“Hail to the Unsung Hero”
John M. Toomasian
Stanford University Medical Center
Menlo Park, California
May 6, 2003 marks the golden anniversary of John H. Gibbon’s successful use of a heart-lung machine in a human being. The patient was Cecelia Bavolek, an 18 year-old college freshman that had a large atrial septal defect characterized by a 9 L/min left to right shunt. During the 45-minute period of extracorporeal circulation in which the defect was repaired, total cardiopulmonary bypass was achieved for a period of 26 minutes. This case was monumental, opening the door for many others such as Kirklin and DeWall to further develop and refine the pump oxygenator. Along the Cecelia Bavolek case was reported in the New York Times on May 8, 19531, Gibbon chose to report his series in an obscure regional medical journal one year after the cases were completed2. The use of the heart-lung machine culminated decades of research in the laboratory and opened the floodgates to intracardiac surgery. The need for a perfusionist for clinical extracorporeal circulation specialists was born on that day fifty years ago.
Gibbon’s success however followed decades of diligent and painstaking research by his laboratory team. Many unknown individuals made significant contributions to the development of cardiopulmonary bypass. At the time, cardiovascular surgery was at its infancy and for the most part had been limited to the pericardium. Shumacker3 and Litwak4 have eloquently recounted the early history of cardiothoracic surgery and the development of the heart-lung machine. It was only 15 years prior to Gibbon’s clinical trial that in 1938, Dr. Robert E. Gross, the father of contemporary cardiovascular and pediatric surgery ligated the first patent ductus5. Four years later in 1942 Clarence Craaford reported the repair of aortic coarctation in infants6. In 1945 Dr. Alfred Blalock performed the first palliative systemic pulmonary connection, with collaboration with Helen Taussig, a shunt used routinely today that bears their names7. At the same time Bailey in Philadelphia8; Harken in Boston9 and Brock in London10 described a closed mitral commissurotomy. None of these extracardiac procedures required cardiopulmonary bypass. However, intracardiac surgery would not be feasible until some modality was perfected to mechanically support the circulation. It was hypothesized that this concept, a “pump oxygenator” could ultimately provide the tool to allow for the heart to be incised and explored from within.
In October 1952 Time magazine published an article describing the use of a mechanical pumping device used during a mitral commissurotomy11. Dr. Forest Dodrill from Detroit’s Harper Hospital used this device as a mechanical substitute and shunted blood from the upper left heart to the patient’s aorta without a gas exchange device. The shunt allowed the surgical team access to the mitral valve during the 50-minute period of extracorporeal circulation. The pump was built by General Motors and consisted of a bank of 6 rubber pistons that was configured to look like a V-12 automobile engine. There were 6 pumps configured for both the right and left heart. The article concluded to say, “The real answer to successful all out heart surgery is likely to be a device which will take over both sides of the heart and lungs”. This article proved to be prophetic 6 months later Gibbon and his team successfully used his pump oxygenator successfully.
Gibbon was credited to be the first to successfully use a pump oxygenator, but he was one of many trying to develop and use such a device. Many prominent physicians and researchers of the day were involved in this research. Was Gibbon truly the first? It is important to note that in Italy in August 1952, Dr. Mario Dogliotti used a bubble oxygenator as a precautionary measure in resecting a mediastinal tumor that was compressing the right heart12. The device functioned well and the patient recovered.
Under slightly different circumstances the first successful use of cardiopulmonary bypass would have fallen to Dr. Clarence Dennis and his associate Richard Varco at the University of Minnesota12. Two years earlier in 1951, Dennis and Varco attempted to use cardiopulmonary bypass in 2 cases. Prior to the second case the “machine operator” had a severe head cold. Medicated with decongestants and working in what could be best described as a “fog”, the level control circuit was not activated. As a result the patient received a fatal air embolism. The first clinical pump accident occurred before the first clinical success.
The concept of extracorporeal perfusion had been described a century earlier by LeGallois13 who thought mechanical support might preserve the life of any part of the body. Over the next century many observations were made regarding the mechanical oxygenation of blood, blood pressure and pumping mechanisms. In the 1930’s the famed aviator Charles Lindbergh described a perfusion system for a mechanical pump be substituted for the heart14. Along with Alexis Carrel, the pair worked on several innovative ideas related to circulation and the interaction of the blood with other organs.
Gibbon did not have the resources to sustain development of his devices had it not been for a $26,000 grant from the NIH and Thomas Watson, the chairman of IBM. Watson and IBM provided additional funding, personnel and engineering support to Gibbon’s laboratory. Unknowns such as engineers Thomas Stakes and John Flick Jr., helped develop Gibbon’s screen mesh oxygenator that worked optimally with a .029″ wire screen. Another key collaborator and overlooked by history was Dr. Bernard J. Miller, who served as the perfusionist and operated the machine in Cecilia Bavolek’s case but was also instrumental in developing and describing early perfusion techniques such as cardiotomy suction, left ventricular venting and controlled ventilation. Much has been said and made of Mary Gibbon, John Gibbon’s wife and long-time research partner. She and John Gibbon’s devoted lab technician Charles Kraul were true unsung heroes. They performed and implemented many experimental protocols relative to the development of Gibbon’s heart-lung machine. In addition development of the heart-lung apparatus and almost all artificial organs would not have progressed without the numerous and significant contributions of Dr. Willem Kolff who not only developed the drum kidney used in early dialysis, but was instrumental in developing gas exchange devices and pump mechanisms that are used widely today. The early heart-lung machines were built from contributions from many unsung individuals who all seemed to work towards a common goal.
Webster’s dictionary15 defines the adjective unsung as “not celebrated or praised”. The noun hero is defined as “a figure with great strength or ability”, “an industrious warrior” or “one that shows great courage”. Many descriptive permutations could be made by combining these two words, but it is probably safe to state an unsung hero does things that do not draw attention, make the headlines or appear in the box score, yet their function is of significant importance to a specific task or role.
There have been countless unsung heroes throughout time and history. Early in the first century AD there was a man living in Damascus named Ananias who was an early follower of Christianity. At the same time Saul, a religious zealot and a man who was processed and convicted to destroy any proliferation of Christianity was on a journey to Damascus to encounter and arrest Christian sympathizers. On that journey Saul was mysteriously blinded. After 3 days Ananias was given a vision to go and lay his hands on Saul in order to heal and restore his sight. One can only imagine the feelings Ananias must have had to go and aid his enemy. Ananias did what he was commanded and as a result Saul’s sight was restored. However Ananias’ touch did more than just restore Saul’s eyesight. Saul was converted and with that conversion became Paul, the great apostle of the early Christian church. Paul was the instrument that spread Christianity throughout middle Asia and southern Europe. Ananias had been the vehicle for Paul’s conversion and it is certainly possible that if it had not been for Ananias, the history of the early Christian church might have been different. Paul had laid hands on his enemies, but Ananias laid hands of healing.
I was raised in an athletic household. My father taught social science in the morning and was the basketball coach in the afternoon at Fresno City College in central California for over 3 decades. I spent many afternoons in my father’s gymnasium learning the game and interacting and helping with the various teams. I recall a photograph that was taken early in his coaching career that showed his team at halftime which pictured the coach, his players. Each team member had a place and filled a certain role. Even the team’s manager and towel boy all served specific purposes. The team’s fortunes were partially due to role of each person and not just to the score of a particular game. Not everyone on the team made the box score after each game but the character and personality of the team was made up contributions of both the teams stars and unsung players, even the towel boy.
In 1972 Bo Schembechler led the top ranked Michigan football team to the Rose Bowl to play Stanford. Michigan was 11-0 and heavily favored to win and secure a national championship. Stanford was 8-3 and was a 2-touchdown underdog. In the third period, Michigan was leading 3-0 and driving for a lead securing touchdown that by all accounts would have established the momentum for the rest of the game. However Stanford prevented a Michigan score with a dramatic goal line stand. One of the unsung heroes on that defensive series was Stanford linebacker Jim Merlo, who made a crucial tackle during that goal line stand. The change in momentum ultimately provided Stanford an opportunity to win the game, which they did by converting a last second field goal. Although Stanford’s place-kicker was the game’s hero, the unsung play of the Stanford defense and linebacker Jim Merlo provided the change in momentum for this great upset.
The field goal in football provides an analogy applicable to the role of a perfusionist in the operating room. In a field goal attempt the participants include the offense (consisting of the snapper, holder, place-kicker and linesmen) and the defense. The goal of the defense is to block or deny the kick, whereas the offense is to score. In most cases the place-kicker gets the glory if the kick is successful, but if the kick is blocked the offensive line may have failed and gets the criticism. What position might a perfusionist play in this analogy?
Many valid comments and analogies have been made relating aviation and perfusion. Many comparisons have been made between pilots and perfusionists. Both use checklists and both attempt to provide a safe environment for the individuals they serve. However there are contrasts to the pilot-perfusionist analogy. Whereas pilots are the captains of their ship, perfusionists are not captains of the operating room. Pilots get more notoriety, by comparison to perfusionists as it pertains to innovation or news in their respective fields. So does the aviation industry have a perfusionist?
A strong case could be made that an air traffic controller is like a perfusionist. Controllers have high technical skills. They often work under pressure situations and are as good as there last take off or landing. In addition air traffic controllers are only mentioned if something goes wrong.
One tool that air traffic controllers use in managing air traffic is what is known as a flight control strip. These computer generated data strips provide information for each aircraft in their route of flight and are used in conjunction with radar. These data strips are produced periodically and show not only the flight number but the aircraft type, transponder type, air and ground speed, the sector within the control center in which the plane is traveling, the Zulu time over a specific landmark, altitude, route of flight and the specific transponder signal that aircraft is squawking. Like a perfusionist, air traffic controllers insure passenger safety and often the air traffic controllers’ work is unsung.
In 1987, the Los Angeles Lakers played the Boston Celtics for the NBA Championship. It was a classic matchup between two storied teams. The participants were Hall of famers: Magic Johnson, Larry Bird, Kareem Abdul-Jabbar, James Worthy, Dennis Johnson and Kevin McHale to name a few. Entering game 6 the Lakers lead in the series 3 games to 2 and were playing at home. A Boston win in game six would force a series deciding 7th game. Students of professional basketball would know that the Celtics are hard to beat in a game 7 regardless of the venue. Therefore the pressure was on Lakers to establish the momentum and win the game. The teams traded the lead back and forth into the 3rd quarter and neither was able to take control. However in one possession the game’s momentum changed. Boston had the ball and attempted a pass to a player inside the key. Out of nowhere Los Angeles forward James Worthy intercepted the ball. His momentum carried him towards the out of bounds line and in order to save the ball from going out of bounds Worthy had to dive head first and tip the ball back in play, while at the same time sacrificing his body by skidding down the end line face first. The effort was successful, for Magic Johnson end up with the ball and scored. The play electrified the crowd and energized the team. In an instant the Lakers had taken command and Boston was unable to overcome it. Los Angeles went on to win the game and the championship; James Worthy was a hero but his unsung play never made the box score.
Joe Theisman was an All-American quarterback at University of Notre Dame and was a finalist for the Heisman trophy in 1979. He played quarterback in the NFL for 11 seasons for the Washington Redskins, being the NFL’s most valuable player in 1983. He played in 2 Super bowl games, leading the team to a victory over Miami 27-17 in 1982. He had a debilitating leg injury in 1985 that ended his career. What many people did not know that both his daughter and father have had open-heart surgery. At the Mechanisms of Perfusion Meeting in 2000, Theisman paid an emotional tribute to the average perfusionist stating: “you (perfusionists) are significant not just to the patients and surgeons you assist and the hospital and operating you work in but to the lives of the people you give back life”. He continued by saying “I want to thank you, each and everyone one of you for your profession, professionalism and what you (perfusionists) do to save lives”.
Tom Wharton was an unsung hero. His impact on the perfusion profession was considerable. He was drawn to perfusion technology, perfusion education and engineering. Tom was the first Executive Director of the American Board of Cardiovascular Perfusion and his name is still listed in the Booklet of Information. Later in his career he worked at William Harvey Research. More importantly, Tom was friend and supporter of the average perfusionist. He never sought notoriety, preferring to blend into the background and remain anonymous. However, he had high standards and believed that perfusionists should seek and maintain elevated educational goals. He believed in this so strongly that he felt compelled to give his own personal resources to fund and help found this Academy. Tom Wharton fits all of Mr. Webster’s definitions.
There are several unsung heroes in perfusion. There have been some significant strides made in the field, both in perfusion technology and education. As perfusionists reflect on the first fifty years of cardiopulmonary bypass, it is important to acknowledge the history and some of the key people, places, and milestones that have shaped the growth and development of cardiopulmonary bypass. First on the list were the pioneers that brought perfusionists together to meet in a scientific setting. The founders and early members of AmSECT, despite many differences had the foresight to press for formal recognition of perfusion as an allied health profession, credentialing and certification for professional status and accreditation for training and educating their successors in formal programs and universities. Others who never got their names in the box score include: the engineers and technicians who developed the devices and equipment that seldom fail or malfunction, the program directors, teachers, educators who train the novice student perfusionist day in and day out, the people who developed certification, licensure and accreditation that made the credential be of value, the perfusionists who travel on foreign missions or outreach to help care for individuals without the same resources available in most western countries, the speakers who present their research at meetings, the authors that have written textbooks and chapters for a field that is relatively very small, the pioneers of procedures related to cardiopulmonary bypass used outside the operating room, and of course the families who put up with perfusion lifestyle. However a big tribute belongs to average perfusionist who dutifully comes to work each day and cares for his patient. These are the unsung that weather criticism, work past adversity, and come into work at all hours of the day and night because they are dedicated and committed. These people know they will never be interviewed on television or be on the front page of the newspaper. They do not seek fame, but insist on the best care for their patients. The best compliment for them is not to be noticed. The unsung hero over the first fifty years of bypass is the average perfusionist in the trenches.
Francis D. Moore, the late Chairman of the Department of Surgery at the Harvard Medical School listed cardiac surgery on the top of his list of the 7 most significant achievements and advancements in the 20th century. He stated “The need to enter the heart openly under direct vision required artificial support of the circulation”16. As perfusion celebrates its golden anniversary, each perfusionist should reflect back on the past and recall some of the great achievements and events that perfusionists have been a part. Perfusionists have been participants in the treatment of congenital, valvular and coronary heart diseases. Perfusionists have had a front row seat for new and innovative procedures such as transplants and artificial devices. Perfusionists have been a part of medical history. As cardiopulmonary begins the second half of its first century, perfusionists should be very proud. Even though technology has and will change what perfusionists do, cardiopulmonary bypass is safe modality and it has benefited millions of patients. For the average “Joe” perfusionist, the unsung hero on the heart-lung machine’s golden anniversary, take a bow for a job well done.
Acknowledgement: My gratitude is extended to Dr. Michael D. Black, my friend and colleague from Stanford University Medical Center for his technical assistance and help in the multi-media preparation for the Thomas G. Wharton Memorial Lecture.
1. The New York Times, May 8, 1953.
2. Gibbon JH Jr. Application of a mechanical heart and lung apparatus to cardiac surgery. Minn Med. 1954; 37:171-80.
3. Shumacker HB, Jr. The Evolution of Cardiac Surgery. Bloomington, Indiana: Indiana University Press, 1992.
4. Litwak RS. The growth of cardiac surgery: historical notes. Cardiovasc Clin 1971; 3(2):5-50.
5. Gross ER, Hubbard JP. Surgical ligation of the patent ductus arteriosus. JAMA 1939; 112:729.
6. Craaford C, Nylin G. Congenital coarctation of the aorta and its surgical treatment. J Thorac Cardiovasc Surg 1945; 14:347-61.
7. Blalock A, Taussig HG. The surgical treatment of malformations of the heart in which there is pulmonary stenosis or pulmonary atresia. JAMA. 1945; 128:189.
8. Bailey CP. The surgical treatment of mitral stenosis (mitral commissurotomy) Dis Chest 1949; 15:377.
9. Harken DE, Ellis LB, Ware PF, Norman LR: The surgical treatment of mitral stenosis. I. Valvuloplasty. New Engl J Med 1948; 239:804.
10. Baker C, Brock RC, Campbell M. Valvotomy for mitral stenosis: Report of six successful cases. Brit Med J 1950; 1:1283.
11. Time Magazine, October 27, 1952, p 59.
12. Shumacker HB, Jr. The Evolution of Cardiac Surgery. Bloomington, Indiana: Indiana University Press, 1992: 255.
13. LeGallois CJJ. Experiences sur le principe de la vie, natamment sur celui des mouvements di Coeur, et sur le siege de ce principe; suivies du rapport fait au mouvements du couer. Paris: D’Hautel, 1812.
14. Lindbergh CA. An apparatus for the culture of whole organs, J Exper Med 1935; 62: 409-31.
15. Webster’s New Collegiate Dictionary. Springfield, MA.: G & C. Merriam Company, 1980: 532, 1274.
16. Moore FD. Perspectives, surgery. Perspectives in Biology and medicine 1982; 25:698-721.