Perspective
A Well-Oiled Machine
A surgeon marvels as a colleague calmly and expertly leads his team through a difficult case.
By David Farley, M.D.
A while ago, a call came into OR 105 while our team was finishing up a laparoscopic procedure. The circulating nurse relayed that one of my cardiac surgery colleagues was asking me to come down to his operating room. “Is it urgent?” I asked. “No, but he clearly wants you down there,” came the reply. “Tell him I will be there in five minutes.”
As I helped a young surgical resident close up our patient’s small wounds, my brain went into overdrive. What might a talented cardiac surgeon with a patient who was fully asleep on his OR table need from a general surgeon like me? To check for an incisional hernia? Comment on a melanoma? Palpate a thyroid mass? Review an X-ray with an abnormal feature? Maybe it was something even more ominous—an elderly gentleman with a big hernia.
Walking into the cardiac surgery room, I could see the procedure was temporarily on hold. The surgeon’s back was to me, the atmosphere was subdued and the mood serious. A quick look at the monitors overhead showed adequate blood pressure, a steady heart rate, and nothing obviously wrong. Having asked for help in my own operating room many times, I was always appreciative of any surgeon who entered with an upbeat attitude and the words, “How can I help?” So I did the same. “How can I help?” I asked.
When the surgeon turned around, he was calm but visibly concerned—you can recognize when another surgical colleague is frustrated, struggling, or upset even when they’re behind a mask. He wasn’t upset. He just looked concerned. I feared the worst; but I was still unsure how I might be of service. He proceeded to tell me in a way that was orderly, insightful, and … worrisome. The patient, a young man, was having his third cardiac operation. Among other problems, the man had previously had his aortic root replaced with a synthetic tube graft, and that graft was now eroding into the back of the sternum—a potentially lethal problem.
I wasn’t smart enough to immediately figure out how I could help, but I nodded as though I knew what was coming next. “The real problem,” my colleague explained, “is that I very well may get into this graft before the heart is fully exposed. If that is the case, then I will need to emergently go on bypass and won’t have any access … because … look.”
Peering over his shoulder, I could see a tiny innominate artery, and then looking to the exposed groin, I could see an exposed femoral artery that was miniscule. The vessels were unusually small. There would be no way to cannulate them. “If we get into this aortic graft, we are going to need you to get us rapid access to his abdominal aorta. That is the only vessel that will give us a chance of putting him effectively on bypass,” the cardiac surgeon explained.
I got it. If the cardiovascular surgeon tore a hole in the artificial aorta, my job was to incise the abdomen and in rapid fashion, move the bowel out of the way and clear off the aorta so that a tube could be inserted. It was the first time I had been asked to scrub for a case where a colleague might make a lethal injury and would need immediate help addressing that very problem.
I scrubbed in. I took my place near the patient’s neck, grabbed a retractor, and let the surgeon and his team proceed. They were a good team. A very good team. Little chatter. Skilled hands. I enjoyed the view of anatomy I don’t often see as a general surgeon. It became obvious to me why the surgeon had called. The scar tissue was brutal. Tissue planes were nonexistent, and dissecting the heart, aortic graft, lung, and vessels away from the back side of the sternum was extremely difficult. It was slow going.
As I dutifully held my hook, and telepathically offered encouragement to my colleague, a sinking feeling came over me. Despite the surgeon’s obvious expertise and meticulous care, it seemed likely to me that a tangential aortic conduit injury was forthcoming. In this obese male, it would take me 10 seconds to get to the other side of the table, a few more to remove the sterile drapes covering the abdomen, and who knows how long to make an incision, enter the belly, pack the bowel away, and effectively expose the aorta for cannulation, presuming the vessel was big enough to cannulate. I felt antsy. Penetrating aortic arch injuries are usually fatal when caused by bullets or knives. In my mind, the cardiac surgeon’s cautery tip counted as a knife.
Although not wanting to break his concentration, I had to speak up. “I think the likelihood is high of entering into the vessel.” He agreed. “That’s why you’re here.” I pushed on: “I think we should get control of the abdominal aorta now … before we cause trouble.” He agreed.
With the luxury of time and a stable patient, we took 10 minutes to make a small vertical laparotomy and expose the aorta. A large omentum and a thick, small bowel mesentery made getting to the aorta problematic. When reached, we both were pleased to find a soft vessel large enough to allow for effective cannulation.
“I feel better,” I said. “So do I,” my colleague replied.
Although my part was done, I stayed. What I witnessed over the next 30 minutes made me proud to be a surgeon, to be part of that team, and to be the cardiac surgeon’s colleague. Everything was difficult, but nobody cursed. Everything was treacherous, but the dissection proceeded without injury to the heart or graft. The team was prepared.
Getting closer to the right atrium hidden within the scar tissue, the surgeon asked for the defibrillating paddles to be available should his electrocautery tip cause the heart to go into fibrillation. The paddles were ready. Is the unit charged? It was. He asked if the pump team was ready in case they had to go on emergent bypass. They were. Is blood ready? Yes, it was in the room. Do you have my special clamps handy? Ready. This was a well-oiled machine.
Suddenly, with a buzz of the cautery knife within the scar tissue, the patient’s blood pressure plummeted and his heart rate escalated. Looking at the heart monitor, I saw that it was ventricular fibrillation. The patient was effectively in the jaws of death.
With complete calm, the cardiac surgeon asked for the paddles and attempted cardioversion. Charge. Clear. Shock. Nothing. The sickening, disorganized gyrations of a fibrillating heart is a difficult thing to watch for somebody hell-bent on making people better. For the two seconds I watched this unfold, my mind raced, seeking a reason the cardioversion failed. Potassium too low? Potassium too high? Calcium too low? Hypothermia? Poor contact because of the scar tissue? I kept coming up with reasons as the milliseconds passed. Silence hung over the room until the scrub nurse calmly took the paddles away from the surgeon and tightened their connections and offered a “Sorry about that.” Shock. The fibrillating heart instantly became a synchronized organ that generated 80 beats per minute and a blood pressure of 120 over 80. Success. The operation proceeded uneventfully.
This is the everyday world of the cardiac surgery team. Re-do operations in less-than-ideal candidates. Ventricular fibrillation, cardioversion, cardiopulmonary bypass, peripheral cannulation, cardioplegia. Terms and situations that imply patient demise unless corrected quickly and carefully. Although television portrays cardiac surgeons as arrogant, overbearing, foul-mouthed egomaniacs, and every patient’s outcome the result of miracles or luck, I don’t see it in my world. What I see daily, and what I saw on this particular day, was a poised leader of a well-trained team caring for a very ill human being with great compassion, knowledge, and skill. While politicians battle about the rights and wrongs of health care, well-prepared teams like this one show up to work every day and efficiently go about the business of helping needy patients. MM
David Farley is a general surgeon at Mayo Clinic.