Month: August 2014

Categories
Clinical Narrative Reflection

On ICU Rounds

Passing through the restricted entrance of the ICU is like stepping foot into another dimension.

A web of clear and blue plastic tubes makes it nearly impossible to determine which machine is wildly wailing as you enter this strange environment. Few patients are conscious. Some might argue that few are truly alive. Passing by rooms with no visitors is depressing but a crowd of family members in a doorway may just choke you up.

I knew I was in a fragile state, at the mercy of sharp memories of previous trips to the ICU, where my own family members shared the same lifeless gaze of each patient that was now before me.

Torn between my current emotional state and desire to learn all I could about the patient on whom our team was currently rounding, I stood between the IV stand and my preceptor as he discussed the course of action with the nurse and me. I was part of the team, part of the conversation, part of the solution. I was in the moment. It was exhilarating.

After discussing our treatment plan, my preceptor and the nurse left the room and I suddenly found myself alone with the patient. I was no longer part of a conversation. I was in a different moment. I was simply an observer that might as well have been family. This patient was no longer a forgettable name on a chart. He was a father, possibly a brother, certainly a son. The poor chances of survival that my preceptor had mentioned earlier echoed in my ears, as I watched the green peaks and troughs dance on his heart monitor. I wondered when he had last opened his eyes, and I wondered who he last saw with them. I no longer felt like the powerful problem-solving medical student that I was just minutes before.

As I stood silently next to the patient, I contemplated a recurrent source of anxiety: the desire to enter into a field of medicine with constant variety and endless excitement, and the potential for high levels of emotional stress. It was then that I realized the subtle yet poignant experience that had just occurred: in the moment, I thrived. I recognized the importance of logical discourse in the treatment of this man, and I was able to focus on the task of caring for our patient. As soon as the tethers of responsibility had been cut and I was free to feel, I felt. The ability to compartmentalize heavy emotions is a necessary skill in the practice of medicine and one that paves the way for balance between successfully caring for our fellow humans and remaining one ourselves.

I proceeded to meet my preceptor outside, bursting at the seams with questions regarding our patient’s condition. Back in the moment. Cool as a cucumber.

And I cried the whole way home.

Featured image:
to much food by wolfgangphoto

Categories
Narrative Reflection

An Ambulance’s Burden

I step off of Northeast Corridor 7871 and into New Jersey. Sunlight makes the tracks look so warm that I feel cheated when cold wind rushes my face. A man walks toward me. He comes close enough for me to smell the rancid recency of cigarettes before he says, “Excuse me.” I look at him and his eyes dart from my face to the door.

“Do you have a cellphone?” he asks.

“Do you need to make a call?” I ask, annoyed at a flash of thought I catch myself engaging, how do you know he won’t steal it?

“Yeah. The ambulance.” he says, casually.

“9-1-1?” I ask as I dial the numbers on my phone.

“Yeah.” he says, emitting a forceful exhale. I have yet to eat and his breath hurls vomit at my senses. I hand him the phone. I imagine my brother scolding me, “Really, Sara, you can’t just hand your phone to people. At least get insurance.”

He won’t take your phone in a train station where there are policemen. I reason with my fear, still guilty over my first-thoughts.

“Yes, hello. I need an ambulance at Trenton station… Suicidal thoughts. I wanna go to St. Francis. I’ll wait in the parking lot outside… OK… yeah… OK.”

He is silent. I imagine a weary dispatcher typing information into a form.

“Yeah, yeah.. suicidal thoughts… yeah, wanna kill myself. I’ll stand outside the station. Uh….” He looks at me.

“Which side we on?”

“The Newark/New York side.” I say.

“Newark/New York side” he repeats, “Jeans and a grey sweatshirt. My name is . . . “

I stop eavesdropping and start thinking about his call. He hands me my phone.

“Thank you.” He smiles, showing gaps between rusted teeth. “You have a nice day.”

“Take care.” I say, trying to reconcile myself to his smile.

If I could not understand English, I might have imagined his call was a take-out order. He was ready with the prompt they couldn’t refuse. “I wanna kill myself.” He expected the questions in the order the dispatcher asked them. He picked his hospital.

What does it mean that his best option is to call for a ride to the hospital that would cost up to $900 if he could pay?  Waiting for my train, I think about his smile. I wonder at the difference between a usual day for him and usual day for myself. What do I know?  Maybe he did want to kill himself. But what if he just needs a place to stay or needs help with the sweating agitation of withdrawal?

How will EMTs, nurses, and doctors think of him? As a system manipulator? Someone who suffers because of gaps in social insulation? Another case? A person who makes choices?  A recipient of charity?

I think of a patient I interviewed who said he came to the hospital to “Get halodol to chase the voices.” When I pressed for explanation, he replied, “You know, get clean. Get outta everybody’s way, get some… some free sleep, take care of my medicals . . . get outta everybody’s way.”

“What do you mean by get out of everybody’s way?” I had asked.

“You know… I don’t wanna bother nobody…be in their way while they trynna do jobs and work and studyin’ and workin’, you know… like get outta their way to not be sick you know… don’t wanna be a burden.”

After the ambulance leaves for St. Francis with the man who borrowed my phone in tow, I wonder whether an ER doc will tell his resident, “He came to get out of everybody’s way.”

Featured image:
Ready by Matt Carman

Categories
General

The Future of Heart Surgery

The work of Dr. Christiaan Barnard was one of the most influential factors inspiring me to pursue medicine with the goal of becoming a heart surgeon. Pioneering heart surgeon Dr. Denton A Cooley shared his opinion about the impact that the first heart transplantation had on the field of cardiac surgery, »But none were, or ever will be, in my opinion, as spectacular as the first human heart transplantation reported from Capetown, South Africa, in December 1967. This event made Dr. Christiaan Barnard one of the best known figures in the world.(1)

Truly the 50s and the 60s were pioneering for cardiothoracic surgery, with novel utilization of cardiopulmonary bypass, valve replacement, and coronary artery bypass graft surgeries (CABGs). Reading about cardiothoracic surgery in its infancy takes over my imagination. That being said, it is important as a medical student to remain ambitious, always inventing the future of ones prospective field. In what manner then, can I give importance to the past while forging forward?

Looking at the field of cardiothoracic surgery today, it is evident that much has changed.  In my eyes, the excitement of the field is no longer as apparent, as this branch of surgery has become relatively routine. Further, the fast progress of percutaneous therapeutic methods is lessening the need for cardiothoracic surgery. Balloon angioplasty emerged in the late 1970s and percutaneous coronary intervention (PCI) is already the procedure of choice in treating coronary artery disease (2). PCI is the main cause for the declining number of CABGs, which represents the major source of income for heart surgeons (3). Without it, a career in heart surgery can be unstable. The number of CABG operations decreased by 28% between 1997 and 2004, while the number of cardiac stent placements increased by 121% in the USA (2).

At the EACTS (European Association of Cardiothoracic Surgery) symposium for the Future of Cardiac Surgery a small survey of 50 invited CT surgeons was taken; 90% agreed to placing a stent rather than CABG for their own hypothetical care. This shows that even surgeons admit the importance of the PCI in treatment of coronary disease (4).

Alongside, and perhaps as a result of this progress, there have been a declining number of applicants for cardiovascular surgical fellowships. There were only 100 applicants for 132 fellowship positions in 2007 in the USA (2). Three years later, only 88 positions were filled out of 113 positions (3). In addition, the number of practicing cardiothoracic surgeons fell in 2003 for the first time in 20 years (2).

An article published in Circulation claimed that a shortage of cardiothoracic surgeons is likely by 2020, while a demand for these specialists could increase by 46% (2). Are we facing the dusk of the field or are there still many opportunities in cardiac surgery?

Minimally invasive cardiothoracic surgery is already a well established practice and an alternative to traditional surgery (5). Robotic aids were introduced into the field at the beginning of the new millennium and currently the following procedures can be performed by minimally invasive surgery: mitral valve repair and replacement, aortic valve repair, atrial septal defects repair, coronary artery bypass, removal of cardiac tumors, and ablation of atrial fibrillation (5,6).

The benefits of this type of surgery are numerous. Improved cosmetic result is the most obvious advantage. In addition, because median sternotomy is avoided keeping the breastbone intact, trauma and postoperative pain are greatly reduced thereby improving quality of life and reducing hospital stay. On the other hand, patients are still exposed to the usual surgical risks such as bleeding, infection (5).

Apart from these ‘classical heart surgery operative targets’ there are at least two important fields where heart surgery will play an important role. First is in the treatment of advanced heart failure. Around 5 million Americans are affected with this syndrome (3). The chronic shortage of organs for organ transplantation has led to a search for mechanical circulatory support. Currently, some research focuses on designing new ventricular assistance devices that may serve not only as bridge for transplantation, but also, a permanent treatment for patients with failing hearts.

Second, atrial fibrillation (AF) is the most common cardiac arrhythmia (7). Surgical ablation may provide an efficient therapeutic approach in patients with medically refractory AF and in patients undergoing cardiac surgery for other pathology who have concomitant AF (7).

We can further expand the list. Some congenital heart defects such as hypoplastic left heart and complete transposition of the great arteries are large operative challenges and will remain in the surgical domain. However, pediatric heart surgery will probably be centralized in a few small centers.
On the other hand, cardiology has become more invasive. Coronary artery disease, valvular, and aortic disease can often be treated with a transcatether approach. Aortic valve replacement used to be completely within the surgical domain; however, since 2003, when first transcutaneous aortic valve implantation (TAVI) was performed, things have changed (8). For now, this method is reserved for high risk patients, but with improvement in technology, we can expect indications to expand further.

Cardiac surgeons responded to TAVI by developing sutureless valves. With this technique, operating time and cardiopulmonary bypass time is shortened, which importantly lessens the invasiveness of surgical treatment. In addition, aortic valves can be replaced through mini sternotomy or thoracotomy.

Endovascular procedures are taking over the care of some aortic pathologies as well (9,10). Over the past few years there have been significant developments in stent-graft technology. Endovascular treatment is an alternative approach to open surgery repair for aortic dissection type B, thoracoabdominal aortic aneurysm and abdominal aortic aneurysm (9,10).

From this, we can conclude that conventional open heart surgery is changing dramatically. In my eyes, the future lies in the formation of one specialty combining cardiology and cardiac surgery. Heart-teams are already being established today. More and more hybrid operating rooms are built-up in hospitals worldwide. The need for the formation of the heart team concept arose from the development of many new devices and approaches for the treatment of cardiovascular disease. To provide the most optimal care the following hybrid procedures can already be performed for the following realms: coronary artery disease, atrial fibrillation, complex aortic pathology, combined carotid and coronary artery disease, valve surgery with PCI, and even congenital heart disease (8). The possibilities are numerous.

Sources:
1. Denton AC: Reflections and observations : essays of Denton A. Cooley ; collected by Marianne Kneipp. Austin, Tex. : Eakin Press, 1984
2. Grover A, Gorman K, Dall TM et al.: Shortage of Cardiothoracic Surgeons is likely by 2020. Circulation 2009 120:488-494
3. Weisse AB: Cardiac Surgery: A Century of Progress. Texas Heart Institute Journal 2011 38 (5): 486 – 90
4. Monro JL: Closing remarks: EACTS Symposium for the Future of Cardiac Surgery . European Journal of Cardio-thoracic Surgery 26 2004: S86-S87
5. Iribarne A, Easterwood R, Chan EYH et al.: The golden age of minimally invasive cardiothoracic surgery: current and future perspectives. Future Cardiol 2011 7(3):333-346
6. Chitwood WR: Robotic Cardiac Surgery by 2031: Texas Heart Institute Journal 2011 38 (6): 691-93
7. Robertson JO, Lawrance CP, Maniar HS et al.: Surgical Techniques Used for the Treatment of Atrial Fibrillation. Circulation Journal 2013 77: 1941 – 51
8. Leacche M, Umakanthan R, Zhao DX et al.: Hybrid Procedures, Do They Have a Role ? Circ Cardiovasc Inter 2010; 3:511 – 18
9. England A, McWilliams: Endovascular Aortic Aneurysm Repair (EVAR). Ulster Med J 2013;82(1):3 – 10
10.  Hughes GC: Endovascular Repair Will Be the Best Option for Thoracoabdominal Aortic Aneurysm in 2020. Texas Heart Institute Journal 2012 39 (6): 834 – 35

Featured image: Provided by Aleksander Garvic