October 31, 2011

You just stop stopping it

When asked how you restart the heart after stopping it temporarily to put it on bypass, the perfusionist said to me:  "It's zen-like, really, you just stop stopping it"

Thursday around noon I scrubbed into my first Cardio case - a CABG (coronary artery bypass graft) surgery on a 74 year old woman who we'll call Elizabeth.  The procedure is done by taking a blood vessel from somewhere else in the body (in this case, the saphenous vein in the leg), disconnecting it from its normal place and reconnecting it to the heart to bypass a clogged coronary artery (artery that supplies your heart).  It's a pretty awesome procedure, but it's also done often enough that the expectations when you have one is that you'll be in the hospital for 4-5 days then go home and have to take it easy for a while during which time you feel so much better because your heart is working well again.

Needless to say, if that was the way this surgery went, I probably wouldn't need to blog about it.  I wrote a five page journal entry of everything that happened and my reactions to it, but I'll spare you most of that and just tell you what I'm still thinking about a few days later.

The surgery started out fine and routine, certainly not light-hearted, but pleasant.  Then slowly but surely everything started to go wrong; we couldn't keep her blood pressure high enough to adequately perfuse her organs, we couldn't get the wound on her leg from where we took the vein graft to stop bleeding, her right ventricle wasn't moving enough to pump blood through to her lungs, her skin was too thin to put stitches in to keep her chest closed.

20 hours and two additional surgeries later, she was left with an open chest where her heart had been attached to an external pump called an LVAD that was pumping blood around her right heart to give it a rest, a ventilator on her face attached to oxygen to make her lungs breathe, a line in her jugular vein, in her femoral artery, in both her antecubital fossas (inner elbows), her legs were stitched together along the whole middle side, like the seam of pants except her skin, she was bruised and swollen from the poking and the fluid and blood we had given her to try to keep blood flowing to all of her organs.

I went home at 4am, exhausted, wondering if she would make it through the night.  The next day I was in the operating room with a bariatric surgeon from 7am until I got a break at 3pm, so as soon as I got out of the OR I went to check on Elizabeth.  She was in the cardiac intensive care unit in the same state but even more bloated and with even more wires connected to her.

The surgeon was just coming by to talk to her family again and invited me to come to that discussion, so I went with him and heard Elizabeth's two sons and their two wives (who happened to be sisters, oh Maine) tell the surgeon that their mother would never have wanted to live like this.  Before deciding to have the surgery, she had decided her code status would be "Do Not Resuscitate" specifically to avoid this situation.  However, the surgeon did not want to accept that they would stop trying and just kept repeating, "we've done almost everything, but there are still a few things we can try; her left ventricle looks great; it's not likely but there's a small chance she will recover in some way; I can't say definitely that she won't have at least some turnaround"

I wanted to scream at him: they're saying that's not good enough - that some turnaround or a small chance that she will recover in some way is not enough of a reason to put her through this suffering.  They're saying they are ready to stop all this intervention.  But he kept pushing it: we can give her more blood, we can run some more tests, we could maybe do another surgery.  To Elizabeth's family's credit, they cried and lamented but they were clear - she would not want this.

When talking about it with another one of my attending from the trauma surgery service later that day, he described this behavior of surgeons: when they don't seem like they are listening and they just want to keep pushing even though it's time to stop, as Tunnel Vision.  He said, and you want them to have tunnel vision sometimes because it takes such focus to take a vein out of your leg and sew it to your heart and have you walk out of the hospital a few days later able to breathe and move again.  But this same focus sometimes makes it hard to see the person as a whole person, as a whole life, instead of just the organ they're working on.  This attending and I also talked about how to have conversations with families where you give them information that their family member is dying - how it should be straightforward, as objective as possible, laying out the options as clearly as possible, and how you should mostly be listening.  The biggest thing, he said, is that it never gets easy - even when you've done it thousands of times, it's always hard to tell someone that someone they love is dying.  And it should be.

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