Informal Report on Open Heart Surgery Observation
Elisa Martinez
January 19, 2004

Note: this report was for an instructor, so it contains abbreviations and jargon; I hope the surgery experience remains clear despite the nurse-talk.

I arrived at the TMF surgery center by 6:15 a.m., checked in with the surgery Lead and dressed in scrubs. After I finished dressing, I joined the OR nurses in the nurses' lounge to take report. Report basically consisted of telling the nurses which room they would be in and whose case they would take first. After report, I went to Pre-op holding with a nurse to meet the patient and get a consent to watch the surgery, a triple coronary artery bypass. The three nurses that would be in the OR decided what they wanted to do: either assist, scrub, or circulate, which was basically charting and being a go-fer. I followed the nurse who was circulating and helped her start to prep the patient while the other two nurses set the room up. She looked over the chart and gave some pre-op medications. Both the surgeon and the anesthesiologist came by to see the patient before he left for the operating room.

After getting the patient in the room, the anesthesiologist put the patient to sleep. He inserted an endotracheal tube, started the ventilator, put in a central Swan line, and did a TEE. Meanwhile, the nurses finished shaving the patient, inserted a Foley catheter, wrapped and tucked his arms by his side, put grounding pads on him, placed a five-lead electrode on the patient and scrubbed him from neck to toe with iodine. They also washed the sternal area with alcohol and later covered that area with a sterile yellow adhesive plastic. The two nurses who were going to be scrubbing and assisting donned sterile gowns and gloves and draped the patient. The anesthesiologist controlled the patient's blood pressure with several medications before the procedure because it was high.

At this point, the surgeon and his assistant, a family nurse practitioner, arrived and scrubbed up. The NP prepared to harvest a vein and the surgeon started cutting through the skin and sub-q tissue over the sternum. The patient had about an inch and a half of fat over the sternum, something that surprised me, because I generally don't think of that area as an area with a lot of fat. They reminded me that heart disease is more common in people who store fat in the chest area, rather than the hips, and then it made more sense to me. After the sternum had been opened, I was allowed to stand at the head of the patient to observe more closely. The surgeon explained what he was doing and quizzed me on anatomy. I did fine, except that I couldn't remember where the internal mammary artery came from… I should have paid more attention in class. : )

The surgeon planned to use the left internal mammary artery for one graft, so he found and prepared that vessel first. He left a lot of the fat and surrounding tissues on the vessel so that it wouldn't get damaged. He clamped off the branches going from the mammary artery with little metal clips. During this time, the blood-lung machine was being set up. After the blood-lung machine was ready, the surgeon inserted tubes into the left and right ventricles with purse string sutures. These tubes were primed with fluids and attached to the blood lung machine so that it could pump blood to perfuse the body tissues when the time came to work on the heart. All of the blood that was suctioned out of the cavity went into the machine. The anesthesiologist administered heparin to prevent the blood from clotting in the machine. 

By this time, the NP had gotten a piece of the L greater saphenous vein approximately 14 cm. long. She had made two or three incisions in the leg to pull it out, inserted a JP drain, sutured and dressed the incisions, and wrapped the leg tightly with ace wrap. The surgeon and NP tied up all the branches coming off of the vein with suture. The vein was smaller in diameter than I had imagined. They squeezed sterile fluid into it (it looked like air going into one of those really narrow, long balloons) to make sure they had gotten all the little holes tied up. 

The heart was slowed down with a small amount of potassium chloride and cooled, in order to lower its metabolism. Once the heart had stopped beating, the blood-lung machine was turned on and the surgeon found the vessels that that he was going to graft into. He used the mammary artery for the RCA first, then the vein for the LAD (which was 95% blocked) and another artery I can't remember. From time to time, he had the guy working the blood-lung machine fill the heart with blood to make sure the grafts would be the right size when the heart was full. Every time the lung tissue got in his way (mostly when he was working on getting the mammary artery), the surgeon would have the anesthesiologist turn off the ventilator. If the surgeon waited too long before telling him to turn it back on, the anesthesiologist would say something like, "You want to turn that lung back on now?"

After the surgeon was done, he watched the heart beat for a while. I forgot to ask what made it start beating again, unless it was just that they warmed it up. Next, the surgeon took out the tubes for the blood-lung machine, tied up the holes with the purse string sutures (very convenient) and cauterized a lot of the inside edges, including the edges of the sternum that had been cut. The patient had been on Plavix and was still pretty anticoagulated. The surgeon inserted two chest tubes, one on either side of the mid-sternal line, and crossed them over so that the one coming out of the left incision lay by the right side of the heart and vice versa. Then he sutured a bit, I think. They returned most of the patient's blood to him, so that blood loss was minimal; basically all he lost was what soaked the towels. 

The most interesting thing was watching the surgeon put the sternum back together with sternal wire. He basically threaded the wire around, and tightened it up by twisting. It was a lot like a twistie on a bread bag, only much larger. He went around about six times, twisted tightly, cut off the ends, and folded them down toward the patient's toes. Then, the surgeon sutured up the first layer of subcutaneous tissue. While the surgeon was doing this, the nurses did an instrument count. The nurse practitioner finished sewing the patient up. For the final layer she used that technique where there aren't any stitches visible. I can't remember whether they used staples or not.

Finally, the nurses put a dressing on the incision and the CT insertion sites. They undraped the patient and covered him with a warm blanket. The anesthesiologist stayed with the patient until he got to the CICU. I got to bag the patient walking down the hall; I couldn't see his chest rising and falling and was worried my hand was too small to be doing it, but the anesthesiologist said it was fine. The OR nurses gave report to the CICU nurse, and a respiratory therapist hooked up the ICU vent. I hung out with the ICU nurse, also a UT grad, until the patient started to regain consciousness, and it was time for me to leave. This whole process lasted from 6:15 a.m. until 1:15 p.m., a total of seven hours.

Because I'm not going into surgery, this was probably a once-in-a-lifetime event, and I thoroughly enjoyed it. One final thing I learned: the internal mammary artery branches off of the subclavian. Keep that in mind if you ever watch a coronary artery bypass surgery.

Copyright 2004, Elisa Martinez, all rights reserved