A Storm Like No Other

Wassim Jawad, MD, BSc Biology
Cardiac Electrophysiology Fellow, University of Massachusetts, Worcester, MA

cardiology-critical-care-fellowshipWhat am I put on this Earth to do?” We all ask ourselves this question every now and then; some of us more than others. I didn’t struggle much with it, at least not early on. I always knew I was going to be a doctor. It’s a long, grueling path, but one I did not waver from. I soldiered through four years of pre-med, four years of medical school (the first year of which was disrupted by a category IV hurricane), three years of internal medicine residency, and was halfway through my third and final year of cardiology fellowship. I felt like I had reached the top of the mountain. After countless punishing night calls, research, board exams and certifications, many are more than ready to move on and be done from training. I was no different in that sense, until I had that “moment” that everyone tells me about.

I could have just walked away. It had been another long day in the invasive cardiology lab, performing procedures and doing consultations. As always I make my way to the Cardiac Care Unit and sign out my patients to the on-call team, then I go home and enjoy whatever is left of my evening. Nobody would have thought twice about my leaving, I had already fulfilled my responsibilities of the day. I was at the nursing station, and I overheard a conversation about a patient that had just been admitted into the unit with a cardiac arrest. I thought to myself, “Okay, not unusual for the CCU, we deal with cardiac arrests all the time”. The on-call cardiology fellow was already on top of it, so I started to make my way out. The next thing I knew, the nurse told me the patient had already been shocked by the paramedics more than ten times, and another 15-20 times in the Emergency room.

Patients with very sick hearts are susceptible to potentially life-threatening “arrhythmias”, or abnormal heart rhythms. If not immediately treated with an electrical shock to restore normal rhythm, these conditions can be fatal. In rare cases, these arrhythmias keep recurring, requiring multiple shocks until the patient either dies, or the underlyinggraduate process is determined and definitive so that timely treatment is delivered. This is called ventricular tachycardia or sometimes a “Ventricular Fibrillation Storm”. What made things even more dire in this case was the patient was 26 years of age.

I walked into the young man’s room, and his emergent care was in full swing. His nurse, a big burly looking guy, was reduced to a ball of sweat trying to keep him alive with what was probably the best CPR I have ever seen performed. The code cart stood next to his bed, each drawer being emptied as drug after drug was being pushed by another nurse. Another nurse stood by his monitor, taking note of the time and which medications have been administered. At the helm was the on-call cardiology fellow, directing traffic and shouting out orders. With every shock delivered, normal rhythm would be restored, only to have the patient degenerate again into ventricular fibrillation minutes later, hence turning the process into a state of perpetual agony. This young man was dying right before our eyes and there is nothing we could do for him it seemed.

How long have you guys been at it?” I asked the fellow. “More than 30 minutes. We’ve tried everything and he keeps going back into V-Fib” she said. While she remained calm, the look of concern was clearly evident on her face. She had been running this code for longer than many would consider a valiant attempt, just hoping he would pull through. She didn’t want to see a 26-year-old man die….Neither did I!

I poured through his chart, reviewing what we knew about him already, as well as his electrocardiograms. At the time, the prevailing thought was that he may have been suffering from myocarditis, an inflammation of the heart muscle, often precipitated by a viral infection. This is commonly seen in younger patients, and can present with V-fib storm. However, all the conventional management approaches did not provide relief.

When your treatment plan isn’t working, you must always re-evaluate your diagnosis. This is a fundamental concept when it comes to managing patients. I began to look and see what else could be going on. In quickly reviewing his electrocardiograms, I noticed that he may have something completely different. I asked the fellow if she had tried treating him for V-fib storm precipitated by Brugada Syndrome (a rare disorder affecting the electrical conduction Wassimsystem of the heart, rendering patients at risk for fatal arrhythmias). She said she had not, and at that point she would have tried anything. We initiated treatment, and almost immediately, the extremely tense and ominous atmosphere had subsided. The patient’s heart rhythm finally stabilized, and our relentless, sweaty nurse who performed the chest compressions stood above our patient, desperately trying to catch his breath. We all stood there in silence, waiting to see when he would go back into V-fib, but it never happened again. A collective sigh of relief overcame everyone in the room. Our young patient lay there, hooked up to the mechanical ventilator, half awake, with tears flowing down the side of his face. After more than 62 shocks, countless chest compressions, and a barrage of medication infusions, he was going to walk out of our hospital. This man’s journey through life did not end on this night.

It was after all this that I realized that my journey through arduous training was not going to end after cardiology fellowship. I went on to specialize further in the field of cardiac electrophysiology (the study of heart rhythm disorders). I look back on this ordeal as one of the most powerful experiences that shaped the direction I wanted to take my career in. I was motivated by my loving family, my wife and my children, who teach me the value of life everyday.


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