DB Week 3

VSD patient

As I mentioned last week, her occulder install didn't go well. There was no way to plug the remaining hole.

I saw her every day on rounds, during the attempt to patch her VSD, during her diagnostics, and through multiple TTEs and TEEs. I saw her suffer from being intubated and from being stuck in the hospital. I saw her family many times, seeing how they became understandably more distraught as things progressed.

On Thursday they were consulted and agreed that she should not be kept on support. Examining her documentation at a computer terminal, one of the items was a DNR, a do not resuscitate order.

The family’s decision was consistent with my thinking, but seeing the DNR made it real.

She was taken off balloon pump support Friday afternoon and passed away early the next morning, according to the night watch nurse.

The doctors and the cath lab would like to have an autopsy done. Indeed it would be amazing to have seen the occulder placed, located on echo, and then to physically see it in place and finally know the topology of her septum.

CT surgery

(AVR) My first open heart surgery was an aortic valve replacement. Seeing the open heart for the first time was awesome, as well as seeing a bypass machine in the flesh. It was hard to watch the details because so many students were around.

To remove the old valve, they simply ripped the calcified leaflets off the valve bit by bit. They used a large number of sutures used to install the prosthetic valve, attaching one end of each suture to the prosthetic and the other to the aortic root (I’m guessing, couldn’t see).

I also was able to observe the patient’s atrial fibrillation. It’s amazing to see something that you would only ever see on an EKG as a different wave form. EKGs usually make me feel detached from the reality of a beating heart, but now I can actually visualize the data on a real heart.

(4xCABG) My next surgery was a quadruple coronary artery bypass graft. At the start, one doctor was sticking a scope up the patient’s leg. There was a pink rope looking thing dangling in side of the patient, which she proceeded to clip it and pull it out. I quickly realized that this was one of the veins they were using to acquire the grafts. The doctor injected them with saline to make them expand (they are super contracted without any pressure inside of them). Simultaneously chest cavity was prepped.

Two surgeons, one a fellow, began identifying the anatomy of the patient’s heart to locate the bypass areas. Some of these were inconveniently located such that a helper had to come and pull/hold the heart at the right angle for access. Fortunately, I was able to see the more straightforward graft in detail. The surgeons carefully placed sutures into the vein and the bypass sites. The fellow made a few mistakes, but the doctor calmly/frustratingly tell the fellow how to either fix an error or to just move on and avoid repeating it. It was very interesting to see someone make a mistake during open heart surgery and see the doctors keep their cool. At one point the fellow was getting yelled at after a mistake. I could notice her hands shaking, but she quickly continued the procedure. The doc also switched back to a calm mode immediately. Lucky for me, this let me learn a bit about suturing techniques.

Before the procedure, the patient’s left ventricle appeared very weak on TEE. The LV was only displacing slightly and was not contracting in most directions EF~=30%. Afterward, the LV was displacing and contracting on all axes EF~70%. It was a reassuring to see a dramatic, quantifiable improvement after such an involved procedure.

More Rounds

I also visited the NICU and PICU this week. I found discussions with the parents to be the most interesting.