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.
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.
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
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
I remember when I first started working in the ICU, and I had to get my first patient off the ventilator. I thought, I have no idea how to do this. Luckily, in that case, I had an experienced ICU nurse who helped me. Getting the standard postoperative patient off the ventilator is now second nature, but I was recently talking to a newer colleague about how to do it, and I realized that a brief review might be helpful for any PA or NP new to the cardiac critical care setting.
Topics: Cardiac Surgery
Any mid-level practitioner who is responsible for running codes in the postoperative cardiac surgery population knows that there are a lot of moving parts in these scenarios. There are a lot of people to keep track of, and a lot of jobs to do in a short amount of time. Practice and experience keep mistakes to a minimum which, hopefully, produces a positive outcome. Unfortunately, I have been in several code situations where, even though we did everything right, there was still a less than favorable outcome. What I'm referring to are situations where ACLS guidelines have been applied, but have failed. For example, you pushed a milligram of epinephrine in a code, and your patient’s blood pressure went to three hundred mmHg, requiring a return to the operating room for bleeding. Perhaps your staff was doing appropriate CPR, hard and fast just like they teach it, and a saphenous vein graft was ripped off the heart, or an aortic suture line ruptured. I've even seen CPR cause a patient’s sternum to cut into his ventricle and cause catastrophic bleeding.
Your patient has made it out of the operating room, and you have succeeded in stabilizing him or her. Perhaps you were able to wean the patient from the ventilator quickly, or maybe the patient was in cardiogenic shock for weeks. Regardless of how the journey started the sign out is that your patient is now ready to transition to step down status, and it's your job to determine if he or she is ready.