Anny Xiao Week 3 General Surgery Day 4

Today began with a surgery & emergency medicine combined morning meeting about a patient who was brought to the ER last month after being stabbed in the chest. The patient was a victim of a multiple homicide that occurred at a subway station in Taipei, which was a significant event for the hospital because homicides are so rare in Taiwan. After arriving in the ER, the patient had a 6cm chest wound, had no pulse and was intubated and given CPR. He was given a total of 10 units of PRBC but his BP was undetectable for some time and the surgery team was called to the ER to help. A CXR was obtained and diffuse pleural effusion was seen, so a chest tube was inserted. A CT showed a broken trachea and internal bleeding and an emergency thoracotomy was done.The controversial thing that occurred was that the patients wounds were sutured shut without further investigation or treatment of internal bleeding and the patient died of hypovolemic shock likely combined with cardiac a tamponade. The presentation was not finished because the doctors spent most of the hour having a heated discussion about what could have been done differently to save the patient's life. Although they had to reschedule the remainder of the presentation for next week, I appreciated being able to watch them discuss and seeing their passion for their jobs and the hospital's medical practice.

After the morning meeting, we went to the OR to prepare for a triple vessel CABG. The patient had a heavily calcified LAD & LCX both with 90% stenosis and a heavily calcified RCA with 70% stenosis. As the chief resident began to work on the patient's left leg to dissect the great saphenous vein, the cardiac surgeon began working on the lima artery. The great saphenous vein was used to bypass the LCX & RCA, while the lima artery was used to bypass the LAD (since it is closest to the lima). A heart lung machine was used so the heart could be stopped during anastamosing of the vessels and a cardioplegic drug solution was given intravenously to stop the heart. After attachment of the coronary side of the 3 vessels, the cardioplegic infusion was stopped and the doctors began preparing and waiting for the heart to begin beating again. Defibrillator paddles were used and I began to feel nervous when the heart didn't start beating on its own after 15 minutes as expected, but the surgeon looked calm as he continued to tap and massage the heart to stimulate small contractions. Another 5 minutes later, the heart began to beat on its own at 31 bpm, slowly increasing to 75 bpm in the next few minutes. The rest of the anastamoses were finished successfully and at the end of the surgery, all the surgeons helped clean the patient and wrap up his sutured wounds and I was impressed to see them working together with the nurses to accomplish this task.

Part of the great saphenous vein to be used for bypassing the LCX

The heart lung machine: the temporary lung on the top right, heart on the bottom right

Top L: Keeping track of how much gauze is used; Top R: the surgeon tapping the heart to stimulate contraction; Bottom L: surgical steel used to close the sternum; Bottom R: the finished product