1st HIV Patient

Today I performed bypass on my first patient that was known to have HIV/AIDS. It was very intimidating even though you're supposed to use universal precaution and conduct yourself throughout every case as if the patient is infected with such a disease. It was very interesting to notice the differences that everyone in the O.R. did because of the fact the patient was HIV positive. It was a good learning point in watching myself in how I payed more attention to what I was doing in handling blood, and knowing that I should use that type of precaution everyday. I found myself always using blunt tip needles, making sure that my glasses stayed on the whole time, making sure that I wore sterile gloves, and also not recapping any blood needles.

Phil Meyer

Heartware

So over the last couple of week one of our surgeons has implanted the Heartware LVAD. It is still under investigation by the FDA, he is also one of the people that helped to design the pump. The last two of them he let me pump them. Usually with an investigational the surgeons only want CCPs pumping but it was a great confidence booster for me that he trusts me with his investigational cases. I think the most important reason why he let me pump them is because of "communication". It is stressed in school so much and now I realize that some surgeons are all about it and others only want to know certain things at certain times. What a great experience.
Washington Hospital Center has been such a great place to learn and the staff has been really nice in helping me along.

Illinois State Perfusion Society Conference 2010

Melissa and I attended the Illinois Perfusion meeting last weekend, and good news! We're said to find jobs! Well we enjoyed ourselves and learned a lot, but there was a lot of really good information from the American Board of Perfusionists and the future of our profession. There are 3,818 certified perfusionist in the United States, there is said to be about 143 perfusionists due to retire and about 160 perfusionists ready to be certified via the boards exam this month, so the numbers are good (not perfect, but good), hopefully they will be creating a few more jobs out there this year for those looking:) Also Midwestern is thought of highly as compared to the other programs. I'm not sure if any of you have similar stories from your preceptors regarding the MWU perfusion students vs. the others. So the outlook is good, and here in the midwest, our program already has the best reputation. So for those of us with job anxiety, I wanted to share some good news:)

Malia

No protamine in the pump please.

As we practiced in all our scenarios in school, turn your pump sucker off as soon as protamine is started. If only it were that simple. Today I pumped an atrial myxoma removal/CABG. We came off bypass, the decannulated the venous line, with the root vent was still running with me occasionally transfusing the volume back to the patient. I guess there was still a lot of air showing up on the TEE, so we continued to do this. Then the surgeon asks for protamine. As anesthesia starts protamine, I tell the surgeon that protamine has been started and the root vent is still on. I'm told that yes, they know, and leave the vent on and continue to transfuse volume back. A few minutes later they took the root vent out, and decannulated the aorta. I went to go bag the blood in the pump, and it wouldn't come out. I kept checking and rechecking trying to find what I was doing wrong. My preceptor pointed out my problem, my pump was full of 'jello.' So the circuit, filled with almost a liter of blood, went straight into the trash. Thank goodness we didn't need to crash back on. Of course everyone had lots of advice afterwards for how to 'handle' that kind of situation. Ultimately, I feel like I did what I as a student could. I informed the surgeon immediately like I'm supposed to, and documented this. Afterward the surgeon said they realized that the pump would clot, but that de-airing was more important. I can only imagine what it would be like to be on pump still and have protamine given too soon.

Kelly Crews

Perfusion Conference/Transplant

Hey Everyone! I hope everyone is having a great time at their clinical rotations! So Brett and I had the opportunity to speak at a perfusion conference at Lake Tahoe that was organized by Stanford. I gave a case presentation on an adult male who we successfully weaned from ECMO after about 48 hours. He had congenital issues as a kid and had 2 surgeries as a child, then came into Stanford in July for a PVR that went relatively well with few complications. After he was discharged, he was home for about 7 days before coming back into Stanford complaining of SOB. Once admitted, they realized he was hyponatremic (Na+ was 120!) due to aggressive diuresis (he has CHF). So he was in the hospital for another 6 days when they decided to do a pleural effusion, he then arrested. They believe he arrested due to Pulseless Electrical Activity, which I had not heard of before and if you haven't either, google it! It's pretty interesting...the simple way of saying it is that the patient has electrical activity (including an active ECG) but the heart is not contracting (therefore there is no pulse). Anyways, we put him on V-V ECMO that same day, kept him on it for about 48 hours, then weaned him from it. He kept failing his swallowing test, so the biggest issue with him is that he couldn't put on weight, making him extremely weak. Eventually, he was discharged from the hospital about 20 days after he was weaned. He is now back in Hawaii where he is from and really enjoying life! It was such a cool experience following him during his entire stay at the hospital! So that's what I presented at the conference. Brett gave a really interesting presentation on coated tubings, which had a ton of information on it. I'm sure he would love to explain his findings to anyone who wants to hear more about them :)

The other cool thing I did yesterday (which some of you might have saw on my facebook status) was I got to go with the surgeons to harvest the donor organs for a heart-double lung transplant. So we took a private jet to the hospital, and I got to watch the entire surgery of removing the donor organs. It was so cool to see all of the other organs besides the heart and lungs (since we have seen those now multiple times haha)! All of the organs had such vibrant colors, I couldn't believe it. The donor was only 13 (sad story) so the organs were all very healthy. We then flew back and I watched them implant the new heart-double lungs into the recipient. It was so interesting to see the entire process of how organs are harvested, transported, and implanted, so if you guys are given the opportunity to do this, I would definitely recommend it!! It was a LONG day since I had already been in the hospital for a scheduled surgery then went back at 12:20 am that night and finally went home around 3 pm so I was a little sleepy but definitely worth it!!

Anyways, I hope everyone is having a great experience!! I heard the new class is even more talkative than we are haha Hopefully we will be seeing each other again in New Orleans for the AmSECT conference!! Talk to you guys soon :)

New Toys at MCCG

Hey I just wanted to show everyone our fun new toys at MCCG. We finally got the new Sorin S5 heart-lung machines, and new heater-coolers (that self clean)!!! We are very excited about them, and I can't wait to pump a case with them. At a later date we will have the new Gem Premier 4000 ABG machines. For the new students that come next year will probably have electronic charting! I will let you know how our first case goes with the new machines.

Sonya Mollohan

Minimally Invasive Robot

Here at Spectrum we have 2 surgeons who perform many of their valves and myxomas via the DaVinci Robot system. The system is very cool, they typically start by grafting the arterial line to the femoral artery (which is great for the line pressure!), they Y the venous and place a venous cannula in the femoral vein up to the inferior vena cava and then into the jugular vein. They also typically try to place the retrograde catheter in via this route as well, but sometimes this can be difficult to accomplish. There are 2 to 3 incisions made, typically one large incision between the costals to reach the right side of the heart. Once all of the arms of the robots are in place the RNFA or the PA will usually place the arms and readjust, replace, readjust the arms as the surgeon needs it. Bypass is typically run as normal, go on early and stay on with vacuum assist as needed. There is really no large differences in our job which is nice, plegia is typically given both antegrade and retro (if they can place it). The system is a nice set up, the surgeon is right next to you working the robot which makes it nice for communication, the actual preparation for surgery takes a bit longer but the outcomes are phenominal being that there is no sternotomy. If you come across this type of pump case, it is interesting and a great learning experience! Don't be afraid of the DaVinci!

Spectrum Health, Grand Rapids Michigan

Spectrum is really a great clinical observation site if you want to stay busy and work with some great teachers. There are 8 male perfusionists at Spectrum and all have been working here for no less than 10 years. They have 6 surgeons and are very busy. There has not been a day during the week since I have been here that I haven't had a case (or two) to pump. There are some specialties that the perfusionists do, like ECMO, VADs, Minimally invasive robotic cases, pediatrics, etc. In two weeks there will be a new surgeon adding to the mix that will be here solely for Heart and Lung Transplants (world renowned surgeon, I hear). Soon they also will be opening up the children's hospital where they will (most likely) be adding new pediatric surgeons. The hospital itself if beautiful, and the cardiac team has been extremely welcoming. The learning experience is great, you sit in front of the pump early (week 1), and they give you a lot of responsibility early on, let you decide which cases you want to do, and work with you on your schedule if there are any conflicts. You do take call, depending on how many students are here with you, I for instance switch with another student who's here, so every other week and weekend. The perfusion department here is extremely respected here by the surgeons and the cardiac team, if you have questions about the site, please email me! malia.goozen@azwebamil.midwestern.edu

Frustration!

Since this blog was made to inform and to educate I have been dealing with some frustration. Nothing at Washington Hospital Center. It has to do with anesthesia. There was a case that I pumped a few days ago that caused the frustration and today enforced this. The patient was small which means small blood volume and low Hgb. The case was a CABG and we were doing many grafts. We went on and the case was going exceptionally well. We maintained a steady volume and were approaching the end of the case. At WHC we use the CDI 500 (absolutely love it!!), as we are approaching the end of our case we had a resident anesthesiologist walked over and looked at our CDI and notice the Hgb was close to 7.5. He immediately walked over and began to check a unit of blood. WHAT!? We had been doing all that we could to increase the Hgb, (Hemoconcentrating, mannitol, etc.) He had already planned on giving this patient a unit of blood based only on 1 number. We also use the Sominetics Cerebral Monitoring (love it too!) the only thing that was a little off was the Hgb, all the other blood gases and monitors were good. It was really upsetting that someone on our cardiac team can destroy all of the efforts that were made for blood conservation, and give blood.

The educational part of this is there needs to be involvement of every member of the team, education is the foremost. This resident didn't look at "the big" picture but focused on only one thing. The perfusionist that I was with was livid. She couldn't believe what she was seeing. She truly was a "patient advocate". I learned that it is my job to stick up to anyone no matter who it is or what the issue is, the patient has a right to the best service. All of this so the anesthesia resident didn't have to work too hard.

Thus the issue today, another small patient, another small Hgb. Prebypass anesthesia gave over 2 liters. The estimated post dilutional hematocrit was 6.3, we ended up priming with one unit of blood. Turns out we had plenty of volume (it was a valve) and could have hemoconcentrated while on bypass to help with the Hgb. Patient did great ended with a Hgb of 9.8 and anesthesia gave over 3.5 liters is a bypass run of just over an hour.

My learning points. 1. Don't jump the gun when deciding to give blood, wait and see what the first gas comes back with before adding. 2. Be more aggressive when RAPing, and VAPing, even if I need anesthesia's help in getting pressure up so I can accomplish this task. 3. Use all of the tools to put together an action for each patient not just a single number. 4. Don't treat a number! Treat a patient.


Greg

About MCCG

Well I guess I will give some of the new students some info about the Medical Center of Central Georgia. We are busy all the time, we currently have 2 students here and we each average about 2 cases a day. Although some days and with certain surgeons maybe 3 cases a day. Perfusion is in charge of all of the cell savers used in all ORs, so if you aren't pumping a case you are probably running a cell saver. So know how to calculated estimated blood loss because they will be asking!!!! We use ACD as an anticoagulant for cell savers, so its setup is quick and easy. Our cell saver is the Medtronic Autolog which we use because of its small footprint. Right now we have the Medtronic Bio console centrifugal pump, with COBE century roller pumps for the vent and suckers, and the MPS Quest for cardioplegia. By the way you will love the quest it truly is one of the best perfusion devices ever created...I have seen a spontaneous conversion to normal sinus rhythm within about of minute after cross clamp removal on 99.5% of all of my cases. I literally believe we have only had to shock 3 of my hearts since I have been here. Truly love this device! We will however, this month be switching to the Sorin S5 heart-lung machines, new blood gas machines, new heater coolers, and possibly electronic charting (don't worry the quest will be here for you to love and enjoy). The staff in the OR is very friendly, but like all ORs politics play a major role, so smile nod and keep quiet for those fun things. Oh...and when a surgeon stops turns around and yells at you just smile and nod, in the end surgeons don't like issues or deviations from normal. Learn to be quick, and always, always anticipate the next step because sometimes the surgeon may not give you a command you understand, and if you know where they are then you know what they want. We have 4 Cardiac ORs and a large CVICU. We control IABP while in the OR and help with insertion in the OR, but the nurses manage the IABP while in the CVICU. Right now we do not used PRP but they did used to do it here, and the supplies are available for you to learn how if you choose. Get used to low volume in your reservoir because almost all of your cases will be 300cc's or less in your reservoir. Last but not least learn a little about the Abiomed Impella LVAD and Tandem Heart LVAD because they both here at this hospital. My final bit of advice...if you don't know something be honest because they love to teach and explain things..some of them like to quiz you and some of them like to give you homework assignments!

Sonya Mollohan

Changing out a reservoir

So to many this may seem interesting...why would you need to change out your reservoir???? Well you will need some background info to understand this one. We had a patient that was in for surgery on a descending thoracic/abdominal aneurysm and CABG. This was the patients 3rd CABG procedure and first aneurysm repair. The approach was a gigantic left thoracotomy extending almost to the groin incision for vein harvest and femoral cannulation cut down. We have a surgeon that has an interesting but effective method for these type of aneurysm repairs, which may also be common at other centers that I am not aware of. We cannulated both arterial and venous femorally, using a Terumo cannula with an 8mm graft already attached for the arterial cannula, and a femoral cadiovasions cannula for the venous side. Here is the interesting setup, a Wye is placed on both the venous line and arterial line from the pump. The second arm of the Wye's are connected with 3/8 tubing, i.e, a bypass line. Normally during the bypass run this bypass line is clamped. However, when the heart becomes too empty because these procedures are done beating heart, the surgeon will clamp the arterial line and open the bypass line to fill the heart by pumping blood up the venous side. Since the aorta is clamped out we have to monitor for both lower and upper body pressures which are completely dependent upon the pump flow. If you flow too high you unload the heart too much and the pressures fall in the upper body. This is really a true balancing act. I had 3 clamps on my venous line when we finally went on bypass so I didn't drain the patient too much. So enough about the setup. After the surgeon did the CABG off pump, they dissected out the aneurysm and determined that we would not be able to clamp the distal portion of the aorta. So we essentially went on sucker bypass. The surgeon clamped our arterial line and opened the bypass line, and all volume was transfused to the patient via the venous side. The lower body of the patient was not being perfused during this period. While on sucker bypass we had 3 suckers on the pump with an additional reservoir setup for the cell saver draining back into our pump (since we use ACD for anticoag in cell savers it was shut off since its a calcium chelator). We had to give 4 units of PRBCs while on sucker bypass, added a hemoconcentrator into the circuit because we did not get the opportunity to RAP the patient. After being on sucker bypass for about an hour we were running our blood through the oxygenator recirculation line trying to keep the blood warm as the patient was cooling down because of the large incision. When we opened the recirculation we noticed our reservoir volume was decreasing significantly even though we were not transfusing to the patient. After adding more volume to the circuit and attempting to open the recirc line again blood began to over flow the reservoir filter and we decided that if we had to go on full bypass that this reservoir was not going to make it. So we had to change out the reservoir. Since this was a beating heart we pumped as much blood as we could into the patient before diverting blood elsewhere to give us a cushion for change out time. We shut off all pump suckers, reconnected those lines to the new reservoir immediately, along with the hemoconcentrator lines, second cell saver line, and all VAVD lines as well. Pumped all remaining volume in the reservoir (just below the outlet of the reservoir) into prime bags. Clamped the outlet, (since there was already clamps on the inlet we just used those) and swapped lines to the new reservoir. We dropped about 500 cc of normosol and 10000 U heparin to wet the filter and prime some of the reservoir, we then recirculated the volume again through the recirc line to remove any air. Finally, we dropped our blood back in the circuit, turned on the suckers, and re-hemoconcentrated some more. We actually would not have ever gone on full bypass if this patient's temperature did not drop so low, but we made a full conversion to bypass to rewarm for about 30 minutes. Surprisingly this patient is doing well. They were extubated in less than 12 hours, sitting up and talking, had good kidney function despite being in chronic renal failure (and no renal perfusion for over an hour), has not received any products since being in surgery, tomorrow will be removing their spinal drain, and hopefully going home soon after that. These are the type of cases that truely amaze me how much patients can handle and how quickly they can bounce back!

Sonya Mollohan

Tandem Heart turned ECMO turned Oxygenator Change Out!

Well here in Macon we generally don't do ECMO cases, so this was a first for a lot of people. So, I thought I would let everyone know how our first case of ECMO is going at MCCG, since it is a very interesting case. We had a patient scheduled for surgery yesterday for a Redo AVReplacement and CABG. The patient was also scheduled to have the Tandem Heart put in (this is also the hospitals first experience with the Tandem Heart as well). The patient had their first AVR in March as a Mini AVR with a tissue valve, in end stage renal failure, and was readmitted several time for pulmonary HTN after the surgery. Due to continued CAD, valvular dysfuction, and CHF the patient was admitted for surgery. Yesterday, the bypass run was relatively uneventful except we had to give several units of PRBCs. The patient was put on the Tandem Heart cannulating the femoral vein using a transeptal cannula into the left atrium and the femoral artery. After the surgery the patient was stable until a few hours after their lungs began to fail, so we added in an oxygenator to our circuit. We also had to pull the transeptal cannula out of the left atrium to sit in the right atrium, so the lungs could rest while on ECMO. The patient became relatively stable on ECMO, and with attempts to wean this morning the patients lungs seem to be recovering. There was some miscommunication issues in that the respiratory therapist thought they were also supposed to wean from the ventilator. As we weaned to 21% fio2 the patient did well until the ventilator a little while later was also at 21% fio2, and before we could establish the ventilator was being weaned we had a fun surprise from the oxygenator (pics attached). We had plasma strike-through after 17 hours on ecmo with the Medtronic Affinity NT oxygenator, thus warranting an oxygenator change out. We did a change out which went relatively smoothly, and we are currently awaiting a Quadrox oxygenator from Emory in ATL if we need to do a second change out. We did at one point attempt to wean the patient from the Tandem Heart altogether to see if they still needed it, and now we believe the patient is in right heart failure. As it stands now we will start weaning the patient again tomorrow and determine if a biVAD is needed, otherwise we will need to re-advance the arterial cannula back into the left atrium to assist the left heart after oxygenation is no longer needed.

Here is how we did the change out, which will be easier to understand from the photo of the circuit setup. We used an standard pump pack, using the arterial filter and bypass lines. We removed the arterial filter, and shorted the bypass line reconnecting it to the 3/8 wye. We have a small pump setup for left heart bypass cases, and we setup the reservoir and connected the bypass tubing to the inlet and out of the new oxygenator for priming. We used normal saline to prime without heparin because the patient was still bleeding quite a bit from the chest tubes. A dead-ender was attached to the oxygenator recirculation port since this port would not be needed. Finally, we clamped the tubing just outside the bypass line on the inlet and outlet of the oxygenator and transferred it to the patient. Since the Tandem heart was off the lines to the patient were clamped, and for the reconnection of the lines we used what is called a wet technique. A person using a syringe of normal saline fills the tubes with fluid as the connections are made as to make sure there is no air in the lines after connection. We could have considered bleeding the lines from the patient but that would have been a bloody mess, and when the patient is sitting at a hematocrit of 18 this is not a wise choice. Once connected and air free the Tandem Heart pump was turned back on and all clamps removed expect the clamp for the bypass line. Let me know if you have any further questions!

Sonya Mollohan

DC Update

We are now entering our 3rd rotations! Hard to believe that a year has gone by since we started at MWU. Now a new class is starting didatic, though I'm sure classes and instructors have been changed around yet again. Hopefully this year with the mentoring that Ed has set up, and maybe even with this blog, we will be able to answer questions for the first students and help them along a little more than we were. I think sometimes we were left in the dark a bit, especially on rotations.

I really am enjoying my rotation at Washington HC. The staff has been very patient, and I most days I feel like I have some idea what I'm doing now : ) Still not a fan of DC itself, I've never met so many rude people in my life! I'm very grateful that I got sent out here despite my initial reservations in being so far from home. Greg and I come in every day at 6am, and on an average day we leave by 3. Some days (rare) are shorter, and some are longer, but it all balances out. We don't take call or weekends here like some of the other rotations, which is okay since there's always several cases regularly scheduled per day. With 6 surgeons, they stay pretty busy.

We've been able to see not only CABGs and valves, but ECMO, transcutaneous AVRs (the Partner study), Centrimags, Heartmate IIs and Heartwares. We've been inserviced on a new device called the Angiovac (though we haven't done a case yet). This Thursday we are even getting flight training since WHC has started doing flight ECMO (only a trial run so far).

Any of the first years interested in getting a lot of experience and exposure to different devices should really consider WHC.

I hope everyone is doing well and enjoying their rotations, and good luck to the students just starting!

Kelly Crews

Heart-Port

Hello Everyone! I hope that your rotations are going well. Yesterday I helped with a minimally invasive procedure known as a Heart-Port Case. In this type of procedure there is no median sternotomy made. Instead a para-sternal incision is made and the arterial cannula and antegrade cardioplegia cannula are inserted. The venous cannula is inserted femorally and the retrograde cardioplegia is inserted into the neck line by anesthesia. There is also no traditional cross clamp applied. A balloon serves as a cross clamp and is located on the inside of the arterial cannula. The balloon is inflated to a pressure of 450 mmHg (which we have to monitor during the case).

These are very time consuming cases to do. According to my preceptors, these cases were more commonly done about 10 years ago but are now making a "come back" because the company has made some changes to the cannulas. If you guys would like anymore information about this type of case, just let me know. The Edwards Life Science Representative said he would be more than happy to send information to anyone in the Midwestern Program!

Bethany

Malignant Hyperthermia Case

I have an interesting case to report, now that I actually figured out how to use this blog. About two weeks ago, I got to pump a case with a patient that had malignant hyperthermia. It seems to be a rare condition, so I thought I would share the perfusion aspects of the case.

Malignant Hyperthermia patients react poorly to anesthesia, so we had to remove all of our gas line tubing from our pump, as it was contamined with Forane. We established all new tubing from the gas blender to the connection of the O2 gas line we use in our circuit. We wye'd the tubing around the Forane, so none of the circuit could get contaminated. It is also important to avoid cold fluids with these patients, so we used warm cardioplegia and avoided adding any cold fluids (warm prime, blood). Thats all I can recall at this time, but it was a cool case. Hope everyone is enjoying their rotations.

Marcus

Abscess at Washington Hospital Center

I had the opportunity to pump a case on Friday and it was a little different than most. We were doing an MVR. The patient had an abscess that was inside the left ventricle. It was just an ordinary case nothing out of the ordinary. He was a retired doctor, so we take extra good care of those guys. He was laughing and joking when he entered the OR and even giving us a little history lesson.

While on bypass the surgeon began to extract the abscess and realized how large it was. It had grown to engulf most of the anterior interior left ventricle. When the extraction was done there wasn't much tissue for the surgeon to work with. He decided to go with a patch on the interior and exterior of the ventricle. The surgeon was a little worried about coming off bypass and the patch holding. The patient came off bypass with no issues. It was a good case.

Today when we were getting ready to transport an ECMO patient I found out that the patient had expired. He was extubated without issue. He was talking, eating, and enjoying his family. The patch had given way and he went straight to asystole. The surgeon had never seen anyone go that fast. There was NOTHING anyone could do for him. While we did everything we could there are still somethings that are beyond our control.

--Gregory Kitchen

Washington Hospital Center ECMO

Well on Friday we placed a man on ECMO he had some really big issues. This morning he looked fantastic. So the Dr. decided that he was ready to come off of ECMO. We started out by weaning him down first to 3.0L/Min, then 2.0 then 1.5 then 1.0 then off of ECMO. He looked great he had great pressure and his sats were all good. THEN....... He crashed. Fortunately we were ready with a pump primed and ready to go. So on bypass we went.

We started out by putting in an RVAD (centrimag) which was a cool experience to be a part of. It is a little different. We run bypass like every other case except for a couple of important points. We don't use Cardioplegia, you don't want to arrest the heart when you are trying to assist. We came of off CPB and he looked good. THEN......you guessed it crashed on the left side. We hadn't de-primed our circuit yet (which you never do until the chest is closed) so we were ready to go right back on.

We ended up putting in an LVAD (centrimag also). It was really interesting to watch this part of the case because the RVAD was still running which made our gasses go all over the place. One second it was perfect then it was all messed up, then it went right back to being great. Last I checked at 4pm he wasn't able to oxygenate himself. Unfortunately it looks like he will be getting a Heartmate II for destination therapy.

All the time during school we talk about death so casually but today it really hit me that this man that I transported downstairs and his wife touched his hand and said, "I'll see you in a couple of hours" may not be able to talk to his wife again. It reinforced to me how serious this profession is and I must to everything that I can to be "a patient advocate" and make sure my skill set is where it needs to be to help these patients.

--Gregory Kitchen

Emergency from the Cath Lab!!!!

Those fun little emergency cases we did, wow, got to see it in real life, but the patient lived:-) Code was called over the loud speaker, patient coming down from the cath lab...rushed them in, opened the chest, and on bypass they went. Harry and Ed were right, they move fast, and they are pushy about getting that patient on bypass NOW. It was obviously different in that most of the pump was set up and dropping prime was the only thing left to be done, but seeing about 25 people running around like mad, and trying to stay focused on the pump and keeping calm and not falling into the nursing staff and their chaos. The cardiologist are disliked greatly in the CVOR here, as they probably are at the hospitals you are at as well...doing "surgical" type procedures, stenting arteries that shouldn't be stented, dissecting coronaries, losing catheters in the right heart, etc. My first piece of advice, when you here the complaining start and the bad mouthing begin (about cardiologists), keep your mouth shut, second if you're lucky enough to be in the room during an emergency case - stay calm, and focused, always be thinking about what you would NORMALLY need to go on bypass, and that prebyass checklist in your head - use it!

-Malia

ECCOR at Washington Hospital Center (WHC)

What a fantastic hospital and clinical site. I wish all of my fellow class mates could have the experiences that I have had at Washington Hospital Center(WHC). First week was ECMO, third week got to pump a heart transplant and today we got to participate in putting someone on ECCOR (extra corporeal carbon dioxide removal). Much of the principles are the same as ECMO but some very big differences in the circuit. There is no pump. The patients heart is the driving force for the circuit. The circuit come out of the patients femoral artery and goes through an oxygenator and then returns to the patient. The major function is to remove CO2. The patient that we had today came in with a pCO2 of 86. We were on ECCOR for 10 minutes and the blood gas returned and the pCO2 was at 46. It was quit a site to see.

There were some other issues involved. The doctor that did the cannulation hadn't ever done it before and had two residents helping him. Lets just say 2 hours later and a blood loss of 500cc we were ready to go. If only they called in one of the cardiac surgical assistants they would have been in, cannulated, and on ECCOR within 20 min, and a blood loss of about 50cc. But I guess it is their opportunity to learn. This was the first ECCOR that was performed at WHC and was exciting to see.

My advice to students is continue to be familiar with all of the things presented in classes because you never know when you will see it and everyone will be looking at the perfusionist to know if its right or not. Having a general idea of how it works really help me learn more about it as it was done.

--Gregory Kitchen

Stanford

Hi Everyone! I hope everyone is having a great time at their clinical rotations!! So Stanford has been a little crazy!! All of the surgeries are really complex and last for hours (I get at the hospital around 6 and leave normally after 6). I can only watch one surgery a day since the cases last so long. One of the coolest things they do here is something called the "Partner cases." I'm pretty sure this a nation wide study, but I'm not sure what other hospitals participate, so some of you might have heard of this as well! It's an aortic valve replacement that is done through the femoral artery. They don't open the chest and they don't require CPB. We are there on stand-by and it is done in the Cath lab. It's pretty crazy! We currently have an adult on ECMO that had a heart transplant like 4 years ago and now the heart is beginning to fail again. So, I would say those have been the exciting things that have happened this past week!
Stanford loves for me and Brett to create reports on all sorts of stuff, which has been a lot of work! All of the preceptors are actually really friendly and the surgeons are very respectful, no yelling in the OR which is very nice. They call it the "Stanford way" haha
So I don't know what else you guys might be interested in so that's all for now. I hope everyone is doing well and enjoying the hospitals! I miss all of you :)

~Catrina

HEART TRANSPLANT!!!!!

Well today for my second full case on bypass I was entrusted with a heart transplant. The case was extremely busy. Thanks to my two other perfusionists we were able to handle it. SO much different from any other case. First we primed with FFP which was really weird to see in the pump (its yellow). Then the bad heart is removed there is no cross-clamp time, they keep track of ischemic time instead. The new heart is then placed in the chest and attached. We had a volume issue the entire time for most of the case we had less than 400mL in the reservior. It was one of the most intense things I have ever been a part of. Our ischemic time was 88 min. and total bypass time was about 120 minutes. Unfortunately we were dealing with such a volume issue we ended up giving a lot more blood products than we wanted to but, it worked. Last update at 5:30 patient was doing well in ICU.

The light bulb moments:
1. The target blood flow is just a "suggestion" you can accomplish good results without flowing at the target. When the venous return was AWFUL, we were able to adjust to it based on our flow.

2. There are a number of things I can do on the pump to get the same result. You can increase your arterial pressure with more than just drugs, use your flow, only if you have enough volume to accomidate that. Your pH can be corrected or changed based on your CO2 content and not just with your bicarb.

3. I have so much to improve on. I see all the stuff that the 3 of us accomplished and wondered how I was ever going to be good enough to be able to do it all by myself. (NO electronic charting). Between running back and for for FFP and units of blood, we still had to keep up with our charting.

Overall an experience I will never forget! I have seen how fun and exciting perfusion can be. We had a fantastic surgeon. He was very understanding (he had about 6 people scrubbed in at the table).

-Gregory Kitchen

From Michelle at Mayo

So I have finally figured out how to post a blog on this thing... only took me forever. Thanks, Kelly, for setting this up.

Mayo has been overall a positive experience so far. They do things so differently than what we ever learned in classes (or in my experience at OHSU for that matter). Marcus and I are back to using roller pumps (no big deal)... the differences are in the following: (1) They use 2 suckers up on the field and both 1/4" tubings are put into one raceway. (2) They talk in terms of cardiac index. For example, "What are you flowing?" and you answer, "2.4"... They never talk about the arterial flow in terms of L/min. But everything else is referenced in L/min. (3) The anesthesiologist who is the one who takes you off bypass and tells you to fill the patient, etc. (4) Mayo has their own set of people who do autotransfusion and IABP stuff. Perfusion has nothing to do with it. (5) We don't have a heater-cooler... we have water lines that hook up to the ceiling and knobs to the right of the vaporizer that control the water and cpg temps. Those are probably the biggest differences that I can think of off-hand. (6) We set up in a pump room and wheel the pump down to the OR (7) Lines are handed from the operating field.

Those were the biggest surprises for me... There are other little nuances that I'm certain I've forgotten to mention... but nonetheless, it's all been interesting to adapt to.

I came home yesterday to count that within the 12 days I had at Mayo, I've had 11 preceptors. I have learned 11 different ways to set up my circuit and 11 different ways to prime. That equates to me not progressing anywhere because I'm always starting at ground zero with each new person. It hasn't been easy for me to develop my own routine yet and I'm frustrated with myself for not doing better than I actually am. But I guess that is where patience has to come into play and I just have to give myself that. Marcus is doing well and I am glad that I have another classmate to chat with here because I don't know who else I would vent to about my feelings of being a retard (pronounced with the stress on the second syllable).

We found out that Dawn is going to work here during the summer. I believe that she starts next week. I am looking forward to seeing her here. Hope that all is well with y'all.

Dearest Students

Students,
Every year at AmSECT, one of the first suggestions is having a database to discuss clinical rotations. You now have this site and it will be offered to the juniors at Midwestern. So here is the deal, for those of you that post 20 posts by April 1 st will be personally invited to my home in New Orleans for a crawfish boil at the AmSECT National. This is an invitation only event. Those of you that don't post, then I don't want to hear you complaining. Please do for the juniors what you wish you had been offered.
Thanks,
Carla Maul
P.S. Neither I nor any other perfusionists will be reading these posts. I had Kelly get me on this time to write my post. So please feel free to be honest.

Washington Hospital Center

I love Washington Hospital Center. After week 2, I no longer get lost trying to find the cafeteria, I can locate supplies much faster, and I almost have all the perfusionists names down. Everyone is very nice and seems to enjoy teaching, there are a few that don't take students, but they are still friendly and have lots of advice for me on things like sightseeing in DC.

As we were told, everyone has slightly different ways of doing things. So far the phrase I use the most is "Okay. Why do you do like to do it that way?" Half of my cases so far have been with the same perfusionist, and that makes things a little easier. She even let me go on and come off bypass already. It was worth all the running labs, stocking, and general tasking over the last 2 weeks!

As I was told by the class that went before me, if you wind up at WHC, stay out of the politics. Everyone knows everyone in this field....and any information is only a phone call away. The surgeons will test you too, but don't take it personally. The surgeons here are excellent, and FAST. There's 4 cardiac ORs, and some days you are done with your second case by 1300.

Hope everyone else is doing well! And I hope this blog is useful. Some of you know Carla, this was her idea. Apparently students keep saying to her they wish they would have known more about the hospitals. Like how great WHC is and how you aren't even allowed in the perfusion room at Johns Hopkins (you literally have be in the OR or sitting in the OR hallway all day!!)

-Kelly Crews

Well...so far I'm amazed at the idea that what we spent time on in lab and class is actually applied in our rotations, just like they said it would be. There will always be little differences between perfusionists, hospitals, groups, etc, so be prepared for that. My notebooks have been filling up, and its only week two. Advice - write everything down, refer back often to those notes - especially write down things specific to what each of your preceptors want for set up/prime, it will get you on all of their good sides. Be prepared to stay until the wee hours of the morning when a valve doesn't go in right, to go off pump, feel like you're going home soon, then crash back on pump, the trick is to always be prepared, stay positive and professional, never express how frustrated you are that a surgery isn't going the way you want, or that you have something better to be doing than saving a life. When, not if, but when you get yelled at, smile under your mask, it's not personal, so don't take it personal. Spectrum has 8 male perfusionists, all of whom have been perfusionists for at least 15 years, they are a wealth of information and all will give you different reasons for doing what they do - don't argue that one of their colleagues has a better idea, just write it down and decide if it's a good enough reason for you...all of which Dawn has told us to do for the last 9 months, find what works for you and be consistent. I like my site, Spectrum is so beautiful, and the surgeons and staff are wonderful...so far so good.

Greg's experience thru week 2

First let me start off by saying all of the preceptors that I have had have been wonderful. They have been more than willing to impart any skill/knowledge that they have gained over their vast career. We have some perfusionist that have been practicing for more than 25 years. Going into this I was a little scared about the pace of things thinking that I wouldn't be able to grasp it all. The pace seems to be a lot more manageable. What Ed said was right, "Hurry up and wait". The surgeons have been great in allowing us to watch and has welcomed us into their ORs with open arms. I have seen several different types of surgeries thus far and enjoy the variety in the cases. For me there have been a couple of draw backs, sometimes I feel like the preceptors think this is my very first day at school. They don't think the knowledge base that we have received is enough to take on some challenges (I guess they have to trust me first), which has been a little hard for me. My recommendations to any future students would be, to make the connections between the didactic and clinical things as soon as possible, and put all of the effort you can into the lab scenarios (even if you already passed one), because this will help with the important foundations that are needed for CPB. Good Luck --Gregory Kitchen

What is this blog for?

This is a blog for us to share our clinical experiences with current and future CVSP students. Please share your experinces to help next years class decide where they would like to go, to find out information about a site you may be going to next, or just ask any questions that may come up.