| In the Balance |

One in a Million

with Zivia Reischer

Question: When is a virus not a virus?
Answer: When it’s heart failure.

The irony of the ER is that even emergencies become routine. Sometimes it feels like a conductor pointed his baton and decided it was croup night, and in come ten croup patients marching all in a row, and you feel like you can just say the same thing to every patient.

But whenever that happens I remember Davey.

It was 3 a.m., and I had just seen six patients with identical symptoms. All were children under the age of ten, glassy-eyed from fever and disoriented at suddenly finding themselves in the hospital in middle of the night. Each child was accompanied by one or both parents who told the identical story: fever, cough, not eating or sleeping, something’s wrong with my kid.

We moved from room to room. Lisa had 104 fever but was alert and chipper, if slightly dehydrated. “Probably viral,” I explained to an anxious Mom, “and the height of the fever is less important than the child’s behavior.”

“I always behave,” Lisa asserted.

I chuckled. “She’s fine.”

I told the same thing to Zorrino’s parents. “Looks like a virus,” I said. “The fever means his body is fighting, mounting an immune response. He should do okay.”

In the next room, Lourdes’s mom said she’d had fever and congestion for a week and had barely eaten in days. “It’s probably a virus,” I reiterated, as the nurse checked her vitals. “Just keep her comfortable and hydrated.”

“She refuses to drink anything,” Lourdes’s mom said a little desperately, indicating a collection of barely started water bottles, Gatorades, and soda cans. “I think something’s really wrong.”

There’s always the chance that one in a million could have something really wrong with him, but our exam didn’t turn up anything unusual. Was the patient refusing to drink because something was “really wrong,” or because it was 3 a.m., and she wasn’t feeling well?

The next two patients presented similarly: varying degrees of fever, congestion, loss of appetite, and loss of energy. I did a full exam for each, checking the ears, lungs, and throat, and then prescribed rest and fluids. I counseled their parents to keep an eye on things, but there’s not much to do for a virus but support the patient through it.

April’s Dad was annoyed. “ ‘A virus, a virus,’ ” he mimicked. “For that I can also be a doctor.”

When I examined Davey, he looked pale and listless, like all the kids before him. Mom and Dad recited the familiar script: fever, congestion, no appetite. Marilyn, the nurse, looked tired. “We’re just gonna check your vitals, sweetheart,” she said, for the thousandth time that night. She took his temperature (102) and his blood pressure (slightly low). His heart rate was a little elevated.

Two paths diverged then in the ER: We could chalk up the elevated heart rate to fever and dehydration like we had done for Lisa, Lourdes, Reina, Zorrino, and April. We could even go a step further and give him IV fluids. Or we could poke around a little more, just to make sure.

We decided to make sure.

Marilyn stuck little stickers all over Davey’s arms and legs and chest (“a sticker collection!” she chirped, but I noted that Davey didn’t smile) and hooked him up to a heart monitor. We looked up at the screen, expecting the familiar peaks and valleys.

Instead we saw a lethal cliff. Davey was in ventricular tachycardia.

Okay, now this was an emergency.

“Acute care team!”

Mom and Dad froze, everyone else started moving. The room filled instantly with people and equipment — nurses, medics, a crash cart. Marilyn filled a syringe with amiodarone. Carolyn applied defib pads to Davey’s chest, Nate inserted a hep-lock for an IV line.

“No fluids!” I shouted to him.

The heart is a pump. If your pump is broken, you get a flood. If we had given Davey fluids before checking his heart, he would have died.

As it was, Davey’s life was in danger. The drugs stabilized Davey’s heart for now; a tech rolled in a portable X-ray machine and performed a chest X-ray. The scan showed an enlarged heart. The blood work results came back then, showing elevated troponin levels and suggesting myocarditis.

Davey was in heart failure.

I turned to Mom and Dad. Their faces were stamped with confusion and fear. These are the conversations every doctor dreads: look a parent in the eye and tell them that their precious child, whom they love fiercely and guard protectively and was riding his bike 24 hours ago, is in heart failure.

I am a parent too. I have kids Davey’s age.

“Kids are fighters,” I reminded them, as the team prepped Davey to be moved to a unit. “And you’re in one of the best cardiology centers in the country.”

“We’re taking him up to the ICU,” I heard Marilyn explaining to Mom and Dad as they rolled Davey rapidly away.

As soon as my shift was over, I went up to the PICU to check on Davey. The attending physician, a cardiologist, and the senior cardiac surgeon were conferring in a huddle outside his room.

“We’re going to put him on ECMO. That will give him the best chance.”

Davey remained on ECMO for two weeks while the machine took over the function of his weakened heart and lungs. There are two good ways to get a patient off ECMO: a heart transplant or recovery.

Davey recovered.

Davey’s story is extremely rare. Little kids get infections and viruses all the time. They don’t usually develop myocarditis and heart failure. Davey had probably started off with a virus, but unlike the other kids I’d seen that evening, it had progressed. He was the one in a million.

Everyone was thrilled when Davey was discharged and walked out of the hospital on his own two feet. But all I could think was, what if?

What if we hadn’t checked his heart?

What if we had given him fluids?

What if we had called it a virus and sent Davey home?

And what if it happens again? How are we going to make sure we catch it next time? Is there a way to make sure we catch it next time?

Every time I see another patient with fever and cough, every night that I see ten patients in a row with the same nonspecific symptoms, every time an initial exam seems to indicate that the patient is “fine,” I remember Davey.

I look much more carefully now. I search for those subtle clues, I listen to that little voice.

When is a virus not a virus? We’re doctors but we’re hunters, up all night searching the ER for that one in a million.

If we’re careful, we won’t miss it — with vigilance, and humility, and a G-d who watches over patients and doctors.

All names and identifying details have been changed. Patient profiles may be based on composite cases.

(Originally featured in Mishpacha, Issue 759)

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