In October of last year, I wrote about the importance of becoming a clinician leader. As I have thought more about this topic, I have come to realize that a big part of being a leader is being able to empower others. I have witnessed this first hand after our practice’s recent development of daily, bedside nurse-led, multi-disciplinary rounds. A couple of months ago, as a response to several factors, we started this practice on both our stepdown unit and ICU. First, our patient population, as I am sure everyone else is experiencing, continues to get older and sicker. The amount of details that need to be kept straight on two large, busy units continues to grow. Second, more than ever, we are being held responsible for complications like central line and in-dwelling foley catheter infections, as well as statistics like extubation time, and length of stay. Finding an additional way to review all of these details has become paramount. Finally, we wanted to ensure that we could still provide the same level of care to our patients regardless of nurse turnover, or the addition of less experienced APPs.
CT Assist Blog
Pulmonary hypertension (PH) is a complicated, and potentially life threatening, disease that is defined as having a mean pulmonary artery pressure greater than or equal to 25 mm Hg at rest. It was first described in medical literature in 1891 by a German physician, Ernst von Romberg, who mentioned pulmonary vascular stenosis in an autopsy. While it is considered a rare disease, being seen in only 1-2 people out of every million across the United States and Europe, those of us practicing cardiac surgery at programs with advanced heart and lung failure patients will likely see a lot of this disease.
I’m not the chief. It’s not my problem. No one cares what I think, or how I act. We have likely all heard or thought these words a million times. I can’t say that I haven’t thought them myself. I’ve written about the importance of functioning as a team in the past, and a large part of that comes from each member looking out, not only for him or herself, but for the team as a whole.
Topics: CT Surgery
At a recent state wide quality meeting, I was introduced to the concept of ERAS, or enhanced recovery after surgery. ERAS is not a new concept, however, it is just starting to make its way into the cardiac surgery community. The concept of ERAS was developed by a study group of surgeons in Europe in 2001. The focus of this group was the quality, rather than the speed, of recovery after surgery. This group developed a model which stressed several key points: a multi-faceted approach to deal with delays in recovery and perioperative complications, an evidence-based approach to care protocols, and the use of frequent, interactive audit of these processes.
Aortic dissection is one of the true surgical emergencies that still exists in the field of cardiac surgery. Any busy practice can say that there are patients frequently turning up in the emergency department with acute and chronic aortic dissection. Smaller practices may not get as much exposure to this type of pathology. In speaking to the emergency department and to transferring hospitals, I have come to understand that there is some confusion among the medical community in general, and perhaps even in the cardiac surgery community, regarding the appropriate classification of aortic dissection. I thought a brief primer in classification might be a useful review.
In a little over 200 years, opioids went from being a promising new discovery to a killer whose fingers reached into every walk of life, killing unsuspecting victims from all socioeconomic classes. Morphine was first created from opium in 1804, and in 2008 drug overdoses, primarily caused by opioids, surpassed car accidents as the number one cause of accidental death in the United States. The saddest part of this whole story is that we, as prescribers, are largely responsible for this crisis reaching epidemic proportions. That’s not to say we have done it intentionally. As healthcare practitioners, we innately want to ease people’s suffering. That need is paired with modern day society’s demand of a quick fix. Patients often want a pill that will make them feel better, and we are sometimes all too willing to oblige. When the prescription runs out, and refills are denied, patients may seek illegal means of obtaining a continued supply of pills.
Whether you are on a team of 2 or a team of 20, any good cardiac surgery service starts with a good team. In preparing for this piece, I looked up the word team in the Merriam-Webster Dictionary. While there are several definitions listed, I found two of them particularly appropriate. First was, “two or more draft animals harnessed to the same vehicle or implement”. I saw this as an interesting metaphor for how I often feel at work. Second was simply, “a group on one side”.
Topics: Cardiac Surgery
Aside from the fact that as I grow older, I become more empathetic to the emotions of my patients and their families, two things have occurred over the past few months that have had a profound effect on the way I approach patients and families. Last month, at one of the quarterly VCSQI (Virginia Cardiac Services Quality Initiative) meetings that I attend, we were introduced to a husband and wife who lost their adult daughter after a series of preventable medical errors. Then, more recently, a friend underwent a heart transplant, only to come out on ECMO with primary graft dysfunction. At this point, we are not sure she is going to survive this. Both of these incidents have really made me think about the fear and emotions that our patients and their families are experiencing after cardiac surgery, and how we can better help them through difficult times.
In my years practicing as a cardiac surgery PA, I have only come across two patients with Takotsubo cardiomyopathy (TTC). Perhaps large teaching centers have higher volumes of this type of patient. When I came across my most recent patient, I was reminded that it is a fascinating, if not terrifying, disease process. Here is a brief review of the epidemiology, causes and clinical presentation, and outcomes after diagnosis. I have also included a few articles I found useful or reference.
Maintaining order on a busy cardiac surgery service can be a daunting task. If you work in a practice where there are several surgeons and advance practice providers, every person is going to have a different idea about how to care for patients. It is true that there are many ways to treat a patient after cardiac surgery, and no medical problem can be solved with a cookie cutter approach. This being said, having a practice manual filled with guidelines can ensure that all patients are getting consistent care, provide new hires with an additional resource, and allow for the surgeons’ vision of how they want patients cared for to be realized without him or her always having direct patient contact.
Topics: Cardiac Surgery