Pediatric Surgeries

Ok, so where was I?   Tuesday night I went to dinner with some very cool people who own property in Cafayate. Wednesday morning I went to a pediatric cardiovascular surgery.  Wednesday night I went to dinner again with some of the same people and two Argentines.  Then yesterday morning I went back to the clinic 8-2 then class 2-6 and I completely crashed last night.  Dinner is a late affair and went from about 8:30-11:30 both nights.  The days have been long but action packed.  Now I am going to try to catch up on what I saw in the surgeries. 

Two days ago I went with Rene to a different hospital: Hospital Publico Maternal infantil. It is a massive new pediatric hospital that is really nice. We went there to do a cardiac surgery on an infant.  As far as I can understand, the surgical team (Rene as the anesthesiologist, and the two surgeons) contains the only people capable of doing this surgery in Salta, Cordoba and Mendoza  (provinces).  

The surgery was quite incredible and went perfectly smoothly.  The baby girl (37days old) was born with a decending aorta that was nearly occluded.  That means that the blood vessel off of her heart gave off branches to each arm and to her head but then the blood supply to the rest of her body, her abdomen and legs, was barely existent. The surgery required clamping the aorta closed after it gave off the supply to the right arm and head (brachiocephalic trunk for my med friends); cutting out the narrow part; and reconnecting the wide part from below to the aortic arch.  This had to be done in less than 20 minutes in order that the baby not be paraplegic. 

It was amazing to see how they did this surgery.  I was expecting that they would have to violently crack open her chest from the front, but that is not how they did it.  They layed the baby on her side and made a cut between two ribs.  Since our ribs are supposed to move up and down it was not difficult to gently move them apart (easy because they were no longer yoked together).  The opening for the surgery was only a couple inches tall and wide.  Then they collapsed the left lung (her right one is enough to do all the work) and they could access the blood vessels.  

The surgeons were great at explaining to me what they were doing and pointing out things like the recurrently laryngeal nerve and the ductus arteriosis. They spoke only in Spanish but slowly and most of the technical language is the same in English and Spanish.  They completed the detatchment/ reattachment in 15minutes seemingly without effort. 

The important aspect from the anesthesiological perspective is that blood pressure in the brain rises when the aorta is clamped off.  The heart slows in response to the pressure change and returns to normal.  However, this can be dangerous when the aorta is unclamped because the blood pressure can drop dramatically sending the baby into a sort of shock.  Therefore, right before the aorta is unclamped it is necessary to increase adrenaline and add blood plasma quickly.  This transition went quite smoothly. 

After the aorta was repaired there was another part of the surgery.  Because the baby’s blood was backed up, the lungs were getting too much blood.  This caused a change in the way her blood vessels to her lungs grew and needed to be corrected so that the pressure in the rest of her body and in her lungs would have the right balance. Until this point the surgery was completely outside of the cavity where her heart is. You could see the beat, but not the heart, only the lung and blood vessels.

It was amazing to see them open up the sack where her heart was (carefully avoiding the phrenic nerve).  Her heart was about the size of the tip of my thumb to the first knuckle.  It was unbelievable. 

The bottom line is, the surgery was amazing and the baby did very well.

The drawing that one of the surgeons, Juan, drew for me.  They had to clamp at C; cut out A; and reattach to the part near B.

Yesterday there was another infant surgery, this time at Clinica Guemes.  Normally they do not do infant surgeries there but the night before a woman had a c-section and her baby was born with some of her intestines outside her abdomen (basically it looked like there was a bundle of intestines sticking out of her belly button.)  This surgery also went very smoothly but Rene told me that these children often have to have more surgery later in life because their intestines do not develop quite right. 

We also talked a little bit about the payment system for surgeries. One problem that doctors face is that they are paid pretty similarly for each surgery, though not exactly the same.  So the insurance pays Rene a little more to do the pediatric cardiac surgery but it takes the entire morning (most of the time is prep and finishing).  At Clinica Guemes he might do six surgeries in the morning.  This is certainly a disincentive to do the complicated surgeries which I find interesting to contemplate, but he really loves to do the peds-CV so he does them anyway.  

Today in the clinic I successfully started my first IV. (!!) and with some assistance I did my first spinal tap.  Very cool, I think.   

There were no surgeries scheduled in the late morning so I left the clinic, dropped off my laundry, and I am at a café.  After I publish this I am going to pull out my Spanish notes and study until class starts. I was completely exhausted last night (veged out infront of the Spanish food network ElGourmet).  I am glad to have a day to catch up a little.  I was so tired for class yesterday that I could barely focus.