High Stakes

Cardiothoracic surgery is a high risk, high stakes field. Although in the community, cardiac surgery is often routine, straightforward, and uncomplicated, at a teritary academic referral center, we get a lot of high morbidity and mortality cases. We evaluate patients for surgery that other surgeons have turned down. We get transfers for post-operative patients from outside hospitals where the surgery went bad. We see a lot of emergency cases and complex transplants. And only at a few centers are technologies such as ECMO and total artificial hearts available.

As a result, the month on CVICU had its trying and serious moments. A patient with critical aortic stenosis and multiple other comorbidities is declined a traditional aortic valve replacement but is offered a chance for treatment with a transcatheter aortic valve replacement done through vessels in the leg. The procedure is complicated by pericardial tamponade or bleeding around the heart necessitating emergency conversion to an open procedure, which he was deemed too frail to survive. Although we got him through the surgery, his heart took too much injury and he passed away in the intensive care unit.

A patient undergoing a double valve repair with a long bypass time simply never recovers his mental status. During cardiac surgery and afterwards in the intensive care unit, many factors contribute to confusion and delirium. The patient doesn't sleep, becomes agitated, cannot communicate, and does not return to who he was. Brain scans and lumbar punctures are normal; all we can do is support the brain's recovery. The patient stayed several weeks longer than anticipated in the ICU, needing a tracheostomy for ventilator support and a gastrostomy for feeding, but eventually he wakes up, interacts with family, and starts on a long road to recovery.

A patient sent from an outside hospital for a bleeding thoracic aortic aneurysm, a disease with a very high mortality. He is rushed to our cath lab where a stent graft is placed. Unfortunately, he continues to bleed into his chest and cannot be resuscitated.

Over and over, due to the acuity, comorbidities, and high risk nature of our patients, we have outcomes that aren't ideal. This is what comes with the intensive care unit, and part of my rotation was learning to engage these situations. "We work in the dark - we do what we can - we give what we have." (Henry James).