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.