Rounds

Rounds happen every morning. During rounds the attending, fellow and various residents come to the bedside of each patient. The respiratory therapist is also there. The on-call fellow gives a presentation of the case and suggests a plan for the day.

In a scene reminiscent of Gray's Anatomy, the Attending gives comments and ask questions of the junior staff and confers with any surgeons or cardiology staff on rounds. Sometimes, s/he points out diagnostic or management issues to the residents and they ask questions. Finally, the plan is set and the group moves off while the details are sorted out with the nurse.

Our nurse during the day is Amy which is a good omen because we loved Nurse Amy in Seattle.

I find rounds very interesting. During rounds the doctors discuss aspects of the case that they do not mention to parents. Typically, I am told the basic plan for the day and that he is doing "well" or that there is something of concern. With rounds, the underlying issues are discussed with the reasons for the numbers we see on the many monitors by the bed.

It is also interesting to see how many facts the younger doctors get wrong when presenting the case. Eg, below: Wren didn't really have just a membrane, when he came in post-op they said he had a RV resection and I heard that he had his aortic stenosis ballooned post-operatively (it was at 6 weeks of age). These were not problems in his care but its odd and the pedant in me wants to correct them.

Some Information from Morning Rounds 11/8
------- ONLY FOR HEART PARENTS AND THOSE INTERESTED IN MEDICAL HOO HA---------------
[Throughout this discussion, I found it informative that the focus was on the mitral valve sufficiency. So far, Wren's mitral valve has been beeping on and off the radar. Before birth, it looked ok. Around 1 year, it was "abnormal" but functioning well. After the latest cath it was "possibly a problem needing surgery". Pre-op it was deemed okay. During surgery the subaortic membrane/tissue was "peeled off the mitral valve where it was attached" and now the LAPs are a worry and there is discussion of mitral stenosis. This is a big deal for Shone's patients due to the complexity of mitral valve replacement and repair and the added difficulty of inflow and outflow tract repairs]

The fellow gave a presentation about Wren:
"Wren is a 22 month old with Shones Complex presenting with mitral valve stenosis and aortic valve stenosis. He has a subaortic membrane, a super-mitral membrane but a normal gradient across the mitral valve. From cath we saw no recurrent coarctation but AV narrowing. From Eco we see a bicuspid AV with super valvar AS and a fibro-muscular ridge. From MRI pre-operatively we saw a peak flow of 115 across the AV and 53 mm post operatively.

During surgery he had a fibro-muscular ridge resection, super valvar patch and some opening of the valve but the AV remains restricted.

He has chronic mitral stenosis with LA pressures aruond 22-25 post-op. They were 18-20 overnight and now 11-18. "

The nurse then hands the chart to one of the doctors who reads out the numbers:

LAP (left arm pressure): 11-17
HR (Heart rate): 136-160
BP (blood pressure): Low 88/44 H: 138/70 Average: 100/50
Saturation (sats): 98-100
Gases very good.

According to the attending he is having "a very nice recovery: and "everything looks good". He had no issues intra-operatively. Post-operatively he had ?? left coronary artery insufficiency. His EKG looked better.

Then the attending gives the final words and plan for the day. The plan for the day is to attempt intubation when he wakes up. Stop the drips of fentanyl and provide morphine and versed and let him wake up a bit more. Diurese him - he is to get lasix because his urine output has gone down a bit overnight but he is only a little fluid positive and not puffy. Overall it is "a good repair", X-ray good, gases good, NG tube can come out.

Another hypoplast
At this point another fellow walks in looking a bit disheveled. Someone asks him if he has seen his pager. He looks embarrassed and gropes around his scrubs: " I fell asleep and when I woke up I thought 'shit, where is my pager?" He pulls up his scrubs.
"You mean SHOOT, where is my pager!" adds someone else looking meaningfully at me.
The NP adds "A new hypoplast was transferred in"
"Oh good!"
"That was the only page. I'm glad I didn't let them wake you."

How long will this take?
Josh wanted to know, so I asked Amy how long she expects Wren to be in the CVICU and Ward if there are no complications. She says that it depends on keeping the LAPs constant. They don't mind them being on the higher side but they hope to see stable numbers not shooting up when Wren is agitated or moves as is the case at the moment.

If there are no complications he could be out of the CVICU in 3-4 days and discharged in a week. This seems very soon to me. Personally, I have read and heard so many things that can happen post-op, I just take things day by day. BUT we need to decide if and when Granny and Frost come down to join us and this gives us an idea.