Dr. Eric Freeman writes from China
Pictures from China by Dr. Eric Freeman5/23/08 8pm
White stuff in the heart room???
The temperature has been increasing here in Nanjing lately, This has caused a great deal of humidity, and unfortunately, my allergies have been suffering
quite a bit. As I stroll into the hospital every morning, a massive crowd greets me in front of the 5 elevators. A lot of screaming and pushing occurs as the slow elevator doors finally open. Today, I was running a few minutes late. I leaped into an elevator that was just about to close. All of a sudden some bells started to go off rather loudly. Amid a lot of commotion, I finally figured it out. Everyone was staring at me. I took that as my cue to exit the elevator. I brought the elevator over its weight capacity. I will blame it again on the noodles. I took the stairs.For the past few days I have been locked up in the cardiac room. I was looking forward to it, not because I love doing hearts, but I was curious as to how cardiac anesthesia is performed in China.
I have been working with Dr. Young and one of the residents. It has definitely been a challenge for me since their English is very minimal, and my Chinese is, lets say, non-existent. I am up to 13 phrases by now.
I have done some CABG’s and valve replacement surgeries. The cardiothoracic attending is a very small, quiet gentleman. I made a little mental image in my head thinking about the Director of CT surgery at Montefiore. He is a very big person, physically, and in his specialty.
I think everyone would be so intimidated by him here. They would definitely have to order him special scrubs and gloves. Like general surgery cases, the cardiac set-up is not nearly as involved. The perfusion team is off to the side and just like the anesthesia machines, the bypass apparatus does the same main functions, yet lacking all of the bells and whistles as the ones back home.
No special treatment for the heart team here. Same start time as everyone else. Patient already on the table awaiting for us after we finish morning conference. The attending requesting to open up a second room is not even an option.
As for the anesthesia set-up for an open heart case, it is not a major production like I am used to.
We draw up so many syringes, tubing, and, needles most of the time they are wasted. For the most part here they draw up meds as needed. No blood warming tubing. The cautery machine was used instead to warm the bags of packed cells and FFP. A simpler, modified version of the Omni flow is used. Sevoflurane is the anesthestic of choice. I miss the large 1000ug vials of fentanyl. It is a bit annoying cracking open little vials with only 100ug of fentanyl in each. One of these days I will cut myself.
Art line pre-induction. I told the patient to “take deep breaths” in Chinese. The attending had all of the meds in his hand. I saw etomidate once before so I expected to see it again in the heart room. Etomidate is white like propofol in China, but this was not etomidate. Huh? Propofol for a cardiac case? Like succinylcholine is not in the OR’s in China, propofol is not in the heart rooms back home.
I think if I suggested to induce a patient with critical aortic stenosis with propofol I might get a few extra Saturday OB calls. I tried to get an answer out of Dr. Young but we had a little language barrier. Patient intubated easily, yet I have seen better hemodynamics on induction. No Zoll defib pads placed on the patient. I don’t think they have any. Next up, internal jugular
catheterization for Swan-Ganz placement. A different kit or course but less extra, unnecessary things inside. Patient in trendelenberg position, with beautiful anatomy starting right at me as she was only 50kg. There was another moment of communication breakdown when I told Dr. Young I was in at 20cm with the PA catheter. Interestingly, there is an extra port on the PAC which was connected to another machine. This was to allow continuous measurement of cardiac output and the SvO2.
A little while later, patient was on CPB. As expected, Dr. Young disappeared. The resident was text-messaging some friends and I cracked a book open. Propofol is infused during bypass since there is no volatile anesthettic connected on the CPB machine.
The CPB run was not too long. It was rather quiet in the room. I am used to hearing the “parakeets”, I mean the perfusionists, repeating everyone word that the CT surgeons orders them to do. During bypass I went through all of the meds in two of the draws with the resident. Most of the drug concentrations are different here. They sometimes used sodium nitroprusside in the heart room. A few of the vials were expired. I threw them out.
Before coming off CPB, Dr. Young checked the echo. What ensued next was rather interesting. Dr. Young was not pleased with the placement of the mitral valve; the aortic was fine.
Back and forth for a few minutes an argument began. I just stood back, understanding nothing, and being a bit amused. A CT surgeon questioning a cardiac anesthesiologist? I am quite used to that. Sure enough, we were back on bypass, and the valve was fixed. Dr. Young was correct. I wonder what the re-bleed rate is here? Just like for general surgery cases using the
propofol/vecuronium and 0.5 MAC of sevo combo, I have noticed that most of the time dopamine at 5ug/kg/min is started when discontinuing CPB. I tried to obtain an answer from Dr. Young but did not get very far.
Case winding down, last sutures placed, and the patient was all packaged up to be transported to the ICU. Oxygen? Yes. Monitors? No. They just do not have transport monitors here. For my own piece of mind, I kept my left hand on the carotid while bagging the patient en route to the unit.
After work I went with one of the residents to the ping pong hall to improve my game.