Tales From a Cardiothoracic Surgeon Wannabe

0

Recently someone made a very popular, albeit fraudulent, post about being a neurosurgeon that seemed to really capture the imagination of many fellow Imgurites. I'm a cardiothoracic resident and figured you arseholes in usersub might like to hear some of my stories from work!

Cardiothoracic surgery primarily entails surgery on everything between the bottom of the neck and the diaphragm. One of my mentors often says, "All surgery below the diaphragm is purely recreational."

... Well I thought it was funny anyway.

Anywho, some of the job titles/jargon might be a bit annoying to read but I'll try my best to explain things as I go.

I'm a resident which, in my country, means I've long since finished med school and have been working as a doctor for a few years now but am yet to enter a specialty training program. I'm currently trying to get on the cardiothoracics program but shit's competitive, yo.

1

So a registrar (or "reg" for short) is basically the next role above resident. They are on a training program but not yet a qualified surgeon.

Cardiac surgery often involves the use of cardiopulmonary bypass (CPB). This is basically a machine that can oxygenate and pump blood around the patient's body "bypassing" the heart. With this in place, we can stop the patient's heart and perform surgery on it or the vessels connected to it.

In a busy surgical unit, it is common for the registrar to prep the patient, open the chest, prepare the surgical field and plumb the patient with the tubes needed to go on CPB before the surgeon enters to perform the actual surgery on the patient's heart. On this particular day the surgeon popped his head in and asked my reg to have the patent ready and on bypass in the time it would take him to change into his scrubs and "scrub in" (wash his hands) to the theatre; obviously an unachievable feat but a direct challenge to my reg nonetheless.

Now in order to put a patient on conventional CPB, a tube needs to be placed directly into the patient's aorta; the main artery leaving the heart that feeds the entire body. It is therefore a very high pressure vessel. One end of the tube is basically inserted through a very small incision in the aorta and held in place with some temporary sutures. The other end has a small, tightly-held but removable cap so that blood doesn't go everywhere while you're placing it in the aorta. Standard procedure is to CLAMP THE FUCKING TUBE before removing the cap to attach the tube to the CPB machine.

But today we were in a fucking rush.

In his haste, my reg forgot to clamp the tube and removed the cap. He opened the cap towards himself so the first open part was pointed directly opposite him - i.e. directly at me. As he removed the cap an arc of bright crimson blood went from my face shield to directly up in the air and then raining back down. But it doesn't end there. Out of reflex, the reg put his thumb over the end of the tube before he could reach a clamp, giving me a second coating.

The patient did just fine.

2

So a common heart condition in some populations is called rheumatic heart disease. It's part of the sequelae of rheumatic fever and it slowly trashes your mitral and/or aortic heart valves. In many cases these trashed valves need to be replaced with an artificial one.

Mitral Valve Replacement = MVR and Aortic Valve Replacement = AVR.

The most common way to access the heart for this and many other operations is via a "midline sternotomy." This literally means sawing the patient's sternum in half, right up the middle, with one of these bad boys https://i.imgur.com/88FdNpm.jpg . After the operation they get their sternum wired shut like this https://i.imgur.com/ylPHABW.png . Easy as pie right?

Well this story's hero is a 20 something year old inmate from a local prison who spoke very little English, was 7' tall, built like a brick shithouse and needed an MVR. Unfortunately, in the days following his surgery it was becoming clear that the bottom end of his sternotomy site had become infected; a potentially devastating complication of cardiac surgery. Also sometimes post-op patients with a significant infection will become quite delirious or agitated and confused.

So our 7-storey tank that understood not one calming or reassuring word spoken to him, whilst handcuffed to his bed, a mind scrambled with delirium, and a sternum made of mush, decided he'd make a break for it and drag his bed with one arm out the door to freedom.

His sternum disagreed. The lower half of which opened up then and there on the ward. Much like my bowels.

3 months, a fuck-ton of antibiotics and a pec-major flap (thanks, Plastics!) later and our hero left hospital back to the loving arms of the local penitentiary.

3

So this story is going to contain some jargon that will need explaining. My hope is that you'll find the technical parts interesting and not be all http://i.imgur.com/6db4AjR.gif .

Immediately following cardiac surgery, the patient will either be moved to the intensive care unit (ICU) or a dedicated cardiothoracic ICU and ideally they will be able to "step down" from ICU/cICU to the ward within the first 24 hours. If you meet this target it usually means things are going pretty smoothly. It's not a huge deal if you're there longer but statistically (and from a drug-resistant bacteria exposure point of view) the more swiftly you move through ICU, the better.

Now you might think that the heart is this fragile, delicate thing but I tell you what, as long as it has blood and oxygen, it will keep on beating. So with modern medicine and surgical technique, death or cardiac arrest after cardiac surgery is actually pretty rare. In fact it's probably less than 1% of patients within the first 30 days of surgery (ballpark figures).

So when a patient arrests on the ward, within 24 hours of their operation, we all shit our pants.

In a cardiothoracic ward, most patients will have a continuous cardiac monitor on. This is for the express purpose of catching arrests or malignant arrhythmias early if not instantly. The classic TV medical drama will show a patient in VF (ventricular fibrillation) miraculously shocked (or "deFIBRILLATEd") back to life with in impressive jolt of electricity.

But this patient had a PEA arrest. And the monitor didn't catch it.

PEA stands for Pulseless Electrical Activity and it basically means that, electrically, the heart is functioning normally but it is not ejecting enough blood with each beat to keep the patient conscious and perfuse their other organs. So the monitor thought everything was hunky-dory but the patient was unresponsive and had no detectable pulse.

In this setting (following cardiac surgery) there are two usual suspects for PEA arrest: 1) Cardiac Tamponade or 2) Massive Pulmonary Embolism.
-Cardiac tamponade means that so much blood or fluid is accumulating around the outside heart (ie from ongoing bleeding after surgery) that it is restricting how much the heart can fill before each beat. Imagine trying to blow up a balloon but you have on a very tight corset. You need to fill your lungs properly in order to blow hard into the balloon but you can't because of the corset. It's the same with a tamponading heart. We place drains around the heart after surgery to prevent this but sometimes (very rarely) it still happens
-Massive PE means a large blood clot has become lodged in your pulmonary artery(s) which, for several complicated and interwoven reasons, is very bad news for your heart.
It was a nurse that first raised the alarm. Through all the other pings and beeps of the ward came the piercing emergency alarm. I was the first doctor to arrive and took over CPR from the amazingly quick off the mark nurse who was already tiring from doing chest compressions. She moved up to the head end to start "bagging" the patient (breathing for them with a bag and mask). Within (what felt like) seconds one of my regs and the cardiology reg were in the room with a bedside echocardiography unit (special ultrasound machine) and had it on the patient's chest. The cardiology reg detected some fluid accumulated around the heart and made the call of tamponade.

Within minutes the attending surgeon and another surgeon were in the room and the nursing staff had prepared the "chest cracking kit". This is a pair of covered trolleys that sit against one of the walls on the ward that hold all the instruments, drapes, gowns, etc needed to open someone's chest on the ward. And everyone is scared shitless of it.

In the time it took me to literally just dump a bottle of betadine (iodine-based antiseptic solution) all over the patient, the attending surgeon had gowned, gloved and was making anincision near the xiphisternum http://imgur.com/pfQihTc . Seconds later he had his hand and a yankauer sucker (http://imgur.com/KY6hoVw) in their chest.

But no blood came. There was no effusion or tamponade.

I then watched the attending surgeon turn his back to the patient so he could discuss his next move with the other surgeon present, all the while performing CPR with one hand outstretched behind him. Ultimately the decision was made to stop and the patient was pronounced "life extinct". Despite the patient being on all the necessary preventive medications, the likely culprit was massive PE and it may not have been preventable.

The outcome was poor. But throughout the whole ordeal, I was amazed at how swiftly and professionally every single team member worked. From the first chirp of the alarm to the final chest compression; I have never felt prouder to be a cog in such a well oiled machine.

4

So immediately before many operations we place a catheter (glorified rubber hose) in the patient's bladder via their urethra. It is essential because it allows us to closely and accurately monitor urine output. It also means the patient doesn't piss all over the table during their operation or the nursing staff in ICU don't need to keep changing a piss soaked diaper every few hours while the patient is still unconscious following surgery.

We usually do this after the patient has been anaesthetised (knocked out) just prior to the operation. Today though, the anaesthetist was running late and the patient was OK with us placing the catheter while they were still awake - so we could be ready to get cracking the second the anaesthetist arrived. I asked if he was happy if the med student had a go as a teaching exercise. He was a young, chilled patient and said that was fine.

So the steps involved in placing a urinary catheter in a male are (broadly)
1) retract foreskin (if present)
2) clean the knob (or urethral meatus and glans penis if you give a shit about terminology)
3) squirt about 10ml (0.3 floz) of lube gel and local anaesthetic into the urethra
4) shove in the catheter right up to the hilt
5) confirm it's in the bladder by sucking out some piss (with a syringe!) then inflate the balloon on the end inside the bladder (so it doesn't just fall out again)
6) replace foreskin (if present) - very important step! Google "paraphimosis" if you don't believe me (if you need a warning to understand that you will see pictures of dicks, you are beyond help).

Now if your technique is shit, or if you are new to the game (ie med student), the lube gel gets everywhere and things get slippery as fuck. It's also fairly common for young, male patients to ... um ... "rise" somewhat to the occasion.

So imagine, if you will, the fumbling, gloved hands of a med student trying to replace the foreskin on a well lubed/slippery as fuck penis that is already at half mast and has a 1/4 inch wide tube down the middle of it.

http://i.imgur.com/CwtfCaA.gif

5

Some patients stay with you forever.

I heard Her before I saw Her. I was walking to meet a new admission to our ward and consent them (get their formal permission) for an AVR. I heard a laugh followed by the most beautiful Highlands (Scottish) accent I had heard in a long time. And my heart sang (my family is Scottish albeit a few generations removed). The only thing brighter than the words I was hearing was the smile they were fleeing. I also have a very Scottish name, and after I introduced myself, we immediately hit it off.

She was a 60-something year old lady who needed an AVR and a "triple bypass". Not immediately, but She definately needed it soon. She also had a sack-full of other health issues that would make Her surgery very risky. But without the surgery, Her heart would continue to get weaker and weaker, Her pain would become more and more frequent and She would eventually die. http://imgur.com/1lpAqyp

We sat talking about Her surgery and life, laughing throughout, for about 30 minutes. I explained the risks involved; there were many. I explained what She could expect after Her surgery and what Her timeline and milestones would be. She smiled the entire time. Then I handed Her the consent form and a pen and She signed it without hesitation. With a smile in my heart, I touched Her shoulder, told Her it was a pleasure to meet Her, then turned and left. I would never hear Her voice again.

She was already asleep when I arrived to assist in theatre. I washed my hands, placed Her urinary catheter then scrubbed, gowned and gloved. I prepped and draped Her with the reg. Then, while he set about opening Her chest, I went about harvesting a vein from Her leg. The excised leg vein is used in the "triple bypass" portion of the operation but I'll explain that in more detail in the next story.

Anyway, I had removed a sufficient length of vein and then placed it in a bowl of special saline. So I then closed Her leg and moved back up to the chest to watch the rest of the operation. The surgeon had arrived and so the reg was now assisting and my "active" role had ended. And, for the most part, the operation was routine. No boogie-men jumped out at us. No sirens wailed. The anaesthetist was doing a sudoku. Due to some quirks of Her anatomy the surgeon had a bit of difficulty "seating" the new mechanical valve and some of the sutures that held the valve we difficult to place but that was it. Soon the valve was in. The triple bypass was done. And when the surgeon called to the perfusionist (person in charge of controlling the CPB machine) to "fill the heart" everyone was kinda bored. This is the first step towards restarting the heart after the operation and disconnecting the patient from the CPB machine. The heart slowly grew as it filled with fresh blood for the first time in over an hour. Sure enough, like a phoenix from the flames, Her heart slowly began beating again and the surgeon set about withdrawing all the tubes that connected Her to the CPB machine. Somewhere between the pump of the CPB machine being turned off and the tubes being removed was where things started to go wrong. On the wall of the theatre is a large screen that shows a continuous trace of the electrical impulses put out by the heart; an ECG (or EKG in some parts of the world). The ECG was showing a sign called "ST elevation" and it's bad news. It means some of the heart muscle is dying due to lack of oxygen. But this can be normal to see at this stage. As the interior of the heart had been open to the air during part of the operation, some small air bubbles can, despite the best efforts of the surgeon, remain trapped in the chambers of the heart that only move after the heart starts beating again. These bubbles can then fly off and down one of the coronary arteries and cause a blockage. The normal thing to do in that situation is to ask the anaesthetist (or the perfusionist if the CPB machine is still plumbed in) to raise the patient's blood pressure (BP) and force the bubble through. So that's exactly what happened next. The anaesthetist gave medication to raise the BP. And rise it did. But only after getting Her BP to levels that would be dangerous outside of the operating theatre did the ST elevation start to go away. It did go away though so the surgeon left and the reg and I set about closing up shop, so to speak. The CPB tubes were out and we had started wiring closed the sternum when the anaesthetist said, "Um ..."

During any valve replacement surgery, the anaesthetist has a special ultrasound probe placed in the patient's oesophagus. It is there because when you lie on your back, the left atrium of your heart sits right on your oesophagus and having an ultrasound probe there can give exquisitely detailed pictures of the heart. We use it in the latter stages of the operation to make sure the new valve is seated correctly and functioning well.

"Um ... we need to go back on [CPB]"

The anaesthetist turned around his screen showing the pictures from his ultrasound. The entire anterior, septal and lateral walls of Her heart were still. Deathly still. More than just an air bubble still.

The surgeon was called back and we raced to get Her hooked back up to CPB. And she never came off it again.

I'm going to gloss over the events that followed as they would only be of academic interest to other doctors. Long story short, She spent the next week in an induced coma, and on a specialised CPB machine called ECMO, while Her suitability for a heart transplant was discussed. However during this planning phase it was discovered that She had a chronic viral infection that precluded Her from organ transplant. So Her life support was turned off. And She died.

Fast-forward to our monthly morbidity and mortality (M&M) meeting where I presented what happened to the unit. The purpose of the M&M is to focus intently on mistakes that could have been avoided or areas to improve on so that we as a team can learn and not let history repeat.

So what happened? During the placement of the new valve, some sutures were placed a little too close to the left main coronary artery (LMCA) http://imgur.com/svWGgrc . This meant that when the artificial valve was snugged down into position, it occluded the LMCA. This was partly due to the tricky anatomy I mentioned earlier and partly human error. Either way, as soon as Her heart started trying to beat again, it discovered that more than half of its blood supply had been cut off. It cried out to us on the ECG monitor and by raising the blood pressure drastically we were able to get a trickle of blood past the occlusion, perfectly mimicking an air bubble. But as soon as Her BP was allowed to come back down again, the supply was cut off again and more than 50% of Her heart muscle died. Her only hope from that point on was a transplant, for which she was not a candidate.

Some patients stay with you forever.

6

This story takes place about 6 months prior to #5 (and is much more light hearted).

So when someone says they had a triple bypass or a quadruple bypass, what does that actually mean? Well the heart, like any other muscle, needs a good blood supply to function and if the arteries that supply your heart muscle become narrowed or blocked you're in trouble. Now in many cases these blockages or narrowings can be reopened using a "percutaneous" approach. This basically means using a needle to pass a thin catheter through a peripheral artery and up to the heart where stents can be placed in the narrowings or blockages http://imgur.com/rMtaY3W . But in other cases (for many different reasons) a surgical approach is required and the patient needs to undergo Coronary Artery Bypass Grafting or CABG ("cabbage" to the cool kids). This is where blood vessels from other parts of the patient's body are cut out and used to create new pathways for blood to travel around the blockages in the heart and supply it with blood. The number of vessels used or "grafted" onto the heart translates to the number of "bypasses" made. I.e. if two grafts are placed, it's a "double bypass". Four grafts = quadruple bypass etc http://imgur.com/gAKrh8u . Now the great saphenous vein (GSV) is a long, superficial vein that travels nearly the entire length of your leg and is a great option to use for CABG. And you can live quite happily without it in your leg.

So on this particular day, I was attempting to harvest a patient's GSV to use for CABG, without any external help, for the first time. The surgeon operating on the patient at the time was both a remarkably brilliant person and a cheeky shit. They had a tradition; that if they were ready to start grafting onto the heart before the vein they needed was actually ready, the person harvesting/preparing the vein had to run around the operating table with their trousers down. I was too slow. So while I was finishing up the vein, the surgeon and reg gave me their best encouragement by reminding me of the forfeit I had made.

So after the operation was complete and the patient's wounds had all been dressed and sterility was no-longer an issue, I dropped trou, completed a lap around the table and, to thunderous applause, jogged straight out the door.

7

A short fluffy story to finish.

When coming off of CPB, most commonly the heart starts beating again in a synchronized and effective way. But sometimes (for a number of different and irrelevant reasons) when the heart starts up again, instead of beating normally, it just wobbles. This is called ventricular fibrillation or VF. Outside of the operating theatre and during any other type of surgery it would be a big deal. But during cardiac surgery, as we have the heart exposed, we can just give the heart a gentle zap with a specialised defibrillator and get it to contract in a synchronised way again. While the defibrillator is being prepped and charged it is common to gently massage the heart with one hand to try and coax it back into a synchronised rhythm without needing to shock it.

During one of my first cases observing/assisting in cardiac surgery (as an intern) we came off CPB into VF. The surgeon asked if I would like to perform the some gentle cardiac massage while he and the anaesthetist were prepping the defib. No sooner had my fingers touched the heart than it started beating normally again. I fell in love with cardiothoracic surgery right there and then.

I hope you have too. :)

Well ... MRI tax to be pedantic.