Heart Surgery in America: Tuesday 7.0

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The Swine Flu: Day 1:

In the middle of the dessert, sandwiched in the flat lands of West Texas, lies a small town that sits upon a giant aquifer.

From the birds eye it is configured like a scrabble board of lights and streets perpendicular like a compass pointing North and West.

In the center lies a loop, and in the loop lies the city, and in that city sits a hospital by the side of a man made lake, that within this structure on the second floor, with a view to the lake, is a room with a window, and on the other side of the pane, a soul looks outward for a breath of fresh air as a scorpion of indecision weighs heavy on his chest.

A pandemic is borne by exhausted breath, and carried on the heels of an ill wind sweeping over the plains of America. And as such, has landed here, becoming owner and landlord of this man’s body…

The Reaper has a new nest found to roost.

The man splayed on the bed before me was aptly named for a Titan. He had the tone and physique of a warrior. A lot of tattoo’s on this man’s arms and chest. It wasn’t the art that suggested strength, but the nobility in his face, untaut with frown or wrinkle, seemingly released from the world’s daily taxes by a medically induced narcotic slumber.

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Our patient had been diagnosed with swine flue, and a dust storm of uncertainty was  creeping over the southern plains of America.

Up until now everything had been pending… a flu epidemic, isolation wards, vaccine shortages, a potential disaster of national proportions, or some sort of near extinction of the species. Basically- your end of time scenario, that looming tsunami unfurling a carpet wave of doom. The end of days?

What was clearly evident to me at this moment, was that a young, 25 year old man had a date with destiny, a turn in the corner that I would join him on- to whatever end I had no clue.

As a perfusionist, putting people on bypass is something I do on a daily basis. We work in tandem with the heart team, in undoing to the heart and body, damage incurred as the end result of a lot of poor choices, genetics, age, or tarnished fortune.

In this case misfortune comes to mind, fate or whatever, just a bad lottery ticket for this guy.

The problem here is not the heart, but the cytokine induced storm that has ravaged his lungs due to the H1N1 flu virus. Placing this patient on ECMO (Extracorporeal Membrane Oxygenation) essentially relieves his lungs of their work load and allows us to assist in making sure his body gets enough oxygen to survive, while allowing his lungs to rest. Essentially we “bypass” his lungs and emulate their function lending new meaning to the term “a breath of fresh air”.

Every salvage operation seems to have a subtle caveat. It’s easy to be heroic when saving the life of the pure and the innocent, but what if the intended recipient of our Herculean efforts has a wrinkle on their resume’? A character flaw, misdeeds in their history, or even jail time to boot? Are they, too- equally deserving of the same drive behind the medical commitment to reclaim a life?

Well that answer is obvious, and it is a yes, but every rescue seems better started off as a fairy tale, rather than the underlying currents of a day time soap opera. “Old Yeller” trumps the Brothers Grimm. Regardless, professional commitment renders the team oblivious to that side of the patient history- and the effort remains untarnished with petty human misgivings or judgements.

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The Swine Flu: Day 2

Ah… It’s Day Two. At least there is a Day Two. The aftermath of a battlefield always seems to have a slow mist rising from it as if a call to fallen souls from Heaven.

The beach after a storm smells fresh and hints at a crisp invitation for renewal to the swimmer, wanderer, or the newly lost. And somewhere stranded between those metaphors, lies the silhouette of yesterday’s efforts. So as today begins, the canvas I walk into is absent color but not without hope. A grainy oil painting telling today’s story, dapples of oil applied with brush strokes for highlights and half tones, all in grey scale.

I had a lot of time to think about our patient last night and this morning. I arrived to the Pediatric Intensive Care Unit at 3:00 pm to begin a shift of 19 hours watching the patient as he had been placed on ECMO late last night.

The night was restless as different scenarios and “what-ifs” comingled with my dreams and rose to the surface faster and more furiously than the bubbles rising and convoluting from the ocean floor that I was swimming over. Certainly his age (25) and outward appearance of great strength and invincibility, made me wonder when whatever felled this oak tree, would eventually turn towards me, see past my shadow, and begin to lay waste.

Memories of a book I had read as a child surfaced, of Walter Reed and his tremendous courage as he studied the origins of yellow fever, eventually drilling down to the mosquito (Aedis Aegypti) as the only plausible vector, and summarily allowing one to infect him- thus proving his theory. So of course the question of potential risk and comparative sacrifice was tabled for discussion.

Discussions of the soul come to mind… When Ben Hur tosses caution to the wind, and clutches his mother to his arms and body, a mother ravaged with leprosy thus subjecting himself to that dreaded scourge, yet freeing him of something far worse, cowardice and indifference.

That sort of discussion may not always set you free, but recognizing courage in yourself if only for a moment, well that goes a long way. But enough of that.

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The question of susceptibility and possible infection is something that each attending nurse, physician, respiratory therapist, and a whole slew of medical support personnel, must ask themselves before committing to rendering hands on care to what is suggested to be a potential deluge of critically ill patients.

So everybody showed up, unvaccinated because of a dearth of supply and government parceling, totally cognizant that the high frequency oscillator that was being used to keep our patient’s lungs compliant, was also an open system aerosolizing the virus into the surrounding room air ensuring everybody’s exposure. Essentially a microbial mist of potential contamination was rising and released to all attending to our patient’s care.

That was our collective Ben Hur moment. We flinched, but we all showed up and stayed.

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The Swine Flu: Days 3 through Day 7

There is a scent of salt after a day of exhausting work. A tilt of the nostril as it captures the heat from sweat splashing the base of your skin like the tide coming in. While most times a shower steams the memory of yesterdays effort onto your bathroom mirror, what isn’t washed away lingers as a restless twitch from an overactive mind as it processes this nights outcome into this mornings dreams.

Our patient lives on. A status quo established, a daily routine outlined, a hedge grove of determination slowly greens towards blossom as each day small hurdles are crossed and minor victories are realized.

The man hours implied over the last seven days are staggering. My own personal time investment clocks in at 105 hours, the staffing ratio is 3 to 1 at a minimum. This salvage involves a primary care ICU trained nurse (24/7), a specialty trained ICU nurse to handle operation of the ECMO bypass machine we are employing to keep the patient alive (24/7), a perfusionist or ECMO coordinator on site to manage the patient’s perfusion related needs (24/7), a respiratory therapist to adjust and manage the ventilator as well as draw and run blood gas lab work on the patient (24/7), and ICU intensivist to oversee the entire show (24/7).

Additional support includes: radiology services at least once a day for chest x-rays as well as CAT scans or other imaging diagnostic tests as needed; pharmacy services required for the complex medications required to keep the patient sedated, anti coagulated, and hydrated; and blood bank services to supply the patient with blood for transfusions as well as blood products such as platelets, fresh frozen plasma, and cryoprecipitate.

This represents the minimum needed to even have a chance at success, and does not include the various other lab tests and blood work that will be needed, the myriad of sub specialty physician consults that might become necessary, and of course, surgical implantation and explantation of the ECMO cannulae, tubing circuit, and oxygenator required to maintain successful pulmonary support as the lungs heal.

Our ability to heal, and steal death away from the fates, is like the Greek myth of the Titan who gave fire to man. It comes with a price. The full brunt of medical technology has come to bear in a struggle to retrieve our patient from the knifes edge of the mountain side before the eagle comes for Prometheus once again.

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The Swine Flu: Days 8 and Beyond

Imminent death doesn’t seem to be the pressing question anymore as much as it is treading water with a purpose. You can see the shoreline from the distance, and you try to ignore the dangers lying in wait- in the form of hidden reefs, rip currents, and unknown predators.

So it goes. You kind of have to throw out the “why do we do this” questions, and ignore the “exhausting our resources” mantra when trying to come to grips with this swine flu thing at the human level. Swine flu is not something that is repaired or fixed, it becomes a seminal moment in your life of something you survived. You really can’t dodge a lightening strike. There are no vaccinations for that. But you can endure- and if weakened can be reclaimed from the edge.

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The Swine Flu: A Rainy Friday .

Well we planted 4 patients in the space of 48 hours. If you think that’s a rough sentence or indiscriminate in terms of the loose delivery, yeah it is.

The people I hold myself accountable to are the patients first, and then I deal with trying to defer the second guessing from all of the rest…

I really don’t know if there was a last day. There were so many times I gazed at the face that seemed to outlast expectations and remain recoverable- there was so much time agonizing the muscle requirements a young man so large could push our membrane oxygenator to such limits. What he never knew was that he never stretched the limits or determination of the nurses, doctors, and perfusionists that watched and managed him 24/7 for 16 days.

Gone are days of literature searches and comparisons to “South Australian” or native “Michigan studies” that typically seem to be the direction one takes when cornered by the realization that hope has become the last dash of salt as an avenue for medical salvation. The bedrock of this storm was the 30- 53 percentile of predicted mortality that would be the end result- depending on which study you took more seriously.

It all happened very quickly.

With the phone call telling me not to come in, with that call went Samson. That was the end. Then we both finally slept our own separate sleep- and went our own separate ways- and became a part of our own separate stories.

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