Not for the Faint of Heart

Ella called this morning; she asked me if everything was fine. I replied, "Everything is fine; Mommy is learning a lot." She sang many songs for me. One particular song rang in my ear throughout the day, "Love is something you give it away, you give it away... It all comes back more." I have not had much continuous sleep since I arrived, probably because I'm too excited about all the adventures and learning opportunities ach day presents. I often wake up around 5am; I listen to Goljan's pathology audio is with my eyes closed, falling in and out of sleep and catching little bits of treasured pathophysiology. I was feeling quite tired last night after a nearly 12 hour day. Ella's singing this morning was the best energy booster.

At the internal medicine meeting, a patient admitted due to fever and lower back/lower ABD pain had been sporadically self treating with steroids containing supplement. She was diagnosed with Batter's Syndrome and Steroid-induced Cushing's Syndrome. Upon physical exam, she claimed lower right ABD pain when deep pressure was applied. However, the CT did not show appendicitis. So the resident focused on treating her fever, with antibiotics. The attending recommended administering dexamethasone, because the fever may be related to steroid use withdrawal.

At the meeting, Dr. Tu asks me if I want to observe a pacemaker insertion for a 91 year old patient. My heart nearly jumps out of my throat with excitement. I am very grateful that he is willing to let Sandy and I follow him closely in the OR. We all wear full armor of lead suit, in 3 pieces, apron, vest, and the thyroid cover. Then we scrub in with iodinated soap (it’s our first time!) Dr. Tu explains that pacemaker, once inserted, stay in the patient for 10 years until batteries run out. So it is crucial to practice stringent aseptic techniques. He methodically and gingerly prepares the patient, putting numerous layers of sterile clothes around the pre-marked incision site. He injects 1 to 1 normal saline/Lidocaine subcutaneously along the incision line. Pulling back the syringe each time to check that he does not puncture a vessel, he injects small subcutaneous pocket of lidocaine. He makes a clean cut and then uses blunt dissection to separate the tissue, "this will avoid injuring important structures." I realize the dissection techniques Dr. Eliot and Mr. Silverman emphasized in anatomy are very useful in surgery.

This case turns out to be very challenging. It takes 3 hours more than the original estimated time. The patient's old age has made her heart and vessels difficult to navigate. The vessels lengthen and become more tortuous with age. Because her 3rd degree complete AV block indicates for dual electrodes, one in the left ventricle, one in the left atrium, the case is even more complex. Dr. Tu starts with 1 puncture for two guide wires/leads. But the space within the vessels and heart chambers are so tight, he has to proceed with 2 punctures. The second puncture takes several tries, because sub-clavian artery and thoracic duct are hard to discern from subclavian vein. Watching Dr. Tu tirelessly try repeated, I learn how immensely more complex and challenging live operations are compared to textbook protocols.

Layers of scrubs, lead armor pieces, hot operation lights, long hours on foot, and repetitive use of upper extremity muscles demand super-human stamina. My feet ache so much that I retire to the watching room in 3 hours and observe the operations sitting in comfortable chairs. Dr. Tu's dedication and endurance is amazing. After successfully embedding the ventricular lead, he begins inserting the atrial lead. This presents another challenge; the second lead intertwines and dislodges the first lead. He backs up the second lead many times, adjusting the shape of the wire and switching to new wires. Some techniques I observe include rotation or jostling while advancing the wires and shaping the wires. I am amazed at his patience. Instead of feeling frustrated, he integrates and executes the advice of many observers (cardiologists, manufacture bio-engineer). At Dr. Tu's request, another cardiologist Dr. Fong enters the operation room for 1 hour to assist atrial/2nd lead insertion. He comes out sharing with us the extreme challenge of the case. Dr. Tu perseveres and finally completes the procedure. My respect and appreciation for dedicated doctors and surgeons like Dr. Tu is beyond words!

We all celebrate and eat lunch in the watching room--Dr. Tu's success. It is such an honor to witness this extremely difficult case. Dr. Chen, the director of Cardiology, says that cases as trying and arduous as this one, present only twice annually. Dr. Chen (Cardiology chief) teaches us about thrombus, embolus, and thrombo-embolus. Virchow’s triad: stasis, hyper-coagulability, and endothelial injury contribute to thrombus. It often happens in prolonged period of immobility and poor flow, like sitting during long flights. Emboli often happen in younger patients, because they are more mobile; likely to dislodge and move fragments throughout the bodies. Venous fragments entering the R heart often are resolved in the lungs. Arterial or L heart emboli often cause more several problems, such as stroke and or digits necrosis. One very special case was a young man with 2.7cm bacterial vegetation on his mitral valve, which sends off septic emboli to the brain, causing cerebral infarction in parietal lobe. He was riding a mopad and experienced left side paralysis due to the cerebral infarction. Thrombo-embolus require thrombogenic AND emoblization conditions, so it’s rare. Deep vein thrombosis often throw small clot into the lungs through the R heart. Healthy lungs resolve them easily.

After lunch, Dr. Chen (CV surgeon) performs two procedures, both on dialysis patients. One patient has stenosis in her endogenous shunt, so Dr. Chen inserts a balloon angiograph. He takes a radiograph of the vessels with contrast, which show two major areas of stenosis. After lidocaine location anesthesia, he punctures the graft and inserts the guide wire. He then uses the bones as landmark for placing the balloon at the stenotic area. As the balloon inflates, he watches closely. Two major principles are: the middle of the balloon exerts maximal pressure on the vessels; the areas inflate the slowest or even forces the balloon to slide away (forward or backward) are the most rigid/problematic area. This vascular responsiveness to the balloon inflation also represents vessel compliance. If an area has extremely low compliance, one should be weary of a higher risk of rupture. After several balloon inflations at the two steonic areas, Dr. Chen checks with contrast imaging. The vessel looks smooth and beautiful. He also teaches us how to distinguish acute thrombus from chronic ones. Clinically, acute thrombus present with 5 P’s: pain, pulse-less, parasthesia, pallor, and poor flow. In angiography, chronic thrombus will present with well-developed collateral circulation, which have high flow and cover wide area. Acute thrombus will stop acutely with weak flow through tributaries.

The 2nd case was a completely occluded graft shunt. Dr. Chen opens the artificial vessel with a 1 cm incision. He uses suction to drag clot out; fresh ones are redder then the harder more organized thrombus. He also injects saline through the cut, towards both arterial direction and venous direction, alternating flushing with suctioning. After meticulously suturing the vessel back, he checks the lumen with contrast.

This concludes my day of many firsts: scrubbing in, wearing lead suits, observing pace maker insertion, hemodialysis shunt balloon angioplasty and open-vessel thrombus removal. Days, months, decades like today is truly not for the faint of heart!