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Georgia
I found this transcript of a TV interview (in the Denver Post) about procedures and what happens in the operating room for OHS. I thought it was kind of interesting.
MARK POCHAPIN, MD: Hi, I'm Dr. Mark Pochapin, and welcome to our show. Today we're going to talk about open heart surgery. Which really is a frightening topic to think about, especially for patients who are planning to undergo open heart surgery. But, in fact, over 500,000 procedures of just bypass alone are done in this country. So it's very common.
Today we're going to actually talk about what happens during the process of going to the hospital and having the bypass procedure done. With me today are a team of doctors and assistants, who are going to help explain today exactly what happens when you go through this procedure.
We have a team from Columbia University in New York, located at New York Presbyterian Hospital. To my left here is Dr. Windsor Ting, who's a cardiac surgeon. He's active in many areas of research, including minimally invasive heart surgery, and consumer access to health care. Welcome, Dr. Ting.
WINDSOR TING, MD: Thank you.
MARK POCHAPIN, MD: Next to him is Ms. Roxana Shaw, who is a physicians' assistant. Now, a physicians' assistant is actually someone who helps in the open heart surgery, and follows patients throughout the hospital stay. Welcome, Ms. Shaw.
ROXANA SHAW, PA: Thank you.
MARK POCHAPIN, MD: Next to her is Dr. Neal Reich, who is a cardiothoracic anesthesiology fellow. His research interests include minimally invasive heart surgery, and anesthesia during cardiopulmonary bypass. Thank you all for coming.
Today we're going to talk a little bit about what actually happens when you get to the hospital, and then how you go through the procedure, and what literally happens during the procedure and right after. Dr. Ting, let's start with you. What actually happens when the patient arrives? Do they arrive the same day, or do they actually come before the procedure is scheduled?
WINDSOR TING, MD: There are several different categories of patients. Nowadays, there are a group of patients that come to surgery on the day of surgery. It's called same-day admit. If their case is in the morning, they will come two-three hours before the operation. So some of the preparation will be taken of while they're home, and then they get to the hospital on the day of the operation.
There are other patients who are in the hospital. They're too sick to go home. They will wait in the hospital until their surgery.
MARK POCHAPIN, MD: Now, those patients, when you say they're too sick to go home, is that more of an emergency type of operation?
WINDSOR TING, MD: They're more an urgent operation. And then you have the last group of patients, which we refer to as emergency operations. Something happened to them while they're in the hospital, they go to the operating room within minutes or hours after the "event."
MARK POCHAPIN, MD: Once they come, Ms. Shaw, is there anything that you tell them when they get there? They must be very, very nervous when they arrive.
ROXANA SHAW, PA: They are very nervous, usually, when they arrive, but they have their family around them in the holding area, and usually there's the anesthesiologist and the nurses around them to calm them down. Once they arrive in the operating room is usually when I see them, and at that time, we just also try to have a calming effect on them and wish them well during the surgery.
MARK POCHAPIN, MD: Let's take a step backwards. Before they actually enter the operating room, what happens to their friends and family members who are with them? Are they in some particular area waiting, or do they stay at home?
ROXANA SHAW, PA: Friends and family are allowed to come all the way into the holding area, which is the room that patients stay in right before their surgery. After that, the friends and family go to the waiting area, and the doctors will come out, surgeons will come speak to them at various different points, either their assistants or themselves, when they have a chance.
WINDSOR TING, MD: Mark, I wanted to raise a point right now. It's important to limit the visitors or company people to the immediate families. It is a major operation, there are many things happening during the day. It's kind of distracting to have so many people around, friends, family, distant cousins. It's good just to have the immediate family members.
MARK POCHAPIN, MD: Dr. Reich, you're an anesthesiologist. What exactly is anesthesia, and when do you meet the patient? How do you interact with them?
NEAL REICH, MD: Depending on which one of Dr. Ting's categories they fit in, we may meet them a week before, the night before, or even the morning of the surgery.
Anesthesia is, as it was described to me, it's part art, part science, part magic. The job of anesthesia is to make sure that the patient is pain-free and amnestic, or has no memory of the occurrences during the surgery, and to control the body functions to maximize the surgery, for the surgeon's benefit and the patient's benefit.
Often nowadays, we meet the patient on the morning of the surgery, and we get some type of intravenous access in them. We use a local anesthetic before we even start that, for the most part. So it's no worse than getting a shot of novocaine at the dentist.
Then we start giving them medication. A lot of patients will find they may not remember even meeting us in the morning. Or they will remember meeting us, but not going into the operating room.
MARK POCHAPIN, MD: Do they actually know that they're being wheeled in? Are they sedated in the process of going from the holding area to the operating room? Or not really?
NEAL REICH, MD: If we meet them the night before and we anticipate that it's a person that's going to be very nervous, oftentimes we'll prescribe some sort of anxiolytic medicine, or anxiety-reducing medicine, the night before.
However, if I get on the morning of the surgery, and I see you're bouncing off the walls, a lot of times once we get you into the operating room and get you safely on the bed, and get some monitors on you, we'll give you some medicine that helps sedate you, calm you, get rid of the anxiety.
And oftentimes the medicine we use actually gets rid of some of the memory before you even came in the room. But most people nowadays, especially at the facility we work at, wait until you're in the room to give you some of the medication, if we meet you the morning of.
MARK POCHAPIN, MD: Now, I know in my own practice that sometimes the paperwork is actually more difficult and more overbearing than actually taking care of patients. And I'm sure there's a tremendous amount of paperwork that needs to be done.
What happens, Ms. Shaw? Do they need to do paperwork when they get there? Is it a family member who has to do that? Or is that all done beforehand?
ROXANA SHAW, PA: Again, based on the category that they fall into depends how their paperwork is taken care of. If they come in as a same-day patient, normally their paperwork is already completed in the surgeon's offices, and will be there prior to the patient arriving.
If they're an in-house patient, meaning their case is a little bit more urgent, then their paperwork will be brought up from the floors that they're at. But, again, everything is reviewed prior to the patient's going into the operating room, just to make sure that he has all the information there.
MARK POCHAPIN, MD: Dr. Ting, who decides whether a patient comes the night before or the morning of?
WINDSOR TING, MD: It's determined by several factors. How sick the patient is, as well as other issues. Let's say you have a patient who lives 50 miles away. It's a considerable distance to travel. In that case, we prefer to have that patient come the day before surgery.
If it's a same-day admit, we prefer not to have the patient be the first case in the morning, because otherwise the patient will have to get up at 2 or 3 o'clock in the morning, drive a couple of hours, and then get to the hospital by 5-6 in the morning for the first case.
MARK POCHAPIN, MD: Does insurance play a role in that? Does the insurance ever say they can or cannot come the day before?
WINDSOR TING, MD: Unfortunately, I think insurance has been a major driving force in same-day admit for surgery. I personally think it's a good idea to have these patients come in the day of the operation. We're talking about patients in their 50s, 60s, 70s. They're going for a major operation. It's a lot to ask them to travel the day of the operation.
It's better to have them in the hospital the day before. They sleep overnight, so they have an opportunity to acclimate to the hospital environment.
MARK POCHAPIN, MD: Okay, so now they've made it to the operating room. I guess one of the first people they meet may be you, Ms. Shaw, and also an anesthesiologist, obviously, in addition to other people. Can you just explain who's around them, and then how is the anesthesia actually induced? Who's in the room there?
NEAL REICH, MD: Basically, we wheel the patient into the room, and oftentimes one of the physicians' assistants will be in the room with us when we come into the room.
Some hospitals utilize nurse-anesthetists, some hospital utilize residents, fellows, and some the anesthesiologist works alone. Oftentimes, the patients will move themselves over to the operating-room bed. Monitors will be hooked up onto them. Nothing that hurts. It's all kind of stickies and clip-type stuff. And then we'll have them breathe some oxygen.
Because heart surgery is such a serious surgery, in terms of we're manipulating some very fine parameters, we have different types of monitors that are not clip-on stickies, that actually involve needles and hurt a little bit. So what we try and do is put an intravenous line or an IV in first, so we can give them a little sedation for one of the other lines that may hurt a little bit more.
Once we get the lines in that we need to put the patient to sleep safely, we have them breathe 100% oxygen for a little while. Get the lungs nice and filled with oxygen, make the body nice and happy, look at the vital signs, and when everything's stable, we start giving them medications.
And there are different classes of drugs, but basically we give them something so that they don't remember, something to blunt the body's sympathetic or nervous or fright-and-flight responses, and then we give them something to kind of let them drift off to sleep. Once they're asleep, and this scares most people when I say it, we put a breathing tube down. But people need to understand that, while you're asleep, air needs to go in and out, so that oxygen can go round and round, and that's the safest way to do it.
So we put a breathing tube down, some other monitors, turn on some gas that helps patients forget as well. Off they go to sleep. And during this whole thing, you'll have a profusion team. You'll have a cardiac surgeon, a nurse-anesthetist, a physicians' assistant, some of the nurses that scrub into the operating room. The whole team is sitting there talking to the patient and reassuring them.
MARK POCHAPIN, MD: Now, does the patient get a chance to meet the surgeon before the procedure, or no? Or does it vary in different places?
WINDSOR TING, MD: It varies in different places. Sometimes, by the time we see the patient, the patient is already asleep. Certainly if the patient is in the hospital the day before surgery, we would like to meet the patient beforehand. Or if the patient is coming in on the day of the operation, we'll meet the patient in the office and get at least an introduction.
I think it's important to point out that, when the patient comes to the operating room, he or she will be meeting lots of people. There'll be physicians' assistants like Roxana, there'll be anesthesiologists, there will be nurses, there'll be medical students, residents, fellows, surgeons. But the important thing to point out: everyone has an important role to play. Cardiac surgery would not be the way it is today without the contribution of all these important individuals.
NEAL REICH, MD: Definitely a team effort.
MARK POCHAPIN, MD: A team effort. That's obvious just talking to you.
WINDSOR TING, MD: And this is very, very big team.
MARK POCHAPIN, MD: Now, let's talk about the procedure. The patient's there, they're asleep, they've made it to this point. What actually happens? You're literally cutting through their chest to expose their heart. That's a very frightening thing. What really happens, and how do you do it? How do you operate on someone's heart?
WINDSOR TING, MD: Depending on the operation, there are several major parts to the operation. One part, the first part, is getting access to the heart.
If it is a bypass operation, the grafts that we use to do the bypass need to be harvested. We call it the grafts. The grafts are almost like the pipes, the plumbing that we're going to be using during the operation. Roxana and the physicians' assistants will be helping in harvesting the veins from the leg.
MARK POCHAPIN, MD: So you take the veins from the legs, you attach it to the heart to try and bypass the area that's blocked, that the blood is not flowing through. It really is a plumbing problem, isn't it?
WINDSOR TING, MD: It's exactly a plumbing problem. It's like a detour on the road.
The next part of the operation is putting the patient on the heart-lung machine. And the third part of the operation is doing the crucial part of the surgery. Whether it's the bypass or the valve replacement, or whatever it is. Then this is followed by taking the patient off the heart-lung machine. And the last part is mopping up, cleaning, stopping the bleeding, and then closing the incision.
MARK POCHAPIN, MD: Now, when you're operating on the heart, does it actually stop beating? You stop the heart from beating. And how do you do that? In every movie you ever see, when the heart stops beating, the patient's dead.
WINDSOR TING, MD: To this day, I'm still fascinated that it works. For many open heart operations, we do stop the heart. We use potassium to stop the heart. But nowadays, we have a new operation. We can do bypass surgery on a beating heart.
MARK POCHAPIN, MD: Really?
WINDSOR TING, MD: That is one of the latest developments.
MARK POCHAPIN, MD: What is that called?
WINDSOR TING, MD: It's called off-pump CABG, and it's also referred to as beating-heart surgery. In the last year or two, there have been several new surgical equipment, new techniques to allow us to do bypass surgery on a beating heart. I think it's one of the most exciting developments in open heart surgery.
MARK POCHAPIN, MD: Dr. Reich, you're responsible for monitoring them, making sure all parameters, the hemodynamic, the blood pressure and the oxygen are all okay. How do you do that when the heart's not beating?
NEAL REICH, MD: It is a little bit different once the heart stops beating. That's where, once again, you have to emphasize the fact that it is a team approach. When you do stop the heart, there's a team of profusionists. They have a machine called a heart-lung machine. And they basically take over the function of the heart circulating the blood around the body.
We put arterial lines in. Just about everybody that's seen a good or bad movie has heard of an intravenous line. We actually put lines in the artery. And that allows us to watch the blood pressure from when the patient's heart is beating, heartbeat to heartbeat. But when the patient's heart isn't beating, it allows us to watch how well the machine, the heart-lung machine, is driving the blood through the heart.
We also have trans-esophageal echo probes, or little cameras that shoot ultrasound to see pictures of the heart, and then we have other types of catheters like Swann-Ganz catheters, which allow us to look at the various pressures in the heart, by floating a little catheter through the neck. We basically can monitor lots of different pressures and pictures.
MARK POCHAPIN, MD: So now we have the patient, the operation is obviously a success. They've come off the pumps, and now their heart has taken over with the new grafts. They're now brought to the recovery area. What happens after the operation? Who greets them? How do they feel when they wake up? Dr. Ting, you want to start?
WINDSOR TING, MD: Usually the patient is asleep after the operation, and we'll keep the patient, usually, asleep during the first 12-24 hours, depending on how sick the patient is. The patient will go to the intensive care unit directly from the operating room.
When the patient wakes up, the patient will be in the intensive care unit. Usually there will be a breathing tube connected to the breathing machine. It's somewhat uncomfortable, but the patient needs to realize that that breathing tube will come out the moment the patient is awake and able to breathe on their own.
There'll be a whole group of new faces. Nurses and doctors in the ICU, physicians' assistants. Again, in the ICU, it's a team effort. These patients can be very sick, and need to be monitored 24 hours. So we need to have a team of physicians and nurses and assistants to take care of these patients.
MARK POCHAPIN, MD: Ms. Shaw, how long do patients generally stay in the intensive care unit, and what's the total length of stay in the hospital after an operation like this?
ROXANA SHAW, PA: Again, depending on the type of surgery that they have had and what their case may be, they may be there anywhere from 24 hours to a prolonged course of stay.
MARK POCHAPIN, MD: You mean in the intensive care unit?
ROXANA SHAW, PA: In the intensive care unit. From the intensive care unit, they move up to what we call the step-down unit. There they're again monitored for another 24 hours, just to make sure that everything goes okay as far as their cardiac function goes.
And then from there to a regular room, where they stay for about another four to five days. Depending on their case, they're there anywhere between five to seven days. They get involved with physical therapy, and by the time they leave, they're usually up and walking and able to climb stairs, etc.
MARK POCHAPIN, MD: Do they actually go home, or is there some type of rehab place that they go to afterwards?
ROXANA SHAW, PA: Again, depending on the type of patient. The elderly patients we like to send to rehab facilities, where there are physical therapists and rehab physicians who work with the patient, allowing them to reach their prior level of activity or even better than that.
Usually in the younger patients, they're able to go home and work on their own to reach that level of activity that they need to reach.
MARK POCHAPIN, MD: Dr. Reich, how do you keep them pain-free? Obviously there's got to be some discomfort after a major operation like this. What do you do for them?
NEAL REICH, MD: That's actually an interesting question, because there is regional and hospital variation. Anything from what's called a regional technique, which includes things like subarachnoid blocks or spinals and epidurals, to what we use at Columbia-Presbyterian, which is mainly IV medication.
You're right, it is painful. However, we give nice healthy doses of narcotics, morphine family, something called fentanyl, which is a narcotic. We give the patient enough that hopefully it will cover the pain of the incision over the chest, and the pain of the incisions at the leg.
A lot of times, once patients regain their faculties and have the tube out, they'll be given something called a PCA or patient-controlled analgesia. That's basically like a little joystick button that, every time you hit the button, gives you a pre-prescribed bolus or dose of the medicine. And it's usually a narcotic, once again.
WINDSOR TING, MD: You know, Mark, I remember when I was doing my training. A patient was staying seven to ten days after open heart surgery. And then it was down to about seven days. Now patients are home five to seven days after their open heart surgery.
With the introduction of beating-heart surgery or off-pump bypass surgery, there is a possibility that that patient can go home even earlier, because we don't have all the side effects of being on the heart-lung machine. It's pretty remarkable.
Having said that, I think, on the whole, we get patients home much too early. Once again, we're dealing with an older population with a major procedure. I think it's important to keep them in the hospital until they are ready to go home.
I have patients, they're terrified. I hear them say "I'm going home, five days after open heart surgery?" They're terrified. And I really understand why they would be afraid of going home this early after the operation.
MARK POCHAPIN, MD: Thank you all so much for joining us today. It's certainly interesting, and I'm sure our audience has learned quite a bit.
Thank you, our audience, for joining us. I'm Dr. Pochapin.
MARK POCHAPIN, MD: Hi, I'm Dr. Mark Pochapin, and welcome to our show. Today we're going to talk about open heart surgery. Which really is a frightening topic to think about, especially for patients who are planning to undergo open heart surgery. But, in fact, over 500,000 procedures of just bypass alone are done in this country. So it's very common.
Today we're going to actually talk about what happens during the process of going to the hospital and having the bypass procedure done. With me today are a team of doctors and assistants, who are going to help explain today exactly what happens when you go through this procedure.
We have a team from Columbia University in New York, located at New York Presbyterian Hospital. To my left here is Dr. Windsor Ting, who's a cardiac surgeon. He's active in many areas of research, including minimally invasive heart surgery, and consumer access to health care. Welcome, Dr. Ting.
WINDSOR TING, MD: Thank you.
MARK POCHAPIN, MD: Next to him is Ms. Roxana Shaw, who is a physicians' assistant. Now, a physicians' assistant is actually someone who helps in the open heart surgery, and follows patients throughout the hospital stay. Welcome, Ms. Shaw.
ROXANA SHAW, PA: Thank you.
MARK POCHAPIN, MD: Next to her is Dr. Neal Reich, who is a cardiothoracic anesthesiology fellow. His research interests include minimally invasive heart surgery, and anesthesia during cardiopulmonary bypass. Thank you all for coming.
Today we're going to talk a little bit about what actually happens when you get to the hospital, and then how you go through the procedure, and what literally happens during the procedure and right after. Dr. Ting, let's start with you. What actually happens when the patient arrives? Do they arrive the same day, or do they actually come before the procedure is scheduled?
WINDSOR TING, MD: There are several different categories of patients. Nowadays, there are a group of patients that come to surgery on the day of surgery. It's called same-day admit. If their case is in the morning, they will come two-three hours before the operation. So some of the preparation will be taken of while they're home, and then they get to the hospital on the day of the operation.
There are other patients who are in the hospital. They're too sick to go home. They will wait in the hospital until their surgery.
MARK POCHAPIN, MD: Now, those patients, when you say they're too sick to go home, is that more of an emergency type of operation?
WINDSOR TING, MD: They're more an urgent operation. And then you have the last group of patients, which we refer to as emergency operations. Something happened to them while they're in the hospital, they go to the operating room within minutes or hours after the "event."
MARK POCHAPIN, MD: Once they come, Ms. Shaw, is there anything that you tell them when they get there? They must be very, very nervous when they arrive.
ROXANA SHAW, PA: They are very nervous, usually, when they arrive, but they have their family around them in the holding area, and usually there's the anesthesiologist and the nurses around them to calm them down. Once they arrive in the operating room is usually when I see them, and at that time, we just also try to have a calming effect on them and wish them well during the surgery.
MARK POCHAPIN, MD: Let's take a step backwards. Before they actually enter the operating room, what happens to their friends and family members who are with them? Are they in some particular area waiting, or do they stay at home?
ROXANA SHAW, PA: Friends and family are allowed to come all the way into the holding area, which is the room that patients stay in right before their surgery. After that, the friends and family go to the waiting area, and the doctors will come out, surgeons will come speak to them at various different points, either their assistants or themselves, when they have a chance.
WINDSOR TING, MD: Mark, I wanted to raise a point right now. It's important to limit the visitors or company people to the immediate families. It is a major operation, there are many things happening during the day. It's kind of distracting to have so many people around, friends, family, distant cousins. It's good just to have the immediate family members.
MARK POCHAPIN, MD: Dr. Reich, you're an anesthesiologist. What exactly is anesthesia, and when do you meet the patient? How do you interact with them?
NEAL REICH, MD: Depending on which one of Dr. Ting's categories they fit in, we may meet them a week before, the night before, or even the morning of the surgery.
Anesthesia is, as it was described to me, it's part art, part science, part magic. The job of anesthesia is to make sure that the patient is pain-free and amnestic, or has no memory of the occurrences during the surgery, and to control the body functions to maximize the surgery, for the surgeon's benefit and the patient's benefit.
Often nowadays, we meet the patient on the morning of the surgery, and we get some type of intravenous access in them. We use a local anesthetic before we even start that, for the most part. So it's no worse than getting a shot of novocaine at the dentist.
Then we start giving them medication. A lot of patients will find they may not remember even meeting us in the morning. Or they will remember meeting us, but not going into the operating room.
MARK POCHAPIN, MD: Do they actually know that they're being wheeled in? Are they sedated in the process of going from the holding area to the operating room? Or not really?
NEAL REICH, MD: If we meet them the night before and we anticipate that it's a person that's going to be very nervous, oftentimes we'll prescribe some sort of anxiolytic medicine, or anxiety-reducing medicine, the night before.
However, if I get on the morning of the surgery, and I see you're bouncing off the walls, a lot of times once we get you into the operating room and get you safely on the bed, and get some monitors on you, we'll give you some medicine that helps sedate you, calm you, get rid of the anxiety.
And oftentimes the medicine we use actually gets rid of some of the memory before you even came in the room. But most people nowadays, especially at the facility we work at, wait until you're in the room to give you some of the medication, if we meet you the morning of.
MARK POCHAPIN, MD: Now, I know in my own practice that sometimes the paperwork is actually more difficult and more overbearing than actually taking care of patients. And I'm sure there's a tremendous amount of paperwork that needs to be done.
What happens, Ms. Shaw? Do they need to do paperwork when they get there? Is it a family member who has to do that? Or is that all done beforehand?
ROXANA SHAW, PA: Again, based on the category that they fall into depends how their paperwork is taken care of. If they come in as a same-day patient, normally their paperwork is already completed in the surgeon's offices, and will be there prior to the patient arriving.
If they're an in-house patient, meaning their case is a little bit more urgent, then their paperwork will be brought up from the floors that they're at. But, again, everything is reviewed prior to the patient's going into the operating room, just to make sure that he has all the information there.
MARK POCHAPIN, MD: Dr. Ting, who decides whether a patient comes the night before or the morning of?
WINDSOR TING, MD: It's determined by several factors. How sick the patient is, as well as other issues. Let's say you have a patient who lives 50 miles away. It's a considerable distance to travel. In that case, we prefer to have that patient come the day before surgery.
If it's a same-day admit, we prefer not to have the patient be the first case in the morning, because otherwise the patient will have to get up at 2 or 3 o'clock in the morning, drive a couple of hours, and then get to the hospital by 5-6 in the morning for the first case.
MARK POCHAPIN, MD: Does insurance play a role in that? Does the insurance ever say they can or cannot come the day before?
WINDSOR TING, MD: Unfortunately, I think insurance has been a major driving force in same-day admit for surgery. I personally think it's a good idea to have these patients come in the day of the operation. We're talking about patients in their 50s, 60s, 70s. They're going for a major operation. It's a lot to ask them to travel the day of the operation.
It's better to have them in the hospital the day before. They sleep overnight, so they have an opportunity to acclimate to the hospital environment.
MARK POCHAPIN, MD: Okay, so now they've made it to the operating room. I guess one of the first people they meet may be you, Ms. Shaw, and also an anesthesiologist, obviously, in addition to other people. Can you just explain who's around them, and then how is the anesthesia actually induced? Who's in the room there?
NEAL REICH, MD: Basically, we wheel the patient into the room, and oftentimes one of the physicians' assistants will be in the room with us when we come into the room.
Some hospitals utilize nurse-anesthetists, some hospital utilize residents, fellows, and some the anesthesiologist works alone. Oftentimes, the patients will move themselves over to the operating-room bed. Monitors will be hooked up onto them. Nothing that hurts. It's all kind of stickies and clip-type stuff. And then we'll have them breathe some oxygen.
Because heart surgery is such a serious surgery, in terms of we're manipulating some very fine parameters, we have different types of monitors that are not clip-on stickies, that actually involve needles and hurt a little bit. So what we try and do is put an intravenous line or an IV in first, so we can give them a little sedation for one of the other lines that may hurt a little bit more.
Once we get the lines in that we need to put the patient to sleep safely, we have them breathe 100% oxygen for a little while. Get the lungs nice and filled with oxygen, make the body nice and happy, look at the vital signs, and when everything's stable, we start giving them medications.
And there are different classes of drugs, but basically we give them something so that they don't remember, something to blunt the body's sympathetic or nervous or fright-and-flight responses, and then we give them something to kind of let them drift off to sleep. Once they're asleep, and this scares most people when I say it, we put a breathing tube down. But people need to understand that, while you're asleep, air needs to go in and out, so that oxygen can go round and round, and that's the safest way to do it.
So we put a breathing tube down, some other monitors, turn on some gas that helps patients forget as well. Off they go to sleep. And during this whole thing, you'll have a profusion team. You'll have a cardiac surgeon, a nurse-anesthetist, a physicians' assistant, some of the nurses that scrub into the operating room. The whole team is sitting there talking to the patient and reassuring them.
MARK POCHAPIN, MD: Now, does the patient get a chance to meet the surgeon before the procedure, or no? Or does it vary in different places?
WINDSOR TING, MD: It varies in different places. Sometimes, by the time we see the patient, the patient is already asleep. Certainly if the patient is in the hospital the day before surgery, we would like to meet the patient beforehand. Or if the patient is coming in on the day of the operation, we'll meet the patient in the office and get at least an introduction.
I think it's important to point out that, when the patient comes to the operating room, he or she will be meeting lots of people. There'll be physicians' assistants like Roxana, there'll be anesthesiologists, there will be nurses, there'll be medical students, residents, fellows, surgeons. But the important thing to point out: everyone has an important role to play. Cardiac surgery would not be the way it is today without the contribution of all these important individuals.
NEAL REICH, MD: Definitely a team effort.
MARK POCHAPIN, MD: A team effort. That's obvious just talking to you.
WINDSOR TING, MD: And this is very, very big team.
MARK POCHAPIN, MD: Now, let's talk about the procedure. The patient's there, they're asleep, they've made it to this point. What actually happens? You're literally cutting through their chest to expose their heart. That's a very frightening thing. What really happens, and how do you do it? How do you operate on someone's heart?
WINDSOR TING, MD: Depending on the operation, there are several major parts to the operation. One part, the first part, is getting access to the heart.
If it is a bypass operation, the grafts that we use to do the bypass need to be harvested. We call it the grafts. The grafts are almost like the pipes, the plumbing that we're going to be using during the operation. Roxana and the physicians' assistants will be helping in harvesting the veins from the leg.
MARK POCHAPIN, MD: So you take the veins from the legs, you attach it to the heart to try and bypass the area that's blocked, that the blood is not flowing through. It really is a plumbing problem, isn't it?
WINDSOR TING, MD: It's exactly a plumbing problem. It's like a detour on the road.
The next part of the operation is putting the patient on the heart-lung machine. And the third part of the operation is doing the crucial part of the surgery. Whether it's the bypass or the valve replacement, or whatever it is. Then this is followed by taking the patient off the heart-lung machine. And the last part is mopping up, cleaning, stopping the bleeding, and then closing the incision.
MARK POCHAPIN, MD: Now, when you're operating on the heart, does it actually stop beating? You stop the heart from beating. And how do you do that? In every movie you ever see, when the heart stops beating, the patient's dead.
WINDSOR TING, MD: To this day, I'm still fascinated that it works. For many open heart operations, we do stop the heart. We use potassium to stop the heart. But nowadays, we have a new operation. We can do bypass surgery on a beating heart.
MARK POCHAPIN, MD: Really?
WINDSOR TING, MD: That is one of the latest developments.
MARK POCHAPIN, MD: What is that called?
WINDSOR TING, MD: It's called off-pump CABG, and it's also referred to as beating-heart surgery. In the last year or two, there have been several new surgical equipment, new techniques to allow us to do bypass surgery on a beating heart. I think it's one of the most exciting developments in open heart surgery.
MARK POCHAPIN, MD: Dr. Reich, you're responsible for monitoring them, making sure all parameters, the hemodynamic, the blood pressure and the oxygen are all okay. How do you do that when the heart's not beating?
NEAL REICH, MD: It is a little bit different once the heart stops beating. That's where, once again, you have to emphasize the fact that it is a team approach. When you do stop the heart, there's a team of profusionists. They have a machine called a heart-lung machine. And they basically take over the function of the heart circulating the blood around the body.
We put arterial lines in. Just about everybody that's seen a good or bad movie has heard of an intravenous line. We actually put lines in the artery. And that allows us to watch the blood pressure from when the patient's heart is beating, heartbeat to heartbeat. But when the patient's heart isn't beating, it allows us to watch how well the machine, the heart-lung machine, is driving the blood through the heart.
We also have trans-esophageal echo probes, or little cameras that shoot ultrasound to see pictures of the heart, and then we have other types of catheters like Swann-Ganz catheters, which allow us to look at the various pressures in the heart, by floating a little catheter through the neck. We basically can monitor lots of different pressures and pictures.
MARK POCHAPIN, MD: So now we have the patient, the operation is obviously a success. They've come off the pumps, and now their heart has taken over with the new grafts. They're now brought to the recovery area. What happens after the operation? Who greets them? How do they feel when they wake up? Dr. Ting, you want to start?
WINDSOR TING, MD: Usually the patient is asleep after the operation, and we'll keep the patient, usually, asleep during the first 12-24 hours, depending on how sick the patient is. The patient will go to the intensive care unit directly from the operating room.
When the patient wakes up, the patient will be in the intensive care unit. Usually there will be a breathing tube connected to the breathing machine. It's somewhat uncomfortable, but the patient needs to realize that that breathing tube will come out the moment the patient is awake and able to breathe on their own.
There'll be a whole group of new faces. Nurses and doctors in the ICU, physicians' assistants. Again, in the ICU, it's a team effort. These patients can be very sick, and need to be monitored 24 hours. So we need to have a team of physicians and nurses and assistants to take care of these patients.
MARK POCHAPIN, MD: Ms. Shaw, how long do patients generally stay in the intensive care unit, and what's the total length of stay in the hospital after an operation like this?
ROXANA SHAW, PA: Again, depending on the type of surgery that they have had and what their case may be, they may be there anywhere from 24 hours to a prolonged course of stay.
MARK POCHAPIN, MD: You mean in the intensive care unit?
ROXANA SHAW, PA: In the intensive care unit. From the intensive care unit, they move up to what we call the step-down unit. There they're again monitored for another 24 hours, just to make sure that everything goes okay as far as their cardiac function goes.
And then from there to a regular room, where they stay for about another four to five days. Depending on their case, they're there anywhere between five to seven days. They get involved with physical therapy, and by the time they leave, they're usually up and walking and able to climb stairs, etc.
MARK POCHAPIN, MD: Do they actually go home, or is there some type of rehab place that they go to afterwards?
ROXANA SHAW, PA: Again, depending on the type of patient. The elderly patients we like to send to rehab facilities, where there are physical therapists and rehab physicians who work with the patient, allowing them to reach their prior level of activity or even better than that.
Usually in the younger patients, they're able to go home and work on their own to reach that level of activity that they need to reach.
MARK POCHAPIN, MD: Dr. Reich, how do you keep them pain-free? Obviously there's got to be some discomfort after a major operation like this. What do you do for them?
NEAL REICH, MD: That's actually an interesting question, because there is regional and hospital variation. Anything from what's called a regional technique, which includes things like subarachnoid blocks or spinals and epidurals, to what we use at Columbia-Presbyterian, which is mainly IV medication.
You're right, it is painful. However, we give nice healthy doses of narcotics, morphine family, something called fentanyl, which is a narcotic. We give the patient enough that hopefully it will cover the pain of the incision over the chest, and the pain of the incisions at the leg.
A lot of times, once patients regain their faculties and have the tube out, they'll be given something called a PCA or patient-controlled analgesia. That's basically like a little joystick button that, every time you hit the button, gives you a pre-prescribed bolus or dose of the medicine. And it's usually a narcotic, once again.
WINDSOR TING, MD: You know, Mark, I remember when I was doing my training. A patient was staying seven to ten days after open heart surgery. And then it was down to about seven days. Now patients are home five to seven days after their open heart surgery.
With the introduction of beating-heart surgery or off-pump bypass surgery, there is a possibility that that patient can go home even earlier, because we don't have all the side effects of being on the heart-lung machine. It's pretty remarkable.
Having said that, I think, on the whole, we get patients home much too early. Once again, we're dealing with an older population with a major procedure. I think it's important to keep them in the hospital until they are ready to go home.
I have patients, they're terrified. I hear them say "I'm going home, five days after open heart surgery?" They're terrified. And I really understand why they would be afraid of going home this early after the operation.
MARK POCHAPIN, MD: Thank you all so much for joining us today. It's certainly interesting, and I'm sure our audience has learned quite a bit.
Thank you, our audience, for joining us. I'm Dr. Pochapin.
