GENTLE VIOLENCE – THE HEART
Our inner body represents a hidden and concealed world. The very thought of breaking into it makes our mind speculate about death and carnage. It is blood in there! One should better keep off! Breaking into our own body symbolizes the most intimate and utmost intrusive act that we entrust to a stranger: the surgeon. The mementoes and the momentary mind’s eye cannot be registered in a consciousness that no longer stays awake. A full and beguiling mystery encompasses these sold out shows: the surgeries. One never knows for sure what lies beyond the white doors of the operating theatre… When passing these doors it is already getting dark. My aim is bringing back memories from the dark, from the patients’ concealed bodies, from the aseptic operating theatres, with no windows and no gates facing the outside world, except for the photographic recording.
PLUNGING INTO THE DREAM
While for the surgeon time starts to unwind, for the patient it comes to a standstill. Seconds are anchored in the narcotic and opioid anesthetic drugs and the patient is disconnected from the surrounding world. Meanwhile, the surgeon has to perform his routine: the thorough hand scrubbing, clothing the sterile gown, dressing the patient with betadine, placing on the aseptic cloths, preparing for the incision. Everything has been already set for the surgeon prior to his arrival. The entire medical team is alloted accordingly, each member following a particular assignment. The anesthesia team is placed at the patient’s head. Opposite, at patient’s feet the nurses are preparing the table with the surgical instruments. Sidewise, the perfusionist is checking the heart-lung machine („the pump”). Nurses are revolving around the operating table, getting various sorts of instruments closer to the operating table. All the maneouvres performed, the drugs administered and their dosages are registered in flow charts. As the surgeon enters the operating room, the teams gather around the patient. A synergy is being created. Surgery beings.
A routine heart surgery procedure involves the cutting of the breastbone by employing an instrument called the sternal saw or sternotome and the opening of the rib cage with a sternal retractor. Deep to the sternum and enclosed by the pericardium lies the beating heart.
DREAM AND REALITY
We contemplate the innermost part of the patient’s organism through the surgical wound. Depending on the surgical procedure and before dealing with the heart, a series of steps must be followed, including the selection and the harvesting of venous or arterial grafts: healthy veins or arteries used for bypassing the diseased coronary arteries. The procedure is called coronary artery bypass and represents one of the most frequently performed cardiac surgical procedures worldwide. Fresh, oxygenated blood will be delivered through the bypass grafts to the ischemic myocardium. The left internal thoracic artery is the most often used graft; alternatively other veins or arteries in the chest, forearm and leg can be employed. The electrocautery (the electric pencil) is used during the various steps of the cardiac surgical procedure, including the harvesting of grafts. When put in use, it is easily noticed by the smoke released into thin air, by the smell of burnt meat and by the accompanying characteristic beep.
Some patients are referred for open heart surgery for narrowed or occluded coronary arteries while others for valvar heart disease, a clinical condition characterized by opening or closing defficiency of one or more heart valves (valvar stenosis or insufficiency). These patients require replacement of one or more of the four heart valves, a procedure which is routinely performed by employing mechanical or biological prostheses (pig aortic valves or bovine pericardial valves). Irrespective to the surgical procedure, the surgeons frequently use to rinse the wound with saline and to subsequently extract it with a suction device. Such maneuvres constitute the routine of the operating theatre, but not of the patient, who lies engulfed in a deep sleep, and who upon awakening re-enters concretness with a sole memory: the surgical scar.
THE SECOND HEART
For most cardiac surgical procedures, the heart is stopped and the blood is moved by an external system called the heart-lung machine (cardiopulmonary bypass). Once the extracorporeal circulation is established, the heart is isolated by clamping the aorta. A cardioplegic solution (with a high potassium concentration) is administered enabling the heart to stop and slowing its metabolism. The blood taken over by the machine is cooled down to 29 degrees Celsius. The heart-lung machine consists of the main pump (the main component of the extracorporeal circuit), the oxygenator (with the role of gas exchanges between the blood and a variable mixture of gases) and the heat exchanger (provides the cooling and heating of the patient’s blood). The onset of extracorporeal circulation is indicated by the surgeon who continuously communicates with the perfusionist during the operation, the latter permanently repeating and confirming the surgeon’s commands. After completion of the intracardiac step of the operation, the heart is restarted with the aid of low-intensity electric shocks. There follows a suspenseful moment at the conclusion of the extracorporeal circulation: the physicians refrain from any activity waiting for the patient to regain the normal physiological parameters: blood pressure, cardiac rhythm, temperature. There is little time left till the completion of the surgical procedure and until the patient will get back to the real world from which he or she was deliberately held away through anesthesia.
A NEW LIFE
The child’s heart appears as a gem: a small piece of priceless tissues, vividly-colored and striving with indefatigable accuracy to keep the vital spark alive and to lead the child into the new world. It will feel and respond to the caresses of the mother, to the warmly touch of the father, to all the emotions and feelings of the developing self.
When the twinkle fades or when it is already destined to die out from the very beginning, there is no alternative except yielding to the skilled hands of the surgeon.
The pediatric cardiac surgeon works as a jeweler, with observant eyes and expert hands, under magnifying lenses and with painstaking care. The seemingly defenseless child while dressed in gauze and bandages appears to deepen in an artificial womb, only to reemerge to a new life, after surgery.