Chapter 4
Tachycardia
DISCLAIMER
This is my true story, with adjustments for artistic license. To protect their privacy, I changed names and biographical details of any individuals depicted. Any stories of patients I treated are fictionalized and inspired by my aggregate experience as a physician.
Any views expressed are mine alone, and do not represent the positions of my employers.
My writing is not graphic, but it does describe medical details.
Feeling my heart racing, seeing the pulse oximeter tracing with the blue line moving up and down in a zigzag pattern, I remembered another time I had seen such a rapid heart rate on a monitor. It was Wally’s, and it was not sinus rhythm.
It was a Monday morning, after I finished a week in the ICU. The preceding Friday, Leo threw up in the car in the parking lot at preschool, so my wife turned around and drove home. In a household with six people, there are few feelings as ominous as that you experience when one child starts vomiting. You know the next few days will be terrible. Leo threw up only once more on Friday, and not at all on Saturday. Everyone seemed healthy Sunday morning, so we wondered if maybe, just maybe, we were in the clear.
I got home mid-afternoon Sunday. It was my “short” day in the unit that weekend. We took everyone to McDonald’s drive-through for dinner, because that both contained them for an hour and meant we did not have to make food. We try to be flexible with ourselves on my service weeks. Bedtime with the kids went uneventfully.
Both exhausted from my week in the ICU, Kathryn and I fell asleep by 9pm. We left our bedroom door ajar, so we could hear down the hall in case the other kids got sick. It was not our first rodeo, so we placed buckets lined with trash bags at our bedside, and in the kids’ rooms. Molly and Brandon each had their own room, and Leo and Wally shared what was technically the largest room. Square footage aside, the shared space was a sore spot. Regardless, the buckets stood guard, warding off the gastrointestinal illness spirits.
Just after midnight, there were footsteps in the hallway and a knock at our door. Tearful, Brandon stood in the dark.
“I threw up. It was so gross.”
I followed him down the hall to survey the damage. Remarkably, he had made it out of the nest of pillows and blankets in his bed, essentially containing the mess to the bucket. Clean-up was quick, and I set him up on the couch in the living room.
“There, the couch is covered with towels, in case it happens again. And the bucket is right next to you. I changed the trash bag.”
“Thanks Dad,” he said, exhausted.
“Try to get some rest, buddy.”
Back in bed, I laid down, hopeful for some more sleep. Twenty minutes later, more footsteps and another knock. It was Wally. I got up.
“I threw up,” he cried.
“Oh Wally, I’m sorry. I know that’s yucky.”
Tentatively, needing but unsure whether I wanted to know the answer, I asked him, “Where did you throw up?”
“In the toilet.”
Whew
“Well, mostly in the toilet. Some in the bathroom.”
The floor is easy to clean
“Well, mostly in the bathroom, a little on the carpet in the hall.”
Ugh
“But not in my room, and not on my stuffies!”
Silver linings
After I cleaned up in the bathroom, and a little on the carpet in the hall, I set Wally up on the other living room couch. With the same arrangement, couch covered in towels and bucket at the ready. While I was there, Brandon threw up in his bucket, and I changed the trash bag again. We were accumulating a pile of trash bags in the garage, tied tight to contain their foul contents. I headed back upstairs, hoping to rest.
I am not sure how long I slept, but our alarm went off at 5:30. Leo seemed healthy now, and we planned to take him to preschool, so we were up to get ready for the day. Molly was still asleep. Miraculously, Kathryn and I were unaffected so far. Tired, but at least not vomiting. I brushed my teeth and went downstairs to make coffee and some breakfast.
While I was drinking my coffee, Brandon was still asleep on the couch. Wally threw up again, and I changed the trash bag. I heard a yelp from just above us. Molly’s room.
“I fwew up!” I heard her little voice through the vent in the living room. “It’s yucky on my jammies!”
Kathryn took clean-up duty for Molly, while I tended to the others. She drew the short straw, yelling down the stairs, “Molly didn’t make it to the bucket!”
By now, Leo was awake, watching a nature documentary about wild horses on his iPad, eating a piece of cinnamon bread, oblivious to the events of the night.
Thirty minutes later, with our infirmary running in the living room, Wally was lying on the couch and looking particularly unwell. I knew he had thrown up several times and not kept anything down since dinner, so figured that was it.
“Daddy, it’s hard to breathe.”
That is not a symptom of gastroenteritis
“Sorry, Wally, what did you say?
“It’s hard to breathe.”
Work of breathing looks OK. Wonder what this is?
With Brandon and Leo’s asthma, it was an evaluation I was accustomed to performing. We have a small-sized pulse oximeter at home, for little fingers. I retrieved it from the kitchen, where it sat among several different inhalers, an ear thermometer, and a pediatric stethoscope I kept on hand. Returning to Wally, I placed the pulse oximeter on his finger. Cast in low-angle light from the lamp in the corner, the vein in his neck appeared to be fluttering.
The pulse oximeter’s small screen showed the blue line. But instead of nice little mountains, it looked like a jigsaw blade. His pulse ox was 98—normal—but the heart rate read 220.
That can’t be right
I turned it off and then back on. 220.
Got the other pulse oximeter, which we kept upstairs. 220.
I held his upper arm, taking his brachial pulse. Thready and too fast to count.
Yikes. OK. Stay calm, Ian
“Um, Kathryn...I need to take Wally to the hospital”
Having had coffee and breakfast by this time, Kathryn was sitting at our kitchen counter.
After a beat, she replied “What?”
“Yeah, his heart rate is over 200. I think he’s probably in SVT.”
SVT is supraventricular tachycardia, a rapid heartbeat caused by an abnormal circuit in the electrical system of the heart. I was diagnosed with SVT in medical school, was on medication for a few years, but had not had an issue in a decade. Kathryn knew what it meant.
“Do we need to call an ambulance?” she asked.
Not the first, or even the second time we considered that question regarding one of our children.
“Well, he seems OK otherwise. I don’t think the EMTs will do anything other than get him there. It’s early, so there won’t be traffic. I think it’ll be faster if I just drive him than to wait for the ambulance. Plus less drama.” Fortunately, I was right.
“OK, please let me know what is happening.”
“I will. Love you.”
“Love you too.”
I carried Wally to my car, buckled him in his booster seat, and was on my way. At every stop, I looked back to check on him. He was awake, but not himself. He looked tired and pale. Thankfully, there was no traffic, and we were in the hospital garage in less than 20 minutes. I carried him to the emergency department registration desk.
“Hello, what brings you in this morning?” asked a kind registration clerk, eliciting our chief complaint.
“I think my son is in SVT. His heart rate is over 200.”
Not the answer he was expecting. The waiting room was nearly empty, and I saw the triage nurse’s ears perk up.
“Sorry...what’s going on with him?” She asked, coming over from the triage room. “And are you Dad?”
“Yes, I’m Dad. He has gastroenteritis, started vomiting last night. Thirty minutes ago, he said he was having trouble breathing. My other kids have asthma, so we have a pulse ox. I put it on Wally and his heart rate was 220.”
I could see she was slightly incredulous. To be fair, the story was unusual. She brought the cart over from the triage room, with a monitor and pulse oximeter, and placed it on his finger. Heart rate 217.
Guess our pulse ox wasn’t broken
Her expression shifted, to apprehension.
“OK, let’s get you back to a room.”
No waiting room for Wally that morning. The last time he was in the waiting room, it was because he stuck a Lego gem up his nose.
The day after Christmas.
During a terrible RSV season.
We were going to have to wait for hours. While we sat, he sneezed, and the Lego popped out into his mask. He thought it was a booger, until it fell into his lap. I put the little pink plastic gem into the bag in which I had brought an identical piece—to let the doctors know what they would be extracting—and showed it to the nurse at the front desk as we left. She clapped.
Carrying Wally, I followed the triage nurse back through the double doors, into the ED. She took us to a large room. I could tell it was one of their resuscitation bays. The airway and procedure carts stood up against the wall, and there were bright, maneuverable lights overhead. I knew what all this equipment was for, trying to block it out of my mind.
It’s OK, Ian. You got him where he needs to be. He is safe here.
We were promptly met by the ED nurse and a resident. I did not encode their names. The nurse hooked Wally up to the monitor and took his blood pressure. The vertical spikes on the green telemetry tracing were very close together. Heart rate 218. The monitor alarmed. I knew the resident would need help, but Wally’s blood pressure and pulse ox were normal, so we had some time.
“Hi,” chimed the resident, in the lilting voice we often reserve for speaking to children, “What’s your name?”
Wally was exhausted, and did not answer her.
I answered for him, “He goes by Wally.”
Turning to me, she asked, “Are you Dad?”
“Yes,” then, given the nature of the problem, and the fact that my description of events would surely give me away, “I’m an ICU doc downtown.”
“Oh. OK...so what’s going on?”
“He has gastroenteritis...all my kids do. Started vomiting in the middle of the night.”
The resident was taking notes on a clipboard.
“This morning, about 45 minutes ago, he said it was hard to breathe. I put our pulse ox on him and his heart rate was 220. I had SVT when I was younger, so thought maybe that was it.”
“Goodness. Any medical history for him?”
“None. He’s healthy, up to date on vaccines, no meds, no allergies.”
“Last thing to eat or drink?”
“Dinner last night. And he threw that all up since midnight. Hasn’t kept anything down in probably 12 hours.”
“Right—you said he had gastroenteritis. Any diarrhea?”
“No”
With enough information for now, she turned back to Wally.
“Can I take a listen, Wally?”
“Yeah,” he said faintly.
The resident listened with her stethoscope to Wally’s chest and back. I’m sure his lungs were clear. And his heart racing.
Turning back to me, the resident said “OK, thanks for the history. I’m going to go talk with my attending and we’ll be back.”
“Sounds good”
Two minutes later, in walked Kai Lee, the ED attending. I recognized him. He had seen one of my other children during a different ED visit. With four young children, this felt like a statistical phenomenon rather than a coincidence.
“Hi Dr. Lee”
Recognition dawned on his face, but I could tell he could not quite place me.
“I’m Ian Barbash. One of the ICU attendings. You saw one of my other kids before.”
“Right!...Well, sorry to see you back. The resident filled me in, so I’ll spare you the questions.”
“Thanks”
“Let’s see what we can do about this SVT,” he said, showing me Wally’s EKG. I was right. No p-waves. But reassuringly, no signs of any other, more dangerous arrhythmia.
He walked over to Wally, listened to his heart, and pressed on Wally’s little fingertips, checking the capillary refill time. Then he checked again. I could tell it was off. An hour with a heart rate over 200 was starting to affect Wally’s circulation.
“OK Wally, can you blow on this like you’re trying to blow out a candle?” he asked, taking an empty 3cc syringe from the nurse and placing the open end in Wally’s mouth. Doing this maneuver prompts kids to Valsalva, which can sometimes break SVT. Wally tried, weakly, but to no avail.
Kai turned back to me, “OK, I think we should give him adenosine. His cap refill is a little sluggish and I don’t want to mess around waiting for the SVT to break.”
“OK, whatever you think is best,” I replied. In this moment, I was Dad, not Doctor. I tried not to let on how scared I was.
I have directed the administration of adenosine many times. Adenosine is an intravenous medication that blocks the conduction system in the heart, interrupting the abnormal circuit of SVT. It causes temporary complete heart block, meaning that nothing gets from the top to the bottom of the heart. There is a “flat line” for a second or two. Awake patients often say it feels like getting kicked in the chest. We always place pacing pads on a patient first, before pushing adenosine. In case the heart block lasts longer, and temporary pacing is required.
Knowing all this did not prepare me to watch it happen to my kid. I needed to relinquish control and place my trust in the professionals around me to keep Wally safe. I am grateful that the trust was well-placed.
“We’ll need to place an IV,” Kai said, to me, and the nurse, “and let’s get a three-way stopcock for the adenosine.”
“We’ll get you feeling better soon, Wally.”
He stepped out briefly.
The IV was accomplished uneventfully. Wally was too exhausted to object, and his nurse used a spray to numb the skin first.
Kai returned, this time with the resident and a medical student. It was not every Monday at 8am that they pushed adenosine on an elementary-aged child with a heart rate over 200.
“OK, so we’ll push the adenosine in this one,” he said, pointing to one hub of the stopcock, “and then turn the stopcock and flush this one,” pointing to the other, “while raising his arm up. That gets the adenosine to his heart faster.” The resident and student listened, intently.
I held Wally’s hand and watched as they pushed the adenosine, raised his other arm—the one with the IV—and waited for the medication to work. We always start with the lowest dose, since the effect varies from person to person. The first dose did not accomplish anything. Wally’s heart rate stayed near 220.
“OK, we’ll go up to the next dose,” Kai said to the nurse, and to me.
They repeated the process, injecting the adenosine, then flushing while holding up Wally’s arm. He was remarkably silent throughout. Doctors are reassured when kids are rambunctious. Wally was not.
This time, the adenosine worked. For just a second, Wally’s heart stopped, the green telemetry tracing briefly flat. It felt like mine stopped for a moment, too. Then, the reassuring sequence of P-QRS-T. Sinus rhythm restored.
Thank goodness
“There we go, he’s in sinus,” said Kai.
Wally looked a bit better.
“I’m thirsty,” he said.
“Want some lemonade?” asked his nurse.
“Yeah!”
Good sign
Kai went back and took Wally’s hand, checking capillary refill again.
“Better,” Kai said, making eye contact with me.
“Thank you, Dr. Lee,” I replied, exhausted from the night prior, and relieved Wally was safe.
“Of course. We’ll watch him, make sure he can keep down some fluids. And set you up with cardiology. I spoke to the fellow, and they’re aware.”
“That sounds great...again, thank you.”
“Our pleasure.”
Kai left, on to help someone else’s kid.
Before we left the ED, a clerk came by with a computer and scheduled our cardiology appointment. This was a wonderful service—to have subspecialty follow-up established before walking out the door. No phone trees, no calling an office, being told the first available appointment is three months away. And Wally was excited. His brothers go to the asthma doctor, and now Wally would have his own specialist.
The cardiology visit was two weeks later. It was one of the smoothest subspecialty visits I had ever encountered. They did his echocardiogram—an ultrasound of the heart—in the cardiology suite, before the appointment. No scheduling a separate visit. The cardiologist read the echo before coming in to see us. Wally heart was normal, healthy. The cardiologist told me what I knew from my own experience, that SVT was the most common arrhythmia in young people, generally benign in patients with a structurally normal heart.
Wally has not had SVT since.
Kathryn and I did not escape the stomach bug. It came for us that night.
God, you guys.