Berlin Heart ECMO

So, I wanted to talk about this crazy case that happened on my first week at Vandy, because this is an awesome story of the versatility of Perfusion!
We had a patient that presented with AVcanal defect, with severe mitral and tricuspid regurgitation. This patient came in for AV canal repair, mitral and tricuspid repair. The patient was not doing well after coming off bypass and went on ECMO support. After a few days on ECMO the patient still suffered from severe MR so the patient was brought back to the OR, they were unable to repair the leaky valve, and required an new mitral valve. (FYI they do not make porcine valves for peds patients so it has to be a mechanical valve, and just think how many times you would have to have surgery again to replace the valve as the patient grows bigger. So putting a mechanical valve is a rarity and is avoided at almost all costs).

The first valve was inserted the patient still had issues post bypass and ECMO was continued. They determined that there was an annular leak around the valve and required further repair. Patient was brought back to the OR for repair. Again, issues remained post bypass, and ECMO was still continued. Then issues began to arise with the mechanical valve, it kept getting stuck open, so the patient had wide open MR. The patient was brought back to the OR again for another valve replacement (this was my first case experience at Vandy and was called back to TN from my turkey day vacation in IN to see this case). The patient continued to have arterial saturation issues and ECMO was continued. Finally, the Berlin Heart implantation was decided for this patient. (Also, FYI the Berlin heart is not FDA approved so to use it on a patient requires FDA compassionate use, and they must approve of this before the device can be implanted).

FDA approval comes, and we move forward with implantation. The LVAD was successfully implanted, and about 20 minutes later the patient began to go into right heart failure and the use of an RVAD was required. RVAD implantation was successful, and then the patient sats began to deteriorate again. The surgeon says we have to go back on ECMO, but there is one major problem, this baby is only a few months old, has been put on bypass over 4 different times, has our current bypass cannula in to transfuse volume, these massive inflow and outflow VAD cannula that seriously swallow they entire patients chest cavity, the surgeon has nowhere else to cannulate for ECMO support. After discussion with the Berlin Heart rep and her making several calls to other perfusion teams throughout the US, and determining that the pressure drop across the Quadrox-iD pedi oxygenator was low enough to not hinder the VAD support. We decided to insert the oxygenator into the inflow cannula of the LVAD for ECMO support. You wouldn't think it but it was successful, the patient did well on this type of "ECMO" support.

Unfortunately, the ending to this story is not a happy one, but it really shows that we as Perfusionists have to think on our feet about helping the surgeon keep a patient alive, and believe it or not, know your IFU's and have them available because without those, this wouldn't have been a possible option.

Sonya

Exciting news at Vandy

So the VAD program at Vanderbilt was just initiated in March of 2010, so it is fairly new, but we just had an amazing experience with one special patient. I will post links to this amazing kid below. It is patients like this that truly defines the importance of Perfusion in the medical field.

This is our patients story, who was born with congestive heart failure. It shows a video of him with his Berlin Heart before we knew he was getting a transplant.
http://news.vanderbilt.edu/2011/01/tennessee%E2%80%99s-first-berlin-heart-infant-receives-heart-transplant/

The transplant was a great success, and yes like all transplants it occurred in the wee hours of the morning!

He is doing well and I believe he will be going home in the next couple of days! We will all miss him in the hospital because he was such an amazing little boy!

Sonya Burrell

Monroe Children's at Vanderbilt

So this is a brand new rotation site for hands-on pediatrics and I am the guinea pig. The cardiac team consists of 3 surgeons (one which was just given privileges last week, so don't know how they will be yet). The two I have worked with very rarely get upset in the OR, and lack the "normal" personality of a cardiac surgeon. One of the surgeons I clearly define as a machine, he will operate all day and night without stopping. My first week here I worked over 40 hours on just Monday and Tuesday, finishing the week off at over 70 hours. My first week at Vandy consisted of a redo RV to PA conduit, MV repair with AVSD repair, Fontan, Interrupted aortic arch, Berlin Heart Bi-VAD implantation with Quadrox-ID pediatric oxygenator in line for ECMO support, Glenn shunt, DORV/VSD repair with arterial switch, ASD PAPVR repair, and bidirectional Glenn Shunt....whew that was a lot.

There are 4 perfusionists here, all are great people to work with. The chief perfusionist is not in the OR as much as the other three but he is there in the office daily, and he is a process improvement machine, so if you bring him an idea he wants to know all about it and be prepared to do the research to back up your stuff! This hospital does A LOT of ECMO which unfortunately is not controlled by perfusion right now, but the ECMO program is going under some major changes so who knows! This site is amazing, I have never done the same case twice, they are never routine, and each day is a new challenge. Be prepared to learn a lot but be patient because they are a little slow to let you pump a case, and you really have to prove your worth to sit behind the main seat. They use roller pumps, with terumo circuits, Terumo systems 1 heart-lung machine, and TLINK charting. This center is 100% electronic charting for the patient records so if your used to paper this is going to be a major change for you. Oh and you are on call 100% of the time (yes this includes weekends)!

Nashville is an awesome place to live! For those venturing here in the winter season expect snow instantly turned to ice (and the people here don't know how to drive in it..lol). If you have any questions feel free to email me sonyaburrell1@gmail.com

Sonya

Washington Hospital Center/Johns Hopkins Hospital

I was at Washington Hospital Center from June until January, I pumped 118 cases and had 40 opCAB or Trans-apical/trans-femoral. The staff is great, they are willing to help you out with anything. There are 11 perfusionists (you only work with 5 or 6 of them) the average day was show up at the hospital between 6 and 6:30 set up and get ready for your case. You must be ready because the cardiac team is very fast (example AVR on bypass 50 min, CABGx4 on bypass 45 min, HeartWare HVAD implant, on bypass 62 min). If you are the only student there you can get in at least 2 cases per day. If there are two students there you can get 2 in if you want to stay later. Overall an excellent site. The staff is very interested in the latest technology and is open minded enough to look at other products and materials to achieve better patient outcomes. On Tuesday mornings you are able to go the their cardiac conferences which are very informative. Great rotation site would recommend it to anyone.

I started at Johns Hopkins Hospital just over a week ago. It is so much different. It is a teaching hospital with many medical student and fellows. The cases are much longer and the variety of cases are more in depth. They use roller pumps. You will spend a lot more time at Hopkins, the student MUST be in the OR before 6am! You are also required to pump 2 cases per day. Depending on the day you could get out anywhere between 6pm and 8pm. The staff is very helpful and willing to help you in anyway. I look forward to the remainder of my time at Johns Hopkins Hospital.

Gregory Kitchen

Cedars-Sinai and Primary Children's

I am currently at Cedar-Sinai Medical Center in Los Angeles, CA. Yesterday I was involved in one of the longer cases I've had and figured I could share it on here. It was a Bentall with circ arrest. However, the surgeon wanted me to go on bypass BEFORE he opened the chest. And during circ arrest for opening the chest. Interesting... huh?

Well, he cannulated the axillary artery with a Vascutek 8mm graft and the femoral vein with a 23/25 Estech venous cannula. We went on and cooled to 18 degrees, turned off the pump, and about 3 hours later we were warm and weaned off pump. However, this is not the end. After 2 more pump runs, a CABG, and IABP, it was determined that the patient needed ECMO. In room time: 0715. Out of room time: 0530. 22 hours. On average, there are 15 surgeries/week. Cedars: 10 Perfusionists, 6 surgeons, 3 fellows, a large VAD/Transplant program (#1 Transplant), the PARTNER trial, TEVAR hybrid standby, cell saver for orthopedic surgery and liver transplant coverage with veno-venous. There is usually at least one day/week you will be at the hospital longer than 20 hours and may be expected to be back for the cases the next day. I pumped 60 cases in 3 months.

Primary Children's in Salt Lake City, Utah was phenomenal for pediatrics. I really enjoyed the staff, surgeons and overall "feel" in the OR. I felt comfortable in pumping pediatrics with great Preceptors helping me learn the Peds side of Perfusion. I pumped 66 cases in 3 months.

I agree with a previous post (Bret's) to be prepared for anything when you go into the hospital and know that there is not much of a routine "schedule" in Perfusion.

If you have an questions about either site, please let me know. My email is ariannagrether@gmail.com or call my cell 541-941-3132.

Good Luck! :)

Intermountain Medical Center

IMC is a very new hospital. I think it was built less than five years ago. There are five perfusionists, but you will only be working with four. One of the perfusionists decided that he didn't want to have students. You will work with the guy that is on first call, unless the first call guy is the perfusionist who opted out of working with students (you will then work with the second call guy.) I have been doing one or two cases a day at IMC. There are five different surgeons and the surgeons are great. They are very patient and very easy to work with. IMC just switched from running rollar pumps to centrifugal pumps. They also have run the Quest Microplegia system. Right now they are part of the PARTNER trial and are doing trans-apical and trans-femoral AVR's in the cath lab which are stand by cases for us. If you have any other questions just send me an email or give me a call and I will be more than happy to talk to you about IMC's program.

Bethany Warnke

Swedish Seattle, WA

The number of case that occur each day can range from 0-5. There were only 3 days when I was there that there wasn't any cases. They only allow 1 student to rotate there at a time so if you go there plan on pumping a least 1 case a day. I got over 120 cases in the 6 months that I was there. There are 3 surgeons and 5 perfusionist. They make you take call 1 weekend a month and at least 1 day during the week. On call during the week means that if a surgeon has a to-follow case you would pump both cases. When pumping 2 case in 1 day you will usually be at the hospital from 6am until 8 or 9 at night. The perfusionist are very nice and always willing to help. They use the Terumo System 1 with a centrifugal arterial pump. They do not have a VAD or ECMO program. A typical day would be getting to the hospital around 6am and leaving around 4pm. They just acquired a liver transplant program so I was able to see 1 liver transplant. The surgeons for the liver transplant said they will typically not use veno-venous bypass but there is a perfusionist in the OR room during the surgery with the pump ready. Overall this was a very good site to do my first rotation and I learn alot.


Brian Perfette

Stanford

So the first thing you need to know about Stanford is that it is a teaching hospital. They have medical students, residents, and fellows. The fellows are the primary surgeons while the attendings are there to assist as well as take over in case anything were to happen. There are 2 fellows that are at Stanford for the entire year, so you will get to know them very well. There are 6 primary surgeons that you will work with. There are 6 adult perfusionists and 4 pediatric perfusionists. Because it is a teaching hospital, expect your cases to be long. We do A LOT of arches and circulatory arrest cases. We rarely do only CABGs, but we do a number of CABG/valve combinations. I rarely was able to do 2 cases in one day. Stanford has a large VAD program as well. Also, Stanford has a fair number of ECMO patients. Don't be discouraged if it takes you awhile to be able to go on and off bypass. The perfusionists will take their time to teach you their ways (and everyone's way is different). So it will take a little while to gain everyone's trust before allowing you to fully pump the case. It's nothing against you, they do this with every student. Another thing to know about Stanford is that you will be asked to do a lot of research on relevant topics while you are at the hospital. They really love research projects :)

The pediatric program is at Lucile Packard, which is a great program. They have a large case load and do all sorts of surgeries. There are 2 major surgeons on the pediatric side. If you are interested in doing pediatrics in your future, I would recommend having a rotation strictly at Lucile Packard where you go to this hospital every day for a certain time period. I was able to pump cases while on the peds side, but it was only after I spent a fair amount of time at the hospital.

Overall, I absolutely loved working there. Palo Alto is absolutely gorgeous and San Francisco is about 40 minutes away. However, it is very expensive to find housing. I lived on Stanford's campus for the first 3 months during their summer break, which was nice because I met a fair number of people. I then found housing through Craig's list, which worked out nicely because I was able to see the house and meet the roommates prior agreeing to live anywhere. If you have this clinical rotation, please don't hesitate to email me at CatrinaMcGrath@gmail.com and I can tell you some more details! Good luck!

Rush-Copley

There are 2 perfusionist, and 2 surgeons. All are great, and really have a lot to share and teach. Michael Djuric was the head of the perfusion program at Rush University for years and is a wealth of information. So take advantage if you get to work with him. The man knows what types of board questions are asked, and has offered up his old exams, and papers to study from. The surgeon is awesome, great attitude, willing to teach and just a fun guy. The heart team is also fantastic. A great site, but a little case load. If you get this site, be sure to confirm with Ed that at least one of your other rotations is high volume, or you just won't get enough cases under your belt. They ONLY do CABGs and Valves, so keep that in mind. Their equipment is all Jostra/Maquet products and they are a model site for others to come look at their setup. It's a pretty fancy machine with some of the newest technology, a very challenging circuit.

Any other questions, feel free to ask!

-Malia

JCAHO

Haven't posted for a while but thought this would be a sort of interesting quick topic. We all have heard of the governing boards and organizations that watch over the medical field, but we don't come in to contact with them often. I am currently at Rush-Copley in Aurora, IL and guess who showed up! JCAHO. The Joint Commission has these standards and rules, and fines are given out if they see or you are turned in for breaking one of their rules. For instance, recapping a bloody needle - $1000 fine (one of the surgeons in MI told me that one.) It is important for the safety of your patients, but also for your safety.

Apparently JCAHO was in our hospital for 2 days, and decided to "follow" our heart patient, an AVR patient. We were warned they would probably stop in to the OR at some point so of course the entire OR was "freaking out". Worried they would stop the nurses while the case was going on and ask them questions, or they would try talking to us while we were on pump, or interrupt the surgeon while he was at work. Well, first hand experience, and a little research...they actually aren't allowed to "bother" us while we are actually at work doing our job, especially in our case, we are on pump and think about it, if they interrupted us to ask a question and something goes wrong with the patient, lets just say they don't want to be blamed for that. So just keep in mind that when they are in the room, they are not their alone, someone is with them at all times typically the ones answering questions (charge nurse or chief of surgery or someone with more authority), and they aren't going to be talking to you. In fact our surgeon is a chatty cathy and he tried talking to the JCAHO guy and they guy waved his hand saying "Pretend I'm not here." So don't be nervous, and don't recap dirty needles in front of them either!

-Malia

support system

Here is something that I will touch upon that I wish someone had better prepared me for... clinicals are overwheming enough but it can be a lot more rough if you don't have a strong support system. Most of us went to these clinical sites without family and were in places where we didn't have friends or family nearby. Although having the didactic portion and beginning clinicals is exciting, I don't feel that the excitement is enough to overcome the sense of isolation you begin to feel after a period of time. I can honestly say that if it weren't for keeping in constant touch with those classmates I was closest with, I feel I would have gone insane. There is only so much family members and (non-perfusion) friends can do to listen and hear you vent... it seems to make a world of difference when you talk with a classmate(s) who is going through parallel situations with you at their respective site.

-Michelle

Feedback from Mayo Clinic and Abbott Northwestern Hospital Rotations

THE Mayo Clinic (Rochester, MN)

This rotation is very overwhelming right when you start. There are on average 13/14 cases a day, but students are only expected to do one or two a day (depending on how long the first case goes). The toughest part of this rotation was trying to learn every perfusionists setup and pump technique. Everyone does things differently and you will get questions for the reasoning for much of what you do during cases. The 17 perfusionist are all very different and it is a very clicky environment. The management team is awesome, they really work hard to make life for the students good and will listen to any comments or problems you may have. The surgeons can be difficult but overall are fairly nice. This is one of the best sites for variety of cases and caseload. You will have oppurtunity to pump pediatric cases if you want to. Every wednesday afternoon is "research" or learning day. Students will have the oppurtunity to do research on Mayo projects or start their own projects. The learning day is spending a couple of hours after lunch or during lunch in a meeting room and going over problems in perfusion or rare cases.

Abbott Northwestern Hospital, Minneapolis, MN

This rotation has been good so far, the perfusionists are very nice. Cases range from 1-6 a day. This site is a complete 180 from Mayo since it is private practice. The entire surgical team is very laid back, everyone is friendly and willing to help. The perfusionists are all nice, but a few of them will be anal about some stupid stuff. There is not a lot to say about this rotation, it has been good so far. There is a decent variety of cases to learn from.

Feel free to contact me for any other questions.

Marcus Williamson

Fine, I'll talk. But this money better be real!

It may be helpful to hear what a week as a perfusionist can be like, so hear goes. The following is a run down of significant events at Mayo Clinic Hospital in AZ for the week of January 9th - 15th, 2011.
Monday: Pumped Triple Valve procedure, patient extremely hypertensive going on(MAP like 130)- used Mannitol, Magnesium boluses, max Isoflurane to create desired pressure drop. Pump run-3.5 hours. Hours at hospital- 6am-4pm.
Tuesday: Day of Observation. Watched Heartware VAD implant from head of table. Hope the long term data is good, the implant procedure is much improved over the HeartMate II. Hours at hospital- 8am-5pm.
Wednesday: Pumped TVR, MAZE procedure, smooth case. Pump run- just over 2 hours. Following, I assisted the head perfusionist on AVR/Ascending Aorta Repair surgery. Pump run- about 2 hours. Patient bleeding a huge issue after, surgeon did not close chest for about 3 more hours. When you get 6 bowls of cell saver, more than 2 units of FFP are necessary, but what do I know. Hours at hospital- 6am-8:30pm.
Thursday: Observed Total Artificial Heart implant, assisted as needed with VAD supplies/transport. Patient required V-V ECMO to come off pump, so I helped prime/initiate ECMO. Hours at hospital- 7:30am-4:30pm.
Friday: No scheduled surgeries. Called in at 1:30pm to set up for Heart Transplant. Pumped the case from about 11pm-2:45am. Left the hospital at 5am.

To be clear, this would be considered a busy week, but definitely not out of the ordinary. I've learned that in order to be happy in this profession, you have to have an open mind about how any day can go. Always be ready for the absolute worst to happen. It's only when you're not prepared that things really go wrong.

Best wishes everybody,
Brett Gehrer

FREE MONEY!!!!

If you are looking for a little bit of free money you need to post something on this blog about your clinical experience and send an email to Catrina (catrina.mcgrath@azwebmail.midwestern.edu) or Greg (gregory.kitchen@azwebmail.midwestern.edu) and they will respond and tell you how to claim your FREE money ($250)! Catrina and Greg have already claimed theirs! Please make sure that the information you leave will help future perfusion students in their clinical experience.