The Patient Was…

The patient was a young boy, admitted to the hospital for a non-cardiac condition during my training years in Cardiology. During his hospital stay, he was, of course, seen by his family every day. Occasionally, the boy’s father was the parental visitor, and there were no untoward events coincident with those occasions. Most days, however, the patient’s mother was the family representative, as one would expect.

With unusual regularity, shortly after his mother left his bedside and departed after visiting him, the boy developed a troubling disturbance of his heart rhythm, namely an unexplained tachycardia or rapid heartbeat. He appeared quite nervous at those times, partly because of the unusual sensation he felt in his chest, and partly because of the anxious reactions of the medical and nursing staff.

Because constant monitoring of his heart rhythm was not available in the Pediatric area of the hospital to which he had been admitted, the decision was made to transfer him to the Cardiology division where constant heart monitoring was accessible.

A pattern quickly emerged.

The boy’s heart rhythm was steady and regular at all times, except after his mother visited him. What was she doing? How did she create the situation where the patient’s heart raced after she saw him? Staff members tried to unobtrusively observe her interactions with her son but saw no unusual activity that made them suspect some malfeasance or inappropriate behavior on her part. She seemed as concerned about her son  —  maybe more so  —as everybody else.

Cardiologists examined the patient and found no cardiac abnormalities. Tests of cardiac function were performed and they, too, were normal. With a normal heart, and an abnormal heartbeat triggered only by maternal visits, suspicion inevitably fell on the mother. Somehow, for reasons unknown and in ways undiscovered, the boy’s mother was responsible for a potentially dangerous situation.

The Psychiatry Division was contacted and they consulted on the case. The belief was that the situation represented some unusual anxiety or stress reaction related to the boy’s mother. Were there unrecognized family  tensions? Did the mother represent a nefarious influence on the patient? Interviews with the patient and his family were not helpful.

The cardiology staff was particularly vexed. All their tests were normal. Observations of the interactions of the patient and his mother were free of any apparent negative occurrence. The boy’s mother appeared loving, caring, and solicitous of her son. As one of the nurses noted during a staff conference, his mother even brought him ice cream at the end of every visit.

Upon hearing this observation about the ice cream, a Cardiology trainee, new to the division and unaware of the details of the case, spoke up.

“Suppose the cold ice cream somehow triggers the tachycardia?”

His question was met initially with silence. Nobody in the room had heard of such an occurrence. There had been medical reports of cardiac arrhythmias, even cardiac arrest, due to severe body hypothermia as in freezing weather, but an abnormal heart rhythm due to swallowing something cold was a new concept to everybody.

Finally, one of the nurses said, “Can we just give him some ice cream? Let’s see what happens. We have nothing else to offer at the moment. Or do we?”

People seemed more amused than curious, but everybody agreed it made sense to “try the experiment.” One of the nurses got some ice cream and brought it to the patient who happily began to spoon it down. Within a minute or two, his cardiac monitor showed the typical tachycardia that always accompanied his mother’s hospital visits.

It was a stunning moment. There was silence from some, expressions of surprise from others, and disbelief from a few. Everybody agreed, though, that it had to be repeated and verified, if only to rule out an extraordinary coincidence of ingesting something cold and the appearance of an arrythmia.

Only repetition could establish cause and effect. And it did.

So, how could ingesting something cold trigger an abnormal heartbeat?

There are two basic elements to the explanation: anatomy and physiology.

Anatomically, the esophagus, the tube that carries swallowed matter from the back of the throat to the stomach, lies in very close proximity  —  sometimes even in actual contact  —  with the back wall of the left atrium. The left atrium is the upper left chamber of the heart (the heart has four chambers) and has tissue that can generate and transmit electrical impulses, signals, and waves.

Physiologically, atrial tissue can respond in different ways to both heat and cold. Extreme temperatures, either hot or cold, can be used to ablate (destroy) tissue that is generating or transmitting electrical impulses. This, in fact, is routinely done in treating one of the commonest abnormal heart rhythms, atrial fibrillation (commonly known, from television advertising, as A Fib). It is also known that cold applied to the left atrium can induce that same rhythm disorder, A Fib. The treatment of cold-induced atrial fibrillation is simple: avoid ingesting cold foods or drinks.

The explanation for the patient’s problem, then, was simple. The ice cream, innocently provided by his mother, triggered the abnormal heartbeat by causing cold-induced atrial tachycardia. The psychological theories were nothing more than speculative nonsense and, in fact, had the potential for causing serious harm within a loving and caring family.

The patient was soon discharged from the hospital in good condition. He was punished, however, in one way: No more ice cream!