*bleep* holder – First Anaesthetic on-Call

So I have just come back from my first call as an anaesthetic doctor (or more specifically, an emergency medicine trainee rotating in anaesthetics who is holding the dreaded anaesthetic bleep very much reminiscent of a hand held grenade with the pin taken out. It may go off any second, heralding news which may be good or bad, usually bad).

So, I started the day taking a handover from my colleague who was the previous bleep holder. Or, I should rephrase that and tell you what actually happened. I waited for them to turn up to the operating theater for emergencies, and when they didn’t turn up after 20 minutes, I bleeped them. I found out they were in the middle of trying to help out a consultant with a dodgy arterial line for an elderly patient (who apparently at 92 had everything under the sun going wrong with her, and having managed to break her femur, was getting it surgically corrected), they rushed to meet me, handed me the bleep and a quick handover of the patients on the list (none!) and 2 patients that might require some analgesia maintenance sorting out later, and headed out the door. My first port of call was the consultant currently in the trauma theater dealing with the dodgy 92 year old. Old lady with CCF, AF on warfarin, small bilateral pleural effusions, past history of CVA (just last year) and a CABG 9 years back. She currently was using a frame to walk, and had tripped over an overturned edge of her carpet and ended up (long story short) on the operating table that evening. Anyway, the procedure went swimmingly, and she landed in recovery wihout any significant problems. My presence, though not directly helpful to the case, was atleast helpful in the sense that my consultant was able to grab a quick meal and some semblance of a hot beverage, and she mentioned she appreciated the chance to talk to someone. So far, so good, the call was going.

I was then bleeped about a potential appendix that was rumoured to have surfaced in A&E and the surgeons were contemplating taking it out. Young male, fit and well I was told. I took the opportunity to go round and see the patient myself, but as I was walking out of the recovery room, Cardiac arrest bleep goes off. In the heart centre (yes, ironic, isn’t it? I couldn’t make this up if I tried!) Apparently just a vasovagal syncopal episode though, as I ran down to the heart centre I saw the ITU registrar motioning me to relax as he seemed to have it under control.

Phew! On to the appendix…but first…ANOTHER CARDIAC ARREST BLEEP! Where is it? Second floor you say, oh the ward FURTHEST FROM WHERE I AM CURRENTLY STANDING? THANKS! I run to said ward, find CPR in full action on a what I understand is a 70 something year old gentleman found unresponsive on the ward (it is an orthopedic ward) and the rest of the history is a little late in coming, so CPR is in full progress, the ITU Reg enters almost at the same time as I do, he asks me if I have control of the airway, I reply in the negative as I am finding it difficult to bag mask ventilate. He chucks an I-gel towards me, which I insert successfully and ventilation is now adequate, as evidenced by the now rising saturations. CPR still ongoing, and there is now return of spontaneous circulation. He is intubated in the interim and post-resuscitative conversations/management are taking place (all this happens within the first 90 seconds of our arrival!) and someone then pipes up with the history (finally) that this patient is a known epileptic, admitted with multiple c-spine and other fractures, s/p corrective surgery for the spinal fractures 5 days back, was last seen alright 3-4 hours prior to being discovered unresponsive/in cardiopulmonary arrest. Based on the absence of pupillary reflexes, absence of any respiratory effort on the patient’s part, and cardiac function likely in response to the drugs given by us during the CPR, as well as the pre-morbid situation of the patient, it was the collective decision of the whole team involved to withdraw treatment. This was also agreed upon by the ITU consultant who we telephoned to ask for advice. The ITU reg offered to write up the notes as I took the tube out, and I went to see the appendix.

Very straightforward appendix – never had any anaesthetic, no family history of anaesthetic complications, last eaten/drunk something 11 hours back and that too vomitted up. Allergic to penicillin, otherwise fit and well young male with a slight language barrier, through which I discerned straightaway that he wasn’t happy about the surgery. He did not wish to proceed with the surgery for now. I stepped out of the room and let the surgical resident handle the situation. They would let me know if he still wanted the surgery. For now I would keep him on our list with an almost question mark. The staff in theaters would know what that code meant!

Bleeped again, this time from A&E RE an elderly female, Hmeatemesis with massive hemorrhage protocol in place, could we rush them into theaters for an urgent endoscopy +/- surgery? Her HB had dropped from a last known reading of 125 a few months prior to 49 on today’s blood gas. She already had a couple of IV lines secure, and the ED team had been excellent in pushing fluids, arranging blood and 2 units PRBC had already been given to her as well as 4 units of FFPs. I quickly pre-op assessed her, gave my consultant a quick phone call: he was happy to drive in (20 mins away) and assured me he would be ready and waiting by the time we got to the theaters. We did, and he was there, and it was an RSI, 4 more units of blood went into her, her last Hb was 98 and they found the bleeding point and treated it endoscopically, there was no need to open. Out into recovery where the ITU consultant also eyeballed her quickly, deemed to have no need for ITU support at that time and then moved to the ward after stable. He did ask me to give her the rest of the blood/FFPs booked for her, and afterwards send off clotting and FBC profile whenever transfusions over. Crisis averted (this took 2.5 minutes to write and around 2.5 hours to manage from start to finish, in which time I was bleeped 4 more times!)

One of those bleeps was from the surgical reg – appendix guy was agreeable and we would proceed for the surgery next. The consultant offered to do the RSI for this next one as well, I drew up the drugs for the case, and left to deal with the 2 pain patients from the handover (which seemed such a long time ago now!) and also deal with the 4 other bleeps that I had while we were dealing with PR bleed lady. 2 were urology cases apparently cystoscopies needed to be done for 2 elderly males, both with long term urinary catheters in place but unable to be taken out as the ballons werent deflating – eerily similar weird cases that were as much of an embarassment for the urology registrar as they were a hassle for the rest of the theater staff. Also while dealing with the bleeding lady, another consultant who was running the trauma list and who is now going home after his procedure has ended hands over 2 of his patients who are in recovery “shouldn’t be a problem but if there is just so you know about them” and walked out. I quickly scribble down their details so they don’t fall out of the back of my mind.

During my assessments of those 2 cystoscopies I got bleeped to remind me to do the bloods for the previous lady. I added it to my growing list of things to do.

I get called back to the theater because one of the other post-op patients in recovery (that the trauma consultant handed over) was being a bit…ummm…difficult. I quickly go see them. One of the other consultants prescribes some haloperidol. He is an elderly gentleman who has had a hip DHS, no prior known comorbids but slight cognitive impairment previously. But nothing as dramatic as how aggressive he was being right now. he was trying to get out of bed, he accused me of stealing his clothes and he accused the blushing nurse of having an affair with his wife, and he had quite a few choice words for how we were treating him. The halloperidol seemed to not do anything at all. It took all of our combined efforts (and a little bit of his analgesia) to calm him down and he went off into a deeply snoring snooze. Sigh. Phew.

9th bleep (or is it the 11th?) Urology registrar (sounding to be at the end of her thether, bless her) calling to tell me the first urology case cancelled as they were able to remove the catheter successfully, but the second case (similar) added to list, yet the consultant urologist was coming in to try to deal with it – should he fail, this was to be done cystoscopically so could we please keep the patient on our emergency list.

Another bleep – another story. A new bleeding patient, this time an esophagael variceal rupture potentially? Has not been booked on to the list but this is the theater staff calling to tell me there is a potential case – and to await further instructions. I swear I stared at the reciever of the phone to register my incredulity. At the end of the conversation I still wasn’t sure if there was or wasn’t a patient with a bleeding/hematemesis situation that needed to be urgently anaesthetized for their procedure. *DEEP BREATHS*

Another lap. appendix. Another x2 bleeps from pain relief point of view: something about a rectus sheath catheter that had dislodged, and another about someone who’s pain wasn’t being controlled despite adequate analgesia (problem was solved by a simple look at the drug chart which informed me that they WEREN’T in fact adequately analgesed!). 3 bleeps from various wards about cannulation difficulties. And finally, the last bleep of the day:

“Oh Hi there, it’s XYZ, coming to take handover – whereabouts are you?” I could have screamed in relief, but I managed to restrain myself till she got to the office where I handed over my bits and pieces. She was more senior than me, and asked how my first on call went, and then looked a more thorough look at me and said, “you know what? I know exactly how it must have gone – go home and get some rest. See you tomorrow!” Uncanny how she could discern from my expression and my hair and the overall dishevelled look and the stains on my OR shoes exactly how my first on call shift as an anaesthetic SHO went.

Just as I was stepping out of the office, I heard the bleep go off. And I was reminded of my own favourite pearl of wisdom: There is nothing worse than the sound of a bleep going off. And there is nothing better than realizing that it is someone else’s bleep that has gone off. I was smiling as I exited the office, and the hospital.

Transfer Training

Attended a Transfer Training course today. I know what you’re thinking, who needs training to learn how to transfer a patient? What rocket science is involved in the few seconds or minutes to transfer someone from one bed to another? Or how much of preparation and thought needs to go into transferring a patient from one hospital to another? It has to be fairly simple right? Atleast thats what I was thinking when I was applying for the course, I thought it’s going to be like a 30 minute session, Bam Bam, thanK you, Ma’am type situation. Boy was I wrong – this was an 8 hour long proceedings, and I actually learnt quite a bit. Some gems from today’s talks:

Movement effects
Movement of any sort brings with it it’s own demerits. So only move the patient if absolutely necessary. Deceleration causes gastric contents to come up; it also may cause fluid to ‘back up into the lungs’.
Acceleration causes the opposite: hypotension, decreased preload. Both may lead to heart failure

Limit affects of any sort by making sure patient is well hydrated; lift the legs up to counter hypotension(during acceleration)

Head end up (15-30 degrees), NG (during deceleration)

Consider if you need Blue light? Is it time critical? Make sure to limit sudden movements, blue light ambulances are notorious for getting into accidents (large vehicles, moving at high speeds, sometimes against traffic and/or against traffic rules)

Specially important is the need to be careful in head and spinal injury patients
Contrary to popular belief and your gut feeling, the more critical the patient, the slower the transfer needs to be. Not faster. Fast, hasty movements make for bad decisions, wrong or sharp turns (as well as deleterious effects of movements already discussed)

Static effects
Hypothermia is the most common problem
What is the first thing that happens when patients are brought in to ED? Their clothes get taken off. Coupled with cold environment, not a good combo
Children/eldery most vulnerable
Monitor patient during the transfer as well for temperature changes; aim for normothermia
HME filter is one way to counter drop in temperatures – ventilator usually gives cold, not-too-moist air going directly into the lungs, bypassing the moistening and humidifying warmth of the sinus cavities; connecting an HME filter to the ventilator circuit effectively prevents the dry cold air going in, and thereby prevents hypothermia.
Blankets and foil may be used, especially in ambulances
Pre warmed fluids may be considered
Cover open wounds/burns (cling film is best as wound is still visible for any changes, is sterile essentially and can be airtight)

Avoid vibration injury/movememt in ambulance/helicopters
Pad and protect soft tissues to avoid pressure sores, and reduce fractures where possible. Ulnar nerve is most commonly injured during transfer – bean bag padding is ideal for such transfers.
Interference can be caused with electronic monitoring by the unnecessary vibration.movement aberrations from helicopters and ambulances; dislodged/trapped leads may also be a concern.

Motion sickness may develop – stop feeding the potential transfer patient. A couple of hours of NBM won’t kill the patient, but aspirating their own vomit, or vomiting when their neck is immobilised can be quite a significant clinical concern. Consider NG (with free drainage) and sitting upright. Avoid rear-facing seats for transferring teams. Do not read/documentation, as can make things worse. Be prepared. Take antiemetics.

Communication
Sirens/alarms make communication difficult. Make sure you can always hear alarms. And, we all are guilty of doing this, but NEVER ignore alarms.

Immobilisation
Need to ensure patient can undergo immobilisation. Make sure patient can actually physically lie flat for CT scans, etc (e.g. may get short of breath if massively obese or really bad CHF)
Consider sedation (and airway protective measures) if absolutely necessary to scan and lie flat.
Make sure you have everything you need before you leave. And before you need it. Always be prepared for every eventuality, every foreseeable complication.

Lying supine can also have other deletrious effects on even patient who can lie flat – secretions can accumulate, reflux might be an issue, V/Q mismatch occurs, inability to cough when lying flat, strapping someone down for a scan may itself cause restriction of lung movements in an otherwise comfortable-in-lying-flat patient.

NOBODY GETS BETTER DURING A TRANSFER! They may get worse, so only transfer if absolutely imperative.

Special considerations?
Trauma
general information about the Trauma network
ED pitstops – their pitfalls

Head/spinal injuries – RTC, falls, sports, assaults, self harm (gunshots), and non-traumatic
Motor aspect of GCS is more important than anything else in the GCS
Immobilise with correctly fitted collars
Aim for Normal pO2
Normal pCO2 is now the new teaching, as low PCO2 (which was previously the guidelines) causes cerebral vasoconstriction, reducing blood flow, and ischemia is a far worse complication than brain swelling, atleast in the initial phase of the post-injury timeframe.
aim for a MAP of 90 (this is ideal for cerebral perfusion pressures to be optimum)
Normoglycemia
Normothermia
Head up, minimize movements
Urgent Neurosurgical care
Maintain parameters at all times, even if the transfer is for short periods
Monitor pupil size, GCS, Heart rate/rhythm strip, blood pressure, pCO2, resp rate during transfer
Immobilisation and transfer methods were also touched upon, various methods to transfer patients, scoops, trolleys, mattresses, sliding sheets, boards etc
Consider Spinal shock if triad of hypotension+poikilothermia+bradycardia
Avoid fluiding with large volumes if unresponsive to fluids, consider escalating to vasopressors.
Will improve on own if spinal shock
Autonomic dysreflexia – injury above T6 (headache, flushing/sweating above level of injury, urinary retention)

Paeds

Rarely transferred. Only ever in cases of trauma/head injury
CATS
WETFLAG
Broselow tape bag
Vecuronium/pancuronium, fentanyl, ketamine (children) combo in children safe.effective cocktail

Balloon pumps- weigh 70 kg, slows movement, runs off battery

 

Anaesthetics – what I have learnt so far…

  • your ODP is your best friend and most of the time your saviour – treat them right.
  • there are literally a hundred ways to skin a cat. And more to come up with a plan for anaesthetic for any given patient. All are right and some may be wrong – try to sift though and pick and choose and delete and save – and come up with your own brand of magic
  • always be on time for a theater list – or 30-45 minutes early! Pre-op assessments are part of your learning and an integral part of why we do what we do when we give a patient a particular anaesthetic.
  • make sure you attend most if not all teaching/training days arranged by the deanery – they’re VERY particular about attendance
  • know your doses – sux, roc, propofol, local anaesthetics, etc. You may be called upon at the most surprising of moments to decide a drug amount (for example the surgeon may yell out during the procedure how much local anaesthetic he can infiltrate in his rectus sheath block and you may need to do your maths to give them the answer. Bring your A-game)
  • get ready to be surprised at how chilled and laid-back everyone and everything is. When I first entered the department I expected everyone to be on their toes, pumped full of adrenaline, dancing around critical patients who were losing their airways and fighting fires along the way – while this is essentially what happens, things aren’t quite as dramatic
  • get ready for a VERY steep earning curve. Very steep. Very. With a capital S (for steep)
  • There are 4 times more consultants in anaesthetics than emergency medicine. Even more than that. 6 weeks into my anaesthetics rotation and I still haven’t worked with or met all of them. And only 4 times have I worked with someone I have worked with already.
  • Anaesthetics is not about intubating everyone. In my first month, I had observed 58 surgical procedures – only 7 of which were intubated. The rest were mostly LMAs/iGels.
  • The best talent to have/learn is not how to intubate; How to ventilate, bag-mask is more important.
  • You will really get good at cannulation. All sorts of difficult, easy, wriggly, invisible, stubborn veins – you will put a cannula in to all sorts. And then some.
  • Will continue to update these as the time comes. Feel free to watch this space.

Interesting Observations on a mock OSCE Teaching Day

Hi all – so a few days back I had the unique opportunity to organize (OK who am I kidding? I helped to organise) a 1-day course for the FRCA OSCE exam in our deanery. We as the juniors of the department of anaesthetics/ITU/Theaters were called upon to help with various tasks: timekeeper for the different stations, be a patient for history taking, or be one of the relatives for counselling, be a mannequin for examinations, etc. I had a multitude of nominal tasks on the day, but what I found to be invaluable to me that day were a few observations that I made observing the various candidates as they filed through the different stations, and I list those observations here in no particular order to be taken as advice for all my colleagues who have OSCEs to take, bear these in mind:

– Be cognisant of time. As you walk up to the OSCE station, whether it gives you 30 seconds to read through an initial scenario or there is a piece of paper with questions written on it that you are expect to answer, get into the mental zone where you can mould yourself to give what is required of that particular station in the time provided. If there is one question that needs to be answered, you can be a bit relaxed, if there are 3 questions on the paper, make sure you are aware of the time you have to divide amongst them all to do justice to all. If the station requires an interaction with someone like a viva or a direct encounter, make sure you have a framework in mind, a mental checklist to check things off during the actual station so that you are not rambling on about your second point when there are 7 other things you need to be talking about.

–  When asked a question, don’t feel pressured to answer as soon as you sit down – take a breath, pause, ponder over the question for a few seconds, frame your answer for the next few, and then open your mouth to speak. Do not repeat the question back to the examiner in wonderment, as if puzzling it over, you may think you are buying time while you collect your thoughts, but it looks unprofessional. If you need time to answer, take it, but do not insult the examiners’ intelligence by repeating the question back word for word. It is a waste of time.

– When asked a question, avoid using pronouns like ‘you’ as a general term. “If you are on the floor for a long time, your creatinine kinase levels may rise.” While correct, it looks like you are addressing the examiner, whereas a more professional way to answer would be “Patients lying on the floor for extended periods of time may have elevated levels of creatinine kinase.”

– Following on from the previous point – when describing the anatomical location of anything, or a function, it is OK to use your hands to express yourself, but do not gesture towards your own body as a descriptor for your answer. In answer to the question Where can an IO needle be inserted? you may think it is the right answer to point to your sternum, your humerus or your tibial tuberosity, but it won’t score you any points. Also please practise certain expressions or gestures, gesturing towards your crotch for instance when talking about urinary catheterisation is inappropriate. And for goodness sake, it is even worse to point these things out on the examiners body.

– Use proper terminology, use buzzwords if you know them (we all know them) and specific things carry specific marks so make sure you attend some sort of course at least once in your life for OSCE practise so that you know what the examiner is looking for in a particular station when they ask you a particular question. Also, examiners know when you are beating about the bush and not getting to the point – so don’t waste their time (and yours), admit you do not know, and move on.

– Having done poorly in a previous station has no bearing on how you can or should perform in the next one – so do not let anything bother you. Yes, you may well have failed the previous station, but if you continue to mull over it or let it get to you, you may ruin your chances of passing the next one as well. Once you step out of one station, close that chapter, and open the next one with a clean slate.

–  Do not try to impress with big words and fancy terms – be simple, logical and just answer to the best of your knowledge. They are there to test your knowledge and see how good you are with using that knowledge. They are not there to ask for your hand in marriage.

–  If there is a written station, please write clearly. In our current professional examination climate, where usually there is a tick box or a fill-in-the-correct-circle type answer sheets, we forget how to answer the short answer type questions. Make sure it is legible. Your right answer is useless if no one can decipher it.

–  Read up on the simple things (in case of our anaesthetics colleagues, anatomy and physiology, undoubtedly – aside from the usual physics etc) – understand the concept behind why something is done or not done, and it will make it easier for you in these exams.

–  Study. I don’t know why it is so under-rated, that OSCE exams are interaction based and so I just don’t need to read up on how to take a history or do a pre-op assessment or perform a physical examination or test the cranial nerves – we do it everyday, and we get into a comfortable zone – but the exam might need for us to brush up on those skills and make sure we are not missing out on anything. MOST candidates missed an important part of the history taking station, as well as the counselling station – points were docked, valuable points, and for some that can mean the difference between passing and failing.

The Day of the Beating Heart Donor

24/08/17

I observed an eye-opening and mind-boggling event today – something I had heard of a thousand times before, and I knew was commonplace and such a great, great gift to give to someone – yet you never think things through and the details and the minutiae and the step-wise journey that gets you to a certain result sometimes just doesn’t register till you are actually on the other side of the coin. Today I observed an anaesthetist keep a clinically braindead patient comfortable on his journey to giving the greatest gift to a multitude of individuals – through his organs that he donated, the gift of life. I am still reeling, and literally have no words to express how chaotic and inexplicably sad I felt on the inside, and what the whole process entailed and how I came to realise and came to terms with what I bore witness to today – I will surely like to revisit this topic at a later point for a much-needed debrief. But not today. I just felt like I had to share something about this day, and I will. But not today.

RIP.

26/08/17

OK – so here I am, it is the following weekend – and I finally have enough time to do justice to this post
the day began with a pain clinic round – for those of you just joining us, I am now in a anaesthetics placement currently, and aside from all the wonderful cases we are meant to preside over anaesthetics-wise in theatres during various surgeries, we are also required to oversee patients in acute painful crises of any sort, and make a pertinent plan for adequate analgesia, whether it be a PCA pump or varying doses of different drug regimens. It was a cheerful day – not because we saw patients in pain, but because we saw the aftermath of what adequate analgesia does – happy, comfortable, asleep patients – patients with broken vertebrae from falling off horses and post surgery patients and patients with chronic pain issues who had become acutely unwell – all were magically comfortable with the various cocktails measured out to them in various dispensers (epidurals, blocks, PCAs, oral/iv/subcut/intramusc meds) – and to top it off, my consultant was a particularly cheerful, fun person; the ward round was informative and collaborative, and we struck up a dynamic where we bounced ideas off of one another, and she made sure I felt included and did not feel as alienated with the whole deal of being new to the idea of a pain clinic as I thought I would be.
Fast forward to 3 hours later and my consultant gets bleeped about being roped in to performing the anaesthetic for a donor extraction surgery – a team from the nearby major transplant centre were coming in to perform the surgery, and to harvest the organ(s) from a patient currently admitted in our hospital. My consultant asked me if I wanted to continue with the day’s pain rounds or would I like to join her in the theater to see this procedure? I excitedly said yes, thinking I would get to see the miracle of someone donating their kidney to their loved one and both donor and recipient ending up side by side on adjacent beds in the ITU. The reality was far from this very romantic notion.
As I changed into theater-appropriate attire – I realised what was going on as the team from the other hospital introduced themselves and told us the story – this was a 50-something male patient, who had suddenly had a massive stroke, and had been declared clinically brain dead the evening before. He was being kept artificially alive on a ventilator, and the family had said their goodbyes and understood the terminal nature of his condition. All of this however did not prepare me for what this procedure actually entailed: We would be providing anaesthetic to a brain dead patient, in order for him to be as comfortable as possible during the procedure which would entail the team of surgeons harvesting whatever organs had been consented for donation (in this case both kidneys, liver and pancreas) and for us to keep his organs as adequately perfused and optimum physiology as possible till the last possible minute, and at the point of removal of the organs, the blood exsanguinated from his body, at which point we were told ‘your services would no longer be required’ meaning to say the patient would then have been declared officially dead. So we wheeled this patient into the operating theater for what were to be his last few hours of life (albeit artificial due to the ventilator). It doesn’t get any sadder than this does it? It does, in fact. Not with anything else that happened during the procedure – but with the multitude of realisations I had over the next few hours.

I have seen asystole many hundreds of times (I am not proud of it, just the nature of my job) but I have never seen a beating heart become…just a heart. It literally was beating enthusiastically one second right in front of me and then it…wasn’t.

I have attended many surgical procedures which involve trying to get the patient to improve – never to mark the end of their life.

I have seen a heart being jump-started by electric paddles to kickstart it to life – never have I experienced the opposite, cardiac activity ceasing as a result of the drainage of blood from the major vessels entering the heart, and therefore from the rest of the body.

I have heard of so many organs that are transplanted into deserving human beings whose very life depends on the organ(s) being amazingly gifted by someone else who no longer requires their use – but I have never quite registered what it means to actually remove tissue of any sort from a ‘alive-till-the-organs-are-removed’ body so that once these viable tissue are removed, the body will essentially very quickly shutdown.

But I also had one other, very major overwhelming realisation: there is no precedence and no other example I feel of such an amazing, voluntary gift, either on the part of the donor, or on the part of the family who consent to the donation – a gift that may well mean (quite literally) the difference between life and assuredly painful death for so many individuals. While I may have initially felt that the procedure meant the end of a life, I was wrong. The procedure that I witnessed did not just mean the start of a new lease of life for the individual(s) who got those organs, but also their families and friends and loved ones and all the lives in turn they will interact with and influence and touch just by being alive – they may go on to teach, to lend, to help, to protect, to heal, to donate; they may go on to hold someone’s hand, walk someone down the aisle, attend a graduation, a christening or a birthday. They all owe every moment from here onwards to this, the procedure that started it all – thanks to the beating heart donor.