Sunday, June 19, 2011

Small Miracles

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."

Still nothing.

"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.

"Still nothing!"

"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.



Named Just Bob said...

In addition to being one of the most intelligent men I have ever met, you are gifted in your ability to put pen to electronic paper. Thanks for being there. On many levels.

Vijay said...


Marco said...

Beautiful post, Wes. Happy Father's Day!

Anonymous said...

You are a wonderful doctor and a powerful writer. Now if I could just change your politics...

Anonymous said...

Sorry. I neglected to say it seems you are a pretty great father and husband as well.

Anonymous said...

That was nice Wes, sigh.


Tacitus said...

High tech, high drama and a big win. You have triumphed and need to savor the moment. Indeed, we need such moments.

But remember what the Romans did. When they allowed a victorious general a Triumph (a victory parade) they always had a slave alongside him to whisper "you too are mortal".

We also await a code outcome, but the patient-a young one-postures and seizes in the wraith world of hypoxic encephalopathy.

That battle was lost pre hospital, but the reminder-also needed-that we are but mortal is poignant nonetheless.

Detritus of Empire

Kim said...

That was beautiful, Wes! : )

Anonymous said...

Thank you for your post! It reminded me of a poem:

But you can have the fig tree and its fat leaves like clown hands
gloved with green. You can have the touch of a single eleven-year-old finger
on your cheek, waking you at one a.m. to say the hamster is back.

more [...]

geena said...


When I first started in ICU (and was only about 6 months out of nursing school at that), one of my favorite doctors - I would have chosen him in a heartbeat (HA!) for myself or any family member - admitted his "favorite patient" who he had been seeing for many years.

We were in the ICU, the patient already had an AICD and the doc was trying to induce an arrhythmia. I don't remember why or what his plan was, but he definitely induced VT ... and wasn't able to get the patient out of it.

It wasn't my patient; I was new and had been sent into the room to watch and I definitely got an eyeful. The doc was absolutely crestfallen.

I cried all the way home that night.

Lovely post.