As the pink eight-inch blood vessel emerges from the calf muscle, Alex Brazell points at the window and exclaims, "Ooh, look at that vein!"
With the replacement vessels in hand, the surgeon is now ready to work on the heart. To make room inside the chest, he inserts a sternal spreader between the ribs and turns a crank. The whole room oohs and aahs as, inch by inch, the chest creaks open. Brazell, who is now kneeling on a counter in front of the window, blurts out, "Oh, damn! Jeez!"
Students from a summer school program watch surgery at Inova Fairfax Hospital's "Dome."
(Photograph by Chris Hartlove)
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Taylor sympathizes with the kids. "To me, even after all of these years, it's intense." She assures the students that the patient is under the influence of anesthesia and feels nothing. Sometimes a person will even snore on the table.
"What do you think about when you're down there?" asks Crone, trying to comprehend how the medical staff can tolerate the blood. A heavily recruited football player bound for the University of Richmond, he has no problems crashing through a defensive line, but watching the surgery has made him increasingly uneasy.
"You're really focused on the job," Taylor replies. "That's what you have to do."
With the ribs spread open, Taylor points out that the patient's heart is flaccid and enlarged. "A swollen heart is bad," she says, shaking her head.
As the heart limps toward each contraction, Taylor explains how a narrowing of the coronary arteries forces the heart muscle to work harder than it should. This added pressure weakens and inflames the tissue. A quick look at the electrocardiogram monitor on the wall confirms this assessment. In a healthy heart, the line on the screen will be punctuated with sharp spikes at regular intervals. But this patient's EKG line has a series of hump-shaped waves that look like swells on the ocean.
"He has a rolling heartbeat," Taylor says. "Instead of the heart going boom, boom, it goes kind of blah."
Reaching into the patient's chest, the surgeon runs his fingers over the surface of the heart, feeling for blockages. Although he's studied the patient's angiogram, which gives him an X-ray of the coronary arteries, the film doesn't pinpoint the exact size or location of the obstructions. For a precise diagnosis, he must rely on his highly refined sense of touch. "You can't see the blockages," Taylor says, "but you can feel them."
A blockage the size of a BB pellet can drop a 200-pound man to the floor instantly.
Each graft is approximately 8 millimeters in diameter, which is about the width of a pencil. The surgeon will need to make 10 to 12 stitches around the circumference of each end using a needle the size of an eyelash and a strand of polypropylene thread the thickness of a baby's hair. To accomplish such delicate work, he first must stop the patient's heartbeat. This can be done with the assistance of the heart-lung machine, a mechanical pump that supplies the blood with oxygen and pumps it through the circulatory system for the two or three hours it takes to sew the bypass grafts.
To prepare the heart for connection to this device, the surgeon plants one plastic tube in the right atrium, which will take blood out of the body, and another in the aorta, the route through which it will return. The moment the tubes are inserted, a stream of dark blood rushes through and spurts into a stainless steel basin. But within a couple of heartbeats, the tubes are attached to the heart-lung machine, and the blood begins to swirl into two turning cylinders that look like the front of a Slurpee dispenser.
The surgeon can now safely stop the heart. Flicking a switch, he sends an electric current through a wire to the surface of the heart. The muscle begins to quiver and, in a moment, the blipping EKG line flattens. With its electrical impulse disrupted, Taylor says, the heart can no longer make an "organized contraction" and is therefore unable to pump blood. The students have just witnessed a controlled heart attack.
An assistant puts on a white cotton glove and slides his hand into the patient's chest. Lifting the limp heart, he exposes an area on its backside where the surgeon will sew a vein graft. The cotton glove keeps the assistant's hand from slipping while the surgeon works. The assistant cannot move even a centimeter for up to 20 minutes; an unexpected jitter could tear a vessel or cause an errant stitch.
