Challenges in the CVICU

The CVICU really puts a resident or fellow's abilities to the test. Over the last four years, I've seen a lot of tricky clinical situations, but none were like the month taking care of post-operative cardiothoracic patients. I've given quick clinical vignettes for the last few blogs, but a few more stand out in my memory. A patient who underwent an "elephant trunk" aortic arch replacement was in cardiogenic shock. He was at maximum doses of epinephrine, milrinone, and vasopressin as well as 1:1 support of an intra-aortic balloon pump. He had an open chest; during his surgery, each time the surgeons tried to close the chest, he became extremely hypotensive, so they put a dressing over it but left the sternum open. When I was on my week of nights, he became frighteningly hypotensive, with augmented blood pressures of 50/20. I wasn't even sure how to code this patient; his chest was open, how could you do compressions? Would you open the dressing, don on sterile gloves, and manually squeeze the heart? In a desperate attempt to advert a code, I gave a large bolus of epinephrine and vasopressin and managed to resuscitate his blood pressure.

A patient awaiting heart transplant had placement of a ventricular assist device for nonischemic dilated cardiomyopathy. His heart was always in atrial fibrillation, beating irregularly, often too rapidly. Whenever he went into rapid atrial fibrillation, his blood pressures plummeted, and he got gram after gram of amiodarone in an attempt to keep his rhythm sinus. Often to keep his hemodynamics stable, we had to shock him. This patient taught me not to be afraid to use electricity to keep a heart in line.

A patient after a routine heart surgery develops refractory hypotension at 5 in the morning when I am pre-rounding. Putting an echo probe on him and examining his central venous pressure waveforms, I recognize that he is going into cardiac tamponade. Blood is filling up the space around his heart, compressing it, and rapidly killing him. I drop everything else I'm doing, activate the operating room, and wheel him back as I dose epinephrine. I stay until the surgeon evacuates the blood and the patient's blood pressures normalize.

Late at night, I scroll through the electronic medical record, scribbling down and calculating cardiac outputs and systemic vascular resistances trying to clarify a mixed picture of cardiogenic and septic shock.

Post-call, I break out of rounds to throw in a dialysis line quickly so the day team can continue seeing patients while I try to rescue a patient from developing pulmonary edema.

At the end of the month, I gained so much more confidence in my medical decision making. When faced with a rapidly changing, highly complex clinical situation, I learned when to rely on my instincts, when to stop back and question my assumptions, when to act, and when to think. This is what medical training is about.