The Ultimate Back-Up

To some degree, anesthesiology is about back-up plans. Even though my days almost always proceed ideally, I plan and prepare for the worst. The alert and vigilant anesthesiologist thinks of worst case scenarios: what if the patient has an allergy to this medication? What if the IV becomes dislodged? What if the surgeons get into unexpected bleeding?

Cardiac anesthesiology introduces me to the ultimate backup, which is really only available to this specialty: cardiopulmonary bypass. All of the most dreaded anesthetic emergencies - a heart attack, refractory arrhythmias, persistent hypotension, inability to oxygenate the patient - can be temporized by putting the patient on a heart-lung machine. Of course, bypass and the amount of time on bypass has its risks, so once the patient is rescued, we have to work quickly to reverse the problem.

This became extraordinarily clear to me during a surgery on a patient who had multiple prior operations on his heart. In the same way our body scars when we get cut, each surgery creates more and more scar tissue, which can be extremely worrisome if the heart scars to the underside of the breastbone. In order to enter the chest, the surgeons cut through the breastbone with a median sternotomy, and if the heart is stuck to that surface, they can cut open the heart.

Unfortunately, this happened. The thin-walled right ventricle was cut during the sternotomy, and we had to crash onto bypass. Even in such dire circumstances - akin to being stabbed in the heart - we remained calm. The surgeons, anticipating this possible complication, had already prepped and dissected to the femoral vessels in the leg. I was equally prepared and began transfusing blood and giving heparin to go onto bypass. We were on the heart-lung machine within minutes and despite profuse bleeding from the injury to the heart, we never dropped our blood pressures. Once we were on cardiopulmonary bypass, the surgeons were able to finish dissecting to the heart, repair the laceration, and continue the operation.