Meeting a Legend

The news came from Houston today that pioneering heart surgeon Dr. Denton Cooley had died at the age of 96. Dr. Cooley was the first surgeon to place a fully mechanical heart into a human patient.  His Texas Heart Institute was one of the most important cardiac facilities in the world. Dr. Cooley continue performing surgery until the age of 87, and was active at the Institute as president emeritus up to the time of his death.

Earlier this year, Dr. G went to the Institute to observe procedures there, and she had a chance to visit with Dr. Cooley.

Dr. Denton Cooley and Dr. Kris Guleserian

Dr. Denton Cooley and Dr. Kris Guleserian

For Dr. Cooley’s full obituary, click here.

The Home Stretch

The manuscript is currently in the hands of Dr. G, who is making final medical and personal edits. (You don’t want to make mistakes if you’re a heart surgeon. You also don’t want to make mistakes when you write a book with one!)

After she finishes, November 1, the manuscript goes to the publisher for final design and layout, and then we roll it out to the public when the calendar turns over to 2017.

I’ve mentioned before how difficult it is to fit a book project in the schedule of a heart surgeon. Well, that’s been made even a bit tougher because, in September Dr. Guleserian accepted a position at Nicklaus Children’s Hospital in Miami (the former Miami Children’s Hospital.) So in between edits, she’s been leaving one job, packing up a house, moving, and starting over in a new city.

Which is to say, we appreciate your patience as we get this project done. And, for a bit of a preview, a mock-up of the cover is below. Let me know what you think.

And thanks, again, for your patience.

Mark

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Surgeon's Story, available in 2015.

SURGEON’S STORY — CHAPTER 1!!!!

Publication day is getting closer. And as we’re now well into the editing phase, we thought we’d give you an advance look at Chapter One — A Day In The Life!

OR-5

Children’s Medical Center, Dallas

November 5, 2009

I’m staring at Claudia. Eleven months old. Lying on the operating table in OR-5, sedated, as still as a doll with no moving parts. She looks smaller than her charted weight of nine kilos (20 pounds). Nurses cover her with sterile blue surgical drapes and all that’s visible is a small patch of skin on her chest. Bright, white lights bathe the center of the table. Doctors and nurses in gowns, caps, and masks crowd around. They look nearly identical. Except for the earrings. That’s the tell. That’s how you know it’s her.

Kristine Guleserian, pediatric cardiothoracic surgeon, is scrubbed in. Known throughout the hospital as Dr. G, she is one of fewer than a dozen women in the U.S. certified to do what she’s about to do – take a scalpel sharper than a dozen razors, cut through Claudia’s skin, saw open her breastbone, and spread her ribcage apart to repair two congenital defects threatening a malformed heart the size of a walnut. It’s just after 9:00 am. Claudia will be in OR-5 until 2:00 pm, along with a team of talented surgeons, nurses, techs, anesthesiologists, and perfusionists. Dr. G is in charge.

October 27, 2009

Children’s Medical Center – Heart Center

Two weeks before Claudia’s surgery, I had a 1:30 pm meeting with Dr. G at her office. At 1:25, I sat in the waiting room. At 1:30, Dr. G came through at her favorite speed – full. She headed for the door while putting on her white, starched lab coat over surgical scrubs and said, “Come on.” We trotted down the hospital hallway.

“This is my world. You wanted to see it. Welcome to my life.”

“Where are we going?” I was struggling to keep up with her, even though I’m a foot taller.

“We have to do a consult.”

“We?”

“I have to. You’ll watch.”

We whisked past the main desk of the echocardiography lab. Dr. G motioned to the charge nurse.

“He’s with me.”

The echo lab is dark and cramped, with barely enough space for the two people sitting at the monitors where Dr. G squeezes in. She introduced me to the two women, Dr. Catherine Ikemba and Dr. Reenu Eapen, both cardiologists. Then she laser-focused on the echo monitors. An echocardiogram is a moving image produced by sound waves directed at the heart and reflected back again as the waves pass from one type of tissue to another. To me, it looked like a blurry, moving x-ray. To the eyes of these three women it was an intimate cardiac road map. A nine-year old boy had a malformed aorta, and the cardiologists wanted Dr. G’s opinion. She was Socratic, asking questions she likely already knew the answers to, saying, “Well, I might do…” so-and-so, and then asking her colleagues for their opinions.

Two weeks later I came back for the first of many long days as her shadow. I wasn’t quite Alice in Wonderland, but the feeling of falling down a hole did occur to me every so often.

November 5, 2009

7:30 am – Heart Center Research Meeting

There’s more to being a surgeon than surgery. This day begins in a windowless media room, the kind of video-meeting-training center you’d find in any school or business. Rows of desks and chairs give it a classroom feel. A/V equipment hangs from the ceiling and a large video screen dominates the front of the room. The dress code is strictly medical, no business attire here. Doctors and nurses in scrubs and lab coats shuffle into the room, many with the ubiquitous cup of Starbucks in hand. This is a presentation of two ongoing cardiac studies being conducted at Children’s Medical Center’s Heart Center. The room is very cold, and Dr. G wears a black turtleneck sweater under her white lab coat. As the meeting goes on, she pulls the sweater neck up over her nose and mouth, seeking warmth. A presenter advances to the lectern, and the unmistakable look of the PowerPoint® presentation flashes on the screen behind her. The title slide reads:

CHROMOSOMAL COPY NUMBERS IN

HYPOPLASTIC LEFT HEART SYNDROME

I had begun my own rudimentary study of congenital heart disease, trying for a foothold in the maze of childhood cardiac problems, before I ventured into Dr. G’s world. Hypoplastic left heart syndrome (HLHS) is a life-threatening cardiac deformity where the left ventricle, which pumps blood to the aorta and then around the body, is so weak that any infant suffering from it will likely die without surgical intervention. The pediatric heart specialists in the meeting room critique what they’ve just heard. A senior cardiologist might question the validity of this or that portion of the research methodology. These are works in progress, not ready for publication. Ongoing study is a part of the job description.

   In the meeting room, the media screen glows again.

ECHOCARDIOGRAPHIC PREDICTION OF SPONTANEOUS

CLOSURE OF DUCTUS ARTERIOSUS IN PREMATURE INFANTS

After only two weeks shadowing Dr. G, I was able to make some sense of this title. The Heart Center team is using echocardiography to predict whether the ductus arteriosus in the hearts of premature infants will close properly after birth, sparing the need for open-heart surgery. I decided I had to dig deeper into the textbooks to learn more about what was beating beneath my own breastbone.

The human heart is a four-chambered muscle. The left and right sides of the heart each have two chambers – an atrium on top, and a slightly larger ventricle on the bottom. Each side is like Dali’s version of an hourglass. The atria and the ventricles are each separated by a thin wall called a septum. The ventricular septum is slightly more muscular than the septum for the smaller atria.

In a normal heart deoxygenated (blue) blood enters the right atrium from large blood vessels called the vena cavae, which bring blood back from the rest of the body after distributing oxygen. The right atrium contracts, opening the tricuspid valve, and blood flows down into the larger right ventricle. The contraction of the right ventricle sends blood through the pulmonary valve to the pulmonary arteries, and into the lungs for oxygenation. The newly oxygenated blood enters the left atrium through the pulmonary veins. When the left atrium contracts, blood is sent through the mitral valve into the left ventricle. The left ventricle contracts, blood moves through the aortic valve into the aorta, and off to oxygenate the rest of the body – the brain, the coronary arteries of the heart itself, deep into the internal organs, and superficially to the skin. Over and over again, on average 100,000 times per day. (Anatomic trivia – The pulmonary arteries are the only arteries that handle deoxygenated blood, while the pulmonary veins are the only veins that handle oxygenated blood. Otherwise, oxygenated blood always flows through arteries, and deoxygenated blood through veins.)

That’s in an anatomically correct heart. But the number of things that can go wrong with the human heart is staggering. Heart disease in adults is usually acquired, although many people born with congenital heart disease show no symptoms and don’t learn of any problems until years later, if ever. When we develop a heart condition in later life, it’s most often our own doing. Smoking, obesity, hypertension, poor diet, lack of exercise, diabetes and more, contribute to the clogged coronary arteries, heart attacks, strokes and other events that make heart disease the leading cause of death in most developed countries. Since infants haven’t had a chance to do much damage to themselves, it’s fair to wonder how a newborn heart can have so many problems. These heart defects, called congenital, occur because of interruptions in normal fetal heart development.

The developing fetal heart contains a series of shunts to keep blood away from the pulmonary arteries and lungs so that blood flow is kept low, and the tiny lungs won’t be overtaxed. Fetal lungs are non-functional, because the fetus gets oxygen from the mother, through the umbilical cord. The shunts in the fetal heart are the foramen ovale, the ductus venosus, and the ductus arteriosus. When something interferes with the natural switch over from fetal to breathing infant heart, physicians call it “persistent fetal circulation.” It can manifest in hundreds of way. In certain situations, it’s never even noticed. More information on all this as needed. And it will be needed.

Anatomy of the Heart 101 is over.

8:15 am

3rd floor Cardiovascular Intensive Care Unit

The Cardiovascular Intensive Care Unit (CVICU) has twenty rooms arcing around a large central desk, modern and corporate-austere in its furnishings. The pulse to the CVICU is the rhythm of the beeping sound common to every TV medical drama. Each patient is attached to a monitor measuring saturation (sats), heart rate (HR), blood pressure (BP), respiratory rate, temperature, and more. The monitors are computers producing different sounds for different reasons. The constant is that audible beep, one for each heartbeat. An infant’s tiny heart beats significantly faster than an adult’s, so the pace of the beeping is rapid, and each baby here suffers from a potentially fatal malfunction of that rapidly beating heart.

Nurses move everywhere, monitoring every child. IV bags hang, six, eight, ten “drips” hung for one patient. Each drip is a different life-supporting medication – sedation, painkillers, antibiotics, anticoagulants, blood products, nutrition and many more. Intravenous drips are hung from poles and flow directly into a patient’s arm or leg or, more often, into a catheter inserted into the chest for easy access. The drips feed into a large control panel with the concentration and rate of flow of each drip handled by computer. All these babies are critically ill, critically tiny, many premature. Most of the kids are smaller than the stuffed animals that sit, unnoticed, next to them.

I’ve been volunteering at Children’s for 13 years, but this is my first time in the CVICU. I’m here for cardiac surgery rounds, following Dr. G as she checks on the progress of patients. Another prop from medical TV shows is on display here – the long, white coat – the peacock feathers of physicians and surgeons. Children’s Medical Center is a teaching hospital, part of the University of Texas Southwestern Medical School in Dallas. The full-fledged, out of residency and into specialty doctors and surgeons wear the long, white lab coat. Dr. G is the shortest of the coat-clad. Sure, she’s only five feet tall, but as they say in the sports world, she plays six-two. She’s not the only woman in the group, just the only one in the long white coat. The young doctors listen to her.

Heart surgeons, ICU doctors, cardiologists, nurses, nurse practitioners, physicians assistants, fellows, residents and students start at one end of the unit to move room by room around the floor. A cardiology fellow pushes the computer on wheels (COW), and presents each case. This young doctor has made several of the basic choices his career path requires. He’s finished his residency and work in various specialties. He’s chosen medicine over surgery, pediatrics over adult, and cardiology over other disciplines, making pediatric cardiology his career choice. He’s just out of residency and down the six-year road it will take to earn attending status, when he’ll be in charge of cases. Then, he’ll be a pediatric cardiologist, a doctor who treats young people with heart disease. He’ll refer cases needing surgery to people like Dr. G, a pediatric cardiothoracic surgeon, whose career path required twelve years to attending status. Cardiologists diagnose — surgeons repair.

Even though he’s out of residency, this doctor is still learning. He stops in front of the door to the first patient room and runs down the important events from overnight – vital signs, patient status, complications, and planned treatment. The male attendings ask questions that are pointed and occasionally harsh. Dr. G draws the younger doctors out with her questions, gently nudging them back on to the right track. “I didn’t hear anything about left atrial pressure there,” she tells the presenter, who immediately refers to the COW screen and spews a series of numbers out in a specific order. The young doctor’s voice is tense, rising a bit, as he makes up for his omission. It’s unlikely he’ll make this mistake again. Terms like “open-chest” and “life-threatening event” are heard on cardiac rounds, said calmly and with nonchalance. Hospital personnel in critical care settings are outwardly detached. It’s a way to stay focused.

The CVICU nurses on rounds are making notes and answering questions concerning how patients fared overnight. Some doctors treat nurses as underlings, but despite the pecking order there is tremendous trust between the doctors and nurses at Children’s. If the doctors are the officers of this army, the nurses are the sergeants, the ones who make sure everything gets done.

        While the rest of the group moves along the hallway, Dr. G stops to look inside the room of the patient just presented. If she sees a family member inside, and they’re awake at this early hour, she goes in to say hello and ask how things are going. She feels a responsibility toward every family, even if the case isn’t hers. It’s not done for effect or because it was part of her medical training. This is the way she treats everybody. It doesn’t matter if your child has a serious heart condition. It doesn’t even matter if you have a child. When Dr. G sees you, in the hallway, in the cafeteria, she says hello.

Rounds end, leaving just enough time to dash up to the eighth floor cardiac unit and check on patients who are out of ICU, waiting to be discharged. One young heart transplant patient has turned up her oxygen level without the nurses knowing about it. Dr. G tells the 13-year old girl, in a firm, motherly way, that medical decisions are made by the pros and here’s how we’ll manage the oxygen for the remainder of your stay. The girl hangs her head and nods.

The moments after rounds, and before the next issue to deal with, present a chance to head down to the first floor food court for a banana. Her pager beeps as Dr. G stands in the register line. She checks the number and heads up to the third floor office suite she shares with her partners and staff. She phones the person who paged her. In a flash it’s out the door and back to the echo lab, a half-eaten banana left behind on her desk.

Two weeks after my first visit to the echo lab I stood to the side again, this time able to make sense of some of what Dr. G and the cardiologists discussed as they looked at the screen. Eleven-month old Claudia’s diagnosis was Tetralogy of Fallot (TOF), a syndrome with four separate cardiac abnormalities:

1) Ventricular septal defect (VSD) — a hole in the wall between the two ventricles;

2) Overriding aorta — the aorta is not positioned properly on the heart;

3) Right ventricular outflow tract obstruction – for any of several possible reason, the blood flow to the lungs is restricted, leading to —

4) Right ventricular hypertrophy, (which surgeons pronounce “hy-PER-tro-phy”) – a dangerous buildup of the right ventricle muscle.

Claudia has alarming episodes of cyanosis where her lips, fingers and toes turn blue because her oxygen saturation rate (sats, in medical shorthand) has become dangerously low. She also has what are called “Tet spells” where her oxygen level drops so low that she loses consciousness. The preoperative indications of most concern to Dr. G are the extremely small pulmonary valve, which leads from the right ventricle to the pulmonary arteries, the significantly thickened muscle bundle below the valve, and the somewhat larger than average VSD.

Thirty minutes later we were walking down a second floor hallway toward the operating rooms. Dr. G walked quickly, straight ahead, focused on the task at hand. She was getting her game-face on.

10:30 am

O.R. 5

Claudia lay motionless on the table in the center of the O.R. The motorized table can be raised, lowered and tilted to various angles at the touch of a button. Claudia’s head sticks through a hole in the draping around her neck, visible to the anesthesiologists. At the head end of the table are the anesthesiologists, concerned with numerous gauges, medicines, inhalation gases and monitors at their fingertips. They’re also in charge of tilting the table at the surgeon’s request, to put the patient at a more favorable angle.

(Example of pediatric cardiothoracic humor – A flight attendant goes on the p.a. and asks if there’s a pediatric cardiac anesthesiologist on the plane. There is one, in the rear of coach. He signals the attendant and asks what the trouble is. “We have a pediatric heart surgeon in first class. He wants his tray table lowered.”)

The scrub tech stands at the opposite end of the table at a series of trays holding an array of odd looking tools; forceps for picking up or grasping things; scalpels which slice through human flesh as if it were air; sutures (thread) finer than human hair, attached to small needles curved like fish hooks.  The scrub tech has it all arranged in the most efficient format for this particular surgery and this particular surgeon. Dr. G knows that when she calls for an instrument, the proper one will be there in a flash. Often, it will be offered to her before she has to make the call.

A six-foot by six-foot metal frame sits to one side of the operating table, containing gauges, canisters, and clear plastic hoses. This is the cardiopulmonary bypass machine, “the pump.” This technology will serve as Claudia’s heart and lungs while her heart is stopped for repairs. Developed in the 1950’s, current day bypass machines still use hoses much like the beer keg tubing in the first experimental models. Two perfusionists sit at the machine, in charge of its operation.

The small patch of Claudia’s chest that’s visible is covered with a material called Ioban, plastic coated with iodine in a further effort to reduce any risk of infection during surgery. Dr. G will make a tiny incision to get at this heart compromised in utero by Tetralogy of Fallot. TOF was first medically described, though primitively, in 1672. Etienne Louis Fallot, a French physician, described the clinical pathology of the condition in 1888. The first surgical treatment for TOF wasn’t even available until the late 1940’s. Dr. G, ever the teacher, drew a diagram of the surgery for me before she scrubbed in.

Dr. G re-enters the O.R. with hands and forearms still wet. She dries with sterile towels provided by a scrub tech who then helps her into a surgical gown and gloves. She has on loupes over her cap. They look like small telescopes growing from each eye, and they give her a magnified view of the tiny area in which she’s working. A fiber-optic cable runs up her back, over the top of her cap and onto a small, bright lighting instrument/video camera at her forehead, to light and televise what she’s looking at on monitors hung around the OR. Dr. G is at the center of the sterile area where only those who scrub in can go. The rest of us, with surgical masks and caps in addition to our scrubs, have to stay away from the table. She gets up on to a small step-stool, to get her five-foot frame high enough above the table to work easily.

She takes a scalpel and makes a four cm incision in Claudia’s chest. The breastbone is cut open with a small saw and retractors are put in place to hold the ribs apart. The first object encountered inside Claudia’s chest is the thymus gland, a small, flesh-colored organ. It has some minor involvement with the lymphatic system, but it gets in the way of open-heart surgery and you can live without it. The gland is removed and discarded.

Dr. G takes an electronic scalpel called a “Bovie” which cauterizes as it moves through tissue. She cuts the pericardium, the sac-like membrane containing fluid to lubricate the heart. The pericardium has extra meaning for Claudia. Dr. G precisely excises a small portion of the sac and places it in a dish containing 0.6% glutaraldehyde, a preservative fluid. She’ll use this patch later to close the VSD, the hole between Claudia’s ventricles that failed to seal itself properly at birth. She works around the small space filled with tiny body parts, freeing up the aorta and the pulmonary arteries from the underlying tissue. Claudia has been given heparin, an anticoagulant, so that her blood is less likely to clot when it goes through the pump. Dr. G inserts cannulae, small tubes, into the aorta and the vena cavae. The other ends of these tubes are attached to the heart-lung bypass machine, connecting to Claudia’s circulatory system. Because Claudia has very small blood vessels, the work is delicate and precise and the tubes they need for bypass, like the vessels in Claudia’s chest, are extremely narrow.

The mood in the O.R. shifts at various moments. Dr. G has been casually introducing me to the O.R. team while routine work is going on – as routine as heart surgery can be. But when the cutting starts, the room goes quiet. Dr. G hovers over the small body on the table, staring down into the chest she has cut open. The view from the camera attached to her loupes doesn’t shake on the O.R. monitors. She’s a human tripod.

The perfusionists are cooling Claudia’s body down to 28 degrees Celsius, 82.4 Fahrenheit, to slow her metabolism and protect her heart. Hypothermia lowers the amount of oxygen the brain requires, giving the surgeons time to perform the needed repairs. They aid this chilling process by turning temperature in the O.R. down to 64 degrees, so cold that several people obtain blankets from a nearby warmer.

Dr. G clamps the aorta. Blood is no longer flowing to Claudia’s heart. Dr. G tells the perfusionists to run the cardioplegia, a solution of chemicals inducing cardiac arrest. In other words, to protect the heart, they intentionally cause something that usually kills when it happens on its own. The cardioplegia solution includes potassium chloride, one of the chemicals used in lethal injection executions. Claudia’s heart stops beating, her blood leaving her vena cavae into the bypass machine for oxygen, returning to her body through the cannula inserted just above the clamp on the aorta. Her heart and lungs have been turned off. There’s no more beeping or EKG activity on her monitor. She has flat-lined. When the patient goes on pump, the heart is like a water balloon with the water let out. It changes in shape from full and throbbing to flat and motionless. The only way to repair Claudia’s heart is to stop it and empty it.

The first task is to examine the heart to see if the preoperative diagnosis is correct. Dr. G uses delicate instruments to retract portions of the tricuspid valve and examine the extent of the defect of the ventricular septum, the wall between the two ventricles. She determines the exact size and shape of the VSD and trims the segment of pericardium she saved in preservative. She cuts miniscule pieces of the pericardial tissue and sutures them along the walls of the VSD, creating anchor points for the actual covering. Each suturing is an intricate dance of fingers and forceps, needle and thread. Dr. G works with a small, hooked needle, grasping it with forceps, inserting the needle through the tissue, releasing and re-gripping with the forceps, pulling the hair-thin suture through, using a forceps in her other hand to re-grip the needle again and repeat. The pericardial tissue being sewn over the VSD has to be secure, and it has to stand up to the pressure of blood pumping through Claudia’s heart at the end of the operation. This isn’t like repairing knee ligaments, which can rest without use and heal slowly. Claudia’s heart is going to restart at the end of this operation, and whatever has been sewn into it has to hold and work, the first time. The VSD repair involves cautious work around the tricuspid valve, and their proximity is a concern because the valve opens and closes along the ventricular septum with each beat. Dr. G and her team find that it’s preferable to actually divide the cords of the tricuspid valve to better expose the VSD. After the patch is fully secured, the tricuspid valve is repaired.

Things don’t go as smoothly during the attempt to repair the pulmonary valve. When Dr. G looks inside Claudia’s heart, she discovers that the pulmonary valve is not nearly large enough, and it’s malformed. It only has two flaps where there should be three. She repairs it by what she later calls “just putting in a little transannular patch.”

Here’s what it’s like to “just” put a transannular patch on the pulmonary artery of a child as small as Claudia. First take a piece of well-cooked elbow macaroni. Tuck it away in a bowl of pasta that has a bit of residual marinara sauce still floating around in it. Take several different sized knitting needles. Slowly, without damaging the macaroni, insert one of the knitting needles into it to see if you can gauge the width of the macaroni on which you’re operating. Then using a delicate, incredibly sharp blade, cut a small hole in the piece of elbow macaroni, maybe a little larger than the height of one of the letters on the page in front of you. Now use pliers to pick up a small needle with thread as fine as human hair in it. Use another pliers to pick up a tiny piece of skin that looks like it was cut from an olive, so thin that light shines through it. Take the needle and sew the olive skin on to the hole you’ve cut in the piece of macaroni. When you’re finished, hook up the piece of macaroni to a small tube coming from the faucet on the kitchen sink, and see if you can run some water through the macaroni without the patch leaking.

That’s the food analogy. Those are the dimensions Dr. G worked with as she patched Claudia’s pulmonary artery. She made it a little wider to give it a chance to work more efficiently, to transport more blood with less blockage, requiring less work for the right ventricle so that the built-up heart muscle could return to a more normal size. It wasn’t the repair she’d planned to make, but it was the most suitable under the circumstances, and it gave Claudia her best chance.

Before restoring Claudia’s natural circulation, the team makes certain that no air was is in the heart or the tubes from the pump. Air in the brain is not a safe thing. When all repairs are done, Claudia is rewarmed and weaned from the bypass machine. She was on pump for 114 minutes and her aorta was clamped for 77 minutes, not an extraordinary length of time in either case.

Claudia’s heart starts up on its own, with a strong rhythm. With her heart beating again, the beeps and peaks and valleys on her monitor return. All is well. A sensor is inserted down Claudia’s throat and lodged behind her heart to perform a trans-esophageal echo, which gives a more detailed view than the normal, external one. Everything looks good. Chest drains are inserted to handle post-operative drainage, and wires placed for external pacemakers, should anything go wrong with Claudia’s heart rhythm during her recovery from surgery. Dr. G draws Claudia’s ribcage back together with stainless steel wires, perfectly fastened and tightly tucked down.

Claudia and the surgical team return to the CVICU and Dr. G monitors her reentry to the unit, making sure the nurses understand Claudia’s condition and the proper procedures to be followed for the next 24 hours. From there, Dr. G enters a small room tucked away from the noise of the unit to meet with the family. Claudia’s mother, father, and aunt are waiting. Dr. G sees Mom wiping tears away.

“Are you crying? Oh, no, no need to be crying, everything is fine.” Her wide smile reassured Mom, who put away her tissues.

She tells the family what she did, and why she did it, using a serviceable mixture of medical and lay terms.

        “I got in and saw the valve and it was really abnormal,” Dr. G tells the family, “really, really small. It only had two leaflets, and that’s not good, it’s supposed to have three. So I did a little transannular patch through a mini-sternotomy, which is really good for her – much smaller scar. Her echocardiogram was beautiful. There’s no hole where we closed her VSD. We know there’s another small, little hole in the muscle, but we all agreed that because it’s in the muscle it’s going to close on its own, so we won’t worry about it. My plan is, once she wakes up later today, to get the breathing tube out.”

There is a noticeable sense of relief evident on the family faces, even though one or two of the terms may have been unfamiliar. Then, comes the caveat.

“The arteries that go to each lung are a little bit small. She’ll need to have a pulmonary valve at some point. Some people need one not so long from now. Some people go a good portion of their lifetime without needing one. My brother had this same surgery when he was little, and he still hasn’t had a new valve put in yet. But he will some day.”

The simple fact that her brother had similar surgery seems to put the family a little more at ease. They know Dr. G has been on both sides of the equation, and she can relate to their anxiety.

 

From there it was off to a brainstorming session with the architects designing new cardiac surgery suites. They wanted staff input on what should go where, how far the doors should be from the operating tables, etc. In the O.R. a matter of a few feet can be the difference between life and death

Lunch came at 3:30, which can actually be early in Dr. G’s world. She debriefed herself from the surgery as we ate, describing to me what had taken place. She would later dictate all this for the official surgery report in medical terms such as, “The right-sided pericardium was fenestrated to approximately 1 cm anterior to the right phrenic nerve.”

If it’s true that, “the heart has reasons which reason knows not of,” it aalso has a language that’s pretty hard to understand as well.

I told Dr. G this was my first time in OR and I couldn’t believe I’d just seen a kid’s heart beating inside her chest.

“You’ve never seen that before,” she asked me.

I reminded her that I’d spent the last 30 years as a sportscaster.

“It’s not exactly the kind of thing you see in the Dallas Cowboys locker room.”

She was genuinely surprised at my sense of wonder.

The rest of her day consisted of phone calls, emails, (which can be difficult as her inbox has over 1,500 emails in it) consults with other surgeons, afternoon rounds through the CVICU, which move much quicker than morning rounds as these are just for checking up on each patient one more time, and the never-ending battle with paperwork.

On rounds at 7:30 tomorrow morning, Dr. G will check up on Claudia to see how she’s doing. That’s assuming she makes it through the night easily. If problems develop it’s likely Dr. G could spend the night here with her.

“We eat stress like M&M’s in here,” said Dave Bartoo, her surgical tech this day.

This is where Dr. Kristine Guleserian repairs the tiny hearts of tiny children.

Come on in.

 

 

A Woman’s Work Is Never Done

It finally happened, an historic moment at Children’s Medical Center in Dallas in the cardiac O.R. An all-female team surrounded Dr. Kristine Guleserian for a heart procedure.

FEMALE OR

Since everybody looks alike in cap and mask, the names are, Kristine Guleserian, Tracy Geoffrion, Alycia Hawthorne, Riley Carpenter, Beth Brickner, Dawn Bryant, Dina Villaraza, and Sarah Clakley. Quote Dr. G: “Eight woman in the OR. Our patient was male. He’ll never be the same!”

The Heartbeat Goes On! (Note! Graphic video!)

The first time I saw it in the OR, I couldn’t believe it.  But it’s true.  Watch the video to see one of the most amazing things about the human heart. This was during a transplant Dr. G did .