Hairy Situation

  1. Hello,

    I am a CVSU RN in a small hospital with about 11 beds in our unit. We have two heart surgeons who pretty much do it all, including the pulmonary, GI, and renal stuff. Very rarely do they like to consult another doctor.

    I have an RN friend who works on the unit with me, and her 50 year old father just found out he had a heart attack, and his ejection fraction is only 15%. He has had no symptoms at all. He quit smoking two weeks before he found out. He was chewing on a nicorette gum one day, and passed out. He had the workup, echo, cath, etc. Her father has severe multi vessel disease, with a 100% occlusion of his LAD, and 3 separate 80-90% occlusions of his RCA. He had good collaterals off of his RCA which is probably why he is still alive. They refused to to PTCA on him, and they've refused to operate on him for now. They want to treat him medically, and then MIGHT operate on him in a few weeks when his heart is stronger. Again I reiterate he has had no symptoms. He does have a few risk factors:smoker, hi cholesterol, familial history. He's a great man.

    Just wondering if anyone had any new ideas on what can be done for him besides an operation? Should we take a chance and have someone PTCA that LAD?

    On our unit, as I said the surgeons do it all. It is a small hospital. We don't use an intensivist for any of the medical care. the surgeons do it. They're always reluctant to consult another doctor. Sometimes it has devastating results. Should her father go to another facility for an operation if needed?
    Anybody feel indifferent about having heart surgery at a smaller facility? Also we both work there, and it would be extremely difficult for either one of us to take care of him. This is a whole other situation. How would you feel about taking care of a very critically ill father of a friend and co-worker? Personally I don't want to do it, but I feel i may have to.

    My friend is also angry at her father for treating himself badly all these years because now he may die and leave them alone. She just doesn't know how to express that anger. What would you tell her?

    Thank you in advance. I just wanted to get the advice of some other nurses out there. I am new to the board. Thanks a lot.

    CVSU RN
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  2. 13 Comments

  3. by   Noney
    What exactly is the reason they are giving him to hold off on surgery? Has he thought about a second opinion?

    "On our unit, as I said the surgeons do it all. It is a small hospital. We don't use an intensivist for any of the medical care. the surgeons do it. They're always reluctant to consult another doctor. Sometimes it has devastating results."


    I have little respect for mds that don't know when they're in over their head.


    The anger you friend is feeling is normal. Give her some time. I would feel uncomfortable taking care of someone I knew well, and what ask for a different assignment if possible.


    Noney
  4. by   jemb
    Is there some reason that he will not get a second opinion elsewhere?

    I wonder if he actually is asymptomatic, or instead denying symptoms. It's just a bit coincidental that he quit smoking so recently.
  5. by   rjflyn
    You dont say where this hospital is located. I would recommend that he seek a second opinion with a cardiologist at a major teaching hopital. He apparently at 50 has very good collateral circulation because a 100% blockage in the LAD is significant and would kill alot of 50 yr old pts.

    With a 15% EF he definately has lost alot of function. He with the collateral circulation is just surviving and is really no way to live, meaning he probably get tired use doing simple ADL's. My experence in following pts we transferred in to out hospital a couple years ago we had like pts that definately benifited from having said blockages cathed- one group of doctors were doing a study- on total coronary artery occlusions, also these 2 doctors would on ocasion balloon and stent left mains that were partially blocked as the pts would prob not survive CABG and would prob totally occlude with in a short time.

    Rj
  6. by   mattsmom81
    Mention to your friend and her father that second opinions are often sought by other patients of yours in these circumstances. While it can be touchy to do this, I have also mentioned there are bigger facilities with more resources in the area, should they wish to consider this. I figure its my job to offer choices and I take my cues from the patient/family. I have been known to plant a seed if appropriate. But I do it carefully.
  7. by   sharann
    I would go with the above advice of Mattsmom. Tell her that pts frequently seek second opinions. With an EF of 15% I can't see him living much longer with any sort of quality. Surgery(CABG or MIDCAB)may be the way. I also recommend a larger teaching hospital, they tend to be cutting edge.Good luck to your friend.
  8. by   moia
    As a CV nurse too I can emphathize with looking after someone we know...very tricky but can be done if planned for.
    With the EF of 15% I just can't believe he is not having symptoms...I think the problem is he has been having symptoms for so long he no longer recognizes them and has adapted his life around them.
    He needs an objective assessment..meaning he needs to have a stress test and he needs someone to follow him for a day and see where his limitations are...family may not even be aware that he sleeps sitting up in a reclining chair..delays showers eats poorly or is easily tired because he has probably become quite proficient at hiding these changes.
    Once it is revealed that he is leading a restricted life he may be much more agressive about pursuing treatment.
    I do not know if your friend was present during the docs appt's , it wouldn't surprise me if he went alone and downplayed much of his situaton to the doctors.
    Doctors do take cues from the patient..this delay in surgery and option for medication therapy may be his choice.
    He definitely could benefit from some bypass or stenting in a cutting edge teaching hospital...medication stenting has become all the rage lately...it may be something to look into and he may be more amneable to this than a big open heart surgery.

    Some patients really need a third party who is completely objective to show them how changed their life has become , once they see clearly how they have restricted themselves they begin to see their disease process more clearly and then they become much more open to treatment.
  9. by   lisaloulou
    He should also consider being evaluated for heart transplant.
  10. by   RNPATL
    I can't offer any more than has been offered here, except to agree that he needs another opinion. A major teaching hospital with a focus on cardiothoracic care would be good. As far as his EF at 15% .... I agree with the others that he must have adapted to his fatigue levels and inability to carry out regular tasks. At 50 years old, I am surprised that he has the collarterals to survive. A second opinion is certainly in order here .... but he may be such a high surgical risk that no one will want to touch him at this point.
  11. by   Pete495
    I'm sorry for your friend's father. You should definitely consider a second opinion at a hospital that does a lot of heart work. Try the cleveland clinic, or similar hospital near by. There are many options not well known in the texts I'm sure. And someone probably would take a chance on that LAD
    Last edit by Pete495 on May 15, '04
  12. by   CVSURN
    No, He has no symptoms at all, trust me. I have been around him for a decent amount of time, especially since this happened. He has felt a little fatigued over the last couple of months, but everyone knows fatigue can be anything. What upset my friend so much about it is that he has never had any symptoms,or any of the telling signs that he was having heart trouble. No Chest pain, no edema, no abn. wt. gain. And now, he is suddenly on the edge of dying. It's not easy. Hell, the day before he passed out, he walked a 3 mile hike turkey hunting without any chest pain or shortness of breath. I do not believe he is denying symptoms at all. He is a truthful person, and sort of a worrier too.

    I've agreed with the idea of seeing another heart doc. at a cutting edge facility, and I believe someone might take the chance to PTCA that LAD with his low EF. My theory is to put in an IABP, and then do a PTCA, and if the PTCA goes awry, take him to the OR(what choice would u have really). I'm not sure he would make it through heart surgery, but I don't see many other options. I've also thought about a MIDCABG. The reason to wait is to do a stress test in about 3-4 weeks, and see if his heart is viable enough to undergo CABG. So they're treating him medically for awhile, hoping his heart will get stronger, and they will probably do surgery on him. The surgeon here even said he will have a rough time post-operatively. Personally, I think it will be less rough at a bigger place, where they can get to him quicker if something happens. My friend really likes the surgeon here because she has a personal relationship with him, and the nursing staff also. I feel the opposite sort of whereas I think other factors could hinder the care he is going to get. I believe if a complication arose he would be attended to quicker, and I also think he might get better medical care elsewhere. I just don't know how to convince her of that fact. Any ideas? I've told her about getting a second opinion, and then deciding on what to do, but I don't think she wants to put her father through that.

    Thanks all for your words.

    CVSU RN
  13. by   TracyB,RN
    "They're always reluctant to consult another doctor. Sometimes it has devastating results. Should her father go to another facility for an operation if needed?"

    I think that you answered your own question. Push for the second opinion & pronto.

    Does Dad realize the severity of his condition?? If the above docs are reluctant to get consults, makes me wonder how honest they were presenting him with his options for treatment.
  14. by   chaosRN
    With a 100% occluded LAD & with his RCA partially occluded, does he have 3-4 weeks to wait? A 50yo is too young too have so much collateral circulation that it bypasses the LAD. I agree with the others, you may want too seek another opinion. I was also thinking about the IABP too. He could stay on the IABP 1-2 days, do an ECHO to see if the heart is stronger with it, PTCA & possibly CABG.
    I wish you, your friend & her father all the best with this & pray for a quick recovery. Let us know how it goes!

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