by Paul Goldfinger, MD, FACC
(Special to the Ocean Grove Record.com)

FASCINATING RHYTHM

It was a July evening, 1973, and the Emergency Room at Dover General Hospital was busy. I had just opened my cardiology practice in Dover and then joined the staff at this 360 bed community hospital. In the beginning, I had a lot of time on my hands, so I walked through the ER to see if there was anything to do. A young woman had just been admitted complaining of palpitations. The ER doctor on duty saw me and asked if I would check the patient’s electrocardiogram (ECG). Since I was new in town, few people knew me, and my reputation was at the starting gate. I appreciated the chance to show my expertise.

“She’s got a supraventricular tachycardia,” I told him. “Her heart rate is 180/minute.” Tachycardia means that the heart is beating too fast. The normal resting heart rate is 60 to 100 per minute. The term “supraventricular” refers to the site of origin of the abnormal rhythm (arrhythmia), originating in the atria, the upper chambers of the heart. Doctors refer to this condition using the shorthand “SVT”. It is a type of cardiac problem that needs to be fixed as quickly as possible, but it rarely causes death. It is, however, an alarming finding, especially in a young person, and it is often a recurrent problem. The ER doc seemed a little worried. “Would you take a look?” he asked.

I walked into the exam room with a nurse trailing behind. The patient was frightened. Her hands were cool and sweaty, but her blood pressure was normal. I wanted to correct the problem quickly, but we had no good drugs to alleviate the situation. We could use intravenous digitalis, an ancient medication, but that could take one hour or more. The use of an electric defibrillator was the last resort option and would involve anesthesia.

When I was in training, I learned that there were only a handful of drugs that were really of much use for cardiac patients, so we sometimes had to resort to other kinds of treatment. The Mount Sinai Hospital, the New York City teaching institution where I was a cardiology resident, had been founded over 100 years prior to my arrival, and I was exposed to the old hands-on bedside approach to medicine, even as the high tech diagnostic and pharmaceutical age was beginning. The physicians I met there relied on careful history taking and physical exam techniques and they were wary of drugs and their dangers. They tried to minimize aggressive treatments and they called this approach “therapeutic nihilism.” The tests they used were relatively primitive by today’s standards, including such things as the chest x-ray and the ECG.

We had no computers, so we learned to analyze the electrocardiogram rhythm strips using an index card and a pencil to measure the intervals. Our teachers showed us some nonpharmaceutical techniques for terminating SVT’s. The quickest method involved rubbing the carotid artery in the neck, but it was uncomfortable and had to be done carefully in order to avoid complications.

Now I had to make a decision, choosing from a limited array of options, and with everyone wondering if I knew what I was doing. I was about to perform carotid massage when I recalled a case report of a new technique that produced the same benefit as carotid stimulation, but in a less risky way. It involved standing the patient on her head. It sounded bizarre and I had never tried it, but if it worked, it would seem like a miracle. If it was unsuccessful, there was the possibility that my competence and sanity might be questioned.

So I turned to the patient and the nurse and said, “I am going to do something that will seem peculiar, but it may solve the problem. Nurse, give me a hand; we are going to turn this patient upside down.” Fortunately the young lady was thin and was wearing pants. She got on her hands and knees, then the nurse and I each grabbed a leg and we turned her head down. Her face turned red. We waited about 20 seconds and then we flipped her upright. Her heart rate was normal. “Magic!” I said. “You’re cured!” I felt like one of those TV faith healers who smack you on the forehead, knock you over, and then you get up and dance off the stage.

The secret of the method was causing activation of the vagal nerve which would, in turn, stop the tachycardia. Some years later, an intravenous drug was developed called adenosine which could terminate SVT’s like this in less than a minute and which could easily be used by the ER staff. Thankfully, in addition to helping patients, this drug also reduced the need for cardiologists to rush to ER’s at all hours to cure SVT.

In the last six years or so, a new technique has been developed to cure patients with this problem so that they would never have a recurrence of SVT. It is called radiofrequency ablation and is done with a catheter technique; no surgery required.

Being a doctor is endlessly challenging, in part because of the constant progress being made, especially in the fields of genetics, electronics and pharmacology. Doctors will rely on such advances, but they must also keep their perspective and maintain their professional values which include the admonitions to “do no harm” and “the patient comes first.” Traditional skills, such as attention to detail, careful history taking, thorough physical examination and good judgment (i.e. the “art of medicine”) will never become obsolete.