October 17, 2017 // Perspective

A different type of storm

Dr. David Kaminskas

The Catholic Doctor Is In

For over 20 years I had the pleasure of taking care of a particular gentleman. He had a severe cardiomyopathy, which means that his main pumping chamber, the left ventricle, had become weak, and his heart could no longer pump blood as vigorously as it should.

One of the most dreaded complications of a cardiomyopathy is a sudden, fatal arrhythmia. To prevent these deaths, we commonly implant a device called an Implantable Cardioverter Defibrillator. The ICD will detect these arrhythmias and automatically shock the heart back to normal rhythm. These devices save many lives every year. Now, back to my story.

This particular man did indeed have an ICD implanted. He went years without using it, but one day he suddenly became very dizzy and got a painful shock across his chest. His wife called 911. In the ambulance on the way to the Emergency Department he received three more painful cardioversions. I have had many patients describe this experience as if they were kicked in the chest by a mule.

On arrival to the Emergency Department, it was not long before his heart rhythm deteriorated again into ventricular tachycardia, or what we call VT. Once again, he was shocked. I was paged, and as I walked in I heard this large man scream in pain as he received yet another shock. I arrived at the bedside, he grabbed my hand and looked straight into my eyes and said to me, “You have to stop these shocks!”

I asked his nurse to get me a magnet right away. She had no idea why, or for that matter, what I was talking about; so let’s just say I could have been a little more eloquent as I told her to go find the doughnut magnet “stat,” or find someone who could!

A long several minutes went by as the Emergency Department personnel frantically searched the area for a magnet. In the meantime my poor patient nearly broke my hand, squeezing it with such great force as he realized the dizziness he was feeling once again was a signal that his heart was back into VT. And yes, he got shocked once more as I stood at the bedside helplessly. Finally a large, blue doughnut-shaped magnet arrived, and I immediately placed it directly over the ICD encasement under his left collar bone. The magnet blinds the ICD software from detecting arrhythmias and therefore stops the shocks. In the meantime, I was administering a very powerful antiarrhythmic medicine intravenously to suppress further recurrence of the ventricular tachycardia. His runs of VT became shorter and shorter until we had given enough medicine to suppress his arrhythmia.

He finally stabilized, and we found the right combination of oral medications so he could be released back home. Despite a very aggressive regimen of multiple medications to suppress his ventricular tachycardia, he experienced VT on multiple occasions over the next few years.

When you have uncontrolled, recurrent ventricular tachycardia it is called VT storm. My team of electrophysiologists (specially trained cardiologists that are electricians of the heart) even did a high-risk procedure call a VT ablation on this man, and it failed to prevent the VT episodes. He eventually developed Post Traumatic Stress Disorder from always waiting nervously for the next shock to occur.

After years of these presentations his heart had greatly deteriorated, and he developed end-stage, congestive heart failure. He was now spending more time in the hospital then at home. One evening, as he lay in the hospital during one of his many admissions, he had his nurse call me to the bedside so he and his wife could discuss end-of-life issues. He told me he had had enough and wanted to know if I would agree to turn his ICD off so the next time he had VT he could die.

Catholic scholars agree that such decisions to end disproportionately burdensome procedures are ethical, especially as in this case when someone has reached end-stage heart disease and death is imminent.

He was a good Christian man and was ready to embrace death. God was merciful. That same night he went into VT, fell asleep and breathed his last.

There is a plaque on a wall in my house given to my wife by a close friend during a particularly difficult family crisis. It reads: “Sometimes the Lord calms the storm. Sometimes he lets the storm rage and calms his child.” This Lord’s child had been calmed.