Heart Surgery in America: Thursday 2.0

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24 Hours… of ECMO

Past Midnight… Ghost Stories & What-Not

3:00 am

Ghost stories

So it’s 3 a.m. and the STS paper work has become a mountainous blur, our ECMO patient is on “cruise control”, the hive activity is down to almost nothing, and there is an empty room down at the other end (the far end) of the ICU.

Note:  The fake flash I put in there to make it look “Ghostly”

The coffee ran out 2 hours ago and any conversations that are contrived at this hour, are there simply forwarded as a push to stay awake as opposed to a “gettin’ to see how you’re doin’ “ kind of thing.

It is a Sargasso Sea moment for the PICU (a sea so calm it almost stranded the 3 ships of Columbus lore).  But calm is good, and this seems to be as a good a time as ever to try to slip in some shut eye- before the next wave of activity.

As with all things historic and iconic (as this West Texas hospital is), this ICU as brand spanking new as it seems to be, is anchored in a building that has been around for awhile, and has seen it’s share of tragedies and miracles over many many decades.

What comes with tragedies and miracles? 

Stories and legends, that are repeated from generations of nurse as they repeat themselves.  So while we urge our patients to “never go into the light” (at the end of the tunnel) we find ourselves seeing a different sort of a light down at the end of the hallway.  And way past midnight, when the lights are out and we are half asleep, our minds play tricks and we get plenty of help on how to interpret shadows and sighs from our friends at work who love to drum up a little mischief for fun of course (because it’s their job to stay awake on the night shift).

So I burrow myself  in like a tick into a narrow visitor’s cot in the small room at the end of the long hallway.  Curtains drawn, my shape barely illuminated into a shimmering silhouette by whatever light is being refracted like a kerosine lamp from the other side of your tent window.  It’s moments like these when the smallest bug on the window can look like the legendary Chupacabra of Mexican lore.

It was funny to see the wide eyed look of one of the nurses further down the hallway as I passed her to head off to sleep.  She looked at me as if I was a condemned man on my way to whatever horrible fate awaited me in that room around the corner.

4:00 am

Sleep and noises.  That was it.  No goblins, poltergeist, or ghosts.  No wind gusts or icy cold frost coming from my mouth as I exhaled.  I slept and heard noises.  It’s a hospital PICU, not the downtown Hilton.

I awoke in one piece, neck untouched (or punctured) and a twinge in my lower back reminding me of what I had slept on for the last hour.

5:00 am

The Chest X-Ray (CXR)

(A sample Image of a “Normal” CXR)

Every once in awhile comes a seminal moment.  That epiphany we are all gifted to encounter once in a while during our clinical lives,  that moment of clarity when the clouds part a bit, and you can see blue sky and a distant shore.  That was the drama of this morning’s CXR.

After a major procedure the day before, to divert the course of the patient’s clinical progress, it appeared that a dove finally had arrived at Noah’s ark, and it was in the form of  a picture of some lungs that were really clearing up, and doing so at an unexpected pace.

It was a bright moment, and it definitely got everybody’s attention.

6:00 am

Coffee up

Time to recharge the batteries.

7:00 am

Shift Change-

Hello Ashley, Meghan, Lisa, Tiffers, and Shannnon…

Adios to the night shift (we hardly knew ya).  I am totally kidding about the “hardly knew ya’ ” part.

This is the part where a perfusionist on a 24 watch becomes a shift nomad.  Always wandering between cohorts and clique’s… never belonging to one.

9:00 am

This morning has all sorts of things going right for the ECMO patient.  The first being a continuation of excellent nursing care from a refreshed crew (Meghan from Duke, and Lisa as the ECMO tech).

The plan is to gently decrease ECMO support to the patient, by decreasing blood flow (cardiac output) from us, and allow the patient to regain control and assume more responsibility in terms of cardiac work load.

He seems to be handling it extremely well, not a blip, not a flinch, and as always I hold my breath and pray that it is all going to come together as it seems, with no unanticipated setbacks or “issues”.  No worries so far…

10:00 am

We are a Village…

There are qualities to the healing process that are immeasurable and impossible to quantify in terms of the positive effect that an outpouring of love and support from family and care givers can have, in assisting the patient’s will to live.  How much that will impacts survival is unknown, but to witness it is to believe that there is a force within us all, that awaits to be woken when we need it the most.

In this case when you truly are at the edge of life’s continuation, the constant interaction that the parent’s and family of this young man rendered forward, were an amazing thing to not only witness, but to become a part of.

Sometimes there is an elegance to bluntness.  And this boy’s father was totally blunt and unwavering in constantly telling his son how much he was loved, how he was going to get better, and how he was going to make it.  It is one thing to say things to people that you love when you know they can hear you.  It takes away some of the powerlessness.  It gives you a sense of some sort of impact, lays out a sliver of  hope that your efforts might make a small difference.  It allows you to believe that you can make a difference.

On the other hand, to do the same when you have no idea whether or not your son can hear you, knowing that most likely the answer is no, then to shout encouragement, and to never give up, is like waiting for your own voice to come back at you from the echos of the dessert canyons.

It is easily done the first 50-100 times, but after that amount of repetition, your own doubt or the feeling that you are talking into a mirror may cause you to waiver.

To go beyond 100- to perhaps 1,000 or more times, never knowing if your voice can be heard, is in my opinion heroic.

It boils down to never giving up…  and so it seems that we may be getting  a growing list of hero’s here, because nobody was willing to give up.

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Noon

This story may seem iintense, but the whole day wasn’t totally like that.  Yeah it’s hard to deal with uncertainty, but the hardest thing today really, was to dare to accept faith and hope, and allow them to creep into the equation.

I’m a machine when it come’s to believing in myself and those around us.  But sometimes I am afraid to hope.  That’s what today was all about.  Learning to not be afraid of the possibility that yeah we did it right !

5:00 pm to 8:00 pm

During the last half of the last half of my shift, we weaned the patient down to 1.4 LPM, maintaining ACT’s @ 250 seconds or so.  All the numbers looked great.  PA’s, SVO2’s, ABG’s, were screaming to take this kid off bypass.  The Intensivist was certainly ready, but unwilling to fully commit so late in the day, in case manpower was needed for something unexpected coming up in the middle of the night.

She charted a very prudent course in my opinion.

Fatigue doesn’t make cowards of any of us, but certainly at this juncture, keeping the eye on the prize (successful recovery) and not changing our strategy when the finish line was getting so close…  That’s how we were going to close this out.  There was no way we were going to fall down this close to home.

So to come full circle, my relief pitcher is Midge.  Her first solo shift as an ECMO coordinator.  She had earned it.

When I showed up at this program, I was a very seasoned perfusionist, but knew nothing about managing an ECMO (my experience to that point had been all adult perfusion programs).  Midge broke me in on my first ever ECMO shift a few years back, and had amazed me with her confidence and just total commitment to the patient and the process.

I kept reminding her of how clueless I was, and she kept reminding me I was a pretty damn good perfusionist.

How odd that while she was the teacher on that day, in my role as the perfusionist / ECMO coordinator,  I was still theoretically in charge of the management of the ECMO (the perfusion side of it).

It didn’t really matter though.  It was never about who was doing what, or in what role or capacity.  We worked together seamlessly as a team concerned about one thing only.  A good outcome for the patient.

So now it was her turn.  Coincidentally, we were starting to trial off as she began her shift.  So I did a bit of dusting and cleaning and last minute STS data stuff, managed to hang out in front of a computer desk, and when all excuses were finally exhausted, peeked into the room as I was about to leave.

Midge never saw me, but she was totally in charge of what was going on (on the ECMO/perfusion end of it), completely focused on the patient, and had successfully navigated the patient off ECMO under the direction of a very gifted Intensivist.  So I walked away.  My throat was a little tight, that feeling you get when you are really proud and relieved at the same time.  Yeah- there was 1 tear drop.

She did it- we did it- and Hope finally had it’s way with us.

On this one day, Hope had it’s way.

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