9:21 a.m. Safer aneurysm surgery. "Don't move," Tom Naslund, chief of vascular surgery, instructs his elderly patient. "Don't breathe." Naslund fixes his eyes on an X-ray monitor that displays the progress of a flexible tube, or catheter, as it is snaked through a small incision in an artery in the groin to a ballooned-out protrusion in the aorta, the body's largest blood vessel. The balloon is an abdominal aortic aneurysm—a weak spot in the wall where the aorta dives down through the abdomen and forks to supply the legs. If it ruptures, death could occur in hours or even minutes. This patient's aneurysm is just above the divide. Naslund will implant a stent graft above and below the split, a pipe within a pipe that isolates the vulnerable part of the wall. It is made of Gore-Tex, backed by a stiff but flexible mesh. In place, it will look like a pair of pants.
Naslund edges the folded-up first portion up to the aneurysm. Bridget Ostrow, a Memphis surgeon here to hone her technique, observes. "Just let it flower out," Naslund says. He releases the stent, which instantly expands into a one-legged pant and grabs the vessel wall with tiny clawlike hooks. Minutes later, the other leg is similarly installed.
Naslund is an advocate for stent-grafting aneurysms through a catheter rather than opening the abdomen and repairing the weak spot. He says recuperation is less painful, the chance of male sexual dysfunction is lessened, and the operation is less drastic for elderly patients. While stent grafts can shift and sometimes seal imperfectly, allowing blood to leak into the aneurysm, fewer than 50 patients out of more than 700 Naslund has treated since the early 1990s have needed another go-round because of such complications. He places the grafts only in patients who commit to lifelong follow-up, usually involving regular ct scans to see how the devices hold up. (Out-of-town patients can send him their scans on cds.) "It's not a safe situation to have a stent graft and not have follow-up," he says.
12:03 p.m. Bypass insurance. Heart surgeons and cardiac interventionalists, who implant stents and perform other heart repairs through catheters, often compete vigorously for patients and don't always see eye to eye. At many hospitals, they are on different floors or even in different buildings. But in 2005, Vanderbilt created a hybrid or, where surgeons and catheter specialists can work separately or together. Four more are planned. Today, David Zhao is adding a measure of safety to a bypass procedure. Zhao prepares to do a coronary angiogram, an X-ray movie that uses a contrast dye to highlight the coronary arteries. It is usually a diagnostic tool, the "gold standard" that points to surgery or stenting, if major blockages are found. But the woman on the table has just had triple-bypass surgery—her chest is still open. Zhao injects a slug of the dye into each of the three bypass grafts one by one and watches on a screen as it quickly highlights the interior of the vessel. Vanderbilt may be the first hospital to use angiography after a bypass to see if a vein graft is kinked or twisted (it happens about 12 percent of the time, says cardiac surgery chief John Byrne). "It proves we did what we came to do," says Byrne, who championed the follow-up.
1:13 p.m. Undrugging patients. ICU nurse Jessica Robertson gently awakens a 55-year-old woman with a breathing tube in her throat and asks her to make eye contact to judge her brain function and depth of sedation. Her patient cannot speak, so Robertson asks simple yes-or-no questions ("Will a stone float on water?") and spells out words, instructing the woman to squeeze her hand only when she hears an "a." Some common ICU sedatives used to calm ventilated patients have been linked by critical-care specialist Wes Ely to longer stays, higher death rates, greater cost, and a likelihood of long-lasting dementialike symptoms, so the goal is to minimize medication and remove the breathing tube as soon as possible. This January, the Lancet published "Wake Up and Breathe," a program devised by Ely and others for weaning patients from ventilators. Patients are periodically roused, and their IV sedative is shut off. If they show pain, respiratory distress, or anxiety, they're restarted—at half the original dose. "You systematically build drug reduction in," says Ely. If a patient can go without drugs for four hours, the ventilator is switched off. The tube stays in and is removed if the patient can then breathe on her own for two hours. The Lancet paper researchers found that compared with standard treatment—turning off the ventilator each morning to see if a patient can do without it for two hours—the "wake up and breathe" patients had four fewer ICU days, three fewer ventilator days, and four fewer days in the hospital, and 56 vs. 42 percent were alive after a year.
