Time of Death II

Please see the previous post for the preface of this story.

I took the patient into the operating room at 6:45am. I started the lines I would need for the surgery and held the patient's hand as I began the anesthetic. He closed his eyes, and none of us knew at that time he would not awaken again. The rest of the anesthesia preparation went smoothly and I was quickly ready for the surgeons.

The surgery itself was hampered every step of the way. The patient's prior sternotomy for an infection years ago had caused much scarring and we encountered a lot of bleeding as the surgeons dissected down to the heart. An injury to the heart itself forced us to go onto femoral-femoral bypass, which luckily we had prepared. When the surgeons finally exposed to the heart, I looked over the drape to see the aftermath of rampant infection; the tissue was macerated, cold and dead looking.

After the surgeons dissected down to the valves, they realized they had to reconstruct part of the heart wall as well because there was so little viable tissue. It was challenging work, as they took synthetic mesh, pericardium, and prosthetic valve, trying to rebuild the heart. They even asked for the opinion of other cardiac surgeons during the operation. We were on bypass for over ten hours before we tried to reawaken the heart.

After reconstructing the valves and part of the heart, we tried to transition off bypass. But as we did so, we realized there was a severe injury to the posterior heart, behind where we could see. The mediastinum welled with blood despite aggressive suctioning. We went on and off bypass several times but the surgeons simply could not repair the injury. It bled too quickly, was located too posteriorly, and could not be repaired. Four cardiothoracic surgeons operated, but there was nothing we could do. With that prolonged bypass time, the patient was also very prone to bleeding; we resuscitated him with generous blood products but to no avail.

In the end, the surgeons called time of death. I gave the rest of my fentanyl and midazolam, turned off my monitors, and unhooked the ventilator. We cleaned him, took out our lines, covered him up. It was devastating. I left the room after midnight. The whole team - anesthesiologists, surgeons, bypass perfusionist, and nurses - had been working to salvage the heart for eighteen hours.