Heart Surgery in America: Wednesday 1.4

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24 Hours… of ECMO

Wednesday 1.3

Getting Past Midnight :   ACT’s & Clots …

11:00 pm

Somehow during the initial debriefing from the previous ECMO coordinator that I had taken over for, the question of reliability regarding our ACT  (Activated Clotting Time) came to the forefront.

What was raised at the table for discussion, was whether or not we could rely on the results of the High Dose Response ACT cartridges to adequately assess the patient’s level of anticoagulation.

It was suggested that perhaps we should consider Low Dose Response ACT cartridges as a more reliable test to measure heparin impact on the patient.

That  discussion was less than rhetorical, but significant in the fact that since we were seeing demonstrated improvement in terms of patient hemodynamics, lower flows were indicated to engage in the process of weaning from ECMO.

Low flows = the potential for stasis of blood flowing through the circuit, which in turn can lead to greater susceptibility for clot formation in the oxygenator or extracorporeal circuit.

So that leads to a lot of scanning.  Scanning for clot formations, which somehow always seem to show up (when using a min-flashlight) in isolated clusters here and there in the circuit, and as long as they don’t spiral into a massive “snowball effect”, represent the same unseen threat as sharks in the Caribbean waters.  You accept the fact that they are there- and until confronted, try to intellectually subvert their implied menace.

The bottom line?  Please don’t get bigger…

More significantly, I was very confident in the High Dose Response ACT cartridges we were using- and have trusted their results implicitly forever (but not with  the blind trust of an Ostrich- I do consider the environmental landscape) .

The variability of heparin monitoring was one of those discussions that would naturally grow a life of it’s own since in all reality, long term heparinization leads to a tempest of so many fluctuating potential hazards that there is no exact science that can truly be relied upon.

You don’t win many hypothetical arguments in front of a board of your peers, supporting your approach and methods based on “intuition”.  But more often than not, time in the profession and gut instinct come into play at this point.

If my belly tingles- well it’s for a reason.

The only thing untenable is being afraid to make a stand.  So go ahead and make it.  Nobody loses if you voice your disagreement.

The only loss is if you were right-  but failed to vocalize it.

Plan “B” options are there for a reason.  The first step to avoiding plan “B”, is to follow plan “A” (Due Diligence).  So we dropped to 1.4 LPM and maintained ACT levels of 220-250 seconds (High Dose Response Cartridges) and it all worked out.

Midnight

Shawn and His Son

Somewhere around midnight I started to take a walk down the long hallway that is the PICU.  I didn’t need the space,  just a little exercise to stay awake and grab a chat and some coffee.

I saw a friend of mine popping in and out of one of the patient rooms and assumed he was checking on a patient (he is an anesthesiologist).

As it turns out, he was checking on his new foster daughter that had been admitted the day before.

He is a guy I have always liked.  Gregarious, so very positive, and always so polite- he knew my first name from when we had met 2 years prior in the OR.  Our common bond was medicine on the periphery, but the open heart arena in particular- was the tarmac for mutual respect.  We had both spent quite a bit of time down the same road.

I have always been a “dude” kind of guy.  You can call a guy “dude” or “bro” and never know his real name, which in this case (embarrassingly), I didn’t.

I had struggled with that before in passing with SHAWN, but it never came to bear as anything but a minor detraction regarding our respect for one another.

So we had a conversation.

It started out with the usual stuff.  Validation of why we are here, ECMO & Daughter,  and during the entire conversation he changed his daughter’s diaper.

Swift and precise.  That is how I would describe his ability to maintain a cogent and caring conversation, while being exceptionally prescient regarding the needs and status of his daughter.

It is rare that two men have a conversation about anything that amounts to much more than the standard fare: dude your cool- it’s ALL good- I fully respect you … blah blah blah… woof woof woof.

During that process, of watching how carefully he attended to his daughter, while still blathering with me, I was reminded how timid life can be- and how important it is that we nurture it.

That’s when he dropped the bomb.

The unknowable sadness that we are all so afraid to bear.

The death of his son, Grant, 2 years ago. How shocking for me to have known him, nameless yet “bro”, to have worked with him during this entire time, and to have never sensed the slightest wave of the tragic storm he experienced yet never shared.

As if you could share that.  I was stunned.  And I was humbled by his courage- that he could be so kind others, while his hopes and dreams had been so swiftly unwrapped…  placed at his feet for whatever path he chose.

So at midnight in the PICU, in the middle of a mix of potential tragedies, here was a truly brave man projecting an amazingly view on the world of possibilities that could be, rather than close the doors to hope and fall away in sadness.

Side by side, his daughter, the memory of his son Grant, and our ECMO patient, all weighed in at the same time- midnight, with the sadly exquisite intention to not to lose the battle.

So that was what this was about….