What a first week it was! First of all, the city has been much nicer than I expected. I had only ever been to midtown and expected everything to be just like that, but thankfully this is MUCH calmer and quieter. I actually can't express how great that is, midtown just isn't really my friend. But, maybe we'll become friends. I guess we'll know in another few weeks. Overall though, I couldn't be happier - and will final revisions of review articles from the semester now done and sent off, I feel like I can breathe, dive into the city, and actually start immersing myself in the hospital
In terms of work, things have been a little overwhelming. I don't actually have a research project and it doesn't seem like there will be one available for me via cardiothorasic. Furthermore, I don't actually have a mentor. I'm just a person who bops around the department but doesn't really have a home. This wouldn't be too bad, but, it doesn't seem like anyone is particularly keen on adopting me either. And the lingo, oh the lingo! As I learned today though, this may be a function of the team I'm currently with. Most chiefs do one, maybe two, open heart surgeries a day. The Doc I'm currently with, Dr. Giraldi, is a beast and does at least three a day, and sometimes more! Time is tight, and no one really talks to me and generally is pretty dismissive when I talk to them and try to ask questions. It doesn't really help that we literally go all day. We start taking patient information at 6am, fellows round to check on everyone at 7am, then attending rounds are at 7:30am followed by a review of everyone's chest X-ray. Then, it's a quick (literally really quick, the longest one was maybe 10-15 minutes to discuss four patients!) stop by a imaging room to look at the CT scans, and echocardiograms if applicable, of the patients who will be operated on. Then its into the OR from 8am until 6pm.
The OR though is really something else. It's silent. And when people do talk, if you are more than a foot away from them its almost impossible to hear. The whole thing is a well oiled machine. The patient is draped in such a way that their body is used as a table and there are pockets for tools (primarily suction, tubing, and cauterizers) along the entire length of the body.The techs responsible for handing instruments up know exactly what the doctor needs and when they need it. They have to, because, as I mentioned, no one talks. The doctors just put their hands out, and the tech hands them a tool all ready to go. Only if something deviates from the pattern, or a tool malfunctions, do the doctors ask for a specific thing. The longest conversation I heard was between Dr. Giraldi and one of the techs because they were slow. He asked if she was okay, and if she needed a break, cause if she did, she had better go take a break and let someone cover for her. Well, and the anesthesiologists talk a lot before the surgery with the chief explaining things or going over hypothetical situations with his fellows and residents. So, I made friends with them because they know a little more than I do and they will occasionally lean over and clue me in as to what is going on during the surgery.
So far I've spent almost all of my time in the OR. I've seen a total aorta replacement, a coronary artery bypass graft (CABG, and pronounced "cabbage") and a reop aneurysm + arch replacement /CABG. The main piece of advice my fellows gave me was to spend time looking up the procedures outside of the OR so I knew what was going on. Today, since Dr. Giraldi is away and doesn't have any cases I'm trying to get caught up on terms and procedures from last week. The total aorta replacement was my first, and most intense surgery. The patient had Marfan's syndrome and this was his fifth open heart surgery. They had to put him under circulation arrest (i.e. there was no blood flowing through his body) for the whole procedure. Even with this, they were having a hard time preventing flooding, which kept they from retrograde perfusing the brain (they perfuse in that direction because the veins don't get calcified so it decreases the risk of dislodging something from the wall that will cause a blockage due to flow profiles that deviate from physiological conditions) and the aorta was so calcified that they struggled to insert the needle to sew on the graft. The graft itself is made out of some polymer, I don't know what, and looks like an accordion tube! I need to do more research into this.There was no blood flow to the brain for just over an hour. There were some concerns post-op, but the patient is recovering fine!
For the CABG surgeries, they harvest the femoral artery endoscopically, and then reattach it to the heart like a sash to deliver blood to ischemic parts of the heart. The 86 year old lady, where this was her main diagnosis, had a waxy yellow/white looking heart compared to the other cases I think because of plaque and loss of oxygenation. The tool for harvesting the artery is pretty cool. Its a ram rod to make space around the artery that then has attachments for holding the artery out of the way, cauterizing the cuts that detach the lesser arteries, a water hose for flushing, and another tool to cut. Once they remove the artery, the nurse finds all the branch locations, trims them off, and sews the holes shut. All the while she tests the integrity using a heparin sulfate filled syringe to blow up the artery like a balloon.
Other than that, fun facts include:
1) They use two different kinds of saw to open the chest. One is like a jig saw (first op), and the other is like a saw that you use to cut plaster to minimizing vibrations (re-op).
2) The pressure sensor is a two-part thermocouple that has a high temp pulse up stream and then measures the amount of heat that remains downstream to determine volume flow and then convert to pressure.
3) During surgery they decrease the temperature of the heart (called pleging (sp?)) to around 10 C by pumping cooled fluid and packing it in ice to decrease metabolism.
That's all for now! Dr. Giraldi is away for most of this week so I'll be mostly around other areas of the hospital this week.
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