Heart Surgery in America: Monday 6.0

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Monday 6.0

It Starts Here …

Deconstructing the anatomy of an open heart  team is like reading the writing on a wall from some war memorial somewhere, remembering a lot of somebody’s, that were in a lot of battles somewhere, fighting for a lot of  something.

Nothing stands out.  Different hats, different times, different weapons, for sure there was a major conflict at sometime.  And you know it’s absolutely important, because it’s written  in granite- so  no doubt it had to matter.

And every day in the heart room-  well it matters…

The process of actually becoming a team is a matter of fact that is most often overlooked by the members themselves, as the day- in and day-out struggle  of trying to avoid imperfection takes it toll on common sense inclinations to back down, reassess, and regroup.  This is a harsh environment with no buffer for leeway, hesitation or second thoughts.  If you’re inside you have earned it, but when the door opens and then closes behind you, then it’s all about integrity of purpose.  It’s a one way door for us, the patient has the same option but is horizontal.  Our goal is vertical.

We are people placed into slots, and the sum total of that aggregate space that those slots take up-  ends up being a team of sorts. The end point of the team, is to do no harm and to optimize patient outcomes.

Because of the demands for consistent performance with no human error,  it may sound like work better suited for robots and the sterility of their implied infallibility, but potential clinical permutations are far too abundant to allow for finite prescriptive responses, so part of the chemistry requires that all the moving parts can think on their own two feet.

The clock ticks on and eventually the soup comes to a boil and simmers to completion.  Same ingredients but a different taste.  Not exactly home cooking, but in a way it is.

As long as it works…

From point A to B.

Four thirty in the morning rolls by and a memory twitch brings your dreams to pause and you slumber on.  Sentinels at alert status as you eyeball the clock at 5:15, and then of course the parachute… the snooze button as the alarm triggers off.

Shit shower shave and shampoo in that order- as you prep up for the day.  One antacid, one anti-hypertensive, a quick kiss goodbye to the  other half of my dreams,  and out the door.

It’s always good when all the red lights are still blinking.  It means you are ahead of the game and basically the lead rat.  An hour or so earlier and the same intersection had last night’s drunks being hauled in after all the bars had closed.  They are kind of closing in to the end point of the Darwinian stream…  But then again a few years back, somewhere, somehow, they outraced a million or so of their other competitors to fertilize that egg…

So back to the dog race.

On the horizon where the freeway meets a shrouded sky, the peaks of the hospital are silhouetted to my right, a sharp contrast to the morning mist on the ground below, and the dew drops outlining the windshield of my car.  There is glitter everywhere, refracted moonlight, midnight street lamps, hospital fog lamps, and the high beams from my car.

Off to the races, as I hit the second floor, coffee up in the doctors lounge, pick up a tackle box full of meds at the pharmacy window, and through several doors finally enter OR room 11.

Before me stands the beast…  The heart lung machine.

Setting it All Up

And then a lot of things happen in a pretty flash forward kind of way.  The pump is tested, supplies are checked, in streaks an orderly, deposited are blankets, saline, suction containers, out goes the orderly, platelet gel components are set up,  in comes the anesthesia tech, a litany of safety checks on anesthesia machine, pressure transducers zeroed and checked, meanwhile my pump is purring, occlusions checked, anesthesia tech finishes monitor lines, meds are drawn and delivered to appropriate ports, in comes a circulating nurse to sniff, out she goes, hello scrub tech- passer number one, heater cooler tested, second scrub arrives, sterile items unpeeled and dropped onto sterile fields, cell saver check, scrub is scrubbed in and off to back table, CO2 flushing complete, ECC disposables to scrub, and the room has filled up with at least 3 or 4 people that are finally  now here to stay.

The first foray of the day rears it’s head as yesterday’s late night case is discussed and dissected for the good the bad and the ugly.

I wasn’t there so I don’t know.  But knowing the players helps you speculate as you continue setting up.

He walks in, mood assessed, and typically no extraneous pleasantries.  The  weather forecast for the OR has now been predicted but is definitely not written in stone.  The question of priming has been answered as the cardiac surgeon leaves the room.

The bee-hive warms to red as the patient arrives and a well choreographed sequence of events is initiated.  A lot of activity, a lot of drones.  Meds are dropped and the extracorporeal circuit is primed.  The patient gets an arterial line, is catheterized,  Swanned, and scoped.  Baseline arterial blood gasses are drawn, and coagulation parameters assessed.  Patient STS and H&P data recorded.

There are monitors within monitors in a world already full of monitors. A mosquito wouldn’t have a chance of getting out of here without a blood pressure reading being flashed on a screen somewhere here in our world.

If  it has a number and it can be measured and more importantly- if a paper was published about it- yeah we will measure it, file it, print it, and database the crap out of it… because we can.  Cardioplegia is primed.

Also Sprach…

The beginning of a title by Nietzsche that reflects the entirety of the open heart experience.   “So Speaks …”  the cardiac surgeon that will manifest the destiny for this patient today.  You cannot  take God’s will out of it, but  in this case as well as all  the others, it is the will of the team that will  have the most profound impact on how well our patient does.

A final verbal review of the patient procedure is done as the surgeon and first assist are gowned and gloved.  Time to cut.

A saphenous vein is taken from the leg, so that becomes the first incision , the next is to the chest and bi-valving the sternum from the xyphoid process north to the  sterno-clavicular notch.  STS predicted mortality and morbidity is calculated and reviewed.

A fiber-optic scope is moved to the foot of the patient to assist in the vein harvest, and a large flat screen monitor placed next to the patient opposite the surgeon, providing a cinematic map of cardiac topography and the currents of the patient’s heart.  A 3D worm is in place by anesthesia through the throat (esophagus) to evaluate the heart chambers, their movement, and how well they squeeze.  Elasticity, contractility, wall motion abnormalities, ejection fractions, and valvular performance are all discussed during this segment.   Heparin dose response established.

Fraught with peril?  I wouldn’t say that.  More so than not, sheer repetition and a few bumps…  Vein harvest complete.

The Heart of the Matter

I consider myself as a buffer.  A veil between the most terrifying possible event versus a smooth ride with no turbulence.  It takes a lot to stay away from the left side of that equation-  75% O2 on.  Most importantly it’s about faith in yourself.  Internal mammary harvest complete.  I anticipate failure in others, and compensate for that-  Lines are clamped. It is my unwillingness to accept personal failure that keeps my edge sharp- pre bypass checklist done. As we pass our lines up to the surgical field and  heparinize the patient, second gear kicks in 1% forane on.  The heart is now exposed, and the surgeon begins the process of cannulating the heart and doing all the things that we are here to do-  shunts and purge lines are off.

Bypass

The edge is tighter now, going on bypass is one of those things that after you jump- you really can’t un-jump.

The heart lung machine is moved up to the patient and sterile lines are passed up to the surgical field.  Patient anticoagulation is assessed, and the heart is prepared to have it’s life blood diverted and assisted by the device I operate. A solid stream of dark red blood to be remixed to an oxygen rich bright red stream destined to all points north and south for the patient as we go on bypass.

When initiating bypass there is always a certain amount of tension.  The closest I can relate that to would be when a plane takes off in flight.  It is that brief moment when so many critical factors need to be assessed to determine if indeed this bird will fly.  There aren’t too many bailouts for pilots, so if they fail it truly is life or death.  Equally so in this arena.  There are so many moving parts and pieces that need to work, that only become tested once the die is cast…  It doesn’t take long, maybe 10 seconds or so to figure out which road you are going to be on.

Patient cooled, flow down, crossclamp on, cardioplegia in, and the heart is stopped.  Now the fix begins.

Mano e Mano, vessel by vessel–  it’s a one at a time scenario in flux.  All the road maps in the world can’t tell you what circulation of a heart that you are operating on will look like.  Imagine the tributaries in Venice, some water ways are flooded, and others drained to the point of bumping into rocks at the bottom.  Then consider the tide as it  rises and falls.  That is when a mechanic becomes an artist.

When it’s My Game

On bypass >cool > fill the patient >flow down >cross clamp on >vent off >give cardioplegia >vent on >fill the patient >vent off >give cardioplegia >vent on >rewarm >down on flow >lidocaine in >cross clamp off >flow down >partial cross clamp on >flow down >clamp off >ventilator on >fill the patient >come off bypass.  Labs and adjusting meds as needed.  A thousand plus variations of said theme apply.  I wish it was that easy…

ps:  do not attempt this in your living room.

Well that sums it up.  Off bypass and all is well.  No back slapping required.

We don’t roll like that.

Because after all- we are professionals.

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