Cardiac Surgery

The management of post-operative cardiac surgery patients at the VA is very different than that at Stanford, a difference that is especially noticeable as I moved from my CVICU rotation to VAICU. At the VA, mostly because it's the "way things have always been done," the goals are quite different. While we usually try to wake cardiac surgery patients up and extubate them within six hours, at the VA, we keep them deeply sedated overnight. The surgeons tend to be quite conservative, keeping pulmonary artery catheters in longer, titrating drips more slowly, and keeping patients in the ICU more time. If a complication like atrial fibrillation brings a patient back to the ICU, they become even more cautious about having that patient leave. As a result, I get a little frustrated and worried that we are exposing patients to risks of the ICU and aren't allocating resources appropriately. In many ways, the VA is a health care bubble that is isolated from the pressures of the private practice environment. The VA doesn't have external pressures from insurance companies to cut costs and meet outside quality standards. This is not to say that the care at the VA is inappropriate; in fact, our cardiac surgery patient outcomes are solid. But there are many ways of delivering health care, and tailoring care to a particular system or patient population is important.