Bernard Lown, MD
I first met Ed K. after he died, or so I was certain. Therein began an experience the ending of which was as bizarre as its beginning.
A dreary winter afternoon was dragging on endlessly. I was interpreting electrocardiograms for the Peter Bent Brigham Hospital where I was a postdoctoral trainee with the renowned cardiologist, Dr. S.A. Levine, in the early 1950s. The three-month rotation was sheer boredom. Suddenly, a breathless, frantic nurse burst in from the men’s public ward across the corridor. She announced that Mr. K had had his “final cardiac arrest.”
“Come quick!” she urged, “I have been unable to locate an intern.”
“What is this all about and who is Mr. K.?” I asked as we were racing back to her station. She was preoccupied with more urgent matters and saw no need to still my curiosity.
On reaching the bedside, I confronted an elderly man, clearly dead. He was not breathing, the skin was mottled with a bluish hue, limbs were flaccid, pupils were dilated, foam was dribbling from an open mouth. The electrocardiogram was running, printing out wads of useless confetti, inscribed with nothing but the straight line of an arrested heart.
Mr. K was beyond the pale of life. When the stopped heart shows a straight line instead of irregular wiggles on the ECG, all cardiac activity has ceased. Even today, with more advanced methods available, resuscitation is invariably futile. It needs to be recalled that the event I am relating occurred in the days before Kouwenhoven and his group at Johns Hopkins Medical School demonstrated the efficacy of external chest compression, so-called cardiac massage. Furthermore, the Peter Bent Brigham Hospital did not yet possess an external AC defibrillator, then just getting into vogue. Patients died prematurely, frequently unnecessarily and without heroics.
“How long has he been in cardiac arrest?” I asked the nurse, to determine whether to do anything at all. She opened the ECG machine, looked at the remaining roll of electrocardiographic paper, and announced that this final episode had begun about four and a half minutes earlier. She explained that as she had finished putting in a new roll of ECG paper, Mr. K. had his fourth cardiac arrest of the day. Each previous attack reverted spontaneously after less than 30 seconds. When this last one did not cease, she let the paper run and raced searching for help. She knew that an ECG roll was good for five minutes of recording and about 90% had been used up. This was a long time to be without a heartbeat. As little as five minutes of cardiac arrest can leave a dysfunctional brain.
Examining the ECG record carefully, I was astonished to note tiny, barely perceptible wavelets firing away at a regular rhythm of about 280 times a minute. These were emanating from the upper chambers of the heart, the atria. Doctors designate this type of cardiac mechanism, atrial flutter. Generally the ventricles will respond to half the flutter waves. In Mr. K. the rapid electrical pulses were completely blocked from reaching the ventricles.
Since Mr. K. notwithstanding his hopeless clinical appearance, still showed a flicker of life, I was foolhardy enough to go through a ritual then practiced of injecting adrenalin directly into the heart. No sooner did I insert the long needle through the chest wall and pricked the heart when a spontaneous ventricular contraction resulted, followed by other erratic such beats. After the adrenalin injection, the heart rate picked up to 30 beats per minute. Surprisingly, with this very slow heart rate, Mr. K. was able to maintain a wholesome blood pressure. He was now my ward and I didn’t leave his bedside.
I had learned that for the past several months Mr. K. had been suffering from fainting spells due to complete heart block, then a potentially lethal condition not uncommon in the elderly, now readily cured with an implantable pacemaker device. The condition resulted from an interruption of electrical signals in the heart. The normal electrical impulse originates in a pacemaker, a cluster of special nerve cells concentrated in the right atrium. Designated the sinus node, it has an uncanny capacity to generate 60 to 80 or more heartbeats per minute with clockwork regularity over a lifetime. A bundle of nerves, serving as an electrical cable, connects the sinus node with the ventricles, the heart’s dynamic pulsing chambers that propel blood through the body. In Mr. K. the bundle connecting the sinus node and ventricles was interrupted. He desperately required a pacemaker but it had not as yet been invented. Even Dr. Paul Zoll’s external pacemaker was still five years into the future. Since Mr. K. had complete heart block, his heart rate was only ranging from 28 to 32 beats per minute and did not speed with exertion or excitement.
It was a miracle that Mr. K. was alive. More miracles were to follow. After about 48 hours he began to respond to painful stimuli. After a week he was quite alert though still dazed. I was astonished that he had not suffered irreversible brain damage since he had been without an effective circulation for about 10 minutes. After another week Mr.K. was back to his old self. His family detected no abnormalities in his memory, thinking or personality.
Mr. K., whom I got to know as Ed, was a man in his late 60s and had never had a sick day in his life. He was a jolly elderly man retired from his job as a salesman of children’s clothing. Ed projected an easy bonhomie deriving from a life devoted to ingratiating himself with all comers, each deemed a potential customer. He was unpretentious, charged with common sense and able to forge easy relationships with all types of people. Born into a poor family, he had only a grade school education. His frequent Jewish jokes had a sharp ethnic skewer of self criticism.
Ed was pleased to be alive. Aside from being unable to hurry after a street car without becoming unduly winded, he was none the worse for having a heart that beat at half the usual rate. I expected recurrent syncopal or fainting spells, but none happened. After a few years I stopped worrying.
I tried to speed his heart rate with ephedrine, an adrenaline-like drug, but stopped the medicine since it made him nervous. Despite my forebodings, he got along remarkably well. He volunteered at my hospital and worked for one of the nursing supervisors, who found Ed a godsend. He would arrive bright and early, considering no job too menial and each one challenging. He straightened out the drug stockroom and cleaned out the laundry storage space. Wherever he worked he brought good order and good cheer. This continued for many years.
Ed was not limited by the heart block except psychologically. This was expressed in an unusual aberration, a strange form of insomnia. Sleep was in little packets of one-hour intervals. He set the alarm clock for one hour. Upon being awakened, he advanced the clock by one hour and resumed sleep. This he repeated through the night. If he did not set the alarm in this fashion, he was unable to sleep. Ed did not try to defend this eccentricity. When questioned, he indicated that he wanted to make certain throughout the night that he was still alive. His wife had to move out of the bedroom. His family was so pleased to have him in their midst, they ignored this particular “mishugas” or insanity. Ed prospered; he had no medical complaints and took no pills.
Twelve years passed uneventfully. Then one day while conversing with a leading cardiac surgeon in a hospital corridor, I spotted Ed coming toward us. With a few verbal brush strokes I outlined his remarkable medical saga. As Ed approached I introduced him to the surgeon, who immediately reached for his pulse. “My you have a slow heart rate! I can fix this.” Nothing more was said as we each went on our way.
Some months later I was informed that Ed had died. In looking into what had transpired, I learned that he died on the operating table during a thoracotomy to implant a pacemaker. The surgeon performing the operation was the one I had introduced Ed to in the hospital corridor. The chance brief encounter sealed his fate.
On recalling this last scene I feel a twinge of guilt. It was like exposing a gullible lamb to a seductive lion. While no one could have anticipated the outcome, should I not have foreseen the possible consequences? Where was my creative clinical imagination that day? Should I not have suspected that if once introduced to a surgeon, a patient with an obviously remediable surgical condition would be coaxed into an operation? How can a largely asymptomatic patient be improved by a risky procedure that carries in its wake potentially disabling complications? The man was doing well; no need to gild lilies.
Even after Ed’s passing he continued to hone my skill as a doctor. Because of that experience, I spared numerous patients with slow heart rates the implantation of pacemakers. I was reluctant to send asymptomatic patients to be operated on unless the evidence was compelling that their survival was otherwise in jeopardy. Scientific evidence is all important but should not trump common sense. In all my encounters with patients I tried to discover what truly troubled them. Only then can a doctor practice the ancient calling as a healer.
*Originally posted on ProCor (www.procor.org), a global communication network promoting cardiovascular health in developing countries. ProCor was founded by Dr. Lown in 1997 to encourage knowledge sharing among a global community about preventive strategies.