Heart, interrupted

An ill-timed kick from a horse sends an 11-year-old girl into a rare form of cardiac arrest that only occurs if the heart is jolted in the 15-millisecond pause between heartbeats and almost always results in death

By STEPHANIE EARLS  /  NY TIMES NEWS SERVICE, ALBANY, NEW YORK

Sun, Oct 07, 2007 - Page 17

It is the body's most vital muscle.

It is a perfect, four-chambered pump, sending blood pulsing, pulsing, pulsing through the lungs, where it is infused with oxygen, then pumping it out to the organs and tissues of the body.

A body can survive without a kidney or a colon or a lung. But not without a heart. If our heartbeat stops, so do we, organ by organ. After one minute, we pass out. Then we seize. For every minute without a heartbeat, our chances of survival drop by 10 percent. At 10 minutes, brain death.

Electrical impulses within the heart control how often it beats. The number of times it beats each minute depends on age, activity level and health.

The heart of an 11-year-old girl beats between 60 and 105 times a minute.

Though the heartbeat feels like a single thump when you press your fingertips to your wrist, it sounds like a spongy lub-dub through a doctor's stethoscope, as electrical impulses open and shut the upper and lower valves.

After the dub, while the heart recharges, is a fraction of a second of silence. At the tail end of that silence, as the heart scrambles to prepare for the next lub, is a fleeting moment of disorder.

Fifteen milliseconds of it, to be exact.

It's a splinter of a splinter of time, so brief it's hard to fathom. It is three beats of a hummingbird's wings. It is the snap of a camera shutter. It is faster than the blink of an eye.

But in that fifteen milliseconds, the heart is at its most vulnerable. A relatively minor blow to the chest, at just that moment, at just the right spot, can confuse an otherwise healthy heart's rhythm and instantly cause cardiac arrest.

The condition, called commotio cordis, is so rare, almost always fatal, that most doctors, even trauma specialists like Albany Medical Center's John Burton, only read about it in textbooks. Each year, commotio cordis kills between 10 and 20 people, almost all children engaged in youth sports like softball.

The factors leading up to it must be so precise, so phenomenally unlucky, that the odds border on impossible. The chances of being revived, unless a defibrillator is within reach, are nearly nonexistent.

But at a crowded horseback riding competition in Rexford, New York, on April 29, the practically impossible happened. Then it happened again.

On that day, Dr John Burton, a little girl named Delana Ringer and her mom, Suzanne, learned that the time between heartbeats can last an eternity.

Delana is a pretty, headstrong tomboy, with shoulder length, dark blond hair that used to fall all the way to the small of her back. She cut it when it became harder to comb than a horse's mane. She is 11 and stands 1.5m tall, a little taller with her English riding helmet and boots on.

By the time she was in kindergarten, Delana had convinced her mom, Suzanne, and her dad, Dennis, to sign her up for lessons at a stable near their Ballston Spa, New York, home. Delana was in the saddle almost daily, until deepest winter, when her frozen fingers would ache long after she came inside.

John Burton lived for the day someone, somewhere, would stand up and yell that one, powerful sentence that would make his heart pound and nerves leap to action:

Is there a doctor in the house?

In a way, all doctors fantasized about that, about being there to help when no one else could. Yet, even at work among the sick in his emergency room, Burton once worried his patients wouldn't take him seriously. He used to wear his thick-lensed glasses to work instead of contacts, thinking they made him look more like a real doctor.

In the spring of 2006, just about the time a then 10-year-old Delana Ringer was learning to jump 0.5m fences on Cocoa 4,800km away, a college acquaintance lured Burton from Maine to Albany, New York. For Burton, the sell was an enticing one: Clifton Park, where he would soon begin shopping for a home, was a good place to raise kids. And it was just a few kilometers from a stable where his younger daughter, Allison, a horse nut, could continue her lessons.

April 29 was a Sunday morning, and Delana and her mom loaded Cocoa into the trailer and drove 32km to the competition at the Double B Farms in Rexford, New York.

The event drew a big crowd to the two-arena locale, maybe 300 people. The riders' parents were there, armed with camcorders and cameras, filling out the packed crowd of kids, horses and ponies on a thick, overcast day at the start of the long competition season.

Delana was set to ride a little past 1pm. When her time came, she would mount Cocoa and guide the 21-year-old pony through a series of turns and jumps, tapping him with her crop, posting up and down in the saddle in time with his hoofbeats - up-down, up-down ... thump-thump, thump-thump.

If she was good enough, fast and precise enough, she would take home another ribbon to add to the dozens displayed on her bedroom wall. Hopefully, that ribbon would be another blue.

As was her habit, Suzanne scanned the crowd for the medical team. She was a mom. That's what she did. She spotted them on the far side of the arena where a girl had been thrown from her horse.

Delana stood by Cocoa, her hand loosely clasped around his reins. Suzanne stood maybe 2m away, talking to another mother whose daughter stood by her own pony, preparing to compete. The pony's backside was turned to Delana, which was nothing unusual in the tight press of bodies.

Suzanne knew horses, though. So when she saw the pony flatten his ears in distress, her worry spiked.

He's going to kick, Suzanne thought. And Delana was right in his path.

The pony took two steps back, leaned his weight forward and bucked high with both hind legs. The animal's two saucer-sized hooves slammed Delana square in her chest, about 15cm below her left collar bone.

The little girl pitched back, but her grip on Cocoa's reins kept her on her feet. Suzanne was immediately at her side.

"It hurts," Delana whimpered. The color in her face was fading fast.

Inside her chest, her heart had stopped.

Two women - both nurses from Vermont who'd seen what had happened - rushed to the scene. One told Suzanne she had to let go of her daughter. They had to get her on the ground. She was seizing. By the time they'd laid Delana on her back in the dirt, the little girl had lost consciousness.

Suzanne's heart slammed. She pleaded with God.

I'm not ready. I'm not ready to let her go. Please.

"Medic!" she yelled, knowing that the Emergency Medical Technician (EMT) was too far away, probably too far to even hear her. "I need a medic!"

Precious, wasted time raced by.

Ten, 20, 30 seconds.

A minute. Two.

John Burton's eyes scanned the crowd of bodies, people and horses.

He'd only planned to be here for a few hours. He had to be back at work, for a 5pm shift. Allison was scheduled to ride early that morning, around 10am, but her time got bumped back to after lunch.

The skies were bruised, threatening rain. He stood by a paddock with his wife, older daughter Caroline and Allison.

His eyes finally landed on the paramedics, tending to a girl in the far paddock. She was on the ground. It looked like she'd been thrown from her horse. Burton considered going over, offering to help, but then the girl stood up.

Guess they don't need me, Burton thought.

But then the murmuring began. First, just buzz: Someone was hurt. The murmurs got louder: someone was really hurt. Without a word to his family, he turned and began to chase the murmurs to their source.

Delana's heart had stopped for nearly two minutes.

Two minutes and 10 seconds, 15 seconds, 30. Three minutes.

As he walked, Burton considered what he might find. Probably an adult, someone's mom or dad who'd passed out from the heat and the crowd. But then he saw the body:

Small legs, small arms, prim riding outfit. A child. Nearby, a tall woman with long blond hair sobbed. Had to be the mother.

The doctor dropped to one knee by Delana's body. "What happened?"

One of the two women by Delana's side told him. The girl got kicked by a horse, then she seized.

"Does she have a pulse?"

No.

One diagnosis, an awful diagnosis, leapt to mind.

It's commotio cordis. My God, it's commotio cordis.

Burton had always been drawn to cardiac medicine, so he knew about commotio cordis. Still, he'd never seen it. Commotio cordis victims didn't make it as far as the hospital.

"I'm an ER doctor. Who are you?"

One was a trauma nurse, the other a cardiology nurse practitioner.

"What were the odds?" thought Burton. Two nurses and a doctor, right here, right now? Still, he doubted there was anything even they could do. If it was commotio cordis, this little girl was beyond help. She was what ER people refer to as DRT.

Dead Right There.

Another five, six seconds.

Delana's skin was ashen. Burton quickly checked her - her airway, her pulse. The little girl's lips were blue. Burton gave her four quick breaths of mouth-to-mouth. Nothing. She was in full cardiac arrest.

One second more, then two, three.

Delana's lungs had shut down.

Four seconds.

Burton knew what he had to do. Chest compressions. It was the only thing left, but it's not something a doctor begins lightly, especially on a child. Odds are you'll crack a rib. Odds are it won't work, especially if this was commotio cordis. Still, once you start compressions, you don't stop until the patient wakes up, or is pronounced dead.

He placed his palms on Delana's sternum, raised himself up on his knees so he was positioned right above her body. He straightened his arms, locked his elbows, and then looked down at her face one last time. She was dead. And she needed him, right now.

Burton pressed using his entire body weight, pushing furiously, not thinking about damages or cracked ribs or Allison.

One-two-three-four ... five.

Inside Delana's chest, her rib cage, resilient as only a child's is, flexed without cracking. Under the pressure of Burton's compressions, her heart was squeezed between her chest wall and spine. The electrical impulses controlling the lub-dub, the impulses that had been short-circuited and sent into fibrillation by the horse kick, reacted to the thump. They charged, restarting from scratch.

... Five ...

Delana's heart began to beat.

Lub-dub. Lub-dub.

Delana's body twitched, and she sucked in a deep breath. The color returned immediately to her face. Her eyes fluttered open, and her vision focused on the faces leaning over her.

"Do you know your name?" Burton asked.

"Delana."

"Do you remember what happened?"

"I got kicked by a horse."

"Do you know how old you are?"

"Eleven."

She was going to be fine. It was unbelievable, thought Burton, but she was going to be fine.

The EMT arrived. An ambulance was on its way to take her to the hospital, and Burton promised he'd see Delana and Suzanne there as soon as his shift started that evening.

Someone wanted to shake Burton's hand.

Two people wanted to shake his hand.

Then three.

"That's the most amazing thing I've ever seen," said one man.

The doctor thought, "You have no idea just how amazing."