Saturday, July 16, 2011

Fifth Chapter

Fifth Chapter
In which we have a look behind the curtain where broken hearts are mended
   Carol is a CRNA, a Certified Registered Nurse Anesthetist, an advanced practice RN who has a Masters degree and certification in anesthesia. She worked as an OR nurse for two years out of nursing school, then for five years in a Surgical Intensive Care Unit before entering her two years of schooling for anesthesia. Carol describes the delivery of anesthesia as “Controlled Poisoning”. She is not far from the truth in this assessment, as all the drugs used in anesthesia could have been used by the Borgias for their deadly purposes. The original anesthetic was Ether, first used by Dr. Crawford Long in the eighteen forties. A persistent legend has it that the discovery was the result of an ether party, a popular pastime of medical students of the day. Currently, anesthesia is induced with an IV injection, maintained by an inhalant, and supplemented with paralysis as needed. The injection compounds are all descended from the barbiturate family and have included sodium pentothal, beloved of thriller stories as “truth serum”. As anyone who has actually seen it used in the OR will tell you,  it’s use as a truth drug belongs to the same mythology as the karate chop to the back of the neck producing unconsciousness. Propofol, of Michael Jackson fame, is now the IV agent of choice. As mentioned previously, ether was the original inhaled agent, now supplanted by Sevoflurane and Desflurane. Nitrous Oxide, popularly known as laughing gas, is still in use. Curare, the Amazonian arrow poison, was the original paralytic agent, and is now supplanted by Vancuronium and Pancuronium.

   At the moment, she is studying for her yearly recertification in ACLS (advanced cardiac life support). All the OR surgeons, anesthesia personnel and nurses must recertify every year. There are changes in ACLS almost every year as new drugs come out or as research refines the process. Algorithms are used extensively in ACLS to define the steps to be taken for all sorts of events and contingencies that can occur in the course of treating cardiac arrest. Below is a tounge-in-cheek algorithm Molly wrote once after the ordeal of renewing her ACLS:

   Carol worked with the Open Heart team, and was proud of the fact that she was the only nurse anesthetist on the team. There were two Anesthesiologists on the team, as well as three surgeons, one fellow, one resident, two perfusionists (who operated the heart lung machines), and six RNs. The King of Hearts was Dr. Hector Charles MacIntyre, a dour Scottish-American of exacting standards, volcanic temper, and magical hands. Standing a Napoleonic five feet three inches, he was an alpha male to the core. He was addressed as “Sir” by all the members of the team, including his two junior partners, Drs. Haley and Thompson. Behind his back, everyone called him Hector. He was renowned for tearing up residents and fellows, reducing RNs to tears, and favoring everyone else with his biting sarcasm. Hector did not suffer fools. He commanded enormous respect due to his consummate skill as a cardiac surgeon. Carol had once watched awestricken as he sutured up a small tear in an artery on the back side of the heart. His only view of the tear was in a dental mirror about an inch and a half in diameter, so he had to do each stitch backwards and backhanded from what he was seeing in the tiny mirror. He was using a 7/0 prolene suture which is about as thick in diameter as an eyelash, on a curved needle about the size of this capital letter “C”.  

   His temper was legendary. There were few restraints on the behavior of surgeons; without them there would be no patients, and without patients there would be no income, and without income there would be no mahogany in mahogany row. Once when Dr. Alberts, an anesthesiologist, cancelled one of Hector’s cases because he felt that the patient was an unacceptable risk for anesthesia, Hector kicked a trash can standing next to the scrub sink into many pieces. His rage and cursing could be heard throughout the OR suite, most people just giving each other a knowing look and getting on with their work. Jim, one of the perfusionists, went online and printed out a clipart of a trash can which he taped up in the substerile room between the two heart ORs. It was alongside of a caricature of a Bovie machine that Hector had demolished on another occasion, and several cut outs of cartoon figures of a persons in surgical attire, which represented residents Hector had kicked out of his ORs.

   There has been research into the influence of music in the OR. Basically, the findings are that music chosen by the surgeon is beneficial to his performance. Music not chosen by the surgeon degrades his performance. The type of music does not seem to be relevant, be it heavy metal rock or Mozart, what matters is the surgeon’s partiality. Hector did not allow any music at all. The conduct of every member of the team was rigidly defined, and each could have had algorithms defining their practice. The only member of the team with flexibility was of course, Hector. Conversation was limited to only what was necessary for the procedure.

   The usual day began in the first of the two heart Ors. Dr. Haley or Dr. Thompson would begin the procedure, the fellow or resident would assist the junior partner, or harvest vein graft from the patient’s leg as needed, and things would be much looser in terms of conversation, etc. When the critical point of the procedure, such as going on bypass, was reached, Hector would be summoned. Things became tighter. Hector mostly placed the grafts or valves himself, or directed the junior partner as they performed the critical part. When the critical point was passed, he would move onto the second room where the other junior partner would have things ready for Hector on the second patient. In this manner four to six surgeries made up the normal working day. Throw in the not normal days and the team members usually put in sixty to eighty hours per week. In the substerile room, there was a poster that showed a bedraggled nurse sitting on the side of a bed with the caption “When you are sitting on the side of the bed with one shoe on and one shoe off, and you can’t remember if you are getting up or going to bed, you do know that you are a member of this team”. The team was subject to recall at all hours of the day or night as needed.

   Having recently read Joseph Wambaugh’s The Choirboys, Carol was inspired to announce “Choir Practice” on select Fridays, whereupon the team minus the King would rendezvous at McSorleys Pub, just near enough and just far enough away, and definitely not a watering hole habituated by hospital personnel. After a drink or two, Carol had a way of retelling the day’s events that put the “choir” into convulsions of laughter. This past Christmas Carol was surprised to receive an envelope from Hector that had “A donation for the Choir” inscribed on the front. Inside were two crisp one hundred dollar bills. Carol would tell of other unexpected acts of generosity by Hector:

   There was Bobby. Bobby was the bottom rung and lowest paid person in the OR. Ever cheerful, he was the one who mopped the floors, dug the bits of suture out of the wheels of all the OR furniture, emptied the suction canisters of their unsavory contents, washed and made up the stretchers, ran the errands, lifted all the heavy objects and patients for the nurses, took out the trash, restocked the linens and solutions. In short, he made the OR the clean and efficient place it needed to be. Perhaps because of his lowly status, he was able to approach Hector with a familiarity that was not dared by others and was certainly not tolerated in anyone else by Hector. Bobby’s passion was the city’s NBA franchise. He would greet Hector with a big smile and share the team’s latest triumph, defeat, escapade, rumor or bit of intelligence concerning trades or draft picks. Hector would respond on the level with Bobby as if there was no difference in their status. He seemed to enjoy the exchange of basketball trivia with Bobby. No one else, not even the junior partners, got that kind of attention from Hector. One day, there was a big change in Bobby. Gone were the smiles and cheerful demeanor. People wondered if Bobby had a death in the family. He wouldn’t talk to people. Reading the sports’ section of the paper, it fell into place. It was announced that there would be an unprecedented hike in the price of tickets for the team’s games. A little calculation revealed that even Bobby’s usual nosebleed section season tickets were now out of his reach. The next day Bobby found a blank envelope taped to is locker door with two courtside season tickets inside.

   Then there was Rhonda, a single Mother, nurse, and not even a member of the heart team. Her son developed a rare metabolic disorder. It turned out that the only physician treating the disorder was in California, three thousand miles away. Hector chartered a plane, and paid for a hotel for Rhonda and her son to make the trip out to California.

   As much as it bothered her, Carol found that patients tended to blend into one another, and unless there was something special or remarkable about one, they were soon forgotten. A name might come up in conversation that would be familiar; but it would require more than just a name or face to retrieve a memory. Given the volume of patients through the heart ORs this was perfectly understandable. There were however two patients that Carol would never forget.

   Frank was one of them. Carol first saw Frank in the ICU. She had gone up with Dr. Miles, an Oral Surgeon, to sedate an upcoming heart patient so that two bad teeth could be removed. This was a not unusual situation. Bad teeth acted as an antibiotic resistant reservoir of bacteria that might cause endocarditis (an infection of the lining of the heart cavity) in an otherwise healthy person, but it was a certain outcome in patients undergoing heart procedures. Reviewing Franks chart, the history and the numbers painted a picture of someone barely hanging onto life. Frank was only forty-four years old. Entering Frank’s room, the first things to strike Carol’s eyes were a number of papers on the walls. They were crayon drawings with legends such as “We Love you Daddy” and “Please get well Daddy”, obviously the work of at least three small children. Carols felt a tight squeeze in her own heart. Frank was already barely conscious, it didn’t take much to sedate him, and the two teeth were quickly removed. Afterward Carol reflected that there must be a great strength inside of Frank to keep him alive at all. The next day Frank arrived in the Heart OR. During the procedure it became apparent that there was extensive damage to his heart, and blockage of the coronary arteries that the stents placed by the cardiologists did little to relieve. Never the less, he made it out of the OR to the ICU. Over the course of the next couple of days, Carol quizzed the junior partners on Frank’s progress. They reported astonishment at the speed and strength of his recovery, and he was discharged to cardiac rehab in near record time. At the last report, he was home and back to work.

   The second was David. At twenty-nine, he was the youngest patient Carol ever had in the Heart OR. David had Marfan’s Syndrome, a genetic disorder of the connective tissue, which forms the structure  and support of tendons, ligaments, blood vessel walls, cartilage, and many other structures. People with Marfan’s Syndrome are often tall and thin, particularly long in arms, legs, fingers and toes. Eye problems are common. Often it is said that Marfan’s Syndrome victims look like Abraham Lincoln, and there has been much speculation as to whether Lincoln had Marfan’s. In the most severe cases, the heart valves are affected. The aortic valve does not fully seal, blood back flows into the heart, causing it to enlarge, and increases the hearts workload. The Mitral valve prolapses, a less significant problem, but contributing to poor oxygenation of the blood and poor circulation.

   David had already had repairs to both of his aortic and mitral valves, and when the repairs broke down, replacements of both valves with artificial ones. Now the artificial valves were dehiscing (separating) from the heart. Because of the difficulty of the situation, a minimally invasive procedure would not be possible as was done previously. This would be old school, involving splitting the sternum and opening the chest wide.

   David went under anesthesia and onto bypass with the heart-lung machine without incident. The valves were exposed and removed. Hector measured carefully for the size of the new prosthetic valves, and special horseshoe shaped reinforcements so that the heart would not dehisce from the valves so readily. Hector placed each suture with great care, placing a clamp on the ends, and then clamped to the drapes so that they were arrayed like the rays of the sun instead of tying them down immediately. When all thirty eight sutures for the aortic valve and twenty nine for the mitral valve were in place, they would then be knotted and the ends cult off. This was to ensure that the tension of the sutures would be even. Denise, the scrub nurse, gave alternating green and white sutures to Hector so that each would be tied without mix up with its closely neighboring sutures. Everyone collectively held their breath as Hector knotted the sutures down, praying that the delicate tissues would not tear. At last the valves were in place, and the heart walls closed. Hector called for the internal paddles, placed them on either side of the heart, called out “Hit It!. Kerry, the circulating nurse pushed the discharge button on the defibrillator, and the electric shock was delivered directly to the heart. It didn’t start beating. Hector ordered the voltage increased. “Hit It!”. The heart didn’t beat. “Restart bypass” Hector directed. The roller pumps began spinning again, squeezing blood through the clear plastic tubes. Carol ran down the status of the electrolytes and the levels of oxygen, carbon dioxide, bicarbonate and pH of the blood. She had been sending off tubes of blood for these tests, called “blood gasses” at regular intervals. The numbers were all good. Hector said, “Give it ten minutes on bypass to rest the heart, and then we’ll try it again”. In ten minutes, the process was repeated. No beats. Epinephrine was given directly to the heart. No beats. It was all repeated again and again. After an two hours of every technique and trick he knew, Hector faced the inevitable. David’s heart would not beat on its own. For the first time ever, Carol detected defeat in Hector’s voice. “Turn it off. Time of death..” He looked up at the clock, “Thirteen twenty-six.” Kerry choked back a sob, Denise was frozen into immobility and looked lost. Hector slowly, silently stepped away from the table and stripped off his gown and gloves, pushed through the door, and trudged off to talk to David’s family.

1 comment:

Anonymous said...

i hope you continue this series. very educational and entertaining!