Along with the "regular" cardiac surgery service patients, we also care for even more specialized patients. The device service is a group of cardiac surgeons and cardiologists that manage patients with complex mechanical heart devices. Most commonly, we have patients with end stage congestive heart failure who get LVADs or left ventricular assist devices. These machines replace the main pumping function of the heart; the surgeons implant a conduit between the left ventricle and the aorta and the machine does all the work ejecting blood from the heart since the heart cannot do it by itself. This is interesting in itself; the LVADs eject blood continuously so these patients have no pulse and sometimes their blood pressure is simply one number (if the heart is not doing any work, then there is no separate systolic and diastolic value). Pre-operatively, these patients often have multi-organ system failure, so when they come out of surgery, they can keep us up all night. Although the left heart is supported, their right heart is not, and that's usually what kills these patients post-operatively. The device can pump blood from the left heart to the body, but if the right heart cannot fill the left side, the device is useless. So we spend a lot of care titrating epinephrine, inhaled nitric oxide or epoprostenol, milrinone, vasopressin, and other agents to support the right side. Meanwhile, the liver, kidneys, and brain are quite tenuous as they recover from surgery. These patients really engage the gamut of critical care knowledge.
Rarely, surgeons will implant assist devices to both sides of the heart: an LVAD and an RVAD. These are bigger surgeries with greater bleeding and infection risk so even though both sides of the heart are supported, patients don't always do well. Although we have done total artificial hearts, I didn't see any during my rotation. The goal of nearly all these procedures is a bridge to transplant; most of these devices are not designed for long-term support, and their ongoing risks are high, so patients undergo these operations in hopes of eventually getting a new heart.
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In ancient Greece, the asclepion was a healing temple dedicated to Asclepius, the God of Medicine. Asclepius learned the art of surgery from the centaur Chiron and had the ability to raise the dead. The Rod of Asclepius is a roughhewn branch entwined with a single serpent.
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Hi! I am Craig Chen, a third year resident physician in anesthesiology at Stanford Hospitals and Clinics. I went to medical school at the University of California, San Francisco. Prior to medical school, I studied philosophy and biology at Stanford University, along with a minor in creative writing.
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3 comments:
On a totally different topic, any idea about whether you'll end up working in private practice or academics?
Out of all the different ICUs, which do you prefer the most?
So sorry I missed these comments! I appreciate the questions. Right now, I'm not 100% sure where I will work, but I certainly like the academic environment and feel that teaching and medical student/resident education is a wonderful privilege and engaging activity. I don't see myself doing a ton of high level research, but an academic anesthesiology clinical position would be a great job.
All the ICUs have their own flavor. I think the general medical ICU has the most variety of patients, involves the most disciplines, and engages complex decision making. I enjoy end-of-life conversations and that has the greatest opportunity for helping families through dificlut times. The SICU and CVICU are shared management ICUs with the surgeons, and that can make politics an issue. Nevertheless, both of those ICUs are great opportunities for anesthesiologists because we understand the perioperative period well.
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