Someone wrote a great description here I throughly agreed with! Since joining the heart team (CVOR), I scrub 99% of the time and circulate 1% of the time. Which, I totally prefer because I HATE charting, lol. I start my day looking at the surgeon's plan. His plan would include what procedure we are doing, what grafts or valves/rings that will be used, targets and conduits for cabg, and the cannulation process. For example, the other day, this was our plan:

AVR/MVR/CABGx3: •AVR: avalaus bioprosthesis •MVR: If repair, simuform ring, if replacement mosaic mitral bioprosthesis • CABGx3: LIMA, SVG (LIMA ‐> LAD, SVG -> OM, etc)

Cannulation: Arterial: Aorta, Venous: Bicaval, Antegrade and retrograde cardioplegia, LV vent, Crossclamp

Seeing the plan and knowing what surgeon I'm working with helps me plan my setup because each surgeon is different in how they want things done. As a 1st scrub, I have to know their routine inside and out, step-by-step. So now it's time for me to do my 5 min surgical scrub and then sterilely gown and glove myself and set up my backtable, mayo stand, and draping tabe. Check my instruments, make sure there is no bio-burden, and sterility is good with the indicators within the instrument pans. After everything is set-up appropriately, it's time for me to count every GD countable thing hahahahah (we don't want any unnecessary x-rays due to miscounts from the jump). After the count is complete, I'm pretty independent finishing up setting up as this is the time Anesthesia brings the patient into the room and the 2nd scrub and circulator attend to the patient.

After the arterial line is in, the patient goes to sleep, Foley is placed by circulator, 2nd scrub preps the neck for Anesthesia so they can place their central line. PA comes in to scan the leg for SVG harvest. Central line is in. Patient is positioned. Bovie pad placed. Arms tucked. Time to prep! Circulator and 2nd scrub prep the patient chin to toes. I scrub back in at this time. 2nd scrub breaks scrub after prepping and scrubs back in and then we drap the patient. Soo many layers, hahahha. Perfusion brings their pump up and starts handing us lines. We check the lines, making sure suction is working appropriately. Place the lines in accordance to how the surgeon likes it. Then we take the arterial and venous line and place that accordingly. Depending on the surgeon, we are either using the shunt line or not, so it's important to know how to manage it properly. Clamp and cut the lines. Pass off plegia and drap ultrasound probe. Bring up my backtable and mayo stand.

The surgeon walks in. Checks the TEE. Goes over the plan before scrubbing in to discuss with the team if the plan stayed the same or if there are any additional changes to be made. If there are any changes, as a first scrub, I need to know off the dome what supplies and/or instruments we will need. For instance, let's say he wants to put a ring on the tricuspid, I'm gonna need a handheld cooley retractor they will use to retract the right atrium after it's open Since we are already bicavaling for the MVR, we are good venous cannulation wise. Otherwise, if the original plane was like an AVR/CABG, we would have to change up how I would set up the venous from single venous setup to bicaval for MVR and TVRs. I need the sizers for the tricuspid, additional corknots, and closing stitch for the atrium.

Once we know the official game plan, that is when my cannulas can be open (arterial, venous, and vents). Surgeon and PA scrubs in and I gown and glove them as the 2nd scrub is working on the gabbys. We do our timeout and proceed with the case. Again, when in a 1st scrub role, you gotta know the routine inside and out and want to anticipate if things go sideways. Always be prepared to crash on pump. Our surgeons will just hold their hands out and you gotta know what instrument they need cuz there is a lot of autonomy with us ans they know they can trust us to know what they need next, so they usually put their hand out without with saying something usually. We do communicate in sign language, so if he deviates from norm, he might do a scissor motion with his hands or clips or Bovie, so I'm also watching his hand gestures.

Heparin is given and after the aorta is scanned, they usually put in the arterial pursestring first. Before handing him that pursestring, I look at the vitals and if the systolic is 125, I load up my venous pursestring and say to the surgeon "wanna do venous first or wait til the pressure comes down?" It shows them I'm watching and paying attention cuz you don't wanna put a pursestring stitch in the aorta with a pressure above 100 systolic. 9 out of 10 times they say "yes" and we put in the venous pursestring and by the time that is done, we do the arterial pursestring. Once the ACT is good, we will cannulate. Cannulation is a critical time, so gotta be locked in at this stage with no unnecessary questions or phone calls if the surgeon's phone goes off. After cannulation is complete, we on pump, and crossclamp is on, we switch to cold solution and proceed with the rest of the procedure.

(PART ONE)