A
Shift in the Life — The Ongoing Story of a Critical Care
Nurse
by Matthew Nathan Castens, RN
“The
Tell Tale Heart” (with apologies to Edgar Allen Poe),
part 1:
Since
I've started writing these stories for Cool Nurse, I've had
a couple of questions about what it’s like to have heart
surgery -- mostly from young adults watching their fathers
go through bypass. While the actual surgical procedure would
take a huge amount of time to explain, I thought I would describe
what the typical post-operative course is for a patient who
has just had open-heart surgery, based on a patient, Robert
(names have been changed), I recovered a couple of weeks ago.
On a typical
day I get report from the night shift at 7am. Unless a person
needs emergency heart surgery, we know how many are going
to be performed on any given day. The patient is usually brought
into surgery around 7:30. Generally, we figure that the initial
part of the surgery will take about an hour-and-a-half. This
first part of the operation consists of a specially trained
registered nurse or physician assistant, known as the 'First
Assist,' cutting into the patient's leg to take out the veins
needed to bypass the blockages in the heart. It is followed
by the surgeon cutting into the chest, using a saw to break
through the breastbone, and cutting into the outer sack that
protects the heart, known as the mediasteinum. It is also
at this point when the left lung is deflated so that the surgeon
can pull the left internal mammary artery (LIMA) away from
the chest wall. This is frequently used to do one or more
of the bypasses because it is stronger than a vein and is
already connected to a blood supply at one end.
The second
stage of the operation takes about two hours. The second stage
begins when the surgeon cuts into the pericardium and exposes
the beating heart. The surgeon then takes two large tubes
and sticks one into the aorta (the giant artery coming out
of the heart to the body) and the other into the superior
vena cava (the giant vein that returns the blood to the heart).
When these two tubes are hooked up to the heart-lung machine,
the heart becomes drained of all its blood and the patient
is said to be "on pump." Now the bypass machine is working
as the patient's heart and lungs.
The heart
is cooled with ice water and a high potassium solution that
stops it from beating completely. (Some heart surgeries are
done with the heart still beating during the operation, these
are called "off-pump" surgeries.) When the patient goes "on
pump", the circulating nurse in the operating room calls up
to our unit to let us know. We need to know the time so that
we can start setting up the patient's room. It's also nice
to be aware of the on pump time because if the pump time (the
length of time that the patient is on bypass) is excessively
long, we can be aware that there might be problems and start
preparations for a more difficult recovery. For our patients
who have started surgery at 7:30, the on pump time is usually
between 9:00 and 10:00.
On our
unit we have one or two nurses a day that start their shifts
at 11:00. Sometimes they recover the hearts, sometimes they
take patients and one of the nurses who was already working
takes the surgery. On this particular day, I was taking the
surgery, so I gave Patty report on my patients and started
getting the room ready. I make sure that all the necessary
medications were available in the room, and that all of the
special equipment I would need was within reach. Once I get
a patient back from surgery, I might not get a chance to leave
the room for three or four hours, so I needed to be prepared.
After
a couple of hours on the bypass pump, all of the grafts have
been sown onto the heart bypassing any blockages that have
caused problems. This usually takes a couple of hours. Once
he's finished, the surgeon starts warming the heart back up.
In most cases, the heart starts beating on its own once it
starts warming. Occasionally, it starts to 'fibrillate,' or
beat too fast and uncontrolled. If this is the case then the
doctor will shock the heart into a normal rhythm. Once the
heart is beating normally, he removes the tubes in the aorta
and vena cava and closes the holes. The heart fills with blood
and is working normally again. On the unit, we get a phone
call that the patient is "off pump."
The final
stage of the operation is when the surgeon closes the mediasteinum
and the left lung is reinflated. The doctor will also place
two large tubes in the patient's chest (called 'chest tubes'
-- go figure), which will drain excess blood and fluid away
from the heart and lung. Just like any other part of the body
when damaged, the heart and lung tissue will collect fluid
and swell. The chest tubes prevent severe swelling that might
compress the heart and make it stop beating. The surgeon will
also stick small wires into the heart before he closes the
mediasteinum. These wires can be hooked up to a pacemaker
if needed. After the surgeon has wired the breastbone closed,
he's done for the remainder of the surgery. The First Assist
takes over to close the tissue of the chest.
It is
at this point in the operation (now about 12:00) that we get
a phone call from the anesthesiologist to give us a report.
My patient
was going to be Robert, a 68-year-old with the usual history:
high blood pressure, high cholesterol. He never had any heart
problems until a couple of days before when he had chest pain
cleaning his basement. He called 911 (hooray!) and came to
the emergency department. From there he went to the cardiac
cath lab where the cardiologist injected dye into his coronary
arteries and discovered several severe blockages. There were
too many blockages to do an angioplasty, so a couple of days
later he had four vessels bypassed. (The medical term is coronary
artery bypass grafting, or CABG -- pronounced "cabbage".)
Everything went smoothly in surgery, and no problems were
expected. He would be up on our unit in half-an-hour. I called
the respiratory therapist so that he would be ready with the
ventillator, and let my nursing partner know the ETA. Whenever
a person comes back from heart surgery there are always two
nurses in the room for the first 45 minutes or so. The first
nurse takes care of the patient and the second nurse helps
get things organized and runs errands. The three of us gathered
in the room and waited with anticipation...
To be Continued! Stay tuned...
About
Matt
Matthew
Nathan Castens got his start in 1994 as a nursing assistant
in intensive care, coronary care, and emergency.˛˛He graduated
from Normandale Community College in Bloomington, Minnesota
in May of 1999 with his Associate’s Degree in Nursing.
Since
January of 2000, he has been on staff as a registered nurse
in the Cardiovascular Intensive Care Unit at North Memorial
Medical Center in Robbinsdale, Minnesota, one of the first
ever units to promote the single-unit stay environment for
open-heart recovery. He also works as a flight nurse for ALS
AeroCare, based in the Twin Cities.
Matt
specializes in the recovery of open heart surgery patients,
trans-myocardial revascularization, and the care of myocardial
infarction, CHF, and pulmonary edema. He is also very familiar
with intra-aortic balloon pumps, dialysis, and continuous
renal replacement therapies.˛˛Matt is a member of the American
Association of Critical Care Nurses.
Matt
is experienced in working with a wide population of patients,
thanks to the availability of experiences in North Memorial's
Trauma/Neuro and Medical/Surgical ICUs.
Visit Matt’s own page at: The
ICU Answer Page! Or go directly to his ICU
Answer Forum...
Browse through his other articles. ...
