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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at Nebraska Medicine. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE
Winter | 2014

A Standing Ovation

Cora Christensen describes her care at The Nebraska Medical Center like that of a well-rehearsed symphony — a welcome relief when much of her health over the past 30 years has been more like an opera with its share of tragic moments.

Having the right care in competent and experienced hands not only saved her life but has given her a sense of peace and harmony. “It’s so much more fun being alive now that I know I have a team of doctors who can take care of me if something goes wrong,” says the 60-year-old Christensen. “I’m not scared anymore.”

Curtis Hartman, MD

Scene 1 of Christensen’s story begins at age 33 when she was diagnosed with familial cardiomyopathy. A condition characterized by thickening of the heart muscle, this can impede blood flow and worsen with age, leading to a host of problems including arrhythmia, shortness of breath, dizziness, fatigue and heart failure. For some 15 years, Christensen treated the condition with medications.

By the time Christensen had reached her late 40s, the drama began to unfold. She started to experience fatigue, occasional dizziness and arrhythmia. The arrhythmias became more frequent and, at age 53, Christensen underwent surgery to have an implantable cardioverter defibrillator (ICD), a device that continuously monitors your heart. If it detects a life-threatening rapid heart rhythm, it sends an electric shock to your heart to restore a normal rhythm. Although the ICD did its job, saving Christensen from serious arrhythmias in numerous instances, Christensen’s condition continued to worsen.

The arrhythmias became more severe and bouts of dizziness, shortness of breath and fainting spells made it difficult to work. A teacher at Metropolitan Community College, she eventually had to quit. At the same time, Christensen was also going to school to get her master’s degree, a goal she refused to give up on.

Then she had a heart attack. Subsequent tests showed her heart was barely functioning. Her doctors sent her to The Nebraska Medical Center’s Heart Failure Clinic where she was diagnosed with end-of-life-cardiac failure. “I was barely cognitive,” recalls Christensen. “They said my ejection fraction was only 7 percent.”

Christensen was admitted to The Nebraska Medical Center and was told that she had to regain her health before she could become a candidate for a left ventricular assist device (LVAD), a battery-operated mechanical assist device that is surgically attached to the heart to help maintain the heart’s pumping ability. Within six weeks, an LVAD was implanted and in March of 2010 an LVAD had taken over the job of her weakened heart.

By this time, Christensen had completed her master’s degree and was teaching online courses at Bellevue University. Christensen says the difference in her ability to function after she received the LVAD was like night and day. “It was amazing,” she says. “I was getting oxygen to the brain again. I felt like I got more done in the first six months after the surgery than I had in the last 10 years.”

Within two months after surgery, Christensen was able to return to teaching. During the spring of 2012, misfortune struck Christensen again when she fell and injured her knee. She tried various medications and cortisone shots but nothing seemed to help. Desperate for relief, she agreed to have arthroscopic surgery, a minimally invasive procedure that allows doctors to look inside the joint and repair any damage.

“The use of echo in noncardiac cases is state-of-the-art. This is a very unique service that no one else offers in the state and fulfills a critical need for the safety of these patients.”
Sasha Shillcutt, MD

After the procedure, her doctor said her knee was severely arthritic and bone was rubbing on bone. What she really needed was a total knee replacement.

The pain was excruciating. “I couldn’t put any weight on it,” she recalls. “And if I did, my knee would automatically collapse.”

Christensen knew that total knee replacement surgery was the only thing that was going to give her relief and allow her to be mobile again but, with her LVAD and history of heart disease, she was told it was a surgery most doctors would not attempt.

Then Christensen was referred to Curtis Hartman, MD, an orthopaedic surgeon at The Nebraska Medical Center. Dr. Hartman had performed orthopaedic surgeries on several cardiac patients before Christensen in collaboration with the cardiac anesthesiology team at The Nebraska Medical Center. He says that he had full confidence that he would be able to perform the surgery safely under the watchful eye of the cardiac anesthesiology team.

Cardiac anesthesiologists have specialized training in monitoring the function of the heart during surgery, using advanced cardiac monitoring tools called transesophageal echocardiography (TEE) and transthoracic echocardiography (TTE). These tools allow them to measure the function of the heart and gives them direct visualization of the chambers of the heart, its valves and the major connecting vessels and veins that supply blood to the heart. While many large medical centers have a cardiac anesthesiology program that provides monitoring of patients during cardiac surgery, few in the country have cardiac anesthesiologists who also monitor cardiac patients during noncardiac related procedures.

“The use of echo in noncardiac cases is a new phenomenon that is state-of-the-art,” says Sasha Shillcutt, MD, cardiac anesthesiologist and director of Perioperative Echocardiography, at the University of Nebraska Medical Center (UNMC). “This is a very unique service that no one else offers in the state and fulfills a critical need for the safety of these patients. Without our expertise in TEE, most non-cardiac surgeons would otherwise not perform surgery on these types of patients simply because it is too risky.”

Sasha Shillcutt, MD

An assistant professor of Anesthesiology at UNMC, Dr. Shillcutt joined the staff in 2007. She received her medical degree from UNMC where she also completed an internship in internal medicine and residency in anesthesiology. She completed an executive fellowship in perioperative echocardiography at the University of Utah Medical Center in Salt Lake City, specializing in both TEE and TTE.

The Perioperative Echocardiography Consult Service includes a team of eight cardiac anesthesiologists who are trained in advanced TEE and TTE. It also includes four other anesthesiologists who are trained in basic echocardiography and use their skills in trauma patients, liver transplants, vascular surgery and critical care medicine. Under Dr. Shillcutt, the department also leads a national perioperative echocardiography training program that prepares physicians across the country in basic and advanced perioperative echocardiography. It is one of a few training programs in the country.

“All of our training is focused on getting a patient through surgery and out of the hospital without having a major cardiac event,” explains Dr. Shillcutt.

“The risk of having a cardiac event after surgery for patients with prior heart disease increases to 10 to 25 percent.

“Surgery is a very stressful event on the body. Even in a healthy individual the body would not be able to withstand the stress of surgery without anesthesia. When you take someone into surgery who already has had heart-related complications, the stress on the heart and potential risks are much more significant. The heart affects every organ of the body. The heart has to be working properly for everything else to work.”

“The confidence they have given me has been the difference between ‘I’m not going to make it to I’m going to be fine.”
Cora Christensen

Dr. Shillcutt describes the role of the anesthesiologist as the guardian angel of the OR. “It is our role to keep the patient alive,” she says. “We monitor the function of all of the organs so they don’t shut down. We administer fluids and extra blood to reduce stress on the organs, help maintain proper blood pressure and administer the proper amounts of narcotics and anesthetics to mask the pain and provide amnesia during surgery. And for cardiac patients, we monitor the function of the heart very closely.

“Using echocardiography in patients with heart disease undergoing major noncardiac surgery only makes sense to improve outcomes. We have diagnosed blood clots, heart failure and holes in the heart during noncardiac surgery. These are patients who might not have made it through surgery had we not been there and had the technology and experience to detect these problems.“

“We’re very fortunate to have this service offered to our patients,” says Dr. Hartman. “With Christensen’s LVAD and history of heart disease, no one else in the state would have touched this surgery. But I knew a knee replacement was very important to Cora if she ever wanted to be mobile again. I would not have performed the procedure without the presence of the cardiac anesthesiology team. The expertise and skills they bring to the operating room are invaluable. I’m quite sure one of my patients would have died on the operating table had it not been for the skills of our cardiac anesthesiology team. Today, that patient is alive because I was able to provide him a total hip replacement and our Heart Failure team was able to put him on the waiting list for a heart transplant.”

The care in the operating room is backed by a team of critical care physicians, the state’s only certified heart failure team, cardiologists and other specialists who are trained to provide follow-up intensive care after surgery. “It’s an excellent example of a multispecialty group of doctors working together to provide the best care for each patient,” says Dr. Shillcutt.

Cora Christensen

Christensen knew she was in good hands as soon as she came to The Nebraska Medical Center. “I remember going to the ER at another hospital after I had my LVAD,” recalls Christensen. “The ER doctor told me, ‘We don’t know how to take care of you. Please don’t come back.’ I never have. Now I wouldn’t go anywhere else but The Nebraska Medical Center, even if I didn’t have an LVAD.”

Before her knee surgery, Dr. Shillcutt came and talked to Christensen about the surgery. “She explained to me what she was able to do during surgery to ensure I made it through safely,” says Christensen. “It was such a relief knowing that there was going to be someone there monitoring me who knew what she was doing. It gave me so much confidence.”

Confidence in her care is something Christensen said she had not had before she came to The Nebraska Medical Center. “The doctors were always in contact with each other,” she says. “The way they all worked together was like a symphony. I would have about five different doctors seeing me. They would all meet together and discuss my case so they all knew what the others were doing and what the game plan was. It was like a medical pow wow. It wasn’t like that at all before I came here.”

The ability to have total knee replacement surgery has allowed Christensen to get her life back again. “I went from barely being able to walk with a walker to doing my own grocery shopping again,” she says.

“It’s scary to think you can’t have things fixed because you have so many things wrong with you. The confidence they have given me has been the difference between ‘I’m not going to make it to I’m going to be fine.’”

After the knee replacement surgery, Christensen gave up teaching to focus on rehabilitation and getting healthy again. She replaced teaching with her talent for crafts. She now makes doll clothes and jewelry and sells them at craft shows and through personal requests.

In what Christensen hopes will be her last “curtain call,” she says, “I’m back to being Cora again. I’m going to be around for another 20 years.“ Words that Christensen couldn’t say with confidence several years ago.

Next article in the Winter | 2014 issue of One Thousand And One:
A Legacy of Influence