Opening chests

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Radetzky said:
People saying “but cardiac surgeons need to take responsibility for training the rest of us” are missing the point. Intensivists are not caretakers for cardiac surgeons. If they’re in my unit they’re my patients, and I don’t really care what expectations the surgeons have or don’t have.

I’m going to take responsibility for training myself to open a chest in the middle of the night when I’m there and the surgeon is half an hour away because that might be the difference between a successful and failed resuscitation.

So don’t pile on the OP for trying to do the same
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I suppose if I wanted to “train myself” to open a patient’s chest, the first person I would ask for a primer would be the surgeon who closed it rather than an online forum of anesthesiologists.

But you’re the intensivist. I’m just an anesthesiologist who doesn’t get the point I guess.
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DesiredMemberName? said:
I suppose if I wanted to “train myself” to open a patient’s chest, the first person I would ask for a primer would be the surgeon who closed it rather than an online forum of anesthesiologists.

But you’re the intensivist. I’m just an anesthesiologist who doesn’t get the point I guess.
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Buddy pls, you all have made your point... go on now
 
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Glad not to be, nor ever having been in the position of 'having to have a clue' here. That said, and just for argument's sake, with all the stuff in mediastinum, drainage tube(s), pacer wires, Gore-Tex conduit, grafts...why is re-sternotomy even a consideration? Just putting in a rib spreader is enough to end the game right there. If someone is hell bent for leather, a left thoracotomy (a la the trauma bay) would seem to be the far lesser of 2 evils given what there is to lose.
 
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Radetzky said:
People saying “but cardiac surgeons need to take responsibility for training the rest of us” are missing the point. Intensivists are not caretakers for cardiac surgeons. If they’re in my unit they’re my patients, and I don’t really care what expectations the surgeons have or don’t have.

I’m going to take responsibility for training myself to open a chest in the middle of the night when I’m there and the surgeon is half an hour away because that might be the difference between a successful and failed resuscitation.

So don’t pile on the OP for trying to do the same
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No, we're not missing the point. I'm an intensivist primarily in the CVICU as well, and think just teaching yourself from online resources without the involvement of the surgeons is asinine. There are things that you can teach yourself by building upon your past expertise with videos/lectures, but this is not one of them. If re-entering the fresh chest is driven by the intensivist group, then there needs to be standardized training, and a lot of input from the surgeons and your partners. Those patients are their patients, too, they know exactly how they close the chest routinely, and can give better advice.
 
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Just curious, how many people have ever seen a fresh postop resternotomy performed by a non surgeon? I have not.

Maybe I’ve been fortunate to work with surgeons who operate only at our hospital, who live nearby, and who don’t go home until their patients are safely tucked away.
 
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nimbus said:
Just curious, how many people have ever seen a fresh postop resternotomy performed by a non surgeon? I have not.

Maybe I’ve been fortunate to work with surgeons who operate only at our hospital, who live nearby, and who don’t go home until their patients are safely tucked away.
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Heard a CTS pgy2 opened a chest last week in our cticu while anesthesia icu attending dealt with peri arrest stuff and our interventional cards person put in ecmo cannulae. Managed to stabilize and eventually went to the OR. For whatever it’s worth CT surg residents don’t scrub any hearts until end of pgy2. But presumably had some experience from their sub-Is and was familiar with the chest cart.


Didn’t get the full story since i was just dropping off and they seemed to have enough hands


I’d say we have 1-2 crash reopenings every couple months in our cticu
 
psychbender said:
No, we're not missing the point. I'm an intensivist primarily in the CVICU as well, and think just teaching yourself from online resources without the involvement of the surgeons is asinine. There are things that you can teach yourself by building upon your past expertise with videos/lectures, but this is not one of them. If re-entering the fresh chest is driven by the intensivist group, then there needs to be standardized training, and a lot of input from the surgeons and your partners. Those patients are their patients, too, they know exactly how they close the chest routinely, and can give better advice.
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DesiredMemberName? said:
I suppose if I wanted to “train myself” to open a patient’s chest, the first person I would ask for a primer would be the surgeon who closed it rather than an online forum of anesthesiologists.

But you’re the intensivist. I’m just an anesthesiologist who doesn’t get the point I guess.
Click to expand...

When I learned how to intubate as an intern, I never practiced under the guidance of an experienced anesthesiologist. Instead, I went to the emergency medicine interest group at the nurse practitioner school and they showed me a link to a glidescope video. I know there are other ways to learn. My attendings even told me that there are resources to learn and practice intubations at the residency. But I will be the one in the unit at night, I wanted to learn it MY WAY.

After watching the glidescope video, I now feel comfortable intubating patients during my ICU nightfloats.

One night I get called to a code in progress. What the f&$# is a McGrath?!?!!! I told the nurse I NEED a GLIDESCOPE, that's what the video I watched taught me to do!
 
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Goodness, nobody is saying don’t ask for help from the surgeons, simply that it’s not their responsibility to initiate your training. Nothing wrong with digging into multiple sources of instruction.

You think the surgeons have simulation models lying around for people to practice on? Unlike intubation, first time you actually are able to do it will be when you have to do it yourself in the middle of the night. The demonstrative videos I had watched certainly made that easier for me when I had to do it, as did tips from the surgeons
 
Radetzky said:
Goodness, nobody is saying don’t ask for help from the surgeons, simply that it’s not their responsibility to initiate your training. Nothing wrong with digging into multiple sources of instruction.

You think the surgeons have simulation models lying around for people to practice on? Unlike intubation, first time you actually are able to do it will be when you have to do it yourself in the middle of the night. The demonstrative videos I had watched certainly made that easier for me when I had to do it, as did tips from the surgeons
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How many times have you done it?
 
We've got a chest reopening trolley in the ICU. It gets used infrequently but enough to warrant being uptodate with its content. We do chest re-opening sims once a year with one of the surgeons. I kind of think of it a bit like doing an emergecy surgical airway where we train for it with the hope we never have to do it.

One of the problems we're told is that some of the surgeons have started using fancy sternal closure devices so you can't actually re-open the chest if you wanted to. Also minimally invasive valve surgeries or ones done under thoracotomy obviously don't have a nice mid-line sternotomy wound.

1704104488867.png
 
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KLPM said:
We've got a chest reopening trolley in the ICU. It gets used infrequently but enough to warrant being uptodate with its content. We do chest re-opening sims once a year with one of the surgeons. I kind of think of it a bit like doing an emergecy surgical airway where we train for it with the hope we never have to do it.

One of the problems we're told is that some of the surgeons have started using fancy sternal closure devices so you can't actually re-open the chest if you wanted to. Also minimally invasive valve surgeries or ones done under thoracotomy obviously don't have a nice mid-line sternotomy wound.

View attachment 380309
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I think those pins are supposed to be easier to remove and open quickly than wires. But as you say, there is a wide variety of sternal closure systems nowadays. Some are simple plates without rapid reopening features. Like other orthopedic hardware, they may need a specific proprietary instrument set to remove them.
 
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nimbus said:
I think those pins are supposed to be easier to remove and open quickly than wires. But as you say, there is a wide variety of sternal closure systems nowadays. Some are simple plates without rapid reopening features. Like other orthopedic hardware, they may need a specific proprietary instrument set to remove them.
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Did a bring back once on a patient that had one of these and the tray with the instrument needed to unscrew the plates wasn’t with the standard bring back cart (or something like that), so surgeons standing there scrubbed, starring at these plates with veins popping out of his head while im hanging blood and giving epi. …his patients only ever got wires after that.
 
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Beeftenderloin said:
Did a bring back once on a patient that had one of these and the tray with the instrument needed to unscrew the plates wasn’t with the standard bring back cart (or something like that), so surgeons standing there scrubbed, starring at these plates with veins popping out of his head while im hanging blood and giving epi. …his patients only ever got wires after that.
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Should've called in ortho, they have all sorts of screwdrivers.
 
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drmwvr said:
Glad not to be, nor ever having been in the position of 'having to have a clue' here. That said, and just for argument's sake, with all the stuff in mediastinum, drainage tube(s), pacer wires, Gore-Tex conduit, grafts...why is re-sternotomy even a consideration? Just putting in a rib spreader is enough to end the game right there. If someone is hell bent for leather, a left thoracotomy (a la the trauma bay) would seem to be the far lesser of 2 evils given what there is to lose.
Click to expand...
Most times taking out the wires opens up enough space to get a pulse back if it's tamponade. Rib spreader is extra sauce, but even that is less damaging than pounding a fresh sternum with wires going left and right.
 
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Ronin786 said:
Most times taking out the wires opens up enough space to get a pulse back if it's tamponade. Rib spreader is extra sauce, but even that is less damaging than pounding a fresh sternum with wires going left and right.
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Yeah you really just need probably the bottom 2 wired our cts says then get a suction in there, that relieves most tamponades...
It's literally a 10 second job. If you've watched a few videos.... joke
 
KLPM said:
We've got a chest reopening trolley in the ICU. It gets used infrequently but enough to warrant being uptodate with its content. We do chest re-opening sims once a year with one of the surgeons. I kind of think of it a bit like doing an emergecy surgical airway where we train for it with the hope we never have to do it.

One of the problems we're told is that some of the surgeons have started using fancy sternal closure devices so you can't actually re-open the chest if you wanted to. Also minimally invasive valve surgeries or ones done under thoracotomy obviously don't have a nice mid-line sternotomy wound.

View attachment 380309
Click to expand...

Beeftenderloin said:
Did a bring back once on a patient that had one of these and the tray with the instrument needed to unscrew the plates wasn’t with the standard bring back cart (or something like that), so surgeons standing there scrubbed, starring at these plates with veins popping out of his head while im hanging blood and giving epi. …his patients only ever got wires after that.
Click to expand...
Styker, kls martin, all make them.

SternalPlate

cmf.stryker.com cmf.stryker.com

I've never opened a chest emergently. Nor do I ever want to.

But even I know those plates can be cut down the middle with a plain wire cutter in an emergent situation.

You know how I know?

I ASKED THE CT SURGEON as he was closing the chest with the plates.

Then I said "alright if I need to save this guy's life and you're not here, I'm cutting it down the middle with wire cutters."

"Yeah do that if he's gonna die".

I was joking, but he was serious. I don't plan on ever doing that ever. Yet somehow I have more buyin from my CT surgeon than OP... Without even watching "dummy beginner" YouTube videos.
 
Also with these people that are saying a fresh post op heart is in tamponade and the only way to help is opening the chest:

Do your pts not have chest tubes that drain the blood???

If you know that is the problem, why not just do a needle decompression?

Addendum: The last part about needle decompression is a really stupid thought in my hasty reply. Most of these are clotted off as many have pointed out.
 
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dchz said:
Also with these people that are saying a fresh post op heart is in tamponade and the only way to help is opening the chest:

Do your pts not have chest tubes that drain the blood???

If you know that is the problem, why not just do a needle decompression?
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Because this usually happens when one of the tubes has clotted off and isn’t draining anymore. And in half the bring backs I’ve done they’re pulling giant clots out of the mediastinum, not liquid blood. You aren’t need decompressing that.

dchz said:
Styker, kls martin, all make them.

SternalPlate

cmf.stryker.com cmf.stryker.com

I've never opened a chest emergently. Nor do I ever want to.

But even I know those plates can be cut down the middle with a plain wire cutter in an emergent situation.

You know how I know?

I ASKED THE CT SURGEON as he was closing the chest with the plates.

Then I said "alright if I need to save this guy's life and you're not here, I'm cutting it down the middle with wire cutters."

"Yeah do that if he's gonna die".

I was joking, but he was serious. I don't plan on ever doing that ever. Yet somehow I have more buyin from my CT surgeon than OP... Without even watching "dummy beginner" YouTube videos.
Click to expand...

Some systems are titanium. Those aren’t coming apart with wire cutters.
 
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Fair enough about the drains.

Beeftenderloin said:
Some systems are titanium. Those aren’t coming apart with wire cutters.
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I question whether or not surgeons are actively putting in titanium plates, but it's a fair point to bring up.

I will redirect to the point is that you get in the OR during closure time to see how it's done if you're gonna be the one opening the chest... No "dummy beginner" videos are gonna teach you to open titanium plates.
 
dchz said:
Also with these people that are saying a fresh post op heart is in tamponade and the only way to help is opening the chest:

Do your pts not have chest tubes that drain the blood???

If you know that is the problem, why not just do a needle decompression?
Click to expand...
Wow you're ragging on me for being a dummy...

So many things wrong here...

look brother, I don't need to put my cv up here to ask a question as I've already stated but today isn't my 1st day. Can you please just let this go... opening chest is in the bloody guidelines... I didn't make the guidelines... but I do work under them. It's part of my job to know them. I can't opt out of them just because I don't like them...


Maybe I shouldn't have said I was a dummy beginner in the op, I'm not... I promise... surgeons like me, I do all my own cases... they do well... and I do a lot of cases. Everything bar transplant. And once a year for the last 5 years I'm faced with having to reopen a chest solo... I have asked the CT surgeons all of these questions. I have scrubbed in on my days off and closed chests... please for the love of God. Let this go... let us have some form of discussion on this... leave your assumptions at home. They're wrong as per ct surgeons guidelines...I don't really care if the CT surgeons themselves are wrong...

Now as to your assumptions...
Chest tubes can clot off, causing tamponade... or clot can be localized causing tamponade... not very uncommon.

Needle decompression of the type of congealed blood that causes tamponade is basically useless. Needles might work for serous effusions but if you.ever do get to see a real tamponade you will see how tenacious the blood has become and agree that a needle has almost no role
 
dchz said:
I question whether or not surgeons are actively putting in titanium plates, but it's a fair point to bring up.

I will redirect to the point is that you get in the OR during closure time to see how it's done if you're gonna be the one opening the chest... No "dummy beginner" videos are gonna teach you to open titanium plates.
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Buddy I'm going to have to report you if you keep up this obnoxious behavior. Idk if that means anything to you or anyone else but pls stop...
Go away...
 
PpfSuxTube said:
Maybe I shouldn't have said I was a dummy beginner in the op, I'm not... I promise... surgeons like me, I do all my own cases... they do well... and I do a lot of cases. Everything bar transplant. And once a year for the last 5 years I'm faced with having to reopen a chest solo... I have asked the CT surgeons all of these questions. I have scrubbed in on my days off and closed chests... please for the love of God. Let this go...
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I would have let it go if you would have said this in the OP.

You're asking for nuanced discussion without stating the nuances. What you're asking for in the OP and what you're really wanting to discuss in the quote replies are two completely different topics:

-OP asked for dummy beginner videos to open a fresh chest.
-Your latest replies want to discuss the best way to open the chest after doing the appropriate things to be a very experienced operator in re-opening the chest.

I have given you the benefit of the doubt and asked for clarifications. But your replies have not been respectful.

If you had spent 1/10th of the effort on the snarky replies to simply clarify a few things, the thread would have been way more productive.

I hope your ego will let you see that. My behavior is no more obnoxious than your snarky replies. Feel free to report and let others be the judge.

I will refrain from future replies in all your threads with one last "productive" quote from the initial reply I made in this thread:

"the best way to learn to open the sternal closure is to watch plenty of sternal closures.

Then reverse the things they do in reverse order."
 
dchz said:
I would have let it go if you would have said this in the OP.

You're asking for nuanced discussion without stating the nuances. What you're asking for in the OP and what you're really wanting to discuss in the quote replies are two completely different topics:

-OP asked for dummy beginner videos to open a fresh chest.
-Your latest replies want to discuss the best way to open the chest after doing the appropriate things to be a very experienced operator in re-opening the chest.

I have given you the benefit of the doubt and asked for clarifications. But your replies have not been respectful.

If you had spent 1/10th of the effort on the snarky replies to simply clarify a few things, the thread would have been way more productive.

I hope your ego will let you see that. My behavior is no more obnoxious than your snarky replies. Feel free to report and let others be the judge.

I will refrain from future replies in all your threads with one last "productive" quote from the initial reply I made in this thread:

"the best way to learn to open the sternal closure is to watch plenty of sternal closures.

Then reverse the things they do in reverse order."
Click to expand...
You're way off man, why do you assume my ego is so off the charts? If that was the case wouldn't I be blowing my own horn instead of downplaying the case count I have?

If I have mislead, I apologize, it was not my intention...

I can't come on here and start talking about all the 100s probably over 1000 cardiac cases now I've done? That's crazy. Literally no one would do that... I don't know what you want from me... show me one example of anyone else doing what you ask?
 
I know some of you work in systems that aren’t dysfunctional and have lots of money but My first thought about cutting the plates was christ those cost a lot of money to be snapping with a bolt cutter
 
T-burglar said:
I know some of you work in systems that aren’t dysfunctional and have lots of money but My first thought about cutting the plates was christ those cost a lot of money to be snapping with a bolt cutter
Click to expand...


Just think of all those ICDs being placed in 90 yo’s 6months before they die.
 
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