Excerpts From Heart Surgery in America: Pump Zombies

Editor’s Note:

This book is NOW over 3/4 written,

It is a rendering of the reality, sometimes sad and at times funny, emotional, and clinical vignettes of the many different aspects relating to open heart surgery- from the perspective of a perfusionist. This book is a commentary not only on the intricacies of heart surgery, but openly engages and describes the peaks and valleys of ethical or moral successes and failures.  It highlights moments where lives are saved by the strength of the character of the team- as well as surgical strategies undone by flaws imbued in the highly trained individuals living and breathing this volatile work environment.

Here is an Excerpt from the book 🙂

Pump Zombies

I woke up at 9:30 this morning having gotten up at 5 o’clock am the previous day in order to do a case that lasted until 1130 or so last night. This is one of those cases that you knew was going to be hard, and hits that imaginary wall that we all know we encounter once in a while where fatigue wants to  overwhelm you but you march on minute by minute, and continue what may appear to others as a task orientated plan of attack, but in all reality it is you having just transitioned from your everyday self to become a pump zombie.

Now being a pump zombie, or transforming into one, doesn’t mean that you become a distorted silhouette of yourself, moving as if you truly were half dead, and although your mind tricks you into thinking that you are moving slow, in all actuality you’re working at close to normal speed but your brain is processing details so quickly that time sort of slows down- and minutes turn to a lot of minutes so to speak. You have hit the wall, met the wall, and now you have broken through the wall to do what it is that you do best – keep this patient alive, fix whatever issues are at hand that are required to sustain a human life, and trudge on, and on, and finally get to that mythical promised land – getting ready to wean from cardiopulmonary bypass.

You find yourself combating hyperkalemia due to the prodigious amounts of potassium chloride that you have administered giving cardioplegia  continuously to protect the myocardium that you somehow got to 6°C. During that process of course, you find yourself doing a balancing act walking that fine tight rope as you titrate insulin to offset the hyperkalemia and at the same time sprinkling in a few small aliquots of D50 in anticipation of secondary hypoglycemia. We get a lactate with every blood gas which along with cerebral oximetry were parameters that an old-school perfusionist such as myself, never learn to rely on during my early days of practice simply due to the fact that that particular technology was not yet available.

For some reason at this particular institution, our TEG monitoring is a joke, as all of our preop TEGs come in as normal, and our re-warming TEGs are equally normal, and in almost every case with that tandem of results in our hand, supposedly to guide our clinical decision-making, we end up giving an ungodly amount of blood products in spite of TEG results that suggest there is no coagulopathy.

Clinical inconsistencies such as this are what separates the seasoned perfusionist from the novice. That is not to suggest that as experienced perfusionists we emulate any sort of ostrich metaphor in terms of hiding our heads in the sand so that we can’t receive pertinent clinical information that we will then have to interpret, analyze, and come to some sort of game plan as to what ever that information we just received is telling us is wrong with the patient.

All roads and pathways eventually lead to a conclusion, the point A to point B meme does indeed have an endpoint, thank God for that.  And all of a sudden- Wow! You have finally arrived at that moment where you are no longer at the mercy of some sort of ill-fated humors, misaligned mojo/karma, or the divine intervention thang, but instead you stand before the sum total of the labors that you yourself invested, in an effort to sustain life and get the patient to the point of where we can actually separate from cardiopulmonary bypass. Time to see if all that stuff you did, whether it’s home cooking, gut instinct, or meticulous application of sound physiological and scientific principles, (regardless of what paradigm you employ to get from on-pump to off-pump successfully), you have arrived there now and it’s time to see the summation of all you have wrought.

While I woke up at 9:30 this morning, as I stated earlier, my first phone call was to our nurse practitioner to assure that yes indeed the patient we had successfully weaned from cardiopulmonary bypass the night before, was doing well. There are so many details that we all encounter during these lengthy processes when pump runs extend far beyond the normal two- or three-hour time line, and sneak past the seven-plus hour mark.  So many thoughts, actions, and decisions having been made in that period of time, all of them significant and necessary to assure a good outcome- that trying to retrieve them this morning is almost like the fog of war now- that mile long stare that people see when they encounter soldiers walking back away from the front lines-  an empty vacant hindsight into last night’s grey scale kaleidoscope of interplaying abstracts and vignettes of a myriad of focal events during the operation.

There really is no report card when it comes to scoring any heart operation of the magnitude of the one we just performed. Patient survival does not necessarily denote an “A”, nor does the unanticipated morbidity confer a grade of the lesser rank. People are not pieces of paper upon which multiple-choice or essay questions are checked or written. Complex heart operations simply cannot be described as purely black-and-white, as it is the gray areas, the sublime moments of clarity or lack thereof – that lead to either making a great decision or committing to poor choices.

When problem-solving and selecting a proper course of action during the application of your trade it’s the gray areas that wake you up at night, the black and white moments are more concise and less susceptible to negotiation when reliving either positive or negative moments of the most recent operation. In this particular case, there were quite a few moments, but all were dealt with swiftly and effectively. When running a marathon, the athlete never focuses on the finish line rather a lamppost along the road that is within his field of vision, thus relegating a somewhat enormous distance into smaller more manageable segments of the race. In every heart operation that I’m involved with I always maintain a global perspective, but when in the heat of the battle I am more of a point A to point B kind of guy. It works for me, and it allows me the luxury of being able to ask that patient the very next day what the square root of 144 is and getting the appropriate answer. It’s always noon somewhere (12).