My first month in cardiac anesthesiology nearly a year ago was rather stressful, with often difficult arterial and central venous lines, intense and dynamic physiological perturbations, and a general haze of confusion when it came to knowing exactly what was happening when. One would think that that a major surgical event like, say, unclamping the aorta, would be heralded with a clear pronouncement, if not a chime, a blast from the trumpeter in the corner of the operating room, the unfurling of a scarlet “Aorta Unclamped” banner, and a few turns of the disco ball above.
Not quite. In the midst of the rocky course of coaxing an octogenarian’s heart off bypass, dealing with hypothermia, metabolic derangement, coagulopathies, and blood volume shifts, I must pick up on quickly uttered words like, “Pressure down, off.”
As a whole, however, I’m enjoying this month much more than before. Knowing the basics already of how to do straightforward bypass graft and valve surgery, I feel like I’m able to pick up on more details, like nuances of induction of anesthesia, performing transesophageal echocardiography, how to better communicate with the surgeons and the perfusionists, and pearls and pitfalls when it comes to coming off cardiopulmonary bypass. Transporting an intubated patient with multiple intravenous infusions in a large ICU bed can still be challenging, but at least now I don’t feel overwhelmed by just setting foot in the cardiothoracic ICU. Having rotated through six months ago, many of the nurses are friendly faces.
Even medical situations that used to be daunting now seem fairly routine. The patient’s on 6 mcg/min of norepinephrine and 4 units/hr of vasopressin? A little nitroglycerin? No big deal. Pulmonary pressures a little high? Let’s start some nitric oxide. And I know it’s bound to come to an end at some point, but my hands have been golden this month. Bright red arterial blood flashes back in my catheter with no redirection; the catheter slides right into the artery. Central lines slip into the neck like slipping my fingers between the sofa cushions. Difficult view on intubation? I’ll just ease a narrow bougie into the trachea and glide the endotracheal tube over that. So that’s at least been rewarding.
My biggest difficulty has come consistently toward the end of a run on bypass, when the circulating blood must be reheated in order to bring the patient’s body temperature back closer to a physiologic temperature. (The patient is cooled during bypass to help decrease the brain’s and heart’s metabolic demands.) Around this time, I page my attending to announce, “We’re rewarming.” That’s the hardest thing to say, with all those R’s and W’s. I’ve even tried coalescing the two R’s into one (“Weereewarming”), but I’m thinking of just shortening the message to “Rewarming.” Or maybe just “Warming,” since, unlike leftovers, this is only the first time I’ve brought the patient’s temperature up. I’ll try some of these out, and let you know what works best.