[[Coping]] # Stress and the Cardiac Surgeon Stress is the constant companion of the Cardiac Surgeon. Stress either rides on his shoulders, legs wrapped tight around his throat like the Old Man of the Sea, or the surgeon walks side by side, hand in hand with it. Not everybody handles it well - Hannein story - Alcoholism The "bread and butter", quotidian case of cardiac surgery is the coronary artery bypass grafting procedure, commonly abbreviated as CABG (pronounced 'cabbage'). In the most common form of this case, the surgeon, having bonded with the patient, driven by threat of a heart attack, by soothing his fears with a discussion of risks and benefits, will go through the following steps: In the most common form of this case, the surgeon will bond with the patient through a soothing discussion of the risks and benefits of the procedure. It is a shotgun wedding, as the patient is driven by threat of a heart attack. The following steps will unfold: - Open up the chest through the breast bone, as perfectly mid-line as possible to avoid healing problems thereafter. - Painstakingly detach a delicate artery from the left side of the breast-bone. If damaged, the lack of this tube for grafting will shave several years off the patient's life. - Supervise the 'harvest' of vein from the legs by an assistant. Will the veins be too large? Too small? Varicose? Characterized by many tiny branches that need to be controlled? Luck of the draw. - Insert a series of tubes into and out of the heart and great vessels that will allow the heart-lung machine to take the place of the patient's own fleshy counterparts. Manipulation of these tubes in an unskilled way when dealing with diseased vessels may end in something as grand and terminal as a bloody death, or something as tiny and devastating as a stroke. - Arrest the heart in such a way as to create a bloodless and motionless field for the operation. Contrary to patient's fears that the heart won't start again, our most common problem is to keep it down as it keeps on woozily trying to get back up. - Expose the coronary arteries that are to be grafted. These range in size from 3 mm to 1 mm in diameter. They can be on the surface of the heart, or variably and unpredictably dive under the surface where they can be difficult to find without digging through muscle tissue at the risk of entering into the cavities of the heart. Along the way, you will find coronary veins that can be hard to distinguish from arteries. If these are grafted, you wont have simply lost the opportunity to do good, you will actively be doing harm. When you do find the vessel, it may be so calcified that it is difficult to open with a scalpel, and even more difficult to pass stitches through it. Your principal guide in finding these targets are a series of two dimensional images of these three dimensional structures, taken from various angles, often with vessels overlapping in a confusing way. These images give little to no warning of the quality of the vessel wall, and are magnified in a way that can be misleading as to their size, in both directions. The studies (angiograms) are performed in a warm beating heart with vessels distended with blood. You are finding the vessels in a cold empty heart. - Sew the harvested conduits to the target vessels to bypass the obstructions. Apart from the zest added by the factors mentioned above, the challenge is to make the connection between the vessels using an often uncooperative plastic suture tipped by a curved needle. The stitches must be precise, spaced evenly, using bites that will not gather so much tissue as to narrow either the conduit or target vessel, but not so delicate as to rip through diseased vessel wall. In creation of the grafts, their length from one end to the other has to be judged accurately on an empty heart, to plan for when the heart is full. Too short is horrible. Too long can be no fun as well. Hope you have enough conduit to hit all the targets. If you don't, which planned connection will you jettison? - The crown of these connections is the marriage of the arterial conduit from the chest wall, the Left Internal Mammary Artery, to what is usually the most important of the three vessels on the surface of the heart, the Left Anterior Descending. CABG is an extremely powerful medical intervention, with an impact on longevity and quality of life that is far stronger than that of most medications. A huge slice of this impact is the LIMA to LAD connection. As I heard from a wag during my training, the most important ten minutes between being born and dying is when your mammary gets sewn to your LAD. - All of this work is done under pressure of time, not the least of which is the time that the heart is arrested. During this time, the heart is starved of oxygen. The longer you take, the worse the condition of the heart and other vital organs at the end of the procedure. As you exert as much precision as you can muster, as quickly as you can, you are performing your task hunched over an often obese patient, down in a confined space deep withing their chest. You are wearing heavy magnifying surgical telescopes fastened around your head, resting on your nose. This weight is augmented by a headlight that you have tightened around your forehead or attached to the telescope frame, and the weight of both is a moment arm focused on the fulcrum of your neck. You are rebreathing your own exhalations through a paper mask. The sensitivity of your hands is blunted by one or two layers of surgical gloves. You are on your feet the vast majority of the four or so hours it will take to complete the procedure. You must focus on each stitch, but have your head on a swivel to coordinate team members and anticipate dangers. The reader is invited to remember the longest time they ever had to maintain focus. Was it more than four hours? - For the conclusion of the procedure, wean from the heart lung machine, balancing filling, heart rate, drugs that stimulate the heart, drugs that alter the blood pressure, all while searching for tiny points of bleeding that if missed now, will inexorably lead to the accumulation of blood into the cavity that holds the heart, threatening the patient's life by impairing heart function, perfusion to other organs, and leading to a midnight call that informs you that you have to return to the operating room. Close the often osteoporotic breastbone as securely as possible, and the overlying flesh, knowing that the obesity, the diabetes, the coughing, the instinct of the patient to pull himself out of beds and chairs will oppose you, and possibly allow an opportunity for an extremely serious infection of that incision. Then begins a vigil that ends when the patient is well enough to leave the hospital. Some of the complications will be evident within that time. Will excessive bleeding from the tissues around the heart require a return to the operating room? Will the damage to the lungs caused by the smoking that led to the coronary disease cause a delay in the liberation from the mechanical ventilator? Will they wake up with a stroke? Will their pre-existing kidney disease be exacerbated by the artificial flow of the heart lung machine? Will the disruption of their sleep/waking cycle in league with pain medications lead to post-operative delerium? Will they go into an irritable heart rhythm? Will the drugs given to combat that rhythm make the heart rate too slow? Even after discharge, complications can still occur, though their risk diminishes with time. As a friend of mine used to say, if it wasn’t for bleeding, stroke, and infection, this would be a wonderful job. It should be understood, time and dedicated application of science has made coronary artery bypass grafting extremely safe. The risks and benefits of this operation have been subjected to statistical analysis more than almost any other intervention in medicine. Complications are rare, and often manageable, but their rarity doesn’t make fear of their occurrence any less palpable for patient or surgeon. Sometimes the complications occur from risks that are not accounted for in any of the statistically studied risks. The patient who goes into delerium tremens from withdrawal from an unacknowledged dependence on alcohol will suffer a dramatically increased probablity of a poor outcome that is not taken into consideration in risk models. Likewise, the patient who has a poor social support system. Correlation with poor outcomes gets you both ways, before and after. The patient who is alone in the world had no-one to nag them into smoking cessation, or dental care. They have no adult children to drive them to appointments and make sure that they have their medications straight. A rehabilitation facility is no substitute for a family. Statistical analysis of cardiac surgery outcomes and its public scrutiny is a very good thing, but it is not an unalloyed good. It has driven the field towards greater safety, and though not always properly interpreted, it has allowed the public to better inform their health care choices. But it can lead to gaming of the system, where statistics are polished through loopholes in definition. It can deny challenging patients access to health care from risk-averse professionals. Complications and mortality are intrinsically demoralizing to any surgeon with a conscience, and you wouldn’t want it any other way. They certainly cause pain and suffering to patients and their families. Apart from these intrinsic negatives, if these events occur they can lead to censure by peers at conferences where the outcomes are discussed. Publically reported statistics may affect the drawing power of the hospital, its relationship to third party payers, and the employment of the surgeon. If a complication occurs , even if predicted by clearly defined risk, an entirely different system exists to exact punishment: the medicolegal courts. A surgeon may find that up to two years to the day after the bad outcome (when statutes of limitations expire), papers are served upon him, often at home, to notify him that he will be occupied for the next five years in depositions, testimony, and courtrooms. A decision against him, either as settlement, or in court, will form a part of his permanent record and affect future licensure, privileging, and employment. A judgment against the surgeon in court will often be motivated more by sympathy for the patient than on any neglect by the physician or his team, and the amounts of money awarded in damages can be unpredictable and breathtaking. The system exists for the protection of the patient, and to weed out the bad actor, but every surgeon is aware of virtuous and skilled practitioners that have been unjustly caught in this net, and even the virtuous and skilled practioner lives in fear of it. The surgeon feels the scrutiny, and knows there is little tolerance for bad outcomes. It is easy for the individual faced with these expectations to become an exposed nerve when confronted with shoddy work ethic encountered in daily life. Every ineffective contractor, mechanic, DMV employee, trash collector is a source of constant irritation. Sure, they can get away with this, the surgeon thinks, but if I did MY job that way…. In this state of irritation, held responsible for outcomes that depend on the efforts and attention to detail of an entire team, the surgeon may reach out for those tools of team management that he saw employed by his mentors in prior generations. Our heroes prowled through the operating rooms and wards with swagger, enforcing compliance through colorful sarcasm and expressions of temper. It can’t be denied that the exercise of that patient-centered moral superiority and cowboy diplomacy was part of what drew us to the field. Who can say how effective these tools where? If they had results in ancient times, it was probably more due to the professionalism of the targets of the invective and the awe and respect with which the surgeons were regarded. The utility of those strategies was probably only in allowing the surgeon to vent energy. Those times are gone, and that outlet is definitively closed. It doesn’t matter how righteous your cause, and how ham-fisted the mistake by the team-member, and how close the disaster came. You must stifle what the Stoics called the “first passions of the soul” and “empower” the team-member to complications - If it weren't for bleeding stroke and infection - Reliance on team members - but harsh language cannot be utilized - Sold a bill of goods by our mentors - The swagger, the obedience - If complications occur, and sometimes even if they don't, fear of lawsuits - So safe that any mistake may also result in censure by peers at M and M, on stats - Hard to compare expectations with those of contracotrs, mechanics, etc. If I did my job that way - The call may come at any moment of the night, waking you up from deep sleep - No one will pity cardiac surgeons for their earning power - but conscious that every year those who pay for health care pay less and less - The hardest thing about heart surgery is getting to do it - In order to get to the point that you are allowed to do this surgery - College - Medical School - multi culti - Residency - Not everybody cares for the hierarchy - Fellowship - Salary while training - Hours while training - Choosing a job - Thirty years How does stress managment get taught? - role models - cowboy - alchohol and drugs - gradual introduction to autonomy - show me a student that doesn't triple my workload - But I'd wade through twice as much excrement - This is the life we chose - We wanted the excitement - Get to be God's mechanic - Get to shepherd people through the dark valley - If you teach, you have a hand in every one of your pupil's victories and lives saved