The cardiothoracic surgery service invites in some residents and medical students each year, but does not rely on them in the same way that other services do. For six months per year, PGY3 residents come in one month at a time. I am one of four medical students who will rotate in this year. Instead of the usual group of residents, an army of advanced care practitioners (ACPs, physician assistants and nurse practitioners) run the OR, ICU, and step-down units (separate wing of the hospital from general surgery’s).
The clerkship director is a portly bald 60-year-old with a truly general cardiothoracic practice: 4 CABGs (coronary artery bypass graft) per week, 2-3 lung resections (removing lung cancer tumors), and 3 esophageal resections per month. “Most CT surgeons that graduate focus on either thoracic or cardiac. If I had to choose, I would focus on more thoracic now just because the lifestyle is better. As I get older, I’m less enthusiastic about being paged in the middle of the night.” He also noted that demand for cardiac operations is weakening due to interventional cardiology with newer stents and endovascular heart valve replacements (e.g., transcatheter aortic valve replacement or “TAVR”).
A typical day requires getting up at 4:30 am to look at the case board on Epic to select interesting operations, e.g., a CABG or an aortic arch replacement. I get in at 5:45 am to pre-round on patients on whose cases I previously scrubbed in. Each attending comes in at a different time to round on his or her patients with the ICU ACPs before cases begin at 7:00 am. I struggle to find them, roaming the OR, ICU, pre-op holding, and step-down units and pestering nurses every 10 minutes: “Have you seen Dr. Johnson yet?” I balance rounding on my patients with preparing for today’s cases and try to find the attending with whom I want to scrub in. I usually find the patient first and introduce myself before getting formal approval from the attending.
The first case is a video-assisted thoracoscopy surgery (VATS) lung resection for a pulmonary nodule highly suspicious for lung cancer. The nodule was not amenable to biopsy. We are removing his right upper lobe (about 35 percent of one lung). The patient’s lungs are terribly emphysematous from smoking. Large black spots and fluid-filled blebs line the lung surface. The attending points out all the relevant anatomy to me, for example, the pulmonary veins and aortic arch. I close the small incision after the PA closed the fascia and port sites. The case ends around 12:30 pm.
(I follow this patient for the next week. A known complication of this surgery, especially when the lung has been compromised by smoking, is an air leak into the pleural cavity from damaged lung tissue. Air seeping into subcutaneous tissue inflates his left chest wall, giving him the appearance of a weightlifter who works only his left pec. After 24 hours, the air has expanded his neck and face to chipmunk proportions and we take him back to the OR to pour water on the lung in hopes of finding the leak. The anesthesiologist will inflate the lung and we spray talc powder wherever we see bubbles. The resulting scar tissue sealed up the lung for this patient. Pathology results came back a week later on the tissue we’d removed. He had adenocarcinoma, stage 1. Translation: we found it in time and cured him, at least until the next smoking-related cancer reveals itself.)
Each attending handles one major case per day, four days per week, and has an additional weekly clinic day to talk to pre-op and post-op patients. I can generally leave at 1:00 pm, but there is usually an interesting patient in the ICU and a lot to be learned from the ACPs. For example, we have two patients on extracorporeal membrane oxygenation (ECMO) after septic shock. While the PA and perfusionist are explaining ECMO indications and options, there is a rapid response on my patient after a post-op day 2 coronary artery bypass graft (CABG)..
Our 86-year-old patient is in atrial fibrillation with rapid ventricular response (“AFib with RVR”; pulse in the 150s). She is conversant, but disoriented and feels lightheaded. “My heart feels like it’s fluttering.” All patients in the cardiac ICU have defibrillation pads on. If there is time, we sedate patients with fentanyl or Versed before energizing the pads, but in this case we just shook her and she yells from the pain before returning to her disoriented haze. Unfortunately, she returns to AFib with RVR quickly. This cycle happens again. Her condition worsens. She goes into ventricular tachycardia, but still has a pulse so we don’t begin CPR (compressions). The ICU team pages the electrophysiology cardiology team for advice. They recommend something we’d already ordered: a bolus followed by a drip of amiodarone, an antiarrhythmic agent. This should have been on the code cart, but it hadn’t been restocked so we waited roughly 6 minutes for our dedicated pharmacist to bring it up.
The attending, our clerkship director, eventually arrives and instructs us to stop the dobutamine drip (heart stimulator). Our patient goes into and out of sinus rhythm and AFib with RVR now. The attending asks whether we are pacing her atrium. The NP running the code grabs the pacer machine. During the surgery, atrial (blue) and ventricular (white) wires were placed in the patient’s heart muscles. They’re capped when not in use, however, and the rushing NP plugs them into the wrong ports of the pacer machine. Due to the switched leads, we can’t program it to atrial pacing. “Who switched the leads?” the attending asks. “Our atrial lead is always blue. Who switched this? I want this written up.” The NP: “I did. I will take the blame for that.” The other nurses and ACPs shake their heads. The attending storms out.
[Editor: Why wouldn’t these leads and ports have connectors such that it was mechanically impossible to hook them up in reverse? How tough is it to crimp a 15-cent connector on the end of the lead instead of relying on bare copper and a color convention?]
As the staff return to the nursing station, my attending continues to unload on the NP: “I also need to talk to you about removing the Swan-Ganz catheter on my patient. When we are using that information to increase pressors, don’t remove it until we have stopped the pressors. How else will we know if we can stop that intervention? How do we know she still needs the pressors?” (He has a legitimate point, the NP should not have green-lighted the removal of the Swan-Ganz catheter while the patient was on an increasing pressor requirement, despite the pressure to remove it under the established standardized protocols.)
Cardiac surgeons have a reputation for being unfriendly to students, but I found them quite welcoming in the OR, if not prone to small talk. Nobody asked about my background or what I hoped to do after graduating.
Statistics for the week… Study: 5 hours. Sleep: 6 hours/night; Fun: 0 nights. Coffee with Ambitious Al at the hospital twice. To boost his resume for plastics residency, he is doing three away rotations, also known as “acting internships” or “visiting electives”.
The rest of the book: http://fifthchance.com/MedicalSchool2020