I returned to Posey’s room and thanked the nurse who had been covering for me while I was out. She said, “nothing happened,” but I would have been surprised if she had actually done more than listen for the alarms.
In the unit, we took breaks when we could – our relief was usually a nurse with nearby patients. Breaks were never long, the nurses that relieved us were just as busy and we were, and watching an additional couple of critical patients was sketchy at best. The charge nurse should have been out of care (without patients,) and available to give us breaks, but budget cuts had ended that practice earlier in my career.
I changed out Posey’s linen again. It got less lumpy, and I satisfied a need for fetish. I looked up at the monitor and notice some changes in the shape of his hearts rhythm. I poked my head out of the room and asked the ward secretary to order an EKG for now. (I requested it, “stat,” but feel the word is overused, and am somewhat embarrassed to admit I even used it back then.)
The EKG technician poked her head out of the room next to mine when she heard my request and looked at me, and then pushed her machine over to Posey’s room.
The EKG showed that Posey was extending his heart attack.
A 12-lead EKG is read in sections. Each section consists of three leads, and they follow the heart from front to back and left to right, showing what’s happening at each specific area of the heart at the time the EKG is done. A heart attack may effect the anterior portion of the heart – this would show up in the V3-V6 leads. A heart attack may damage the inferior side of the heart, and this would show up in leads Avl, V1 and V2. By knowing the leads you are looking at, you can see the damage that’s being done to which part of the heart.
Posey had been admitted with a large anterior infarct. The EKG’s done up until this point all showed inverted T waves in the anterior leads. This was what was expected – after the death of an area of the heart, the T waves turned upside down. This was seen in Posey’s V3-V6 leads, and was consistent with all the EKG’s he’d had since being admitted to the unit.
The new EKG showed ST elevations in the inferior leads and also in the lateral leads. The ST elevations were present in all 6 of the leads adjacent to the anterior ones, but the elevations were higher and more pronounced in the leads directly closest to the anterior part of the heart.
ST elevations are an indication of oxygen starvation – ischemia – The areas of the heart next to the one that had died three days ago were now dying. If Posey had been awake, he would have been having acute chest pain –probably much like the pain that had brought him into the ER. Since he was unresponsive, the EKG was the only symptom to indicate what was happening – that he was having another heart attack. Because it was occurring next to the original attack, the term for it was ‘extending’ instead of ‘new’ -- much like we call it an aftershock for an earthquake that happens on the heels of a larger earthquake.
The EKG indicated that the rest of his heart was dying.
I thought, “shit,” as I walked out to the nursing station. When I got there, I saw Dr. S sitting at the station and reviewing Posey’s chart. I told him that he was too late, that Posey was extending his heart attack. Dr. S looked at me and said, “let’s go then,” and picked up the phone next to him and called the OR. When someone on the other end picked up, he told them to, “be ready, I’m on my way with him,” and hung up.
With that notification, we were now officially on Dr. S time --a time of masterful brevity and dervish action. We both went to Posey’s room, and with the charge nurse, a respiratory technician, and a couple of additional shanghaied stragglers he’d rounded up on the way, we took apart the machines, placed the important things we needed for monitoring on portable monitors and headed out the door. It took less than five minutes to undo my days of work.
I asked him if he needed a consent signed by Mrs. Posey and he said he had one, though how he had gotten it in the ten minutes I’d been away from her I didn’t know. We careened down the hall, him pushing, and me dragging the balloon pump machine behind him. The respiratory technician was bagging Posey with portable oxygen, and the shanghaied stragglers were trying to keep everything on or attached to the bed as we raced to the OR.
When we reached the double doors that opened into the OR, a hall monitor stopped us – all of us were unclean, and access was forbidden. As the OR nurse shunted us off to the changing rooms, Dr. S pointed to me and said, “I need him,” and she let me pass, balloon pump and all, after slowing me down long enough to put paper booties on my feet, and to hand me a mask to put on before I traveled further.
In the OR room: Posey’s bed was pushed to a padded metal table centered in a large tiled room -- even the walls were tiled. A nurse pulled one of the draw sheets underneath him up and to one side and a roller board was placed under it – then Posey was yanked to the table and the board was removed.
Dr. S grabbed a squeeze bottle of dark brown povadine solution and, like a backyard grill master preparing his charcoal, spewed the solution in jerks across Posey’s chest, then wiped most of it off with a clean towel. He took a scalpel and slashed deeply into the midline of the chest, tracing the outline of the sternum, dipping the blade down to the bone of it. He picked up a medical version of a combination jig-saw/skill saw, turned it on (if it had a pull-start, I would have fainted) and cut Posey’s sternum lengthwise, and completely, into two long pieces. Grabbing the two-piece retractor set, that was connected together after being placed on each side of the chest to form a spreader – He cranked the chest open with a ratchet wide enough to set a dinner plate on, or four big and active fists.
With the chest open, and exposed by the deep cut he had made, Dr. S slashed a line across the pericardial sack and opened it up, then cutting it back to the edges of the opening and dropping the skin of it into a basin offered by the scrub nurse. The heart now exposed, he stuck his left hand in to do internal cardiac massage and to get a feel for what he was going to have to work with.
From the time Posey hit the table, all of this took longer for me to write than it took for him to do. As Dr. S worked, the rest of the room was frantic with semi-controlled movement as well. It was like structured chaos in the room, there were patterns but they were complicated and hard to differentiate from the random.
I found my tubing, and the wall outlet, and restarted the balloon pump. Two scrub nurses set up large flat tables on either side of Posey, and laid out instruments and tools, the perfusionist brought in his by-pass machine and continued the process of setting it up, the anesthesiologist gave Posey injections of narcotics to take him even more under and out, and running around like a crazy person, the circulating nurse circulated and made sure everyone had what they needed to do what they needed to do.
This was my first time in the OR since I’d left it years earlier (after my short career as an orderly.) I recognized the pace of it, but still was just getting impressionistic snap shots of what was actually going on around me. I could break down the generalities of things – He does this with that, the next step is, -- but not the skilled parts of the action – the special tools, the specific sutures to be used, the learned order of events trained over time. But the pace I understood – it was fast.
Dr. S continued massaging the heart with one hand until Dr. R arrived, cleaned and scrubbed, from the anteroom, and took over the massaging. S then left to get properly scrubbed and gowned for the procedure.
The heart uses a tremendous amount of energy – it has to contract 80 times a minute, every day, for a lifetime. The heart is supplied the oxygen it uses for the energy by arteries that run across it and around it. The arteries get the oxygen through the blood that comes through two openings in the aorta, just above where the aortic valve opens.
One opening goes to the right side of the heart – the right coronary artery (RCA). It supplies a large area, but since it’s mostly for the low requirements of the right side, it’s sort of a backwater for concerns and attention.
The other opening is for the left main artery – this is a short fat tube that almost immediately branches into two other arteries – the left anterior descending artery (LAD), and the left circumflex artery (LCX.) These are the biggies for heart flow.
(People truly are different, and sometimes the RCA is the major artery, and sometimes they are born without parts of the arteries—and sometimes they have extra arteries. It’s hard to know for sure until you look.)
A heart attack happens when a clot obstructs one of these arteries, or the one of the arteries gets too narrow to allow blood to flow past it. By-pass surgery is when you take a vein and attach it to an area where the blood still flows – above the obstruction, and then pass the vein over the area that’s blocked, and then attach the other end of the vein to an area that doesn’t have a blockage – somewhere below the obstruction.
To do the bypass you need to stop the heart in order to tie the knots -- the hair width sutures, the dozens of sutures – on both ends --one end of the vein to the artery, and then the other to the other end.
I’m talking very small sutures that are connecting a high-pressure tube to an active pump. It’s harder than it sounds, no matter how hard you think it sounds.
When you stop the heart, you need to continue to supply blood to the rest of the body, so you by-pass the system with a machine that pumps blood for heart while it’s in the shop. A perfusionist runs this machine, which is large and bulky and looks like sometime on the ban list for exporting to unfavored nations. The machine takes on the role of the lungs – it adds oxygen to the blood as it bypasses the heart.
When Dr. S returned to the room, he took the large cannula’s offered by the perfusionist and stuck one in the arterial side – in the aorta above the heart, and the other in the vena cava, below the right side of the heart. When the perfusionist started the machine, the blood started to flow around the body, but minus the action of the heart. (I had stopped the balloon pump when the perfusionist handed Dr. S. the cannulas.)
Dr. S stilled the beating heart with an iced solution of saline and minerals – to cool it down and to stop it from contracting. When the heart stopped moving, he started digging though the yellow fat that covered the heart to find the first artery that he wanted to bypass. He started his digging around the mushy part – the dark blue of damaged areas, places obviously dead and necrotic, and the areas right next to them.
The veins for the bypass were being removed from the legs. As Dr. S worked the top half, a elderly old-timer surgeon made long incisions to the inner parts of the thighs and removed pieces of the saphenous veins – placing them in a basin of salt water for Dr. S to use as tubing for the bypass.
Not technically difficult, harvesting the veins paid well, and the cardiac surgeons gave the job to old mentors and other potentially useful doctors out of tradition, and as a sort of homage to the early adopters of thoracic surgery – those old doctors who, when faced with unemployment due to a cure for tuberculosis, found another outlet for their skills – open heart surgery.
Dr. S, with Dr. R holding it in place, took one end of the supplied vein, and using a microscope placed over the retracted opening of the chest, starting tying the vein to the artery. Each connection took dozens of micro sutures, but each took Dr. S only ten minutes to tie them together – he was very fast and accurate.
Having identified four blockages that he wanted to go around with the new veins he had, it took less than an hour for him to find and then finish the work on them. The only words I heard him say during this hour, that consisted of more than three consecutive syllables:
“This is like sewing wet tissue paper together.”
When finish with the last suture, Dr. S took two paddles from the tray of instruments next to him and had the circulating nurse connect them to a defibrillator. Placing one on each side of the heart, he shocked it. He shocked it again, and then he shocked it again. After the last shock, the heart started beating, weakly and without force—it sort of quivered with regularity.
Many times after heart surgery, the heart acts like it’s stunned for a while, like a fish kept too long out of water, so we all stood there and waited for the heart to come to its senses and gain enough strength to rejoin the body.
Once, when unemployed, I’d scheduled a job interview near my house for noon. At ten, I started watching a movie about an alcoholic, planning to watch only until he saw the light and got into recovery. Fifteen minutes before my interview, he was still drinking. Five minutes before my interview, he died -- drunk and alone, with his body resting near a dumpster. He never got it, and I missed my appointment. It was that kind of waiting.
After a half hour, most of the people in the room had drifted off. Dr. S asked the perfusionist to turn off the bypass machine and removed the cannulas from Posey. The heart continued to beat, but without enough force to give a blood pressure to the rest of the body.
Dr. S removed the sutures attaching the balloon pump to Posey’s groin, and pulled the balloon out of the artery. He asked me to hold pressure at the site, which I did.
The scrub nurse that had remained in the room then pushed the two large trays of instruments away from her, and laid out a few items on a smaller tray and scooted it nest to the table where Posey lay, then took the rest of her equipment and left.
After an hour, Posey’s heart stopped. Dr. S did not try to restart it. Taking wires from the small tray, he attached them to a needle holder and pushed the wires through Posey’s sternum to tie the bones back together. When he finished, he asked me to clean up, and left the room.
In the end, I did the things that nurses are always left to do. I removed all of the tubes and lines that were attached to him. I held pressure on the places that leaked, until they didn’t leak. I got warm water and towels, and used them to wash his body until it was clean again. I walked out of the room and got a gurney, returned and rolled him onto it, and then covered him with a clean white sheet.
I felt no goodbye, and sensed nothing from him. I left the room with only my memory, and only a prayer that the memory would be good enough.