Ebb & Flow of the Heart

No artwork really does it justice, but we’ve put up so much about the heart here, I thought a diagram might be in order.  Apologies to all you med students who already know this stuff.

The red blood, coming from the lungs, full of oxygen, goes through the heart and into the aorta for delivery throughout the body.  The “blue” blood, which has already been depleted of oxygen by that trip around the body, goes from the right side of the heart, through the pulmonary artery and to the lungs for a fresh load of oxygen.

The four chambers of the heart, and the blood vessels.

The four chambers of the heart, and the blood vessels.

And here’s what a real one looks like.  Generally speaking, each of our hearts is about the same size as our clenched fist.

Heart, surgery, hospital

Heart ready for transplantation

 

Before the Beginning

Before every operation, as the patient is being prepped and anesthetized, the routine is the same.  Dr. Guleserian gathers the entire OR team around the table.  She then goes through a litany that includes the patients name and ID number, the procedure he or she is about to undergo, the name and duty of everybody in the OR (including people shooting photos like me), and other pertinent data.  If anybody hears anything incorrect, they are supposed to speak up.  No margin for error in here.

Dr. G checks the patient and does the pre-op checklist

Dr. G checks the patient and does the pre-op checklist

When One Doc Operates on Another Doc’s Kid

Occasionally, Dr. Guleserian will wind up with a young patient whose parent, or parents, both happen to be doctors.  And that, she says, can make for an interesting situation.

One was an anesthesiologist and one was in internal medicine and they were actually quite lovely. Their son needed an emergency operation, it needed to be done that night, had a pretty good risk of having complications and actually the child did very well and the parents were incredibly lovely, understanding and didn’t make you feel at all uncomfortable. But my nature is that I’m very truthful to everybody, I explain things, I will ask if I know they’ve have a medical background, how detailed do you want me to be, because sometimes you have a medical background but it may not necessarily be in the area of pediatric cardiothoracic surgery and so just like for me, in speaking to my family members’ physicians, just talk to me like a regular person because maybe I am not so familiar with neurosurgical procedures and things, anything like that. Anyway, I think you just need to be truthful.

Dr. G chalk-talks the surgery she is about to perform on an 8-month old girl.

Dr. G chalk-talks the surgery she is about to perform on an 8-month old girl.

Making Life Better for Children

That’s the entire mission statement of Children’s Medical Center Dallas.  And they make life better for children through folks like Dave Bartoo.

Dave Bartoo, surgical tech at Children’s Medical Center, part of the Pediatric Cardiothoracic team, is one of a number of people who work on every case that comes to the hospital.  And Dave and his team always have only one goal – the health of the patient.

I can’t convey enough about my team, my surgeons, that they do those little things every day like we will take their favorite stuffed animal, and we’ll put a little dressing on it – They have a heart dressing just like you do and everything, and we give them these little heart-shaped pillows. I’ve had adults that are 40 years old that we work on here, and they’re like, “Do I get a pillow? I see the other kids – ” You know like, “Do you want one?” I’ll go up, and we sign it and wish them luck.

To illustrate.  Here’s a shot of two-year old Rylynn being wheeled into the OR for her transplant.

Nurse (l) tells Rylynn they will take care of her baby doll for her.

Nurse (l) tells Rylynn they will take care of her baby doll for her.

Dr. G. is on the right.  On the left is a nurse who tells Rylynn that she will take care of her doll for her, and when she gets back to her room, her doll will be there.

So, how did the very busy Cardiothoracic Surgical Nurses, prepping for an long, intense operation, take care of a little girl’s doll?  Did they put it in a plastic bag, write her name on it and put it aside?  No… they did this.

Rylynn's doll waits for her to come out of surgery.

Rylynn’s doll waits for her to come out of surgery.

 

Around the Table

Two surgeons, two techs, and an adviser hover over the OR table.

Two surgeons, two techs, and an adviser hover over the OR table.

During a procedure to implant a Berlin Heart ventricular assist device, Dr. Kristine Guleserian (2nd from left) is assisted by a fellow surgeon, two surgical techs, and an adviser.

Despite the high stakes involved in the OR during a pediatric cardio-thoracic procedure, it’s a surprisingly calm place.  This is the major leagues of pediatric heart surgery, all these people are all-stars and the job is done efficiently and quietly.

Talent for Sewing

The sutures used in cardiovascular surgery are so fine that they can actually be hard to see.

The sutures used in cardiovascular surgery are so fine that they can actually be hard to see.

There is a great deal of sewing in the OR.  Sutures sew valves onto hearts, sew hearts into bodies, sew grafts onto aortas, and on and on and on.  And the sutures, and the needles used to push them through tissue, are so fine that you sometimes have to look awfully close to see them.

And the other amazing trick of the OR is that the sewing isn’t done “by hand” but by tweezer.  The needles and sutures are handled with instruments only, which requires even more dexterity.

Berlin Heart – Bridge to Transplant

One half of a Berlin Heart, a mechanical ventricular assist device, is prepared for insertion into a patient.

One half of a Berlin Heart, a mechanical ventricular assist device, is prepared for insertion into a patient.

 

The Berlin Heart is a ventricular assist device which is used on patients whose heart pumping action has become insufficient to sustain proper circulation.  It is referred to as an “extra-corporeal” device because the pumping mechanism is outside the body.

Rylynn had a Berlin Heart implanted by Dr. Guleserian and the team, and was on the device for about three months prior to a suitable donor heart becoming available.

Bartoo Watches Over his Lair

Children's Surgical Tech Dave Bartoo presides over the instruments during heart surgery.

Children’s Surgical Tech Dave Bartoo presides over the instruments during heart surgery.

 

 

 

 

“It never bothered me to come in for a transplant because I always felt you were definitely doing something life altering and good for this child. You’re buying them a better quality of life, pretty much, and usually, when these kids – Depending on their age – You can see the suffering and the toll it takes on their body when you’re born with a bad heart, and it’s gut wrenching, and the families, for God’s sake. Some of these kids that aren’t born with congenital defects that get cardiomyopathy from Strep throat or something like that, I can’t even fathom. Your whole life is completely changed when that diagnosis comes in. You’ve got a healthy kid, and two weeks later, you’ve got a kid that’s maybe listed for a heart transplant, and you’re talking about – You’ve just cured a lifetime of operations now, and your life expectancy has dramatically changed. For the family, you thought you had a healthy kid. Now all of a sudden, you’ve got a kid that’s very sick and might die if they don’t get a heart, and that always appealed to me that it was my way of really making a difference, helping people make a difference.”

Dave Bartoo

Surgical Tech

The Drug Store in the O.R.

Obviously, during major surgery, the doctors and nurses and techs working on hearts at Children’s Medical Center of Dallas are going to need any number of different pieces of equipment, and drugs/IVs/solutions, etc.  And they can’t just dodge out to the local CVS for something.  They need everything close at hand.  And while the OR maintains its own pharmacy, each room has a large, cabinet-like device called an Omnicell, which holds many of the items needed during surgery.

The OmniCell, which holds drugs, instruments and equipment during surgery.

The OmniCell, which holds drugs, instruments and equipment during surgery.

Everything in the OmniCell is keyed into the patient file so that all proper charges are made automatically.  And the computer also updates the central supply so that items can be replaced as soon as needed.  Only certified personnel can open the OmniCell, by means of the computer keyboard on the left-hand door.

The Harvest Team

One of the most delicate parts of any transplant procedure is the “harvest,” the removal of organs from the donor patient.  Surgical Tech Dave Bartoo had made it plain from the start of Rylynn’s hospitalization that he wanted to be a part of the process.  He assisted on the harvest, and he describes what goes on at that end of the procedure.

We’ll take the heart first, but what happens is, it’s a string of situations that happen. The liver teams work below us. We open up the sternum. We get the heart ready. We dissect out what we have to dissect out. We put in the cardioplegia needle and what we do is, we let the liver team know we’re ready to go. “Are you guys ready to go?” because they have to plege the liver after we’re pleging the heart and cutting the heart out. This all happens  at the same time.

We take the heart out a lot quicker than they do with the liver and the kidneys. They’re not pressed for time like we are, so once we put the crossclamp on, give plegia, we start cutting the heart out. These steps start in place the minute the crossclamp goes on our heart, the clock is ticking for us. We have to make sure that they’re ready to go in the abdomen before we can put the crossclamp on. We just can’t put the crossclamp on and sit there and wait for them, because that’s ischemic time for us. We have to wait and unfortunately, sometimes, the liver team will even be en route, and we’ve been told we’ve got a time in the O.R., and we’re sitting in the lounge.

I know of a time that Dr. Forbess and Chuck sat for eight hours before they actually went in and took the heart, so it’s a culmination of all these people from across the country, different states, trying to get in the same area. Another thing is is that anything that comes in trauma wise or emergently into that O.R. takes precedent over a harvest. A harvest can be put off until they can do it, so you’re at the mercy of a lot of different things when this takes place. It could be very quick, where you’re in and out, or it could be very long and tedious for you, sitting around, drinking a lot of coffee for hours.

Surgical Tech David Bartoo brings in the cooler containing the donor heart.

Surgical Tech David Bartoo brings in the cooler containing the donor heart.