“Let’s go on Sucker Bypass!”

There are two common denominators that starting a fresh chapter for a new book and going full throttle into an emergency open-heart operation have in common.

In both cases the ending has not yet been written and there are no numbers on the pages just yet. In terms of the actors involved, cursory introductions are loose at best, and clarity is not yet established.

An emergency open-heart operation begins at zero and accelerates to 60 mph pretty much before you can catch your breath, only occasionally slowing down enough to allow a quick view in the rear-view mirror to assure you that your patient is breathing as well.

What you don’t want to see in that rear view mirror?  The T-Rex of doom chasing you down, because we all know that “Objects in the Mirror are Closer than they Appear”.

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You find yourself here in the moment because earlier in your career you made a choice. Everyone in the room made that choice. It’s not a matter of who is picking the short straw.  That short straw is already dedicated to the patient in front of you. It was picked for them, and they had no opportunity to choose in the matter.

Welcome to my life, welcome to this book, and say hello to the flirtatious energy that the process of saving a human life requires from each and every member of the open-heart team.

Time of arrival? Approximately 17 minutes from initiation of the call.

The situation

Never good when the heart surgeon picks you out from the thistle of minions that are now racked, stacked, and packed like curious sardines assembled outside or in the hall and staring through the OR doorway into the heart room.  A room which now resembles a long tunnel with a sliver of light shining at the end of it.  The air is thick as a lot of CO2 is being expelled into an operating environment that is typically kept at 55 degrees Fahrenheit, but due to the sheer numbers of fast gulping plankton, it has now morphed into a steamy jungle. 

It’s a symphony of synchrony as various members within the triad that represent the heart team retain their composure as they confront this house of cards to prevent it from tipping over and allowing fear or insecurity to have their way.

Fear breeds fear

Now- getting back to that heart surgeon…  Your ears are for his voice only and you punctuate what he is telling you as you scan the OR and assess just how critical the situation in front of you is. There is no sign of excessive bleeding, nor is anyone pumping on this patient’s chest, which is good in the sense that at least we haven’t crossed that boundary yet, but very similar to the dark green clouds you see prior to a tornado touching ground.  When you see clouds like that you know what’s coming…

“Be ready to go on sucker bypass immediately!”  Those few words cross over many years of training, and there is no answer required here.  We have the tools in place;  power up the heart-lung machine, zero your transducers, prime your extracorporeal circuit with crystalloid and/or blood- connect your membrane oxygenator to the appropriate heater coolers, make sure your oxygen lines are intact and working, quick look at your vaporizer to make sure your anesthetic gas delivery system has enough Iso or Sevo in it, assess patient size and calculate the heparin dose required to anticoagulate this patient and not kill them due to massive blood clots destroying your circuit, set up a cell saver, calibrate sensors, power up anticoagulation monitoring devices, make sure you have cardioplegia available (that Icey solution we inject into the heart to stop it from beating and keep it from dying) and about 1,000 other things that have to absolutely function seamlessly in order to get this plane off the ground and put this patient on bypass immediately.

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Priming Up

You drop 2,000 cc’s of crystalloid prime into a venous reservoir that will harbor the patients entire circulating blood volume.  A silky smooth process where bubbles are the enemy, it’s gotta be clean and pristine. We chase air out like PacMan eats red blood cells.  This process is smooth, fast, efficient, and in 2 minutes?  You are ready because you have practiced this countless times and yeah… you are that good.

This is not a movie set where you get the luxury of doing take after take until you get it right.  This is one shot.  You can’t undo a mistake at this level or part of the operation.  Because the procedure hasn’t started, and the operation depends on you having your shit together and getting it right the first time.

You are in a zone now, a very cool and necessary place to be as you find order in this explosion of curious and vicarious angst that make us all turn our heads to watch even when we don’t want to see what we know we are going to see.  We become kids shielding our eyes with our hands while keeping our fingers wide apart.

That may seem like a lot to process in the middle of a crowd, but we have already stepped into that “fight or flight” mode where everything around you slows to a crawl and flows like molasses, extraneous voices are filtered and muted, the only things you are in deep connection with are equipment sounds, monitors or alarms, and most importantly?  You listen for the absence of sounds that you should be hearing if everything is working properly. 

It’s what we don’t hear when we should hear- is what grabs our attention the most, and separates seasoned professionals from book readers, students, and amateurs.

You are moving twice as fast as you think you are, as you have subconsciously crossed over to fully automatic mode. 

Time has been folded and you pass through a worm hole where your eyes dilate, your breathing slows down, and your subjective experience has gelled into a moment of clarity. This is the same conditioning that special forces teams rely on when placed in adverse or crisis situations.  As you separate yourself from chaos, muscle memory and repetition overcome fear paralysis and tunnel vision.

Always keep in mind that when people start speaking quickly and loudly it usually means that fear has entered into the equation. Sometimes less is more.

A shower of betadine hits the patient’s chest like a like a firemen’s bucket parade- dousing a fire, surgical drapes are thrown down, lines are passed off and divided, chest or femoral incisions are made, patient is heparinized and when that ACT hits 350 seconds?  We are going on bypass Baybee! 

Faster than we may want to- but we have safety buffers built into everything.  It’s only safe until it’s not.  We are not afraid of flat lines, we make those flat lines.  It’s what we do.

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Pump Strong!

Frank Aprile BBA, LP, CCP

Author:

The Tips of Spears: An Inside Look at Heart Surgery in America

Publication Release Date: Aug 13 2025

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Editor and Founder:

CircuitSurfers.com

TipsOfSpears.com

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