In April 2012, Dr. David Dean performed the first successful heart transplant at Piedmont Atlanta Hospital. It was a milestone for Piedmont’s heart surgery program and made the institution a tertiary cardiac care provider.
While it takes a skilled surgeon to perform the delicate and risky heart transplant, it also requires a staff of highly skilled and committed nurses to bring a patient to recovery. Piedmont’s ICU Red Team is such a staff.
When heart transplant patients are rolled out of the operating room, Nemia Ruffes wants to be there. Along with fellow ICU Red Team nurses, her job is to navigate patients through a complex postsurgical transition.
“They could be hooked up to five or six machines: balloon pumps, a coronary artery catheter and possibly an LVAD [left ventricular assist device],” said Ruffes, RN, BSN, CCRN. “Their kidneys could need help with continuous dialysis and there will be a ventilator and possibly an ECMO [extracorporeal membrane oxygenation] device for respiration. They could be on as many as 10 to 15 drips of continuous IV medication — all at the same time.”
As a member of the ICU Red Team, Ruffes specializes in caring for patients who have had open heart surgery or heart transplants. What might be daunting to others is exciting for Ruffes, who has worked in cardiovascular intensive care units for 25 years.
“These are my kind of patients and this is my niche,” she said.
Ruffes has seen cardiac disease treatments expand ever since she started caring for heart patients in 1987. She has worked at Piedmont since 1996 and has seen the establishment of the Piedmont Heart Institute, which aims to advance cardiovascular research, education and clinical excellence in cardiac disease, as well as the Advanced Heart Failure Center, which serves patients threatened by acute heart failure.
“I’ve been here for 17 years and I can’t remember ever slowing down,” Ruffes said. “Piedmont doctors started by doing CABGs [coronary artery bypass grafts] and valve surgery, and have progressed through surgeries for ventricular assist devices. The unit has grown from 10 to 14 beds, and we need to enlarge it again.”
In February, the Piedmont Heart Institute launched its heart-transplant program, becoming only the fourth such center in Georgia. Ruffes helped interview heart surgeons for the program.
Dr. Dean was recruited from Allegheny General Hospital in Pittsburgh to launch and grow Piedmont’s heart transplant program in 2010.
“Heart transplants are special because people think that the heart is the soul of the body,” Dean said. “There’s nothing like it; no other organ beats or looks like it’s working, but when you put a new heart in and put the patient’s new blood in, the heart spontaneously starts.”
Careful selection takes place before surgery to ensure that a heart is a good match, but the outcome is never certain and postsurgical care is very important. Nurses and doctors must prepare for the possibility of complications, infections or organ rejection.
Ruffes has completed multiple classes and training sessions to learn how to care for heart transplant patients and to use the complex machinery involved in the process.
"There's always something new going on in heart surgery, and we've seen the patient population change a bit as well," she said. "They often have additional health issues other than heart disease.
"After surgery, a patient can be doing really well one second and not [well] the next. We're monitoring so many different vital signs and pressures, and if there's a change, you need to address it immediately."
Ruffes relishes the autonomy and using her critical-thinking skills.
“You develop those skills and learn to act quickly, because things can really change fast,” she said.
A patient hooked to multiple monitors and machines just after surgery looks like a chemistry experiment at first, says Gene Ramey, clinical educator and staff nurse on the ICU Red Team. But Ramey, who has worked with heart transplant patients since 1998, is well aware that he’s caring for a human being who has undergone the replacement of his or her most complex organ.
“As a nurse you have to be 'on’ from the moment you get there until you leave,” said Ramey, RN, CCRN. “Your ear is always to the monitors, listening for the slightest change. You need to be pro-active rather than reactive. It can be pretty stressful.”
His job starts with waking patients, removing them from respiratory support and getting them off machines and drips as soon as possible. He also gets them up and moving around and then educates patients and families about postoperative care.
Success is transitioning patients to a stepdown unit within three to four days, on average.
“The psychological aspects of transplant are different,” Ramey said. “Someone who is newly diagnosed with heart disease and rushed into bypass surgery may not even have realized his risk, but a heart transplant patient has been sick a long time.
“He may have been in a cardiac care unit for several months without the strength to get out of bed. People react to the news that a new heart is available with both hope and fear.”
Doctors and transplant coordinators prepare patients for surgery, but a nurse is usually the first person they see when they wake up.
“We’re there 24/7 to get them through this critical time, and they learn to trust us,” he said. “Surprisingly, transplant patients make progress quickly, because they feel better.”
Seeing someone go from not being able to walk 10 feet to walking down the hall and knowing that they will go home to family in two weeks is enormously satisfying to Ramey.
“It’s a new world for them and it feels good to have been a part of that, to know that you’ve helped to change a life,” he said.
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