Our last case was Wednesday: a male patient in his late 40s with severe aortic stenosis.  He was scheduled for an aortic valve replacement with an On-X mechanical valve.

The lines were placed, the patient was asleep, then the patient was prepped and draped.  Andrew, the anesthetist, led the time-out and Dr. White asked Daniel to pray. 

Daniel Scrubs for Cardiac Cases.  Also a Pastor 

Daniel, a scrub tech as well as the pastor of a village church, asked God to give the team wisdom, to protect the patient from any harm, and to help the replacement to be successful.  He asked God to do this, so that when this man went back to his village, it would be evident to everyone that God had done a great work through the team at Tenwek and that God would be glorified by what was about to happen in OR-2 that morning.  

The procedure went according to plan. Once we were on bypass, the heart was stopped and the aorta was open.  It was evident that this was a heavily calcified valve and the annulus, where stitches would placed to hold in the new prosthetic valve, was also heavily calcified. It took a little over 80 minutes to place the valve and close aorta before the clamp could be removed.  In every cardiac procedure, there is a moment of truth: when the cross clamp is removed and blood is allowed to perfuse the heart muscle, again. 

Andrew is an anesthetist

There is always a sigh of relief when the heart slowly begins to contract in normal sinus rhythm.  But sometimes, the heart fibrillates and it will not beat; the team must take action to re-establish a normal rhythm.  These abnormal rhythms may be a sign of something very serious; a piece of calcium could have become lodged in a coronary artery, the drug that is given to protect the heart while it is not getting blood flow (cardioplegia) may have been ineffective and the muscle may be damaged, or perhaps one of the valve stitches was inadvertently placed through a coronary artery and the heart muscle is starving for oxygen and blood flow.   These are a surgeon’s worst nightmare.  Perhaps the heart is just irritable, and administering a drug to make it less irritable and a  single counter shock will break the abnormal rhythm pattern and establish a normal rhythm.

“Charge the paddles to 40- discharge.” No change   “Again, to fifty,” no change.  “Has Lidocaine been given?  Okay, charge to seventy.”  For more than 30 minutes, a normal rhythm could not be established, and the pacing wires were not capturing.  Also of note, the blood pressure was reading a low number and then a high number, and the wave pattern was confusing.  It was very tense in the room.  Was this man’s heart damaged?  Would it never again regain function; would he die on the operating room table?  I am sure that everyone in the room was reviewing everything that had transpired and was wondering if there was possibly something they could have done better. 

Dr. White began a dialogue with Agnetta, the surgical resident assisting him, and with Andrew Bii who was giving the anesthesia, and with me.  What were our options?  Someone reached under the drape; a pulse was palpable in the patient’s foot.  It was also noted that the rhythm was improving.   It was decided that Angnetta should place a catheter in the femoral artery, to get an accurate pressure reading.  This new line revealed a blood pressure of 75, a good sign.  Over the next 40 minutes, we slowly weaned the patient from the heart lung machine.  He had a very strong heartbeat; in fact, he had a high blood pressure. The patient was on cardiopulmonary bypass nearly 4 hours, but was now stable.  His chest was closed and he was transferred to the recovery area, in stable condition. 

It is evident that God heard and answered the prayer we had prayed with Daniel. 

At the end of the day, as I reflected on this case, I was reminded of Tenwek’s mission statement:  Tenwek Hospital is a Christian community committed to excellence in compassionate health care, spiritual ministry, and training for service.  Yes, the care provided by the cardiac team at Tenwek is excellent.  I witness each member of the team brings their whole person to the cardiac operating room each day.  There is a passion in each team member to do the very best for each patient. I also noted team members acknowledge there fallibility and their dependence on one another and on Jesus to use them as instruments of His healing. 

How a team performs when the unexpected occurs defines a team’s character.  When confronted with an abnormal rhythm and blood pressure issues, this team was able to communicate and come up with the best plan to overcome the challenging obstacle.  I am very proud to have been part of this surgery team these past two weeks.   On Wednesday evening I returned to the ICU to see the patient who was quite stable and onvery little pharmacological support.  Thursday was a day of completing inventory of supplies and cleaning and storing equipment.  When I dropped by the CTICU to check in on Wednesday’s patient I was do pleased to find that he had been extubated.  He grasped my hand thanked me personally and praised God for delivering him from surgery and healing his heart.  He told me it didn’t really matter what happens to tomorrow or the next day because his life was in God’s hands.  He introduced me to his daughter.  It is humbling to witness this attitude of joy, thanksgiving and complete dependence on God in a patient still recovering from major surgery.  

Our last patient the day after surgery