The first patient we rounded on is worse again, and we run back over to see. One of the multiple devices keeping them alive seems to be malfunctioning. . . or is it that their cardiac function is suddenly deteriorating even more dramatically? The device rep happens to be around, but can’t seem to come up with a solid answer; and if he can’t tell what his own device is doing, it’s pretty hopeless. The cardiology attending shows up, and one of the cardiac surgery attendings. A lengthy discussion, and finally out of the confusion, a decision: an OR room has been opened, the patient is going there right now. It’s an immediate decision, laid down by the attending, but it takes nearly half an hour to execute: the cardiac anesthesia team has to come over, get at least slightly acquainted with the myriad drips and machines surrounding the patient, and then a procession is organized to move the patient (being bagged), three iv poles, and two machines at the foot of the bed, through the twisty corridors to the OR.

I try my best to urge the intensivist to finish rounds expeditiously, without actually saying that I want to escape over to the OR. Finally, an hour later, we’re done, and I leave him considering some more electrolytes, and slip over to the OR. It’s an emergency case, so the fellows are tied up in the scheduled procedures, which means I can scrub in and assist with the PAs. I’m not much good in a normal cardiac case, let alone an emergency, but I have learned enough not to be in too much danger of tripping over the bypass cannulas, and I’m starting to be able to see what the attending is trying to accomplish, and help get that done. I think about putting on my loupes before scrubbing in, but decide that it’s going to be a long case, the structures are big enough to see without, and I’d rather be able to see the operative field, and help with the equipment, than be trapped in the tiny field inside the loupes.

The case drags on and on. One obstacle after another, and with every one the patient’s blood pressure slips lower and lower, and the rhythm tracing looks more and more erratic. The mediastinum fills up with blood, and it’s a non-stop job to suction enough for the attending to see what he’s working on. I fight back an impulse to point out what the blood pressure is. He knows well enough already (there’s a large monitor placed to be visible to the surgeons), and pointing out how desperate the situation is won’t help him get a difficult job done faster. Another attending comes in to help, but things don’t get any better. Both of them start making pessimistic remarks, warning anesthesia that things are not going well, and are not likely to improve. The circulating nurse is occupied, either in a whispered argument on the phone with the blood bank, or searching through the supply cupboard for the increasingly exotic sutures that are being requested in the hope that they’ll hold where others have failed. The attending has the ICU charge nurse called to go convey to the family that things are not looking good, to prepare them for him to arrive with the bad news in a little while.

Eventually, he calls it. There’s so much blood in the mediastinum that it’s impossible to clear, let alone put stitches that have any chance of helping; the mean pressure has been around 30 for who knows how long; and then the heart goes into fibrillation right in front of us. One attempt at defibrillation, with the sterile paddles that are laid at the top of the table for every cardiac case with the hope that they won’t need to be used, and then we admit defeat. The attending scribbles on the requisite papers in the OR, and goes out, to talk to the family and dictate some approximation of a report, leaving the PA and me to close up. I’ve never actually been in the OR with a dead patient before (except on transplant, and that isn’t supposed to count; we weren’t trying any more to stop those deaths). I wish I were more shocked, but actually everyone knew what the outcome would be from the beginning of the day, let alone the beginning of the case. The PA offers to let me put in the sternal wires (too much chance of hitting lungs and major arteries for me to have ever been allowed to do that on a live patient), and with that excitement, and the thrill of having actually been first assist on a big case, I try to forget the family members I had seen crying in the waiting room all morning.

Then it’s back to the ICU. There are still more lines that need to be put in, consultants’ plans that need to be checked on. Have to go and see who was put on a spontaneous breathing trial this morning, who looks like they’ll get off the vent in a day or two, and who is still too sick to wean. Check on the chest tube output of the patients from the OR this morning, since there is nothing guaranteed to get a cardiac attending yelling at you faster than neglecting to inform them soon enough that the output has been approximately 200cc/hr for a few hours. (I know, because I’ve tried it more than once. If you keep checking every 15 minutes, somehow it doesn’t seem like so much blood; but then you add it up after two or three hours, and it’s a lot, enough to be worth opening for, and you get chewed out – again.)

Out by maybe 6pm, but too often, we end up opening a chest in the ICU from earlier in the day, when the volume in the chest tubes, and the amount of blood transfused, passes the attending’s threshold; and then we’re there even later. No rush, the next day is just going to be the same all over again.