[HSF] Ahh, the Holiday Transfer. Would anyone do anything different?

[Michael Firstenberg]

I did, very briefly think about non-operative management and discussed the
entire plan with my Boss prior to starting, I was very concerned about his
on-going pain and that is was neuro/renal intact.  I know some places (which
better or worse will go nameless) sometimes watch and work-up these people
to see who may self-select into survivors - but I did not have the courage
to watch and do nothing.  Watching "viable" people die when there is
something to be done (even if near futile) is very painful.  We had a woman
in her 60's come in with a Type A and a moderate stroke - she was alert
enough and her entire extended family refused surgery - see eventually
extended her stroke, resp failure, intubation (another discussion), coded
and died.  Very hard to watch since I think she would have done well........

During the case - since I never found the LIMA the heart was being fed the
entire time and I was a little surprise coming off pump was as hard as it
was - but there was tons of air that was hard to get rid of and it kept
going down the coronaries........


-michael


On 11/26/07, Mark Levinson <mmlevinson at hsforum.com> wrote:
>
>
> On Nov 25, 2007, at 5:47 PM, Michael Firstenberg wrote:
>
> >
> > Please comment as I know many of you have been there (either on-
> > line or in private)..........
>
> I would have handled this case the same...and the outcome would be
> the same.....you did everything right and
> to the best of your ability.     The cards were dealt before he
> arrived.     Acute aortic dissections have
> a high mortality rate...
>
> Non-operative therapy has been recommended in some cases of acute
> type 1 as discussed by Tom Martin, but most
> of us are not in the position to defend this decision and quote the
> odds to the family....whereas we know the outcomes
> with surgery.      I reserve non-operative therapy for patients who
> have organ death on arrival (dead bowel, brain, liver)....and
> these patients die soon thereafter.     If you decide against
> surgery, you will have to defend this decision with some
> evidence that it is better than trying to fix it.
> Controversial....
>
> I think you handled this case as best it can be....
>
> Mark
>
> Mark Levinson, MD.
> Founder, Editor-in-Chief
> The Heart Surgery Forum(R)
> Multimedia Cardiothoracic Journal
> URL: http://www.hsforum.com
> URL: http://newoptionsinheartsurgery.com
> Emali:  mmlevinson at hsforum.com
>
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