Today’s post is going to be a little different from the standard of this site. No, I’m not writing about Firefly, but I’ll get to that connection in a bit. I would like to take the opportunity to give the readers of Nothing in Biology Makes Sense a brief glance into an aspect of medicine that few get the opportunity to experience.
I am talking about surgery, specifically, Cardiothoracic surgery, or surgery that takes place by opening up the chest of a patient and putting them on cardiopulmonary bypass in order to operate on the heart (doing coronary bypass, valve replacement, or placement of assist devices). The reason I feel the need to post about this is because I know I have been given the opportunity that few people (physicians and medical students included) get the chance to experience first hand. For the last 6 weeks I have been on my surgical rotation, and was lucky enough to be able to spend two of those weeks working with the Cardiothoracic surgeons observing and assisting with open heart surgeries.
To begin with, being on surgery is an experience in and of itself and some things need to be understood before trying to go into detail of a specific type of surgery. In any given surgery every person in the OR has a specific role. First you have the surgeon themselves. Then you have the anesthesiologist, who makes sure the patient is asleep and all vital signs (blood pressure, heart rate, breathing etc.) remain within normal limits. Next, the scrub nurse maintains the sterile field—and yells at any medical students who are even thinking of moving into or out of said sterile field.
An easy rule to remember, once you are scrubbed in and sterile, is to keep your hands on blue. All things that are sterile in surgery are draped in blue cloth. See, the Firefly point comes back around.
Finally, you have the circulating nurse, who retrieves supplies as needed and keeps track of the instrument count to make sure everything that was used during the surgery is accounted for at the end. Then you have the medical student who does his absolute best to stay out of the way of the scrub nurse and assist the surgeon if at all possible (as well as try and answer any random pimp questions the surgeon asks of him).
Cardiothoracic surgery was by far the most amazing thing I have gotten to experience thus far in medical school. The surgical team is like a well oiled machine compared to many teams and with good reason. As the one attending put it, “death is following us all the time.”
The first time that I witnessed a living person’s chest being sawed and pried open to reveal a beating heart, I was filled with an absolute sense of awe. Then the surgeon began to prepare the patient to be put on bypass, inserting various tubes into the right atria and aorta. I stood on the other side, holding the still-beating heart out of the way I couldn’t help but be amazed at the calm at which they did this, as if this were a perfectly normal and ordinary thing to do. Then, once all the lines were in place, a clamp was placed on the aorta, completely isolating the heart from the circulation of blood in the rest of the body. At this point, the heart is cooled down with ice and infused with a solution that arrests it in the phase of contraction called diastole. This is when the timer starts: From this point on the surgeon can operate for up several hours without any damage occurring to the heart.
There were several types of operations that began in this same way. First, there was the coronary artery bypass. In this procedure, a vein or artery was transplanted from another site of the body (arm or leg generally) and ever so carefully sewn between the aorta and beyond the area of blockage on vessel on the heart itself. These were probably the most fascinating as they involved very intricate suturing. I have a hard enough time using a regular sized needle and sewing up a fairly large wound. The steadiness of hand required to sew one small vessel onto another is beyond amazing in my eyes. The second type of surgery was valve replacement. Here, the surgeon would cut open the heart and remove a defective valve, replacing it with a new one (either mechanical or tissue). The third type of surgery I observed was the placement of ventricular assist devices. These are internal pumps that aid a currently failing heart to pump blood to the body. This last surgery is actually performed on a beating heart—the surgical team put the patient on bypass, but they do not stop the heart. Again, here I thought suturing something that wasn’t moving was hard. This procedure requires placing stitches into a moving object.
One final note, as this is a science journal blog I did prepare an evidence-based medicine report on this article from the New England Journal of Medicine. Briefly, the article goes describes a new technique to replace a damaged aortic valve using a transcatheter approach (i.e. not an open surgery but more like what is done when somebody has a stent placed following a heart attack). The report showed that certain patients who were very poor surgical candidates, secondary to other conditions that would increase their risk of death when undergoing such a major surgery, benefited from this less invasive technique. Prior to development of this technique, these patients’ only option was medical management—treatment without surgery.
According to this study, compared to that medical management, patients who underwent the transcatheter insertion of an aortic valve showed decreased rehospitalization and death and the recovery time is significantly less than that of an open heart surgery. Is this likely to replace open heart surgery for valve replacement? Possibly, but for now the outcomes are not as good as patients who undergo open heart surgery. But it’s very interesting to see the steps toward advancement of less invasive surgeries that will likely become more mainstream as they are perfected.