There are very few things that qualify as electrophysiology emergencies, but recurrent ventricular tachycardia with subsequent implantable cardiac defibrillator shocks is one of them. Especially when it continues despite your best efforts to quell the arrhythmias with our most potent antiarrhythmic medications. The options are few at that point: attempt a ventricular tachycardia ablation, refer the patient for possible transplant, or turn the device off and move the patient to hospice care.
For patient's in their mid-70's, the options wean to two of those - do or die - literally.
So after long discussion with the patient and his family, the young electrophysiologist booked the case, knowing full-well it's difficulty but hoping to locate the focus of the predominant ventricular tachycardia in hopes of buying a bit more quality time for the patient free from the painful mechanical hourly disruptions.
Things progressed well at first: The patient was anesthetized and device deactivated. Access was reasonably easy. Monitoring lines were placed without difficulty. A complicated array of sophisticated mapping equipment was installed into the various chambers of the patient's heart. Before long and a few ventricular extrastimuli later, several forms of ventricular tachycardias were easily induced. Regretfully, these were not the clinical arrhythmia. But with perserverence and a few more extrastimuli, there it was: sustained monomorphic ventricular tachycardia just like the patient's clinical arrhythmia - a moderately fast, tough-to-pace-terminate beast.
"Burst at 360." (our lingo for pacing at a 360 millisecond cycle length, or 167 beats per minute)
Nothing. The arrhythmia continued.
"Burst at 320."
"Burst at 300."
"Doctor, his blood pressure."
"Okay, let's shock him."
The defibrillator charged and delivered the life-saving jolt across the patient's chest. And there it was. A paced rhythm. A moment of relief. Then,
"We've got no pressure!"
"Give him a second." Pacing was fine, just no mechanical movement.
"Start CPR! How about some EPI! Anything? Check the airway! Call for an echo, stat! I'm deflating the mapping array.... Continue CPR. Anything?"
"Got a little pressure with CPR..."
And on and on it went. Seven minutes that felt like a lifetime. Finally, a pressure without CPR. An exhausted staff. An anxious anesthesiologist. An uncertain electrophysiologist.
Thoughts flooding: "Will he be okay? Did I do the right thing? What went wrong? I never had that happen before. Such a nice guy..."
The hours after passed quickly as the patient was transferred to the ICU, pressors infusing, the patient still asleep under the merciful mix of general anethetics as the ventillator moved his chest up and down. The walk to the waiting room. The discussion about what happened, the uncertainty of how the patient would fare. Then returning to compose the note that could never captivate the sense of helplessness of the moment while still not knowing what had happened. No effusion, heart looking as it had, the chest x-ray unchanged.
Finally, after rounding on several of other patients that had been left neglected during the kerfuffle he returned home, exhausted both physically and emotionally, questioning his ability, his career choice, his resolve. Did he do the right thing? Would he ever do that again?
He parked his car, then walked inside and collapsed on his sofa, just wanting to escape for a brief moment to peace, quiet and solitude for a moment all his own.
Then he felt it, a tiny hand upon his cheek.
He turned, and there was is 18-month old son, with outstretched hands peering up into his flooded eyes, grinning with a fragment of mascerated Goldfish cracker in his lips and holding a fist-full more in an attempt to feed him.
And in a flash, as if sent by God himself, all was right with the world.