I was lying on my back on a narrow
stone ledge. A bandana was draped over my face, my legs in a Trendelenburg
position, and my wife was trying to drown me by pouring ice water onto my face.
It was at about this point that I was contemplating the next logical step in
breaking a run of supraventricular tachycardia (SVT). I had tried the valsalva
maneuver over and over, nearly to the point of popping out an eye like an
excited Chihuahua. I also struggled with the carotid massage, locating the
carotid bulb and rubbing my neck to conjure a genie. I even attempted to do
both at the same time, bearing down with the image of birthing twins and burying
two fingers into my neck like I was looking for change between the cushions of
my sofa. No good.
My personal history of palpitations
and tachycardia started years ago, in 1991, during a dehydrated mountain bike
ride up the face of a legendary local Boise hill, where my heart rate hit 204.
At the bottom of the downhill side my heart rate monitor was still showing a
rate of 160. A few simple deep coughs broke the cycle and I was on my way - and
my SVT has followed me intermittently for the rest of my years.
In the mid 1990’s, near the top of
the Grand Teton, I again felt the pressure of a runaway heart. “Not good,” I
thought, climbing at a slower pace. I tried the usual valsalva moves, anything
that would increase my intrathoracic pressure and trigger my vagus nerve.
However, all that accomplished was to redirect my concentration from climbing
to my tachycardia. I needed to pay attention to climbing. To my benefit, my
climbing partner that day was Mark, a cardiologist. I slowed, then stopped, and
waited for him to climb up to me. I am
sure he was wondering why it appeared as if I was trying to force a spirited
bowel movement, but within seconds he realized my plight, palpated my
indiscernible pulse, and said, “Do you know where we are?”
Like a well-rehearsed magic trick, a
few seconds of Marks experienced kneading to my lateral neck instantly broke
the reentry cycle and I was symptom-free. In fact, I felt so good that we climbed
on to the summit. I was grateful, and also quite pleased that my vessels didn’t
yet have enough plaque in them to replace the SVT with a cerebral vascular
accident.
Incidents involving your heart seem
to be quite clear in your memory, like they were inscribed with a soldering
iron. So, after mining the history of my rare episodes of SVT, the perpetrator
of my rapid rate seemed to be a cruel combination of caffeine and dehydration.
Since that day I have monitored my
hydration status closely during any outdoor adventure, as well as my coffee
intake. I contemplated a visit with an electrophysiologist for a possible
ablation, but decided instead to avoid the ‘burn’ and the rate-limiting
medications that were suggested by various well-intentioned associates. Instead
I decided to live normally, although more thoughtfully, and have only had a few
repeat instances of SVT, all of which were vanquished without any more than a
protracted valsalva - until Nepal.
We had just passed the village of Pangboche
when palpitations and a rapid heartrate beat me into submission. Even though I
was drinking three liters of water a day, I had discovered Starbucks Singles,
which I had shamefully abused. I attempted the usual - cough, valsalva, cough,
and valsalva again - but tachycardic I remained. I hiked further and then threw
in the carotid massage for luck. Nothing. My pace was slowing. “I wonder if I
could just hike in short bursts until we got to the Pheriche clinic? Surely
they have some Adenosine there,” I thought.
It’s a strange feeling, a runaway heart; like
you are moving against an invisible force, as if someone has thrown the weight
of ten quilts over your legs and arms. Your head becomes disturbingly light;
enjoyment of the world melts away and clouds of negative thoughts replace
reason.
Once I was stopped and supine (I
would like to add here that to continue any stressful activity involving a strained
electrical system will undermine any conversion tactics) my trekking friend,
and ER physician, proposed the solution -ice water immersion. I had never tried
the diving reflex myself, but at this point it was my only option.
I hoped the embarrassing display of
my impromptu waterboarding wouldn’t raise the attention of every medical person
on the trail, creating a Gore-Tex funded rugby scrum, but thankfully no one
seemed to mind the spectacle. Within seconds of the icewater plunge, my pulse
was radially palpable at a rate of 65 bpm, and my symptoms of fatigue and
lightheadedness instantly resolved. So immediate was my relief that I was able
to sit up, stand, and hit the trail within thirty seconds of conversion. I
swore off caffeine for the remainder of the trek and began drinking water
nearly to the point of obsession – to ensure a reoccurrence was less likely.
I found out later, the Pheriche
clinic does not carry Adenosine, has no defibrillator, and relies entirely on metoprolol
for tachycardias. The only answer might have been a rescue helicopter back to
Kathmandu. My solution for future adventures will have to be more than just
traveling with a cardiologist. It will involve the potentially lethal combination of dehydration
and caffeine.
Until then, my heart remains a
jack-in-the-box, and I continue to turn the tiny handle, waiting for the thrilling
moment when I am faced with another manifestation of the SVT jester.
