PACU

(Trying to catch up on old ideas... this actually happened last week... pretend it's today.)

Not a typical day for me. I was the faculty covering the post-operative recovery unit. It's actually not a particularly tough job most of the time since there is a resident assigned to field most questions and problems. There's the occasional problem... nothing big today. Staffing ECTs. (electroconvusive therapy) Done three times a week in the PACU. Signing patients out (i.e. administrative whatever-you-want-to-call-it)

One thing that was unusual was that we had two physicians come through as patients. I guess doctors need surgery too. Didn't want to give special treatment, but did stop by and say hi to both the pediatric anesthesiologist and the cardiac surgeon (who spent the previous saturday on a stretcher in the pump room while his partner finished a surgery they had started together).

Bladder cancer

Had patient here this AM for a cystectomy (bladder removal) for bladder cancer. A tough man... clearly trying to hide the fact that he is terrified (rightfully so.. a big operation) Among the last things he said before going to sleep (taken anonymously without permission.)

I'll be badder without a bladder!

Tough Day

Thursday was a tough day. I was the cardiac faculty on call, so I knew from the start it was going to be a long day. I came in early because there was a conference on echocardiograms that I wanted to go to. Anyway I was wandering in, and my pager went off... never good in the morning. "Case going on in room 7" I change quickly and get in there. A heart transplant. Just starting really... It's patient with bad heart failure that has a Heartmate (a type of left ventricular assist device). Of course he's had about three previous heart operations so there's lots of scar tissue in the chest makin the operation much more dangerous and complicated.
Anyway... the new heart is in the patient about 3 pm or so. It's not going well as we come off bypass, but we're doing reasonably. All of a sudden, the blood pressure drops and I see a bunch of air on the echocardiogram. Part of the hears stops functioning well... So I assume some air has gone down one of the coronary arteries. We crash back on bypass... Left heart starts functioning a bit better but now the right side doesn't look so well. We end up after struggling a bit assisting the right side of the heart with Abiomed right ventricular assist device. This are settling out, the all of a sudden the left side of the heart is starting to look bad.... Now a discussion ensues on if they need to put the patient on ECMO (extacorporeal membrane oxygenation). Ends up they endup supporting the left side of heart with a left sided Abiomed.
Now we are supporting both sides of the heart, and the patient is relatively stable We're pouring clotting factors and blood so the patient will stop bleeding. They'll try to wean the patient off assistance early next week. So this patient came into the hospital with a bad heart and a Left ventricular assist device... now has a different heart and assistance for both sides of the heart. Only time will tell. By the way it's 9pm we're finally done. a quick 16 hour case. I'm so exhausted.

Interviews

As a new attending... I got to participate in resident interviews for the first time. As a resident, I did attend a lot of interviews, and I gave a lot of tours. On the other side it's a little weird. I don't know if I like having any influence at all on people's futures. I can say that the applicants as a whole were insane... everyone had great (not just good) board scores, publications, etc. I can't say that I would have gotten into this residency program now if my life depended on it. Seems though overall that people were pretty nitpicky. Which is okay I guess. We're trying to stratify a couple hundred really top-notch applicants. Don't know if I was too harsh or not. I guess my rankings were close to everyone elses.

Make a wish

Okay... I NEVER watch the news. nothing ever interesting is going on. especially when I can read things on the internet. Especially never local news. Unless I want to see a skateboarding bulldog or a waterskiing squirrel. Anyway, my roomate was watching something and the news was on after it. And they started talking about the make-a-wish foundation and so on. So I was about to turn the channel... then they mentioned an 9 year old and a name I recognized. It was a generic name and could have been anybody, but there he was, a child I took care of as a cardiac anesthesia fellow.

The reason I remember this kid is that he was truely one in a million. The surgery he was having as an eight year old was a coronary artery bypass. He had a disease called hereditary familial hypercholesterolemia. The problem for this kid was that he had the worst kind. He had cholesterol levels 8 to 10 times what a normal person would have, thus he had premature disease of the arteries feeding his heart. Most patients who have this type of surgery are in their fifties and above.

What killed me was that on the news report they did say he had coronary artery disease, but they said that "Sometimes he doesn't feel well" and left it at that. I guess you can't say "Sometimes his heart doesn't get enough blood" on TV. Well at least he got a new puppy.

More Prisoners

So I was on call again last night, and we had a trauma flown in. Now this is not completely unusual, since we are a major referral center, but since the town in relatively suburban, not a lot of violence. Anyway a prisoner apparently had barricaded himself in his room and cut his neck from the middle of the neck to the ear with a razor blade or something. This seems weird to me for several reasons. One, seems like prison is all about being barricaded into places whether you like it or not, so the part where he barricades himself somewhere is weird. Second, I thought you weren't allowed to have razors in prison. Next... you'd have to be pretty determined to slice yourself that wide open. ouch.

Now I understand this guy is a violent criminal, but they bring this guy up to the OR... he's intubated and paralyzed... big wad of bloody bandages on his neck... but despite this fact he still has his arms shackled to his waist. Like he's getting anywhere while he's paralyzed. Then again with the sitting outside the OR while he's under general anesthesia. Oh well. I'm sure the guards are just doing what they're told.

Good news for us, he didn't hit anything too big that we couldn't control the bleeding. (plus they had time to fly him in from up north in the helicopter). Bad news for him... seems like he didn't feel like living anymore.

P.S. I was ending another case with a CRNA and she had only heard part of the story so she only knew we were operating on a self inflicted neck wound. So she said "Life can't be that bad can it?" I then mentioned that he was a prisoner apparently in prison for violent crimes. She then seemed embarrassed "I guess it can be that bad." I chuckled. (proves again -- I'm a bad man)

prisoners in the OR

Had a prisoner as a patient the other day. It was very surreal as always. having two armed guards sitting next to the patient instead of family members. Also the leg chains have some sort of surreal quality to them also. A fellow faculty has the habit of looking up these patients on the Department of Justice homepage. Apparently you can just look up anyone with a criminal record or is currently in prison. I prefer not to know. I think I would be a better person than to let the knowledge of his crimes affect his care, but I prefer not to leave that to chance. The man seemed very nice. Also weird is the insistence that they sit outside the OR for the entire surgical procedure. Like they're going to get off the table and run out while they're under general anesthesia.

A couple of years ago I had a patient undergoing cardiac surgery he was in his mid-seventies. Apparently he had been in prison for twenty or more years. He was a pretty feeble man... still those guards were there sitting outside the OR for the entire case. I really don't know what he did if he had been in prison for that long. He also seemed very nice.