Chow, Grant V. MD
Dr. Chow is a cardiology fellow, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, Baltimore, Maryland; e-mail: firstname.lastname@example.org.
It was July 1—my first day of fellowship. I was assigned to the cardiac ICU at Hopkins Bayview, the same unit where I had taken my first call as an intern and where I had run my first code.
Moments after receiving sign-out, an overhead page sounded, “CICU fellow, pick up line seven-five.”
It took me a moment to realize that the call was for me. I picked up the phone.
“I'm calling from the emergency department. You need to get down here, stat. We have a patient in VT storm.”
“VT storm?” I asked, with a squeezing sensation in my stomach. “Are you sure?”
The voice replied, “Yes—his ICD just went off again!”
Hurrying downstairs, I glanced at my pager. Somehow, I'd expected my first hour as a fellow to go a bit differently. Preparing for the worst-case scenario, I silently rehearsed a familiar mantra: “Epi, shock, amio, shock.”
Arriving in the trauma bay, I pulled back the curtain... and breathed an immediate sigh of relief.
At the bedside stood Joe Marine, my mentor of four years. Even more advantageous for the situation at hand, Joe was also the director of the Bayview electrophysiology division.
“Hi, Grant!” he said, clicking on a device programmer interfaced with an implanted ICD.
“Hello there,” our patient chimed in.
Surprised, I glanced at the bedside monitor. It read a systolic blood pressure of 88 mm Hg, associated with a regular, wide-complex tachycardia at a rate of 135 beats per minute. “Nice to meet you, Mr. E,” I said, trying to hide my incredulity at his clarity of mind.
His face grew pale just an instant later.
Over the next hour, Joe orchestrated a series of intertwined, deliberate events. I looked on as my mentor's hands signaled for boluses of intravenous amiodarone, triggered bursts of antitachycardia pacing, and attempted cardioversion. Simultaneously, he shared comforting words with our patient and his wife, empathetic pats on the shoulder, and continued dialogue with our emergency department colleagues. After 60 minutes that felt like mere seconds, the arrhythmia was controlled, and Mr. E was admitted to my unit.
Then, there were pearls for me. Joe explained that monomorphic ventricular tachycardia may present with minimal symptoms. We discussed the appropriate dosing of amiodarone as well as device-related maneuvers that might terminate the arrhythmia.
That evening, I returned home and relayed to my wife how I'd learned to “weather the storm”—and avert a cardiovascular catastrophe—in the best possible way.
Two days later, I received an urgent call from the medical ICU.
The indication? VT storm.
I hurried over and pulled back the curtain. My patient was Mrs. P, a delightful and ornery octogenarian whose ICD had fired three times in the past hour. My eyes flashed to a 12-lead ECG at her bedside.
Monomorphic VT with a heart rate of 139.
A load of amiodarone. A call to the electrophysiology fellow for antitachycardia pacing and possible cardioversion. Comforting words for my patient and an empathetic pat on her shoulder. For my resident, clinical pearls—monomorphic VT may present with minimal symptoms. We briefly reviewed the use of amiodarone and the maneuvers that might be performed to terminate this arrhythmia.
And in the best imitation of Joe that I could muster, I taught another physician how to weather the storm.
Grant V. Chow, MD