“Funding A Future For Perfusion”
David Ogella, CCP
William Manchester’s brilliant biography of General Douglas MacArthur, American Caesar1, described the life of one of the most successful military minds of the Twentieth Century. MacArthur was born in 1880 and spent his early years traveling from one military post to another following his father who commanded horse cavalry in the United States Army during the final years of the so-called “Indian Wars”.
Young MacArthur was witness to the last warfare conducted in the United States with bows and arrows by warriors riding ponies into battle. He attended West Point and fought and saw his first hostile action in World War I. Like so many of his contemporaries he was a product of the Industrial Revolution and witnessed the complete revolution of warfare. In his later years, as Supreme Allied Commander for the Allied Powers during World War II he witnessed the deployment of the first atomic weapon. MacArthur never mentions whether he ever contemplated the irony of living in an age when technology grew so quickly and evolved so profoundly that he lived to witness warfare being conducted with bows and arrows as well as with atomic weapons. All of this took place within 65 years. A chronological blink of an eye.
In December of 2003 we celebrated the 100th anniversary of the first manned, controlled powered flight by the Wright brothers at Kitty Hawk, North Carolina. These visionaries, who cracked the code to aerodynamics, accomplished what no one had been able to accomplish since man first began to dream of flying. Yet only 65 years after the Wrights flew, Neil Armstrong and Edwin “Buzz” Aldrin landed on the moon. Technology had advanced from the “Wright Flyer” made of muslin and able to stay aloft for a few seconds and travel just over 100 ft., to a ship able to leave Earths atmosphere and land on Earths only moon within a span of only 65 years.2
The anniversary of the first open-heart procedure performed with an artificial extracorporeal device was celebrated by the world last May of 2003, just fifty years after Dr. John Gibbon and his wife culminated a life of research to perform the successful closure of an atrial septal defect on a human. We celebrate his courage for accomplishing this task. Many critics considered operating on the heart a foolish whim. Something akin to malpractice. Likewise the Wright brother’s critics considered flying something better left to the birds. The common saying at the time was that if God had intended man to fly he would have given him wings. Dr. Gibbons invention at the time seemed a frivolous waste of time and energy. The common thought at the time was that the heart was out-of-bounds; that no one would ever successfully operate on the human heart.
Dr. Gibbon proved that artificial extracorporeal circulation was possible. This quickly led to many advances and many failures. Eventually, bubble oxygenators proved commercially viable and lead to the development of membrane oxygenators. This is not quite as profound a leap of technology as going from bows and arrows to atomic weapons or flying 100 ft. to landing on the moon, yet open heart procedures have advanced in the past fifty years from a handful of congenital operations to one of the most commonly performed and safe operations in the world. And even though adult cardiac disease remains the number one killer in the United States, cardiac surgeons at least have a reliable way to treat this disease. And what began as a relatively inefficient, complicated array of glass tubes and metal connectors is now a sophisticated, highly efficient system of disposable products. We can be justifiably proud of the advances we have made.
When the first successful open-heart procedure was performed using an extracorporeal device the job description of the heart-lung pump technician was straightforward. This individual would operate the heart-lung pump to support the patients circulation while the surgeon operated on a non-beating, bloodless heart. The early heart-lung machines were operated by doctors since it was felt that cardiopulmonary bypass would require complex physiological monitoring and corrections. Eventually, this task was turned over to technicians who had little if any formal training in perfusion. Perfusionists were drawn from all walks of life and often found themselves reading medical journals and textbooks to explain the physiologic problems they were facing during cardiopulmonary bypass.
This early learning curve was very steep. Many patients suffered while surgical and perfusion skills were being mastered and mysteries solved. Such is the consequence of all new technologies. Not all technology can be learned in the laboratory and consequently much is learned in the operating room.
Though venous occlusion and cross-circulation techniques allowed for some early successes, ultimately, the use of extracorporeal circulation with cardiopulmonary bypass allowed for the widespread acceptance of open-heart surgery. At first, cardiopulmonary bypass science evolved at a rapid rate with a plethora of devices being invented. This flourish of research paralleled the refinement of cardiac surgical operations and cardiovascular diagnostic technology. This era lasted for approximately thirty years. Then interest in further development in cardiopulmonary devices entered a stagnant period while cardiac surgical procedures continued to improve. Today cardiopulmonary bypass has remained essentially unchanged for nearly twenty years whereas open-heart surgery has evolved in some very exciting ways.
With today’s robotic technology a surgeon can perform an operation, real-time, half-way around the globe. This can certainly be equated in the same category as having progressed from bow and arrows to the atom bomb or from flying 100 ft. to landing on the moon. Not even the most imaginative visionary could have predicted this advanced technology.
Cardiopulmonary bypass has always been considered a necessary evil and has been the focus of attention first to improve the process and eventually to eliminate it entirely. The question is whether our profession has found itself at a technological dead-end. Since the implementation of diagnosis related groups (DRG) we have found funding for research into improved technology slowly dwindling. The emphasis has been to eliminate cardiopulmonary bypass rather than to spend limited research dollars finding a more unique, and bio-compatible technology to replace conventional cardiopulmonary bypass. With the exception of membrane oxygenation and myocardial preservation techniques, the technology of bypass has changed little since the 1960’s with the invention of the disposable plastic bubble oxygenator.
In the early Twentieth Century mitral valve disease carried with it one of the highest mortality rates associated with any cardiac condition. Rheumatic heart disease killed thousands. Yet today through dedicated research into surgical solutions, mitral disease carries a very low mortality and is one of the most successful operations performed on the heart. Cardiopulmonary bypass should have a similar reputation. At this point in history, a surgeon should have no reservations about placing a patient on cardiopulmonary bypass. Though the risks are much lower than they were in Dr. Gibbons day, we still have many surgeons willing to take the risk of poor long term outcomes, longer operations and incomplete revascularizations all for the sake of avoiding cardiopulmonary bypass.
Funding for further research in cardiopulmonary bypass began to evaporate in the mid nineteen-eighties and consequently momentum was lost. The rapid growth of perfusion technology had ended and the status quo took over. Improvements came slowly and did not take us to the next level of technology. We should be standing here today looking back at twenty years of stunning accelerations in technology involving cardiopulmonary bypass.
However, it is never too late to start. We can no longer rely on manufacturing to fund research into extracorporeal development. The financial burden is too heavy to be subsidized by the private business sector especially during these difficult economic times. However, there is funding available for those willing, and motivated enough to discover how it can be accessed.
In the early years of perfusion, heart-lung pump “techs” were trained on-the-job and were recruited from all walks of life. Many were not suited to become perfusionists. We gradually realized a more formal method of education was needed to gain uniformity of training to insure patients received the same standard of care. The foundation for this training became a formal education, research, practical training and continuing education. With the development of oversight by the Accreditation Committee-Perfusion Education, Standards and Guidelines were developed to insure uniformity among the training institutions.
Current perfusion training programs require a Bachelors Degree or its equivalent upon graduation. The awarding of advanced degrees has been traditionally criticized by our profession, although, I believe unjustly. Many wonder at the wisdom of this progression, whether the job requires a doctoral level of study; whether precious resources could be used more wisely elsewhere. Actually, those graduates who possess post-graduate degrees are ideally suited to become the individuals who lead the next technological revolution in perfusion technology.
Without trained scientists our profession will not progress and eventually we will disappear as a mere footnote in medical history. Unless we reinvent our profession periodically it will not survive. We cannot continue to be satisfied punching a time clock, pumping a case and going home. If we do not discover new avenues for our talents we will find ourselves being replaced by new technologies not yet invented. Scientists trained in research methodology, grant writing, and administration will conduct the research necessary to invent new technologies which will give us direction towards our future.
The key is that these individuals possess the intelligence, training, specialized education and leadership skills to find untapped funding that is available to those willing and able to procure it. They will establish the independent laboratories of the future and develop the technologies that we cannot, at this moment, even imagine.
Through a generous endowment, the Cleveland Clinic Foundation has recently laid the groundwork for a new type of medical school which will train medical students to become specialists in research medicine. The goal will be to bring science to medicine.3 Perfusion must adopt this far-thinking attitude and train research oriented practitioners. These individuals will be responsible for operating laboratories dedicated to developing new perfusion technology.
For the past fifty years we have had the notion that our technology was secure along with our jobs. We were indispensable and we thought our future was secure. This was an assumption we should have never made. Medicine like all technology evolves. Those that succeed and remain relevant are the ones who are flexible enough to change with technology and adapt.
Technology has caught up with our profession. Dr. Floyd Loop, Chief Executive Officer of the Cleveland Clinic Foundation stated that, “Medical science exists for humanity. To advance, we must create.”
The challenge is to discover what we can do to contribute our support to new technologies and offer our expertise to make it successful. This may take us out of the operating room environment which has traditionally been our workplace.
It will take intelligence and curiosity and a will to step outside of the box; to take a chance. We can re-invent ourselves as all professions must do from time-to-time.
Though the job market for perfusion is still strong and most graduates find employment without difficulty, we should not be lulled into a false sense of security. The future will probably not support our technology for another fifty years. We must be prepared to move on and find out what our future holds for us as a profession. It is said that wisdom is knowing what to do next; virtue is doing it.
This lecture is given each year at the annual meeting of the American Academy of Cardiovascular Perfusion in honor of Thomas G. Wharton. This visionary gave his own money to fund this organization. Though I never met him personally I believe I have come to know him by listening to this lecture each year. He possessed many of the ideals which I most admire in my perfusion colleagues. Perfusionists are intelligent, dedicated and hard working. They are also curious and it is this trait above all others that propelled many of us to this interesting profession. Once again, this curiosity, which was so instrumental in bringing so many of us to this point in time will once again be our inspiration to take those tentative next steps where our future lies.
I would like to leave you with a short anecdote. One bleak afternoon during the Civil War, Abraham Lincoln was meeting with his Cabinet when one of the men said, “Mr. President, it appears we are stumbling.” Lincoln sighed and said, “Please, God, that we are stumbling in the right direction.”
1. Manchester W. American Caesar; Douglas MacArthur 1880-1964. Boston: Little, Brown and Company, 1978.
2. The Plain Dealer, Wednesday December, 17, 2003.
3. The Plain Dealer, Thursday, September 18, 2003.