Slowing Down

This article has been deidentified to protect the anonymity and confidentiality of the patient in the story. Any matches in names or circumstances to other patients are entirely coincidental.

“But that’s the thing, doctor, I don’t have any pain, I’m just sick to my stomach.” She was 94 years old, generally healthy, and had come in because she’d passed out and hit her head while standing in the lobby of her living facility. A CT scan showed she had a small brain bleed that was stable. More concerning was the EKG that showed a slow heart rhythm with missed beats. I’d introduced myself as a resident who was one of the overnight ICU doctors. She said, “Now, I’m 94. My two husbands are gone, I didn’t have any biological children, most of my friends are gone. I’m ready to go. I don’t want you to save me if I go. I know that makes doctors upset; it’s your job to save me.” I tried a gentle corrective. “God bless you, ma’am. It doesn’t upset me. My job, as I see it, is to do right by you, whether keeping you around or letting you go.”

Passing out with a fall is one of the classic medical problems. I was now far enough in intern year to have worked up this problem three times already, and could mentally enumerate all the reasons why it happens. I took her history and methodically eliminated almost all. She’d been fatigued since January and had been having dizzy spells for a month, regardless of whether she was sitting, standing or lying down. Most likely, the reason was her heart. But why was she having a slow heartbeat? More questions, more laboratory studies. Of the possible causes, she didn’t seem to have an active infection or joint pain symptomatic of Lyme disease, her urine toxicology was clean, her lipid panel was low even without taking a cholesterol pill, her cardiac enzyme levels were normal, her thyroid was functioning normally, and she wasn’t taking any heartbeat-altering medications. The best remaining reason was age. Age builds fibrotic tissue that in the heart can impede the electrical pathway.

Her EKGs showed it. In one recording, she was in normal heart rhythm, at a normal rate. Another time, she was in a slow heart rhythm, and it wasn’t clear that all – if any – of those beats were being conducted. (A cardiologist later pointed out to me that one or two of the initial waves in her EKG were actually conducting, a condition known as high degree AV block.) You read the EKG by watching for two waves: The first is the initial electrical impulse; the second is a larger wave, following the first, that shows that impulse being conducted. The relation between the two waves — the wave forms themselves, their amplitude, their frequency, and the time between them — sets the criteria for how to evaluate an EKG.

Friends, have you ever been in a wave pool? The machine creates an initial impulse that grows and propagates through the whole pool. But if the timing isn’t right, a prior swell will bounce back from the wall and swamp the new impulse the machine is trying to build. The electrical conductivity of the heart is like that. Impulses that begin in the electrical nest of the right atrium propagate through the rest of the heart, mediated through certain electrical nodes that make sure the signal is carried at the same time to the pumping chambers of the heart, the right and left ventricles. But if a new impulse is transmitted while the old one is returning to baseline, it will swamp the new one, and no new wave is formed: No impulse is conducted, the ventricles do not beat, the body pauses, and the patient feels a sense of unease and nausea.

These pauses were the reason for her fatigue, her nausea and her fall. In these situations, I told her, we would usually put in a permanent pacemaker. “But I don’t want to live longer,” she said. There are two devices we can put in to stimulate your heart, I told her. A defibrillator restarts the heart when it stops; a pacemaker keeps the heart beating on schedule. A pacemaker is a palliative measure, I explained: It will not prolong your life, but it will improve the quality of your life by relieving fatigue and nausea. “Some of my friends have pacemakers,” she said. “I’ll think about it.”

She’d come in just in time. By the morning, the ICU recording devices of her heart showed several episodes of four-second pauses, when no electrical conduction happened at all. The heart block was progressing. She was very nauseous. Later that morning, she got a pacemaker.

Related Content

• Pieces of a Life
• A Lingering Question, A Fading Heartbeat
• The Often-Overlooked Side of the Physician-Patient Relationship
• Managing Burnout: Advice for New Medical Trainees

Want to read more from the Johns Hopkins School of Medicine? Subscribe to the Biomedical Odyssey blog and receive new posts directly in your inbox.