Hey, everyone!  I’m up to my elbows in hearts this week, the second week of my cardiothoracic surgery rotation.  This week focuses on adult cardiac surgery.

It was very long, but amazing and eventful day.  In no particular order:

  • This was my third scrub-in.  Scrubbing in is where you’re sterile, and at the table with the surgeon(s), the scrub nurse, and the patient.  Today the surgeon was assisted by a surgical resident,  but often, it’s a PA.  So it was me and the surgeon on one side of the patient, and the resident and scrub nurse on the other side.
  • Doing surgery on a structure on the inside of a heart is like building a ship inside a bottle, if the bottle were in a bag that is inside of a box.  The bottle is the inside of the heart, the box is the pericardium, and the box is the opening in the sternum.  Once the heart is open (through the right atrium, which sits toward the front of the chest), you can only get to the mitral valve on the left side of the heart by cutting through the interatrial septum.  But once you’re in there, the mitral valve isn’t just looking up at you because it’s oriented front to back, not up and down.  Kind of like building a ship that’s in a bottle, on it’s side in a bag, in a small box.  How?  Long forceps, long needle drivers, and telescopic lenses on the surgeon’s headgear (as above).
  • The wound is so deep that I had to stand on a raised platform so that I could peer deep down into the chest.  For most of the day, my face was about 2 feet from the surgical field.  Amazing view!
  • Knowing nothing (relatively speaking), I focused on two things: helping anyway that I was able, and not causing a problem.  If I had any doubt doing something, I didn’t lift a finger.  I some instruments, suctioned a lot of blood, and helped to keep all of the tubes, wires, instruments, towels, etc. straight.  At several points I was needed to to hold a structure to the side with my Yankauer suction while something nearby was carefully sutured.  Just for fun, the surgeon had me reach in and feel the diaphragm, which was a much stouter muscle than it looks in a textbook.
  • There were multiple problems that needed to be corrected, so it was a long surgery.  I started at 6:30 AM, and saw it to completion at 6:30 PM.
  • I stood next to the surgeon and helped in any way I could for 10-1/2 hours!  That’s 10-1/2 hours without eating, going to the bathroom, scratching your nose, turning around, or stepping away from the table.  I wasn’t going to surrender the second-best seat in the house for anything short of an earthquake.  Besides, surgery is a no-whining specialty.
  • Yes, my back and feet are really tired and sore at the moment.
  • To do open heart surgery, as we did today, the patient is put on heart/lung bypass.  The large vessels, one at a time, are cut into and “cannulated,” or connected to the bypass tubes.  The bypass machine oxygenates the blood, and returns it to the body.  The heart is out of the circulation loop (hence the term BYPASS).  The heart is then stopped with “cardioplegia,” which is a solution of potassium.  The potassium hyperpolarizes the heart’s muscle and pacing cells, which causes it to stop beating.  The heart is then periodically cooled with ice, which decreases the heart’s s need for oxygen.  Once this is complete, the heart can be opened and doesn’t need to be circulated.  The perfusionist controls the bypass equipment, which controls the pressure, temperature, vessel of flow, direction of blood flow, and medications, depending on what is needed during the operation.
  • open heart surgery

    The valve "parachutes" into the bottle, within the bag, within the hole. The many tubes that can be seen connect to the heart/lung bypass unit.

    During open heart surgery to replace a valve, 9 to 12 suture lines are run through the annulus (ring) left behind in the heart where the original valve’s leaflets are cut out.  The sutures are then run through the annulus on the replacement valve.  When all are the sutures are pulled simultaneously, the valve “parachutes” down into the heart, right where the old one was.  Each suture is tied securely in place.  Voila – a new valve.  FYI – this is not a patient from my rotation.

  • It doesn’t take long to lose the sense that you’re operating on a person.  There are drapes over everything, including the head.  Once on bypass, the heart isn’t beating, and the chest isn’t inflating.  It’s an eerie thing to see.  The patient was without a beating heart or breathing lungs for about 7 hours!
  • Tomorrow at morning report, I have to verbally present the patient to a team of surgeons, interns, and residents, and it’s no simple patient.  Intimidating for sure, but this is what I signed up for.  I don’t know if I will ever practice surgery as a PA, but I wanted to get the full surgery experience, and I’m definitely getting it.

I’m up at 4 AM tomorrow to go back and do it all again…