soaked to the skin III

Now to help the patient you have to relieve the pressure around the heart.
Usually this is (relatively) easy. You use a sternal saw and cut through the sternum. (middle of the chest where the ribs come together).

In this case it was more difficult. He's had cardiac surgery before. Which means they've already sawn (sawed?) through his sternum in the past. This is problematic because there's sometimes lots of scar tissue there now, so if you try to get in through the sternum quickly, you make have to go through scar tissue. And in that scar the patient's aorta, which is the biggest artery in the body, may be scarred together. The other option is to go in through the side of the rib cage. Since he hadn't had any surgery on his chest from the side, there's less chance of scar tissue and bleeding.

Now, the next scene is as close as you may see to a medical drama on TV. Usually as a medical professional you say "Naw that never happens!" and you criticize the accuracy of things on TV. But, now they tilt him to the side, the surgeon throws on sterile gloves, no gown, and starts cutting though the side of the chest to get to the sac around the heart. He's got blood all over his arms, he's calling to have someone page one of his partners to help him out. In the meantime, I'm giving him lots of medication to keep his heart pumping(pressors), because now it's squeezed down from the blood on the outside of it.

His partner shows up. also throws on sterile gloves, no gown. The nurses are checking blood and giving it. All of a sudden, the blood pressure shoots up to 3 times normal.... They've relieved the pressure around the heart by opening up the pericardium. Now the heart has no more pressure around it and all the medication that we're giving to help the heart squeeze is working too....

But now there's bleeding all around the heart... they need to look for the hole that caused the blood to escape the heart and fill up the pericardial sac in the first place. It's dark in the EP lab, because most of the procedures are done looking at video monitors. Even with all the lights on it's dark in there. At this point they've fillup a whole suction container with blood (1.5 liters) we're giving blood. they're a good way towards filling a second. He asks for a certain kind of stitch... of course they don't have it in EP lab. Why would they need a cardiac surgery stitch. he puts his finger over what he thinks is the hole and yells to have them call up to the OR and get the stitches he needs. I yell to have them call up also and have them get a cardiac OR ready. I assume we'll need to go up there eventually, if we make it.

He finally gets the stitch he needs... puts in a couple more.... still bleeding from around the heart, now there's some bleeding from there entry into the chest too. "I don't know how we're gonna get this guy upstairs" he says. A couple of more stitches, some more blood given, more pressors given. he finally decides that he's got some marginal control of the bleeding and to pack some pads around the heart, to hopefully place pressure on the hole and give us a chance to get up to the OR where the proper equipment and help can be used. The pads go in, 2 stitches to hold the rib cage closed, and a big sheet of sticky plastic (think medical grade iodine impregnated contact paper) to keep the area, marginally clean. I'm a bit surprised we've managed to keep him alive this far.

We roll the patient over to get him over to a stretcher. This is what starts the soaking of my clothes. we get him moved over. we rush to the elevator and up to the OR. It takes several minutes to get up there, we're giving blood and pressors like crazy. we need to position the patient on the side more properly so he has better access to the side of the chest than he did downstairs.

I help roll the patient again, i'm leaning over the wound and it's starting to well up around the plastic sheet. now it's leaking over me, warm. I can't stop, because I know this guy's going to die, and I can't let it be my fault. We finally get organized and they're prepping the patient to go back into the chest.

we're sort of stable now on lots of pressors, but giving a little less blood... until they open up the plastic.... blood starts gushing out again. we scramble a bit. One of the other cardiac anesthesiologists shows up, asks if I need a hand. I ask him if he can help the residents out so I can change.

I scurry down the hall, my belly and crotch covered mostly in blood. I must be a sight. I go to my office, take my scrubs off, my underwear is bloody too. yuk. Luckily I have a clean pair if my office (for call nights) I go wash my hands and I'm back in the OR.

Twenty minutes later, the surgeons can't find the hole, and they're bleeding from all around the heart and incision and multiple transfusions and medications later the man's 80+ year old heart gives up.

I ask the resident if she's okay to tidy on her own and we all walk out of the operating room defeated.

Unfortunately we can't win them all.

soaked the skin

As an anesthesiologist you shouldn't need to go to your office and change your scrubs in the middle of a case.

No I didn't soil myself because the case scared the heck out of me because it did, but I was covered in blood from moving the patient on to the bed.

I'm on call today and I was headed down to the Electropysiology (EP) lab to relieve the anesthesiologist down there so he could go home. I'm poking around looking to find out which room he's in. I pop my head in one room, I see a CRNA... have you seen Dr. X? Oh he was just here but he's probably next door... they're having trouble.

Hmm... that's not a good sign. I go into the room and usually the room is dark and quiet, the patient is on the bed under light sedation... they're usually pretty sick, but generally unexciting. Anyway... I go into the room, there's a ton on noise and they're doing chest compressions (CPR) A cardiac surgeon is standing near the bedside and they're pulling out surgical equipment.

(More later)

Black Cloud

(Sorry that postings have been so sparse. I'll fit in more time)

Some say that I have a black cloud. They're wrong. I have a storm cloud following me.

Let me clarify. In the medical profession, (I don't know if this concept exists in other fields) if you attract all the worst, bad, complicated cases, or when you're on call everyone and their mother has to come to the hospital, then you have a black cloud. It's possible to have a white cloud. And sometimes the white cloud cancels out the black cloud.

Anyway, I think the origin of my black cloud was my first day of residency. To sum it up... out of the 2 patients I took care of that day, half of them did not live to see the next day. Not that I was responsible, but it was still traumatic nonetheless. I had patients die the first two times I was on call as an attending physician.

Friday night, this continued. When I came in during the afternoon, here's a partial list of what was left to start -- 3 liver transplants, a heart transplant, and 2 endovascular thoracoabdomical aortic aneurysm repairs in addition to a myriad of other smaller cases. Also on the table was a facial reconstruction that had been going 8 hours so far, an open thoracoabominal aortic aneurysm repair, and liver resection that had lost six liters of blood.

Needless to say I was up all night. Two liver transplants had been finished (I was not responsible for this) the heart transplant also (not me as well, yay) The thoracoabdominal aneurysm finished after 15 hours of work, the facial reconstruction had been going 24 hours with no end in sight, and another ENT reconstruction case had not only finished, but had gone back to the OR 3 times in addition because things didn't look well. At least I was working with good residents and colleagues. It makes things a bit more manageable.