IT'S 7:50 AM AS I STEP through the double doors and into the outer shell of the operating suite. I pass through the deserted holding area on my way to the office, where an entire wall is occupied by a dry wipe board. In ink of many colors, the day's itinerary reads from ceiling to floor.
"Mitral Valve Repair/Replacement 8AM." That's where I'm headed. I'm directed to the cart in the hallway where scrubs, masks, shoe covers, and gowns are kept. In a few minutes, I emerge cocooned from the changing room and am led into the inner shell and OR 3.
On a table in the center, the patient's inert, naked form, starkly illuminated by the halogen light above, dominates the scene. A Foley catheter has already been inserted and drains down to the bag hung on the table frame. The scrub nurse and the circulating nurse silently prepare the patient with povidone iodine while the nurse anesthetist keeps quiet vigil at the patient's head.
Promptly at 8, the surgeon enters and quickly dons his lighted head gear while saying hello to the two student observers. A scrub nurse helps him into a sterile gown.
The surgeon asks that the table be raised to waist level, then nods to the circulating nurse at the other end. She flicks a switch and the radio blasts out "Scar Tissue" by the Red Hot Chili Peppers. With one quick, deft movement, the surgeon makes an incision down the center of the patient's chest, cauterizing the edges as he goes. He inserts a surgical saw into the lower sternum area, saws up along an imaginary line, then spreads the ribs, exposing the thoracic cavity. He makes another incision through the mediastinum.
Before my eyes, a living, pumping myocardium is revealed - and the countless words of poets over the centuries, written in honor of this enigmatic, throbbing mass, suddenly seem devoid of meaning. My reverie is interrupted when tiny plastic tubes are inserted in the heart chambers, sutured in place, and clamped off.
The technician at the controls of the bypass machine tweaks and tunes his dials.
"OK, Bill," the surgeon calls out, in between making up words to the popular Latino song blaring across the room. "Yo quiero - come and take me! - bailamos," he intones.
"100 ccs, Joe?"
"Yes - now 250...good. Now 500."
The machine extracts the patient's blood directly from the vena cava and returns it to general circulation via the pulmonary artery. The blood is then shunted from the pulmonary veins to the aorta. One by one, the heart chambers are clamped. The blood is cooled to vasoconstrict peripheral blood vessels and eliminate any pressure on the heart.
Potassium chloride, the final drug of choice for death row inmates, is injected directly through the pericardium, and the cardiac monitor announces to the room: flat line.
The surgeon makes a slash through the pericardium, followed by a tenderer incision through the myocardium itself. Once inside the left heart, he examines the mitral valve and deems it useless.
Twenty minutes pass as the surgeon removes calcified tissue from around the valve area. He briefly lays it atop the sterile coverings so we can see him unravel its parts. As he sutures in the endocardial prosthesis before inserting the new valve, he explains that "over the life span, the turbulence around this valve nicks away at the endocardium. Eventually, pockets form, and any free-floating piece of junk can set up housekeeping in there. Pretty soon it has its own fibrin network and blood supply, impairing the function of the valve and the ventricle."
Twenty-three sutures are placed to secure the valve, with seven knots in each. Why seven? "It's my lucky number," says the surgeon. "I like seven - it works for me." He then laces the myocardium and pericardium back together as if it's child's play. "OK, Bill, 100 ccs."
The bypass machine hisses and swishes.
"OK, another 250." A moment passes. "OK, we're looking good.... And again."
Slowly the heart volume is restored, and the conversation turns to golf - until, that is, the bypass machine is turned off. The silence is deafening as the team waits for the heart to warm up and fire on its own.
The surgeon massages the heart - nothing. He places paddles on each side of the heart and fires - nothing. Again - and nothing.
"Five ccs of Epi. and three of Levophed."
Moments pass, then "Five more Epi."
The cardiac echo machine with full crash cart facilities is pulled close to the operating table. "Everybody back!" the surgeon commands. "And again." The limp body jumps with every jolt.
It appears the right heart has developed Epi-induced hypertension. Time passes, then a weak, feathery stage one A block appears on the monitor. A temporary pacemaker is hooked up directly to the pericardium.
A check of the esophageal cardiac echo monitor indicates that the new mitral valve is working. Still, the heart shows no sign of doing the same.
Eventually, an intermittent disturbance shows up on the screen. The nurse anesthetist breaks the silence. "Joe, is that the patient's heart?"
"Switch off the pacemaker," says the surgeon. All eyes are now on the monitor, and time seems to stand still. Suddenly, the team cries out in unison, "Sinus!"
The surgeon turns to the nurse anesthetist. "Good call, Jean." He starts suturing, layer by layer. Soon after, something resembling florist's wire is threaded through the rib cage, twisted, and cut, with the sharp ends forced back through tissue. "That's gotta hurt," I hear myself think. "The guy'll probably set off airport security alarms for the rest of his life."
The surgeon thanks everyone and leaves. I look at my watch - postconference has already begun, but I want to follow the patient to the postanesthesia care unit to reassure myself that he's OK - then I look at the team and realize he'll be fine.
After changing back into my student nurse uniform, I go out the double doors and come across a gray-haired woman with dark, Mediterranean eyes. She looks at me expectantly - it's obvious she's the heart patient's wife. The woman in me wants to give her a hug, the healer in me wants to give her good news, but I'm sworn to silence.
So I give her the widest, warmest, most loving smile I have in me - and a wink.
"Mitral Valve Repair/Replacement 8AM." That's where I'm headed. I'm directed to the cart in the hallway where scrubs, masks, shoe covers, and gowns are kept. In a few minutes, I emerge cocooned from the changing room and am led into the inner shell and OR 3.
On a table in the center, the patient's inert, naked form, starkly illuminated by the halogen light above, dominates the scene. A Foley catheter has already been inserted and drains down to the bag hung on the table frame. The scrub nurse and the circulating nurse silently prepare the patient with povidone iodine while the nurse anesthetist keeps quiet vigil at the patient's head.
Promptly at 8, the surgeon enters and quickly dons his lighted head gear while saying hello to the two student observers. A scrub nurse helps him into a sterile gown.
The surgeon asks that the table be raised to waist level, then nods to the circulating nurse at the other end. She flicks a switch and the radio blasts out "Scar Tissue" by the Red Hot Chili Peppers. With one quick, deft movement, the surgeon makes an incision down the center of the patient's chest, cauterizing the edges as he goes. He inserts a surgical saw into the lower sternum area, saws up along an imaginary line, then spreads the ribs, exposing the thoracic cavity. He makes another incision through the mediastinum.
Before my eyes, a living, pumping myocardium is revealed - and the countless words of poets over the centuries, written in honor of this enigmatic, throbbing mass, suddenly seem devoid of meaning. My reverie is interrupted when tiny plastic tubes are inserted in the heart chambers, sutured in place, and clamped off.
The technician at the controls of the bypass machine tweaks and tunes his dials.
"OK, Bill," the surgeon calls out, in between making up words to the popular Latino song blaring across the room. "Yo quiero - come and take me! - bailamos," he intones.
"100 ccs, Joe?"
"Yes - now 250...good. Now 500."
The machine extracts the patient's blood directly from the vena cava and returns it to general circulation via the pulmonary artery. The blood is then shunted from the pulmonary veins to the aorta. One by one, the heart chambers are clamped. The blood is cooled to vasoconstrict peripheral blood vessels and eliminate any pressure on the heart.
Potassium chloride, the final drug of choice for death row inmates, is injected directly through the pericardium, and the cardiac monitor announces to the room: flat line.
The surgeon makes a slash through the pericardium, followed by a tenderer incision through the myocardium itself. Once inside the left heart, he examines the mitral valve and deems it useless.
Twenty minutes pass as the surgeon removes calcified tissue from around the valve area. He briefly lays it atop the sterile coverings so we can see him unravel its parts. As he sutures in the endocardial prosthesis before inserting the new valve, he explains that "over the life span, the turbulence around this valve nicks away at the endocardium. Eventually, pockets form, and any free-floating piece of junk can set up housekeeping in there. Pretty soon it has its own fibrin network and blood supply, impairing the function of the valve and the ventricle."
Twenty-three sutures are placed to secure the valve, with seven knots in each. Why seven? "It's my lucky number," says the surgeon. "I like seven - it works for me." He then laces the myocardium and pericardium back together as if it's child's play. "OK, Bill, 100 ccs."
The bypass machine hisses and swishes.
"OK, another 250." A moment passes. "OK, we're looking good.... And again."
Slowly the heart volume is restored, and the conversation turns to golf - until, that is, the bypass machine is turned off. The silence is deafening as the team waits for the heart to warm up and fire on its own.
The surgeon massages the heart - nothing. He places paddles on each side of the heart and fires - nothing. Again - and nothing.
"Five ccs of Epi. and three of Levophed."
Moments pass, then "Five more Epi."
The cardiac echo machine with full crash cart facilities is pulled close to the operating table. "Everybody back!" the surgeon commands. "And again." The limp body jumps with every jolt.
It appears the right heart has developed Epi-induced hypertension. Time passes, then a weak, feathery stage one A block appears on the monitor. A temporary pacemaker is hooked up directly to the pericardium.
A check of the esophageal cardiac echo monitor indicates that the new mitral valve is working. Still, the heart shows no sign of doing the same.
Eventually, an intermittent disturbance shows up on the screen. The nurse anesthetist breaks the silence. "Joe, is that the patient's heart?"
"Switch off the pacemaker," says the surgeon. All eyes are now on the monitor, and time seems to stand still. Suddenly, the team cries out in unison, "Sinus!"
The surgeon turns to the nurse anesthetist. "Good call, Jean." He starts suturing, layer by layer. Soon after, something resembling florist's wire is threaded through the rib cage, twisted, and cut, with the sharp ends forced back through tissue. "That's gotta hurt," I hear myself think. "The guy'll probably set off airport security alarms for the rest of his life."
The surgeon thanks everyone and leaves. I look at my watch - postconference has already begun, but I want to follow the patient to the postanesthesia care unit to reassure myself that he's OK - then I look at the team and realize he'll be fine.
After changing back into my student nurse uniform, I go out the double doors and come across a gray-haired woman with dark, Mediterranean eyes. She looks at me expectantly - it's obvious she's the heart patient's wife. The woman in me wants to give her a hug, the healer in me wants to give her good news, but I'm sworn to silence.
So I give her the widest, warmest, most loving smile I have in me - and a wink.
