My Perfusion Job Shadowing Experience: Day 2

(Reprint 2014)

Editor’s Note:

This is part 2 of what is a 3-part series- these first two posts presented by a young, soon-to-be medical professional who job shadowed for two days with me.  

He is soon to graduate from a very prestigious university here in Texas, and has more than established his unwavering commitment to medicine and human welfare- not only with a clearly direct and dedicated effort during the process of job shadowing- but prior to this- committing himself to a medical mission to the Republic of the Philippines, and spending time there with an anesthesiologist I truly admire.

My own experience as a Hospital Corpsman, in the United States Navy included a 15 month stint working in an emergency room of a very significant Naval Base in Subic Bay, Republic of the Philippines.

So I had a pretty good idea of what he and the Mission had to go through to accomplish their humanitarian effort.  Outwardly friendly, yet many political and local agendas that need to be incisively negotiated.  Uncertain surf so to speak.

CARDIAC GREASE MONKEYS

I woke up around 4:15 making sure I wouldn’t be late for the surgery. The night before I could hardly sleep I was so excited to see this surgery. I will admit I had some butterflies when thinking about it. Was it going to be too much to handle? Will I be able to see myself doing this? Many more questions swirled in my head and I had no idea how they would be answered. I had been placed in difficult situations before with my EMT basic training. I knew the adrenalin rush you got when some ones life is on the line and people are asking you to help save it. But I knew this would be a different field with different complications that I would encounter. You not only have to be know medicine but you also have to be a mechanic, a cardiac grease monkey. I arrived at the hospital around 5:30 am and met up with Mr. Aprile to go in and prime the machine.

PREPARATION IS KEY

I went in to the OR and saw that complicated machine again and began to assist in priming the machine. You must prime it to ensure the blood is entering the tubes with an environment close to that of the vessels. Starting them in a dry tube will cause air bubbles and the blood to stick to the sides, which will eventually activate their clotting mechanism. Crystalloid solution is added into initially to get the machine ready for blood. We checked for kinks and air bubbles through out the system to stop any unneeded issues during the surgery. Mr. Aprile prepared the different medications and had them all ready for use. The blood was then dropped into the system, this in my opinion was the coolest looking part of the whole process. Seeing the blood slowly push through the tubes and mix with the solution made for a pretty cool site. After everything was primed we then just had to wait for the patient.

CALM BEFORE THE STORM

            I had been introduced to a different perfusionist before to talk to him about the school that I planned on attending. Everyone was joking around and had very high spirits before they went to “war”. I really enjoyed how friendly and welcoming everyone was. You were immediately a target for jokes when you enter that OR, this of course was to lighten the mood and loosen everyone up before it was time for them to get to work. Everyone there has a set job they need to do and they do it in a specific order every time. This is to ensure that everyone is on the same page and reduces any human error while preparing. Once the patient and staff were in the OR the fun was about to start.

THE DOUBLE VALVE BATTLE

I went in to the OR and first stood next to Dr. Miller as he looked at the valves through a camera that is inserted down the esophagus. He does this to check to see if the valves that are scheduled need to actually be replaced by the extent of the valve damage. This decision is very important because if the valve does not need a replacement the patient will have a much greater life expectancy if they do not operate on the valve. If it is in fact damaged and they do not operate however, the patient will have to come in for another surgery causing more stress on their body. After carefully looking at it with different blood pressures to see what they did under stress, Dr. Miller decided the mitral valve needed repair and aortic needed replacement. The OR staff was very good at knowing where to be and what they needed to do. I could only imagine the nerves they were feeling as they prepared for this surgery, I myself had no responsibilities and was feeling nervous. The pump was ready, the patient was out, and the surgery was about to begin.

Mr. Aprile told me another key thing to do was to read the room, see how everyone is acting if they are joking and laughing all is well, if the room is quite and no one is talking while they franticly work there is an issue. The surgeon was in and was being very nice but like a good general kept everyone in their place. I loved watching how the surgeon interacted with the staff, he would make sarcastic remarks and bust peoples chops all in good fun. This really showed me how good of a relationship everyone had and made me excited to have that type of relationship in the future. Once the cannulas were in the right atria and aorta Mr. Aprile began to give the cardioplegia medication potassium to stop the heart and start bypass. Due to my lack of experience there were other processes that I am having trouble remembering. Everything seemed to be going right until the first problem was presented.

The heart was stopped but the first thing that you need to look for is the flat line on the EKG. The patients was still reading activity, Mr. Aprile quickly found out that it was the pump showing up as an artifact on the reading. This was then communicated with the doctor and he then knew that it was okay to begin.

The whole time in the room as I watched these modern day heroes work to save this persons life I sat and wondered if this was something that I could see myself doing. Would I want to be exposed to this high stress environment everyday to save a person that I don’t even know? This concept is easy to answer until you actually have the opportunity to do it. My mind was reeling with all sorts of questions as I wondered if I even had the right make up to do something like this.

Medicine is a very stressful but rewarding field and I see it as a better way for me to help society. I was still sitting pondering my outlook when I heard the surgeon had finished the mitral valve. The room still was very relaxed and everyone still conversing as they began to start the aortic valve replacement. That was when the room started to stand still..

AIRLOCKED

            I had no idea what this meant, no idea what trouble it could cause. The surgeon expressed frustration when he started and his field of view was blocked by blood filling up the field. The issue was found to be an air lock in the venous tube. The tube looked as if it was a carbonated beverage as air was seeping into the system and causing the heart to fill with blood.

The room stood still. Everyone was dead silent and tension was so thick you could almost choke on it. The surgeon was very vocal in his frustrations as he tried to make very difficult and meticulous sutures while battling the loss of view.

In the minutes that followed time seemed to stand still….. Mr. Aprile had to clamp off forward flow as the surgeon worked and then return flow once he stopped. This incredibly difficult maneuver was like if you were to stop your heart’s flow and start it again periodically. It didn’t take me long to see how dangerous that could be.

Constantly monitoring the body’s metabolic rates was key to prevent acidosis and keep the patient alive. The surgeon was very quick and worked frantically as Mr. Aprile intently watched and clamped at the right times. I could not believe the case that I was getting to experience.

I was excited to be watching an actual hard case but nervous to be seeing such a dangerous surgery. The patient was rather small making this even more difficult to maintain the right levels. Pressures and CO2 sats. were rising and falling fast and if Mr. Aprile wasn’t so good at multitasking the patient would have died.

While all this was occurring the whole staff was still very in control, I was nervous but I found comfort in the confidence everyone showed. I saw it as an up the creek without a paddle situation, but they saw it as something that they knew they could fix. The only way I could describe the atmosphere I felt would be back when I played football in high school. The game was winding to an end the other team was driving down the field and only defense that I played on could stop them from scoring. Everyone is nervous in these situations, but we know our assignments and all we can do is follow those responsibilities and be confident we will stop them.

Death was driving down the field but the OR staff knew what they needed to do to stop it. Everyone performed their duties with confidence and in the end they beat death. The replacement was a success and the surgeon was back to busting Mr. Aprile’s chops as a way to almost saying he did a good job.

As stated before, keeping a good relationship with your coworkers is one of the many key factors to survive in this field. The one between Mr. Aprile and the surgeon was a good one. Both trust each other and just like football both will keep each other accountable when things start to hit the fan. They then began to take the patient off bypass and started to sew up. All was well, tension faded and the patient’s heart started to beat on its own.

After the surgery we started clean up and threw away disposables of the machine and got the new ones. Mr. Aprile bestowed my next great challenge, put the machine back together. He left the room and told me to put together as much as I could. I stared at that machine for at least two minutes thinking of where in this world I would start.

I but in the pumps and the reservoir and connected the venous tubes to where I thought they should go. I was very happy to see when Mr. Aprile came back and I connected most of the parts correctly. He was very encouraging and said I did well even though he did need to correct some things.

The day was over; and I was even more tired and more excited than the first day. This whole experience made me realize how challenging this could be. I cannot wait to meet the challenge head on and start to learn more about it.  I realized this was something that was worth the stress. I cannot wait to start in this rewarding field and save lives just like the one Mr. Aprile helped save that day. Since that day I have not been able to stop looking at circuit surfers and other sites to read more on this field.

I would like to extend my thanks to Mr. Aprile, Dr. Miller and the whole OR staff that let me sit in and watch for the last two days. I hope to take this experience and implement it into practice in the future.