Tamponade

(preamble: I've been told by a good friend that sometimes my stories feel like they are over her head. I'm sorry. Most of these anectdotes are written for medical professionals rather than the lay person. But I don't want to exclude the lay person so I'll try to explain more as i go along. Sometimes though the stories need to be written in a technical way. i'll try to do better... today's story will be technical.... i'll call you later and I can clarify things)

I've been on cardiac call this weekend (as faculty). This means I sit at home waiting for my pager to go off, dreading any possible emergency cardiac cases that come in. I'm usually a wreck all weekend for two reasons. One, i know as soon as I plan to do something like meet friends for lunch or go to a movie, Murphy's law will kick in and I will get called in. Two, as a relatively new cardiac faculty, I'm probably not as confident in my skills as I should be and I have doubts about whether I can handle what comes it.

At 2:45 this morning. I get a page... "emergency bring-back bleed.... phone number blah blah blah" I call in and someone's coming straight down from the ICU. Now this isn't all that unusual. People have heart surgeries all week long, and sometimes they bleed more than they should afterwards. They ooze for a few hours, they are indecisive about coming to the OR... finally in the middle of the night they decide they've had enough and need to operate. They come down to the OR, the surgeons poke around a little and they use their electrocautery to buzz a few little blood vessels, say they can't find much, and then you go back upstairs. No big deal. The reason this is considered an emergency is that there is a possibility that there is a major bleed somewhere and it can compromise the way the heart functions. The heart can stop working because there can be blood clot all around it (rather than blood pumping through it)

So I assume it's one of those slow oozing bleeders, but you need to come in anyway and take care of the problem. I roll out of bed, do my best to fix my bed head and hop in the car. I'm at the hospital within 15 minutes, and changed in the locker room less than 10 minutes later. I walk into the OR expecting the nurses to be setting up and waiting for me to bring the patient down. Instead I see the general call residents and staff hovering around the patient. She's pale looking and her eyes look like they're half rolled back in her head. Now I'm thinking "aw, crap... this is for real" The cardiac surgery resident is throwing a few lines and we're scrambling to get this patient ready for surgery.

Now this is one of the special circumstances in anesthesia. You need to have the patient ready for surgery BEFORE they go to sleep. These compromised patients are using all their reserve to keep up their blood pressure, catecholamines rushing though their systems, peripheral vessels clamped down, all trying to compensate for this unstable state. When you put them asleep this relaxes their compensation and they can "crash" as soon as they're asleep. Also our medications to put you asleep tend to lower your blood pressure too. So to combat this, you have them prepped and drapped for surgery with the surgeon standing there ready to operate as soon as they are unconscious.

The cardiac surgeon pops his head it to see what's going on. His resident lets him know that this is the heart transplant patient from earlier in the week and that they need to get started NOW. They wash hand quickly while the nurses rush to prep the field. The drapes go up. And they let me know they're ready. I put the patient asleep and they get started immediately. My anesthesia resident puts in the breathing tube under the drapes and the surgeons open up the chest. Immediately you can see blood welling up out of the chest and a squirting bleeder. Immediately the blood pressure drops. We've lost about 2 liters of blood in about 10 seconds. We get the rapid infuser going and pump in some blood quickly and I give the patient some epinephrine(one of our stronger drugs) to get the blood pressure back up. Luckily they get the bleeder under control and about 2 hours later we get back up to the ICU.

We were pretty lucky today. I can help but think that if it had taken me 10 more minutes to drive in, or that if the team in the hospital hadn't been so proactive in getting the patient to the operating room that this lady might be dead. I'm relieved.

It's 530 am. I'm tired, i'm thinking of going home. I over hear the cardiac surgery resident, "blah blah blah accepted a lung transplant blah blah blah..." I know I'll be back later today.