Patient deteriorates quickly after cardiothoracic surgery
I was a physician assistant working in cardiothoracic surgery at a Veterans Affair hospital when I met S.F., a 78-year-old man. I didn't notice anything unusual or unique about the patient on first greeting or during the history and physical consult. He had CAD, atherosclerosis, mild diabetes, and hypertension. He also had post-traumatic stress disorder and smoked cigarettes.
The patient was quiet and shy, so trying to get a history out of him was time consuming and frustrating. He was scheduled to have an aortic valve replacement and coronary artery bypass graft of two arteries the next day.
The surgery itself was typical; however, the patient had some trouble coming off pump. This was finally accomplished when he was taken to the ICU (about 60 yards from the OR) and underwent the usual post-op evaluation — chest x-ray, ECG, arterial blood gas (AGB) and labs.
As I was waiting for the test results to come back, the patient became unstable with hypotension. He then developed ectopy with non-sustainable ventricular tachycardia. During a two-hour period things were turning bad, quickly. We rapidly had to evaluate and treat each nuance to try to stabilize him. However, nothing improved and his overall condition worsened — ABG, profound hypotension and pulsus paradoxus. This man was dying.
There was no time to take him back to the OR, so we opened his sternum in the ICU — which immediately improved his VS. Once stable enough for transport and with the fellow's hand placed over the patient's heart (ready for cardiac massage), we started out down what seemed like a very long hall to the OR. As we did, visitors passed us and were able to look into the patient's thorax and see his heart and lungs!
Finally arriving in the OR, the patient's chest was copiously irrigated. However, we were not able to close his sternum due to falling BP. Instead, the retractors remained holding his sternum apart, and his mediastinum was sealed with towels and Ioban drape. The following day, he returned to the OR and his sternum was successfully closed. The patient was in a critical but stable condition. He stayed in the ICU for about four days — two days intubated and on pressors. There was no initial evidence that he suffered a stroke or permanent disability. After another week, he was discharged to rehab in stable and improved condition. The patient never developed sternal wounds or a mediastinal infection.
I next saw the patient at one month post-op. His disposition had completely changed. He was very friendly and gregariously thanked me. In addition, he started keeping a journal and mentioned that he would send me a copy.
Later when I received his journal, I was stunned; it was about 14 pages, filled front and back with words. I did get a gist of his new views on life and the way he saw things – but most didn't making sense to me. I found this bizarre, and completely juxtaposed to his pre-op persona. I was sure it was related to prolonged hypotension and post-op comorbidities.
During the ten years that I worked at that hospital, I would occasionally see this patient in the hallways. He always remembered my name and thanked me. Not only had he survived a very close call, but also his whole attitude towards life had changed.Tell us about your most memorable patient by December 15, 2010, and you'll be eligible to win an Apple iPad!