First assistants give surgeons more hands
Program evolved from Army medic's wartime experience
By Peggy Peck
MedPage Today Senior Editor
Editor's note: CNN.com has a business partnership with MedPageToday.com, which provides custom health content.
CLEVELAND, Ohio (MedPage Today) -- The landing gear of the sleek corporate jet had barely brushed the runway at Burke Lakefront Airport when Mark Kapes unbuckled his seat belt and moved quickly for the door.
In less than a minute Kapes was seated in a security van, surrounded by a police escort and was racing toward the Cleveland Clinic's main campus. His precious cargo was in an Igloo cooler that never left his sight.
Ten minutes after the aircraft touched down, the cooler was opened in an operating room at the clinic and surgeons carefully unwrapped the heart within, ready for transplant.
Mark Kapes, B.S., R.N., C.F.A., had once again beat the clock.
It was the latest race for Kapes between a viable donor heart and the clock. Once a heart is removed from a cadaver donor, it must be transplanted into the recipient within four hours or the heart muscle will be damaged and the new heart will not pump efficiently.
Kapes is a member of the elite heart surgery team at the Cleveland Clinic, which for the past decade has been rated by U.S. News and World Report as the number one heart center in the United States.
As part of the job, Kapes spends every sixth week on call for procurement of donor hearts and lungs that become available at centers "within a two-hour radius of the hospital."
The clinic keeps a private jet fueled and ready for takeoff at a moment's notice, Kapes says. "The last time I was on call I went out Friday, Saturday and Sunday to procure organs."
The work of repairing damaged hearts
The on-call organ procurement work is actually just a small part of Kapes' job as a certified first assistant.
By 7 a.m. on most days he is gowned and ready for work in one of the clinic's 11 gleaming steel and terrazzo operating rooms. There the clinic's cardiac surgeons will spend the day repairing or replacing any and all damaged parts of the heart.
With 11 cardiac surgery operating rooms the clinic is set up to handle 22 heart procedures a day, Kapes says.
These rooms, where operations often last eight hours or longer, are not far from Solon, the Cleveland suburb where Kapes grew up and where medicine was the last thing on his mind.
Biology, however, fascinated him. He went directly from Solon High School to Cleveland State University where he picked up a B.S. degree in biology.
But after graduation, he says, "I didn't have a career path in mind, so I went to Kent State to get certified as a biology teacher. I found out pretty quickly that I didn't like teaching, and at that point a friend suggested nursing.
"It seemed like a good idea, so I enrolled in the nursing program at Lakeland Community College," he says.
Armed with a nursing degree, Kapes started at Cleveland Clinic in 1989, first working in a step-down unit, which cared for patients after heart or lung surgery.
"I worked there for about a year when I heard about a position in cardiac surgery," he says.
He jumped at the chance for a job in the operating room and spent the next five years working as either a scrub or circulating nurse on the "HeartMate team," which pioneered in the use of a mechanical pump to take over the work of pumping blood in people with heart failure.
The 'amazing' part of the job
Patients who received the tiny HeartMate pumps, called left ventricular assist devices, or LVADs, were "literally brought back from the dead," Kapes says.
"I remember going to a party for former patients and I saw one of the first patients we implanted. Thanks to the pump, he was able to survive long enough to get a new heart," he says.
"Before surgery he had multi-organ failure. His body was shutting down; he was dying. But there he was at the party, looking just as normal as anyone else. That is the amazing part of my job -- I get to help bring people back from the dead."
As gratifying as the work with the HeartMate team was, Kapes felt he needed more challenge. "So I looked into the first assistant program."
The "certified first assistant" is actually a surgical innovation developed by the Cleveland Clinic in the aftermath of the Vietnam War, Kapes says.
"Corpsmen returning from the war had a lot of surgical experience, and hospitals like the Cleveland Clinic were challenged to find a way to use that experience."
Kapes told the story of an Army medic who came to the clinic 37 years ago, James Filisky.
Filisky showed up at the clinic just a year after surgeon Dr. Rene Favaloro made medical history by performing the first coronary artery bypass operation. Favaloro stitched veins taken from the patient's leg into the heart to bypass clogged arteries.
Favaloro offered Filisky a deal: If he could harvest the leg veins as safely and quickly as Favaloro's surgical residents, the former corpsman could have the job.
"And that was how the first assistant program started," Kapes says. "Filisky is the grandfather of all of us."
After Kapes completed the initial first assistant training course, he went on to take additional courses and to take a certification examination offered by the state of Ohio.
He was first assigned to thoracic surgery, where he assisted at "all surgeries in the chest, except heart surgery." In 2000 he joined the cardiac surgery unit.
Today, Kapes spends a fair amount of every working day the harvesting greater saphenous veins (the veins which run from the ankle up into the groin) and radial veins (arm veins) for use in bypass surgery.
As a certified first assistant, he stands "directly across from the surgeon, cutting tissue, suturing, doing whatever needs to be done."
Surgeries are usually more complicated
"At the clinic we often get the sickest patients, so the surgeries are usually more complicated than heart surgery at community hospitals," he says.
For example, Kapes says that a when patient's chest is opened in one of these difficult operations, it often reveals "so much scar tissue that we cannot immediately make out any distinctive organs."
Dissecting through that scar tissue, which is a job usually handled by Kapes, can take "anywhere from 30 minutes to hours," he says.
Days spent standing over an operating table take a toll on all members of the operating team, and Kapes notes that he now has varicose veins in both legs -- "the legacy of terrazzo floors, and my ankles are usually puffy at the end of the day."
And while surgeons have a chance to interact with patients and families receiving either everlasting gratitude or smoldering scorn depending upon the outcome of surgery, Kapes and his colleagues must rely on one another or on their own families for words of encouragement and comfort after surgery.
In Kapes' case he says his wife, Beth, and children, Lauren, 9, and Collin 7, are his biggest supporters.
"They are very proud of the work I do and Beth has been my biggest supporter," he says. "She is the one who encouraged me to move up to become a first assistant."
His colleagues also offer encouragement and sometimes consolation to one another.
"We know we've done the best job that we can," he says. "And we know, too, that we've saved more lives than we lose. But the culture of surgery is not warm and fuzzy. We don't get a lot of 'Great job, guys' comments."
Closing his locker and heading out to the employee lot after a day that started on a Runway 12 hours earlier, Kapes sums up his job this way:
"I love it. I love the people I work with, and we all support each other. We're in the trenches every day and if we didn't do our jobs, the surgeons couldn't do their jobs. We make a difference."