Chapter One – Palpitations!

The wedding day had been on March 20th.  It was one of the happiest days of our lives. The weather had been unseasonably glorious and Ann had looked utterly stunning in her excruciatingly expensive Mother-of-the-Groom outfit. Every second had gone to plan and the whole day was flawless. Ann had whirled around the dance floor until the early hours (as she always did) and looked the picture of a healthy, happy, elegant and still very beautiful woman having the time of her life.

For my part, I just couldn’t stop smiling. It was as if the grin would be permanently fixed on my face, it had been there so long. Ann had recently completed a fiendishly complicated porcelain veneer job across eight of my front teeth and was convinced that this was the reason for my fixed grin. The truth is that I was just bursting with pride and overjoyed to see my family so happy. We both were.

It was only around a week later that Ann noticed the first ‘palpitations’. They were nothing significant initially. In fact, she didn’t even bother to tell me until it had happened a number of times. I had been working in the United States part of that month and so had been blissfully unaware of what was happening.

Over the next six weeks, she suffered the episodes with increasing frequency and severity and on two occasions, she briefly lost consciousness (which she kept from me until later). The rest of the time, she felt absolutely fine and she suspected that she was suffering the effects of an unusual viral infection and so continued her normal routine and fitness regime as usual.

On Wednesday 13th May, she attended an appointment at our local GP surgery. I don’t recall this being arranged in advance, I believe she made an urgent request to be seen after a particularly powerful episode of palpitations.

I came home from work that night to find Ann crying on the sofa. She told me about her visit to the GP: She had been instructed to stop work with immediate effect and that she would be receiving an urgent appointment at the cardiology department at Castle Hill Hospital.

It is worth taking a short break from the narrative here to explain the unusual (and in my view highly unsatisfactory) set up for cardiology services in our part of East Yorkshire. The services are provided by the Hull and East Yorkshire Hospitals NHS Trust. Cardiology services are provided at the Castle Hill Hospital in Cottingham in a modern, relatively new unit, purpose-built in 2009 at a cost of around £48m. These include Interventional Cardiology (catheter-based treatment of structural heart disease such as fitting stents to open up the coronary arteries to prevent or after a heart attack); Cardiothoracic Surgery (including bypass surgery, valve replacement and so on) and Cardiac Electrophysiology (the diagnosis, treatment and management of electrical abnormalities of the heart – much more of which later).

The Emergency Department (ED) or Casualty Department, where many cardiac patients inevitably start their journey, is located at Hull Royal Infirmary – some 5.5 miles and 16 minutes away by the shortest possible route from Castle Hill. Hull Royal Infirmary has NO cardiology department. Indeed, they regularly have NO cardiologists physically present on the site.

So, if you arrive as a cardiac emergency by ambulance at Hull Royal, the chances are that you will not have expert cardiology doctors there to help save your life. There are many highly trained emergency care doctors of course, but if cardiologists weren’t better at cardiology, there wouldn’t be any, would there? Of course, we didn’t learn this until much later. At the time, we assumed that such expertise was available on site 24 hours a day.

Enough for now.  Back to the story.

We were both stunned. An urgent referral to Cardiology?! How could someone who had looked after themselves so well and who was so conspicuously healthy need a cardiology referral? Ann was devastated. I was scared. It just felt utterly surreal. How long would the appointment take to come through? What might they find? Would it affect Ann’s work long term? Was her life actually in danger? Would she need surgery? The questions poured out of the ether like a waterfall for both of us.

The next day, Thursday, things went from bad to worse. Ann had eight further episodes of what felt like a very rapid heartbeat accompanied by mild chest pain. These increased in severity over the course of the day and by evening, were becoming scary. By bedtime, we decided that we couldn’t wait for an appointment so I drove Ann to the Emergency Department at Hull Royal Infirmary. It didn’t even occur to us to call an ambulance.  At this stage, we still didn’t understand the seriousness of her condition.

We arrived there at 11.30pm. The car parks, usually full to bursting, were all but empty at that time of night and so we were able to park right in front of the building. By the time we got there, the episode seemed to have passed and Ann asked to be taken back home. “I feel fine now”, she said. “I don’t want to make a fuss, let’s just go home”.  “To hell with that” I replied. “We’ve come this far. You’re getting checked out!” Eventually, she followed me from the car.

I don’t want to be too disparaging about Hull or this hospital but the truth is that Hull Royal Infirmary is about as depressing as any hospitals gets.  It is a 13-storey tower hospital built in the 1960s when my fellow architects were deluded enough to believe that concrete brutalism was cool.  Hull Royal is one of their more spectacular crimes against humanity. It should have been razed to the ground years ago. At 11.30 on a Thursday night, its limited charm is not improved by the collapsed drunks or the seriously ill patients who have struggled outside for another elicit cigarette. It feels more like war-torn Syria than East Yorkshire.

Nevertheless, in we went and having pressed the appropriate buttons on the robotic check-in machine, we were seen very quickly. Evidently, the chest pain button had resulted in an immediate escalation. So far so good.

After Ann’s details had been taken, she was immediately dispatched for a 10-second, 12-lead ECG and I was allowed to stay with her. The nurse who attached Ann to the machine made no attempt to hide her boredom.  I suspect she took one look at Ann who outwardly seemed like a picture of health and concluded that this was a complete waste of her time. Having completed her wiring, she stood with her back to us during the test and worked hard on her chewing gum. Then the machine ejected its printout and the nurse tore it off and took a glance.

Her eyebrows shot up. “Bloodyhell!” she exclaimed, and she ran from the room.

We came to appreciate much later that Ann had been extremely lucky in that 10 seconds. Her condition is very hard to detect most of the time. It is by its nature very episodic – there one minute, gone the next. Mostly gone. Had her heart rhythm been as normal during that ten seconds as it was most of the time, the chances are that we would have been sent home (and she could have died as a result).

But we weren’t sent home.  Clearly, the ECG was far from normal and Ann was moved immediately to the brand new ‘Majors’ unit. Opened only a few weeks earlier and a stark contrast to the other areas of the hospital, the state of the art 42-bay major trauma and resus unit is as modern and well-equipped as any in the country. There, we were met by an extremely pleasant doctor (a senior registrar I would guess – I’m afraid I don’t remember his name and so don’t need to change it but we will call him Dr A anyway) who wasted no time in placing Ann in a cardiac monitoring bay and attaching her to a 12-lead heart monitor and pulse oximeter.

It is hard to describe our feelings. In the months that followed, we would grow used to the never-ending little wavy lines drawing themselves across the monitor screens. The constant beeps and alarms would become part of our daily sound landscape, as normal to us as birdsong and distant car horns, even though those alarms might be announcing that a life might be about to end. They would become part of life’s background and could be more easily ignored.

That night though, they were the centre of our world. It was as if we had awoken in an unfamiliar foreign country, and we could not speak a word of the language. The beeps and alarms seemed as loud as a thunderstorm and it was impossible not to watch the monitors, even though we did not fully understand what they were telling us.

Dr A explained that the ECG had shown marked cardiac arrhythmia – an irregular heartbeat – and even with our limited understanding, it was obvious from the monitor screens that this was still the case.  Even to my untrained eye, it was clear that the distance between Ann’s heartbeats was not consistent and her heart rate fluctuated wildly, even though she wasn’t moving at all.

Once Ann’s history and blood samples had been taken and Dr A had heard about Ann’s positive lifestyle, he said that he had a ‘gut feeling’ that there was something more significant going on. He said he expected the continuous monitoring would reveal more in due course.  He positioned his seat at the island staff station directly opposite our cubicle such that he could see Ann’s monitor at all times. And there he sat whenever he wasn’t directly involved in dealing with other patients, one eye on the wavy lines and heart rate number. And I sat beside the bed, holding Ann’s hand and also stared at the screens.

At 4.00am, when Ann was snoozing intermittently and seemed a little more stable, he came over. He put a kind hand on my shoulder and gently urged me to go home. He said that my being there wasn’t going to change anything and I should go and grab some rest whilst I could. He promised that he would stay at his station all night and keep a very close eye on her. When Ann agreed that I should go, I reluctantly headed back to the car.

At that time of the morning, the city is at its quietest. Even the clubbers had made their way home by now and the dawn chorus was yet to begin. The car park was utterly silent. I had never felt so alone and so scared for her. I couldn’t bear to leave her but I drove myself home and went to bed where I very quickly fell into an exhausted sleep.

Two hours later, as I slept, and Dr A continued his vigil, his earlier prediction came to pass.

Between 6.00 and 6.30am, Ann went into sustained ventricular tachycardia. For no apparent reason, her heartbeat shot up to 240 beats per minute – and stayed there. Her heart was beating so fast that it didn’t have time to refill with blood before the next beat. Not enough blood was therefore being pumped around her body and not enough oxygen was reaching her vital organs. If her heart continued to beat that fast for too long, she could die.

Unfortunately, just when the tale is becoming a little more dramatic, it is necessary to interrupt it again to provide a basic understanding of cardiac arrhythmias and to do that, we must first do a little refresher on cardiac anatomy. It is very hard to know quite where to pitch these medical interludes – they are likely to be annoying or even patronising to some readers with medical knowledge but I hope that they are helpful to at least some of the others, many of whom may not have seen a diagram of a heart since they were studying for GCSE’s (or O Levels if you’re as old as I am). At this early point in the story, I knew almost none of this medical detail. I learned it over the months that followed the events we’re now looking at.

So, starting with the basics, the heart is divided into 4 chambers – two at the top (called the atria – the plural for atrium) and two at the bottom (called the ventricles, which are a bit bigger). A single heartbeat begins with the contraction of the atria, quickly followed by the contraction of the ventricles. This gives the heartbeat its characteristic ‘ba-bam’ sound and makes the heart a very efficient pump.  The ‘ba’ is the atria contracting, the ‘bam’ is the ventricles following suit.

Arrhythmias (basically bad heart rhythms) are caused by electrical anomalies and tend to affect either the atria, or the ventricles. Basically, electrical signals are arriving in the heart that shouldn’t be there. I won’t get into all the different types and sub-types but the following arrhythmias turn up in our story so we should have a basic understanding of the differences between them.  Eventually, we’ll need to look at what causes them and how they are fixed but for now, we’ll stick to the basic differences. The names and abbreviations vary slightly around the world so I am using the common UK terms and acronyms:

Atrial Fibrillation (AF): Fibrillation means twitching, of a muscle in this case. So, atrial fibrillation is twitching of the muscles of the atria resulting in a rapid and irregular beating of the heart. AF is the most common arrhythmia. It is often associated with high blood pressure or heart valve disease and most cases of AF are secondary to some other medical problems.

Supraventricular Tachycardia (SVT): Tachycardia means an unusually fast heart rate, usually well over 100 beats a minute.  Supra means above.  So, supraventricular means above the ventricles. This is a very fast heartbeat originating above the ventricles. Technically therefore, AF (above) is one of four main types of SVT. Unlike VT below, SVT is not usually life-threatening.

Ventricular Tachycardia (VT): This is what was happening to Ann. VT is an unusually fast heart rate (VT is usually above 120 beats per minute and can be as high as 300 beats a minute) originating in the ventricles (towards the bottom of the heart) and it can be very dangerous. Non-sustained VT lasts up to 30 seconds. If it lasts longer than that, it is described as sustained VT. It can often lead directly to cardiac arrest, or to ventricular fibrillation (below) and from there to cardiac arrest.  VT and SVT can be difficult to distinguish.

Ventricular Fibrillation (VF): As with AF, VF is twitching or quivering of the heart muscles but this time in the ventricles. It is caused by chaotic electrical impulses in the lower chambers. Here, it is many times more dangerous than AF and, without intervention, can be quickly followed by cardiac arrest and death.  Regular watchers of TV hospital dramas such as ‘Casualty’ will have heard many times the line “Quick, he’s in VF!”. The line is always followed by the rapid deployment of a defibrillator – so called of course because it is designed to stop fibrillation.

OK, nearly done with the medical stuff for now.  There are a few more terms which we should probably get familiar with first however. The first is sinus rhythm. In simple terms, this is the heart’s normal rhythm, which basically means that everything is happening in the right order. We might get to what those things are and in what order later but that is sufficient for now. The ‘Casualty’ watchers will have heard “It’s OK, he’s back in sinus” many times.

Next, cardioversion. Cardioversion is a medical procedure by which an arrhythmia is returned to normal sinus rhythm. It can be chemical cardioversion, the use of a drug, or electrical cardioversion, the use of a defibrillator. Sometimes, patients will cardiovert themselves back to sinus without intervention.

Finally, defibrillation is electrical cardioversion using a defibrillator to deliver an electric shock to the heart. Many think this is to restart the heart. I believe it is often more accurate to say that a defibrillator usually stops the heart, which is beating too fast or is quivering, and so allows it to restart in normal sinus rhythm. The correct description is that a defibrillator ‘depolarises’ the heart.

OK, cardiology lesson one over.  It’s time to get back to Ann. It is 6.30am, I am fast asleep back at home and Ann is alone, terrified and is in sustained VT and in danger of going into VF.

We were told later that Ann was in sustained VT at around 240 beats per minute for about 35 minutes. As far as we know, the nearest cardiologist was at Castle Hill, 6 miles away on the other end of a telephone line. What we know is that Dr A and the Hull Royal team was getting extremely concerned about whether Ann would be able to survive this episode and they had put in a cannula in readiness for a chemical cardioversion. After 35 minutes, just before they were about to intervene, she cardioverted back to sinus rhythm by herself.

The moment this happened, the ER staff arranged an ambulance transfer to Castle Hill Cardiology unit, where she could receive the expert care she so desperately needed. Ann had her first ‘blues and twos’ ambulance journey.  It would not be her last.

It is of course impossible to say whether her treatment would have been any different if cardiologists had been on hand to advise on her treatment during her emergency. Suffice to say that when these episodes were repeated in Cardiology at Castle Hill, they intervened much more quickly. Nevertheless, Dr A did an amazing job for Ann that night and morning.  I hope he reads this and in case he does I want to say an enormous thank you to you Sir. You are one of the heroes in this story.  Your hunch was on the money. Your vigilance was justified. You did everything right. We are in your debt.

 

Continue to Chapter Two

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