Hello. Indeed, cardiac surgeons and cardiologists should both know what they are doing in the ICU. Further, a good cardiologist should be familiar with cardiac patients immediately post-op. This case is disappointing to hear on multiple levels, but I find the interaction between the surgeons and cardiologists especially disturbing.
I believe the cardiologist does have a place in the care of these post-op patients. There is continuity of care, because the cardiologist usually refers the patient for surgery, and he/she will be taking care of the patient after the surgery (if the patient survives, that is...). I agree with the previous poster who stated that both parties are equally invested in the outcome of this patient. Because this patient is post-op, I assume she is in the SICU. The cardiologist SHOULD know better than to be insulting and condescending to involved team members. Further, he/she should be trying to teach you more, because if you (I assume a housestaff physician) are not confident with strategy for hemodynamic management of the patient, there is an impact on the quality of care. The lack of professional courtesy in this case is troubling, especially since this isn't even his/her home turf (i.e. the CCU). At the institutioin where I work, the surgeons are usually thrilled with the contributions of the cardiologists, and are always trying to get us more involved. In fact, the patient's care is usually better for it. Collaboration is the name of the game, and it should streamline and clarify the patient's management. Not muddy it.
As for this patient, I can't tell you with any certainty the optimal pressor management because I don't know what's wrong with her. What I can say is that one of the most potent factors in her hemodynamics is her IABP. The milrinone/epi combination is standard post-CABG. What I see as a problem is that there appears to be no clear idea of what her physiology is, i.e. cardiogenic vs. distributive/vasoplegic vs other, so the kitchen sink is being thrown at her. Pressor management is as much art as science, and one way to clarify the picture is to pare down the combinations such that you have a clear picture of the outcome from manipulating a specific drug. I question titrating vasoconstrictors when the patient is on an IABP (the most potent afterload reducer, and kinda like spitting in the wind). If the patient is vasoplegic, is the BP better with the IABP weaned? The combination of Neo with Dobutrex or Milrinone doesn't make much sense either (opposing physiology). Aside from the pressor management, why is this patient not flying? Is the patient incompletely revascularized? Is she infected? What does the ECHO look like pre and post surgery? Is there right-sided dysfunction? Does she have pulmonary hypertension? Any new valvular abnormalities (like MR)?
Irrespective of this patient's outcome, it appears that the surgeons and cardiologists in this case need to work on their professional relationship. Unfortunately, it appears that you are caught in the middle. When the team works well together in a collaborative environment, the patient gets better care, and all the participants learn from each other. If anything, the communication may clarify the team's stance regarding overall disposition.
In any case, I really wish you and this patient much luck.
Cheers.
