Well, it’s been a few months and I have completed some of my rotations where I was acting chief resident but for the past month (give or take a couple of weeks) I have been chief resident on Cardiothoracic Surgery. It has been a stretch for me since I love thoracic surgery but hate the cardiac stuff. If I am going to sew down a graft, I want to sew it down in an extremity and not in the chest. I have to admit that I really enjoy the CT office patients though. It has been fun to work them up, review their caths and get them ready for the OR.
Every patient comes with a CD-ROM that contains movies of the cardiac cath. Thanks to my CT surgeon, I am getting very used to reviewing these and plotting a strategy for the surgery and post op. I can actually tell from the cath how much of a problem the patient will have post-op. I am also getting a good review of my autonomic pharmacology.
We are using a drug call Trasylol for most of out patients. This cuts down on cytokine release after being on the pump. It also cuts down on bleeding so patients need very little blood. I am also closing all of the chest incisions with wires and Dermabond instead of sutures. The incisions look good and stay cleaner. The patients go home with glue instead of sutures which works great.
I have one case that I will likely publish next month. It was a thoracic case that turned out to be a great surprise. I am now getting the literature together but it will be a neat paper.
Well, off to study. I have to finish a presentation on esophageal replacements. Should be fun with lots of photos. One of the guys that was my chief resident when I was an intern has just been appointed to the Trauma Surgery faculty here. I am sooo happy to have Jeff in Cleveland. He was the first person who showed me how to do a perc trach. He is just the greatest teacher and I will be doing some things with him so totally cool.
Well another week ends on the Cardiothoracic service. My patients are doing well and I said farewell to one of the best interns that I have ever had. Her shoes will be difficult to fill. She started the service knowing almost nothing about cardiothoracic surgery and finished being able to handle most of the service problems on my days off. She is on her way to the University of Cincinatti to do an elective in ENT, the residency that she will go onto at the end of this year.
For the uninitiated (and unwashed) M & M is the dreaded weekly event where the chief residents have to explain any complications on your service. You have to defend every part of the patients operative procedure and care. The attending physicians grill everything that you generally do not think about with patient care. It is supposed to be a learning exercise but it becomes a general “slug-fest” on some Wednesday mornings. These sessions are generally the most stressful part of practice and every good surgeon gets grilled and becomes better. On the Wednesday coming up, I have to defend a death on my service.
I have memorized every moved that was made during the surgical procedure. I can justify every decision that I made during the post-operative care too. The patient died on my watch and this patient was my responsibility. I can’t say that I am looking forward to this session but I can say that I am prepared. This is the side of medicine that they do not teach you in medical school and this is the side of medicine that prepares you to defend your actions in a court room should this become necessary.
Generally, you bring radiographs, photos, autopsy reports and photos, operative film footage, cath reports etc. and you present the hospital course from beginning to end. As the chief resident, it is my responsibility to justify every decision that was made in this patient’s care. The attendings all sit around and ask questions such as why didn’t screen for this and that? Why did you decide to do a Hartman’s procedure instead of a loop ileostomy and come out? Why did you use dopamine instead of phenylepherine? Why didn’t you float a Swan earlier? When did you decide to re-intubate the patient? There can be hundreds of questions.
Mortality and Morbidity is closed to all except physicians. (Geoff had a rare opportunity to observe one of our milder sessions when he shadowed me a few months back) It is our way of investigating all complications and deaths. It is also our way of keeping a very high level of practice.
Can’t say that I am looking forward to my upcoming session but I will defend my actions. Did my patient get good care? A resounding, “yes” but the outcome was bad. Could this have been prevented? After conference with one of the specialistes that I colaborated with, I do not think that this death was preventable. It is likely that my attending physicians will not agree with me. Would I change anything that I did in this patient’s care. No, I would not. Upon that point, I am certain. It’s all part of being a surgeon.
I know you will do well in defending your surgery and aftercare in the M&M meeting Wednesday. If you are sure that you did nothing wrong, then I am sure you are correct. People die, with or without surgical intervention. I am sure you will handle the attending’s questions and challenges admirably.
Anyone whose ever had any surgery should know that there are always risks. And, those risks are greatly increased with cardiovascular surgery. After all, the cardiovascular system is one of the two centers of our living (can’t forget the tired old brain). And usually, if you have to have CV surgery, it’s not in the best of shape to begin with.
Anyway Nat, I know you pretty well. You’ll handle it with dignity! Keep up the good work.
M & M went very well. I was able to defend all of the decision-making in my patient’s care. I had one small mistake in my slide that was easily corrected by my attending. It was also a good learning experience. When you put on this mantle, you put it on for 100%. Every piece of every decision can come back to haunt you and you have to justify everything that you have done in the patient’s care whether the patient lives or dies.
I did two great thoracotomy cases yesterday. I always find the lung cases totally absorbing. They are not technically difficult but management is something of a challenge. I was able to get the fluid balance exactly correct, something that can cause headaches when there is significant pulmonary hypertension. My favorite drug is milrinone.
My intern is rapidly getting up to speed once again. I guess I must be a pretty good teacher. He was pulling wires and chest tubes like a pro.
Natalie you are my surgical hero! If I decide to be a surgeon, you’re top on my list to get in touch with!
Also, thanks for the response on SDN
You’re a hero for me, too!
I’m glad to hear it went well! That’s no surpise though. Thanks for telling us about your experiences!
I have been doing lots of lung surgery on this rotation. One of my faculty members has been a superb instructor in doing these challenging cases.
We first enter the thorax most commonly through a posterolateral thoracotomy incision. This incision allows us to obtain access to lung parenchyma and esophagus if necessary. We place the patient in a lateral decubitus position with the side of interest facing up. It is of paramont importance that every pressure area is thoroughly padded. Anesthesia assists us in the patient positioning.
Other things that anesthesia becomes key are: providing epidural placement for pain control post surgery and intubation with a double lumen (Carlin’s tube) so that we may deflate one lung for operation while ventilating with the other lung. Anesthesia also reviews the pre-operative pulmonary function tests to ensure that the remaining lung is able to provide enough respiratory function to support the patient during the case. Here is where that respiratory physiology comes in. When medical students complain about the difficulty of pulmonary physiology, I can give direct examples of what you absolutly need to know as an anesthesiology and thoracic surgeon before you make the first cut. Learn this stuff well because a poor decision can mean death for the patient. The anesthesiologist is also the master of neurofunction in the thoracic level. The optimum epidural provides post-operative pain relief but allows the patient to ambulate and take deep breaths. Too much epidural and the patient is too numb; too little does not provide enough pain relief for good pulmonary toilet.
Now the patient is intubated and anesthetized with general anesthesia. The double lumen Carlin’s tube is in place and I make an oblique incision from a point between the spinous processes and the medial border of the scapula inferiorly to about one fingersbreath below and in front to the tip of the scapula. First I cut through the skin using the scalpel and then use electrocautery to divide the latissimus dorsi muscle. I typically cut through facia near the serratus anterior but not through this muscle. It can be mobilized for more exposure. I will buzz little bleeders as I go. The less bleeding the better the case. Any larger vessels may be suture ligated. I also make my initial incision over top of the fifth rib and then I enter the chest cavity through the fifth intercostal space by just dividing the intercostal muscles (You should know their names and where the blood supply is located). My assistant will elevate the scapula with a retractor and I use a periosteal elevator to gently sweep away the periosteum and get down to the pleura. I will enter the pleura at this point and then use my finger to sweep the lung away. Great care is used not to cut into the lung parenchyma as it may be adherent to the pleura at this point (Second years: Why is this?). Once the pleura is entered, the lung usually drops away (OK you first-year students, why does this happen?) I can also ask the anesthesiologist to deflate the lung at this point too. Once I get into the chest cavity, I use a rib spreading retractor to retract the ribs so that I can sweep the lung parenchyma to the side and expose the hilum of the lung. There I can divide the bronchi and vessels to resect any lobe (lobectomy) or the entire lung (Pneumonectomy). After the surgery is complete, I close the incision in reverse order but place a thoracostomy tube (chest tube) that will go to underwater seal and suction. (Again why do I do this?)
The post operative care of these patients involves respiratory therapy to administer pulmonary toilet.Nursing to get the patient out of bed and deep breathing. Anesthesia continued for post-operative pain control. I will write orders for these patients to do incentive spirometory every 30 minutes between the hours of 8am and 10 pm along with nebulizer medication delivery for those who have obstructive airways disease. I am also a huge fan of posteral drainage and percussion while the patient is in bed. They must be up in a chair for all meals and ambulate around the bed three times daily beginning on the first postoperative day. Again, anesthesia is paramount is providing epidural pain relief for these patients.
On or about the third or fourth postoperative day, I will place the thoracostomy tube to water seal only. (What do I mean by this third years?) If the daily chest film shows pneumothorax, I will pull the chest tube. I will generally keep the patient another 24 hours to access pain relief and then home with continued incentive spirometry therapy.
Other important post-operative care points: Daily chest film as long as the thoracostomy tubes are in place. I will also place a triple lumen central venous catheter for medication delivery and blood draws. If the patient goes to the ICU, they go with arterial line for pressure monitoring and ABGs. If they go to the floor, I will have continuous pulse oximetry monitoring.
Pneumonia from atelectasis which is caused by inadequate pulmonary toilet and deep breathing. This is where respiratory therapy becomes invaluable.
Patients who are smokers should be smoke free for a minumum of two weeks pre-op (not always done) but should quit smoking post op. I am a big user of nicotine patches for this surgery.
Co-morbidities: COPD (chronic obstructive lung disease), hypertension, coronary artery disease. I have to get patients back on home medications as soon as possible.
Deep venous thrombosis: patients should be on prophylactic heparin with PAS (pneumatic antithrombic stocking) therapy at all times even when they are up in the chair.
If I have done a lobectomy or pneumonectomy for cancer, the oncologist is on board at this point for planning of chemotherapy. They will generally meet with the patient and discuss options as the full pathology report(pathologist) becomes available. The pathologist would have provided all of the necessary staining and microscopic analysis that will give a final diagnosis of the tumor.
If no cancer is involved, a pulmonologist(internal medicine physician who has advanced training in treating pulmonary diseases) may assume the care of this patient. After about three weeks post-op, the role of the thoracic surgeon is over.
Thoracic surgery patients like vascular surgery patients will often require the care of a number of specialists in making sure that they receive optimum care. I guess this is why I have enjoyed these cases both from the performance of the operation to the seeing them in office post-op. They are not easy and often in the case of advanced cancer, they are difficult to cure.
For the first and second year medical students:
Why would I not want to divide the serratus anterior muscle?
What’s the nerve supply to the trapezius muscle and where does it run? How could I make a mistake and damage this while making my incision?
Where is the blood supply to the lung and how does it run? How does the location of the lung blood supply make my job easier?
What happen’s if the patient does not end up with enough lung function post lobectomy or pneumonectomy? How much is enough?
Why do I “run these patients dry” post-op? “Running dry” means avoiding overhydration at all costs. What would the chest radiograph look like if the patient becomes overhydrated?
What kinds of patients are candidates for lung transplantation? How would I optimize them to perform this surgery both from a physiological and immunological standpoint? What do I need to know as a surgeon before I perform this procedure?
Ooooo, distance-pimping!!! I think I got about half of those questions…
Seriously, thanks for pointing me to your threads, Natalie, and great posts! I hope you find the time to keep them coming.
One of the procedures that we might perform on the Cardiothoracic service is called a Pericardial window. This procedure involves cutting a hole in the pericardium (sac that surrounds the heart) so that fluid might drain out. When excess fluid accumulates in this sac, the heart is not able to pump as effectively. This is called cardiac tamponade. The fluid, in question, might be blood (in the case of a gunshot wound or a knife wound) or in one of my patient’s case, serous fluid. If 20 ml of blood collected in your pericardial sac, you would die very quickly unless I did a procedure in the emergency department called a pericardiocentesis.
In my patient’s case, the fluid colleced over a month thus the pericardium had stretched to accomodate this serous fluid. While the heart was somewhat congested by this fluid, the patient had been tolerating this situation fairly well.
We did the pericardiocentesis through a laproscope. Attached to this post is the photos that I shot while doing the procedure. In photo A, I have identified the pericardium and lifted it up off the surface of the heart. I am using a non-traumatic grasper to hold the tissue. In my right hand is a pair of hooked laparoscopic scissors for cutting. In photo B, I have clipped through the pericardium and you see the yellow (serous) pericardial fluid gushing through the tiny slit that I have made. In the foreground is the right lung. In the background is the chest wall. For this procedure, the anesthesiologist has dropped the right lung so that I can insert the camera and instruments.
In photo C, you can see that I have clipped a fairly good-sized chunk out of the pericardium. In photo D, I have completed the job and I am inspecting the hole. You can see the surface of the heart through the hole.
After the procedure is done, I inserted two chest tubes into the chest, one anterior and one posterior. (Again, why would I do this?). I removed the scope and instruments and then had the anesthesiolgist re-inflate the lung. I attached the two chest tubes to a Y-connector and then to a three-chambered water-seal suction chamber device.
The patient at that point has a nice hole in the pericardium so that fluid will not connect. Any small amount of fluid will just drain into the chest cavity and be removed by the chest tubes. When I removed the chest tubes, the hole remained in the pericardium but the chest cavity was sealed. How does the fluid get out?
I hope you have enjoyed this case as much as I did. It was totally fun to do!
Thanks so much for sharing your story and photos with us. WOW, the photos made the description immensely more meaningful. When you can see exactly what you are talking about, it really helps bring the situation to life. However interesting, it still hasn’t made me yearn to be a surgeon. What a wonderful world that we all have our different specialties that excite us.
I was wondering how long the patient will need to have the chest tubes in place? How long is a typical patient like yours hospitalized? I would imagine since the procedure was laproscopic that recovery would be fairly quick–provided the chest tubes can be removed in a relatively short amount of time.
I just wanted to thank you for taking the time to post your clinical correlations. Like others, I am in anatomy right now. For me, the case scenarios really help make anatomy “real” to me and focused on how important knowing your anatomy well is.
For Amy and others: I am glad that you have enjoyed my posts from my experiences on Cardiothoracic Surgery. I am finishing up this rotation for now and heading for Akron to do Pediatric Surgery. No doubt, I will have some fun experiences with the kiddies. I have one more full week where I have a couple more thorocotomies (Chest cases) planned. I tend not do do the CABG patients because I just do not care for sewing down coronary artery grafts. If my favorite CT faculty member requests my presence on one of his CABG cases, I will definitely scrub but he knowns that my attention is better spent elsewhere. He is saving an esophagetomy case for me next week and I am excited about doing this wonderful case. In an esophagectomy, we remove the entire esophagus through both an abdominal and thoracic incision. We cut some of the vessels to the stomach and pull the stomach up into the chest to substitute for the exophagus. For the anatomy buffs: How can I cut the blood vessels feeding the stomach and use it for an esophageal conduit?
Mobilization of the stomach is one of the most wonderful cases for a general surgery resident. There is always good anatomy to see. One of the fifth year chiefs will scrub this case with me.
I have another mortality to present on M & M. THis one is going to be a hot one but I am ready and waiting. The irony is that this patient had the same last name as the last patient that I presented in M & M. These are not common last names like Smith or Jones either. Anyway, it will be an interesting presenation before I go off to kiddie world.
Enjoy the peds! I got a whole new glimpse into that world yesterday doing rounds with an ID specialist at Texas Children’s in Houston. It was wonderful.
I love your thought-provoking questions, but as I am a pre-med I usually don’t know the answer.
Could you provide a clue for those of us who are clueless–maybe in 2nd email so it doesn’t spoil it for those who are more advanced?
Not being one to frequent this forum, I just came across Dr. Belle’s post. Let me just say… wow. Thank you, Natalie As a post-bacc interested in anatomy and surgery, the level of detail, the open questions, and the pure clinical applications were very interesting.
Thanks so much for all of the descriptions of your rotations and the great photos.