. Simply unavoidable, because the mechanism that had always made avoidance possible was temporarily dampened.
What Was Behind the Dam
They say your life flashes before your eyes just before you die. Prednisone makes it happen sooner.
What came through when the filters went down arrived in waves, without the editorial control that would normally have managed the sequence.
First: the realization that time had been spent, and not always well. No matter how much had been accomplished—and there had been real accomplishment—the sense that more had been owed, more should have been done, arrived across every domain simultaneously. Not guilt exactly. Something more like an audit that hadn’t been requested and couldn’t be closed.
Then the relationship accounting. Every mistake surfacing unbidden. Too harsh in that moment. Should have handled that differently. Didn’t love enough here, didn’t accept enough there. The ledger opening itself without being asked, presenting entries from decades of interactions, some of them a long time unexamined.
Then the sourceless emotions—the ones that couldn’t be tied to anything specific. They had always been present, filed somewhere below the threshold of daily awareness. Now asserting themselves without context or explanation, arriving with the full force of things that had been waiting.
And then the oldest material. Failures from childhood. Formative experiences fifty years buried, belonging by now to a version of the self so far back as to seem like someone else. Returning with complete fidelity to how they had originally felt.
This is what the prednisone had unlocked, and the time had made unavoidable.
The Time Problem
Hospital. Recovery ward. The couch at home. Weeks of enforced stillness, with nothing to occupy the hours that had always been filled with work, problem-solving, and the hundred small tasks that had made it possible to not-think about things that needed not-thinking-about.
Some transplant patients bring gaming systems, streaming sticks, crochet—the tools of distraction, the means of keeping the mind occupied while the body heals. Some don’t have that. What they have instead is time. The ceiling. The couch. The thoughts that have nowhere else to go.
I had time. Lots of it. And the thoughts came.
The Buspar Debacle
The transplant team recognized what was building. They pushed for Buspar—professionally, with sound clinical reasoning, and with more persistence than I found comfortable.
The resistance was my choice. I did not want anything that might interfere with the functioning of the instrument I depended on most. The intellect was the tool I had always used to manage everything, including this. Adding a pharmacological variable to a brain already under considerable stress seemed, to me, like the wrong move. The negotiation stretched over weeks: their clinical rationale, my reluctance, the eventual agreement reached more from exhaustion than conviction.
And then the transplant happened, and the medication was simply dropped.
It had never had a chance to establish at therapeutic levels. When it was discontinued, I was fine with that too. I hadn’t needed it before. And now, with a new heart pushing significantly more oxygen to the brain than the failing one had managed in years, I didn’t need it now either. I suspect the team knew this. The timing of the discontinuation, whatever its cause, turned out to be correct.
What It Actually Looked Like
Not losing control. That framing is wrong and it matters that it’s wrong.
The intellect was present throughout—observing, understanding, naming what was happening in real time. What the experience actually was: becoming overwhelmed by emotion while still watching it happen. The structure held. The pressure found the gaps. Those are different things from losing control, and the distinction is not semantic.
The lability moved in both directions. Laughing for no reason—and even though it was utterly ridiculous, it felt good. Then tearing up, again for no identifiable cause. The nervous system expressing whatever it found, without the usual governor, in whatever direction it moved. Understanding exactly why it was happening changed nothing about the fact that it was happening.
Humor served as a pressure valve throughout—dark humor, specifically, the kind that acknowledges the weight of a situation while refusing to be crushed by it. It had always been part of the operating repertoire. Under these conditions, it became essential.
There was a moment—documented more fully in Dignity—that belongs here as well. After a small blow-up, with a nurse who had not deserved it, I apologized. What followed is what I remember most. She put her hand on my shoulder—a quiet signal, the kind that says it’s going to be all right. Something in me released. I dropped my head to her shoulder for a moment and let it pass through me—the weeks, the pain, the frustration, the accumulated weight of all of it. She did not take it personally. She understood completely. That small grace, offered without drama, cost her nothing and meant everything.
Watching all of this weigh on the people who were present was its own particular weight. The burden accumulating on faces that mattered, with nothing available to relieve it. The powerlessness of that—not the illness itself but the secondary effect, the inability to protect the people absorbing what couldn’t be contained.
There were people who showed up. Mom was there. Niles was there. Eric, for a while. These were real presences and they mattered.
There were people who were supposed to be there who weren’t. This carried its own disappointment and emotional weight. This experience will expose relationships that are not what you thought they were, and that is difficult to work through.
Accountability
When the dam cracks, you will experience the water. You will say things that should not be said. You will remember things best left forgotten. And while all of that is understandable—the mechanism is real, the pressure was genuine, the chemistry was working against you—none of it constitutes a free pass.
You still need to do the right thing. That means acknowledging the behavior and apologizing for it. Not explaining it, not excusing it—acknowledging it. The cause does not transfer the responsibility.
Some of what surfaces—those memories and feelings that had been filed and left to fester—may be doing more than just surfacing. Not everything that comes up under pressure is simply an artifact of the chemistry. Some of it isn’t noise; it’s a signal. Things from the past left too long unaddressed, making themselves known through the only door that was open. The crack is the message. What you do with it is still up to you.
Judaism has a practice called teshuvah—a form of repentance and return that is, in my view, one of the wisest frameworks any tradition has produced. It is not a moment; it is a process. I write about it at greater length at Many Lamps, One Flame, but the outlines of it belong here.
As these memories and feelings surface, you experience genuine remorse for past actions. The prednisone may have brought it to the surface, but the remorse itself is real—just unfiltered. You recognize that you cannot continue the behavior; in most cases, you have long since abandoned it. But that is not sufficient. Teshuvah requires taking full ownership of what was done, how the transgression occurred, and then reaching out to the person wronged. You ask for forgiveness. You express the remorse. You do not insist upon forgiveness—it is theirs to grant or withhold, on their timeline, not yours. You make a sincere commitment to never allow it to occur again. And when you are faced with a similar situation in the future, you do not let it happen again. That last step is where the process either becomes real or reveals itself as performance.
This is the time for it. Everything has come back. Apply it. Deal with it.
PTSD and the Anger at the PTSD
The conditioned stress response is documented elsewhere in this series—the triggers, the beeping appliances, the hypervigilant nervous system that had not been told the emergency was over. What hasn’t been named directly is what accompanied it.
Anger. Directed inward.
PTSD is understood—culturally, instinctively—as something that happens to soldiers. To victims of extreme violence. To people whose circumstances are categorically different from a medical procedure, however extreme. Medical trauma is real, documented, studied, present in the clinical literature. The body and nervous system do not distinguish between the source of sustained threat—they respond the same way regardless of whether the source is a battlefield or a hospital room.
The intellectual framework knows all of this. Has read the literature. Understands the mechanism.
And still generates anger when the conditioned response appears. Because understanding it should be sufficient to override it. Because a person who operates primarily from the rational should be able to correct a documented irrational response. Because this is not what PTSD is supposed to look like—not on someone like this.
It isn’t sufficient. The anger at its insufficiency is its own additional load on a system already at capacity. We are simply not prepared, as a culture, to recognize medical trauma for what it is—not in others, and not in ourselves.
The Restoration
No therapist. The Buspar never established and was dropped appropriately. No additional pharmacological intervention after that.
What happened instead was the slow return of the instrument. As the prednisone stepped down and the cardiac output continued improving, the cognitive capacity came back online—gradually, then more noticeably, then substantially. The filters reasserted themselves. Not fully, not immediately, but directionally.
What that meant for the material that had surfaced: it didn’t go back under. Some of it was looked at, turned over, set down in a different place than it had come from. The contemplation, over months, of things that had needed to be contemplated for a long time.
Not a clean resolution. Not a therapeutic success story. A man running on his primary instrument, at higher load than it was designed for, processing what it could, carrying what it couldn’t resolve, eventually finding something that functioned as equilibrium.
The intellect didn’t fail. It was stressed beyond designed capacity. It held anyway.
Rupture
The dam doesn’t break. It cracks. The structure holds, and the water finds the fractures, and the water recedes, and what remains is different from what was there before.
For a man who has always lived in the mind, being flooded by what the mind had always contained is not defeat. The things that surfaced needed surfacing. The reckoning, however unwelcome, did work that decades of careful filing had deferred.
The water receded. The instrument came back.
Different. But back.
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