Megan Lung Cardiology Week 2 Day 4

Today we followed Dr. Wang in the echocardiography. One particularly interesting case was a 23 y.o. male who had an ASD, MVP, and systolic murmur. Dr. Wang told us that measuring QP/QS would measure the magnitude of a left to right shunt. QP= volume of blood going into the lungs and QS = volumes of blood pumping into the system. QP/QS in a normal person should be one, since the blood going into the lungs should be the amount of blood going to the body. However in a person with atrial septal defect, the QP/QS ratio will be bigger than 1. ASDs will usually close on their own, but the patient was sent to another hospital with an occluder that could close the left to right shunt. Dr. Wang determined the ASD based on the color doppler ultrasound which showed blood flowing from the left atrium into the right atrium.

 Picture is of the ASD. Left bottom corner is the left atrium. right bottom corner is the right atrium. The red color marks blood moving towards the transducer, meaning it is moving through an ASD from the left atrium to the right.

the "special ops" surgeon

arthur watching on the big screen

I also had the opportunity to shadow surgery and emergency medicine today. In surgery we watched a bypass of the left anterior descending (LAD) coronary artery using the left mammillary artery (LMA). The distal end of the LMA is cauterized and connected to the part of the LAD with stenosis. Blood can then flow from the aorta through the LMA and oxygenate the heart. Anatomy is important here. Unfortunately the LMA was not long enough to connect to the LAD so the surgeon had to take a portion of the great saphenous vein.

This bypass was a beating heart surgery due to several reasons. First, the patient only needed one bypass. Second, the bypass is the LAD, which is on the left side of the heart. This is more easily accessed through the intercostal space than the other coronary arteries.


There are many surgical equipments and technicians necessary for this surgery as well:
1. the "pumpist" who operates the heart-lung machine that keeps the heart and lung functioning during stopped heart surgeries.
2. the anesthesiologist who monitors the amount of anesthesia for the pt. Of utmost importance when BP lowers and raises according to what the surgeon might be doing.
3. cell saver - a blood recovery machine designed when medium to high blood loss occurs. It "cleans" the blood and is mixed with heparin to prevent clotting.
4. a device that clamps down on a part of the heart to keep an area stable compared to the rest of the heart.

During my foray into surgery and emergency medicine, I see the importance of team work and interprofessionalism. The surgery room is run on a tight ship with each person knowing exactly what is expected of them and how the course of the surgery will unfold. The "pumpist" wasn't needed today since it was a beating heart surgery, but he could still explain to us exactly what was going on and what would happen. Every person had their role and their ability to communicate and anticipate each other was of utmost importance. Emergency medicine was also the same way. Doctors and nurses worked closely with each other, often with the nurses anticipating the doctor's needs. When stakes are high or when patient volume is high, being able to work together is truly a necessity.

sterile equipment we had to stay
2 feet away from at all times

the asst. surgeon was a little short

all of the lights

the nurses keep track how much gauze was taken out. 

I feel like this hospital or maybe the Taiwanese culture in general is extremely resourceful. They work efficiently, quickly, and with a smile on their face. They use whatever is given to them. That surgery room should be 8 ft by 8ft, but since it is only 6 ft by 6 ft, they reorganized the room so that many of the equipment is attached to the ceiling and lowered down to save room. That step the asst surgeon is stepping on could be from anywhere and repurposed for use. I see reused boxes in offices all the time used for various storage purposes. In the ED, they are only give four big open rooms. There is no privacy, yet the patients, nurses, and doctors all coexist in chaotic harmony. It works. It has to work. They make do with what they have.