Hairy Situation

[CVSURN]

I thought I would post this here to see what you smart guys/gals thought of the situation.

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. No chest pain or shortness of breath. he walked a 3 mile turkey hunt without difficulty at all. He has been a little fatigued over the past couple months, but that is it. 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.

[athomas91]

CVSURN -

i am sorry to hear about your friend's fathers condition and i hope all ends well...

here are my thoughts which are in no way the absolute right answer - just my opinion

many times surgeons will wait for a time after an MI to allow for any healing that will happen to take place - it is unwise UNLESS life or death to place someone under anesthesia if they are not in their peak condition (which may be how he is now - but they need to give him a chance to improve w/ medications etc...)

i wouldn't push the ptca - he needs a CABG - and waiting for his body to heal as much as possible prior to that will only aid in his ultimate recovery. i would however in a few wks push for the cabg...he seems healthy and active otherwise and would benefit from an increased EF.

again - just my opinion...good luck

[kdst]

I had my mom as a patient in our SICU s/p A/P resection. One night I was in charge and poked her for an ABG. I broke out in a cold sweat and just got someone else to do it. Everytime I walked past the room and saw her sleeping with her mouth open it freaked me out, seeing her on my unit as a patient. I just shouldn't have been working. I know it was hard on my coworkers who took care of her. The worst was when she took a turn for the worse after transferring to the med-surg floor and developed nosocomial pneumonia. They just kept turning up the oxygen as her sats slipped into the high 80's. Thank God the surgeon had given me her home # and I called her at midnight to tell her and she gave me orders over the phone and had the resident come assess and transfer back to the ICU. None of the nurses thought anything was wrong, had not called the dr. and thought I was nuts! Of course I thought they were completely incompetent (didn't hang her 6pm antibiotic til 11pm after a bowel surgery! don't even get me started) and they thought i was one of those "snobby know-it-all ICU nurses that can only take care of 2 patients at a time."

My point is if he can get worked up in a bigger facility where neither of you have to care for him i think it would better for all of you and then i recommend posting someone at his bedside at all times just in case.

[deke]

This is only an opinion. I am an ex-CV nurse, also some ACCU experience and my wife works in the Cath Lab.

The only reason I could see for waiting would be if he was in heart failure and they wanted to resolve that before proceeding. In my opinion, he needs surgery, the sooner the better. The LAD is 100% occluded and it feeds the workhorse of the heart as we all know. That is not a situation that can wait can it? If he has severe multi-vessel disease, that in and of itself rules out a Stent unless you were bridging from the CAth Lab to the OR.

I am sorry for the circumstance, he is awful young to have 15% ejection.

I hope everything works out for you all and soon.

[NCgirl]

If you can wait six months after an MI before revascularization, M&M drops dramatically. That's probably their line of thinking. And from a former CCL nurse, we just don't normally open up chronic 100% occlusions. If they just shut the vessel down, then yes. If you try to open a chronically occluded vessel (meaning this pt's LAD), then the chance of dissection and rupture go up significantly. And if if you do get it open, it'll just quickly reocclude b/c of the collaterals.

I am so sorry to hear about your friend's father, and I hope everything works out for the best. I would from my personal experience absolutely recommend he have surgery at a large facility, with surgeons who like to collaborate on care with other specialties.