“Perfusion: The Missing Link “
Sherry Faulkner, CCP
It is with great humility I stand at this podium to deliver at the 26th American Academy of Cardiovascular Perfusion meeting, the Thomas G. Wharton Memorial Lecture. Tom Wharton was a man of vision—a vision centered on perfusionists rising from their multiformity to become contributing health care professionals. Unknowingly, I saw the early years of perfusion when, as a student in radiologic technology, I observed Charles Reed performing cardiopulmonary bypass at Baptist Hospital in Little Rock, Arkansas. The year was 1966. At that time only one or possibly two cases were performed every few months in Little Rock.
I remember one particular patient who had a single graft coronary bypass. There was concern of bleeding. Not knowing what any of this meant, I was picked to be the “rabbit.” Somehow, I felt this was very important but was not sure what the rabbit did—I just knew it must be important. I went with the technologist to perform a portable x-ray, and I only stood by and watched as the nurses, Charlie, and two cardiovascular surgeons gingerly placed the x-ray cassette under the patient. Alarms went off, nurses grabbed things, Charlie was right in the middle of everything (saying a few choice words), and the surgeons just backed away. The x-ray was taken and the cassette removed with again alarms going off, nurses grabbing things, and Charlie in the middle of everything saying those few choice words.
Charlie turned to me with the cassette and grinned that silly grin he had and said, “Quick, like a rabbit.” At last, my mission had been declared, and quick like a rabbit I ran down five flights of stairs, across the length of the hospital to the radiology department to process the film. I stood waiting for the film to come through the processor when the phone rang. It was Charlie calling to see if I had made it to radiology yet. I grabbed the film, ran across the length of the hospital, up five flights of stairs and completed my mission by handing the film to Charlie.
Many years later, Charlie and I were laughing about this story when he told me he had a reason for making me the rabbit. It seems my first rotation as a student was through the operating room. And as I dressed out and went with my supervisor through the swinging doors into the OR I fainted. I fell like a stiff board and got my feet stuck on one side of the door with my body on the other side. Bets had been taken as to how long I would last in the Baptist Hospital School of Radiological Technology. Charlie was the only one who bet I would make it. He later told me he based this upon my attitude. Another time he had watched as I was manipulating an x-ray table when the patient was shocked and accidentally defibrillated me. He was impressed that I continued to work the rest of the day when most people would have gone to employee health and been excused for the day. I thought it was part of induction into the class.
So where do these adventurous stories lead me? In a roundabout way, they lead me back to Tom Wharton’s vision of perfusion as a health-care profession. We have come a great distance in this profession’s short time of existence. And yet we have a great distance to go towards accomplishing Tom’s vision, as well as our own. Perhaps realizing where we have come will aid us in achieving where we wish to go.
Perfusion was not created just by desire, such as nursing or respiratory therapy were. Perfusion was created by courage and confidence in the pioneer perfusionists’ hearts. These pioneers had what was then “state-of-the-art” equipment, most of which was made in a garage or workshop. They realized that at any moment the equipment could stop working, and they would be required to try and correct the problem within a brief period of time. Much like early aviators with bailing wire and bubble gum, some of our essential tools in a crisis were bone wax, a 21-blade, and lots of adhesive tape.
The learning curve was steep in those early days of perfusion, yet most stayed with the job. Where did these individuals come from? Many came from research laboratories; some came from nursing, but a majority of them were simply interested in research and medicine. They had no specific training but were wandering in search of a purpose. They were hungry for knowledge. Purpose and knowledge allowed these individuals to evolve into what is now known as perfusion.
We often hear of the “Missing Link.” This is a term used to somehow explain an unknown entity, which brings an organism from point A to point B in the organism’s advancing development. I feel that cardiovascular perfusion is the “Missing Link” in medicine today. In order to understand this phenomenon we must realize where we have come from and how we reached this point. Again, the pioneer perfusionists were persons with great imagination and courage. They would train with buckets of water in order to maintain their skills, and if they were real lucky they would have an animal lab available to find out the limits of their equipment and how quickly perfusion could cause harm if not managed properly.
Back then, patients requiring cardiovascular surgery were the sickest patients who could not survive unless operated upon. This meant that the odds were stacked against a good outcome even before the perfusionist came to the Operating Room. Yet the surgeon, the patient, and the perfusionist came to the Operating Room in the name of humanity.
A large price was paid for the advances made during this time. The first survivors fueled encouragement to continue the evolution of perfusion. There were no great meetings to share the information, there were very few articles generated to document the techniques, there was merely word of mouth. Surgeons coveted their perfusionist. Nursing staff stood in awe at what these individuals did.
And so was born “the pumper.” Success brought more and more patients, which resulted in more surgeons, which created a need for more perfusionists. On-the-job training became the catch phrase in perfusion. There were no schools to really speak of. And so it was back to the buckets of water and animal laboratories to train the new recruits to this exciting field. The OJTs came from nursing, respiratory, radiology, laboratory, and other hospital-based jobs. Perfusion was growing but from a very diversified field of medical disciplines. Schools began to appear along with textbooks. Local gatherings of “pumpers” to share war stories began to occur. The sharing of knowledge had taken hold, and the patient survival increased.
Larger gatherings of “pumpers” evolved into national meetings. As the knowledge grew, the natural desire to share it with others led to the first medical literature regarding perfusion. This knowledge evolved into the desire to set a standard whereby patients were guaranteed to receive the best perfusion possible. And so accreditation of training programs and certification of perfusionists took center stage. Desiring to raise their dignity and achieve formal recognition from physician organizations, the “pumpers” began referring to themselves as “perfusionists.”
I have taken you through the evolution of perfusion in a few short paragraphs. However, the cost of not only development of equipment but of human life has been almost insurmountable. The benefits are beyond belief and yet the benefits for patients continue to grow. Along with the growth comes new technology but, alas, the sickest patients. Still perfusion continues to evolve.
The evolution of perfusion has not been without a price. The original mystic person that ran the big machine in the Operating Room is suddenly cast out among the rest of the caregivers. Our vulnerability is where all can see. Tragically it is realized we are not mystical but actually human, equal to all other humans. Herein lies where difficulties can arise.
The first law of chaos according to the Foundation of Inner Peace in “A Course in Miracles” says each person has their own truth.1 In our profession we are constantly in a life or death situation. We are trained to think two steps ahead of the moment. We are trained to anticipate the worst-case scenario and have the answer. That is our job. That is what we do every day we walk into the Operating Room. We are periodically reminded that this is what we are paid for. We hold each patient’s life in our hands.
Surgeons and anesthesiologists know this and trust us, just as we know their roles and trust them. Yet those outside our arena do not have this insight into our world. Fear of the unknown along with loss of control in their environment causes nursing, respiratory, cardiology, and other professions to view us with reservation. Their reluctance sometimes evolves into skepticism and mistrust, all of which will eventually lead to negative feelings. It is a well-documented psychological fact that animals will instinctively try new behavior. However, if the result is not what the animal wishes to accomplish they will always revert to what they know has worked. Humans behave in the same way. Summed up, chaos and conflict often dominate our workplaces. All of this is felt by the one common denominator each health care professional is there for, the patient.
What is the solution? What is the “missing link” to complete the circle of all round good patient care? I feel strongly that perfusion can be that golden link. You may ask why? We must look at the diversity of our backgrounds. In the beginning our pioneers came from a multitude of professions, each bring their unique backgrounds and diverse expertise.
Today, we still have a multitude of professions represented in the students entering perfusion school as well as those that have graduated and are certified perfusionists. This remarkable mixing pot is having a phenomenally positive impact on development of techniques, devices, and, most important, patient care. The close bond between perfusionist, surgeon, and anesthesiologist has been loosened as larger and larger teams are formed. However, with the rapid growth in perfusion technology the bond is returning as surgeons hear of success stories from their colleagues and then ask the perfusionist to incorporate the technology into their practice. Yet there is one group, which is still not being included in this affirmation—those who work outside the Operating Room. This is where the “missing link” can be placed to complete the circle.
We as perfusionists have the opportunity to reach out and embrace those who push us away. Impossible? For the profession that has played such a vital role in ventricular assist, extracorporeal membrane oxygenation, extracorporeal CO2 removal, artificial heart assist, I say nothing is impossible. A strategy from Sun-Tzu in “The Art of War” is called, “conquering the enemy and growing stronger.” 2How can we conquer those who impede our objectives? Through knowledge and inclusion we can circumvent the negative. Through strong leadership in our institutions we can build a reputation of professionalism while demystifying our profession. By taking the unknown out of what we do during emergency procedures we can build a stronger union of individuals working toward one goal, to save the patient. Abraham Lincoln expressed this strategy in a slightly different way; he said, “The best way to destroy your enemies is to make them your friend.” Think about that next time you are confronted by someone in the hospital in a confrontational or adversarial way.
I worked with a surgeon, Jonathan Drummond-Webb, who would sit down and quiz me about what I had seen or learned whenever I went to a meeting or even to another hospital. He made it clear that it was my responsibility to him, the patient, and the team to grasp every opportunity to gain knowledge and share that knowledge. The first time I was quizzed I made the mistake of saying I had not learned that much at a particular meeting. He proceeded to inform me that I had not paid attention, that each experience had vast knowledge of what worked or did not work. It was the professional’s job to sift through the information and identify portions that were useful. Thus was instilled in our perfusion group the desire to bring our individual areas of expertise to medicine for the collective good and a sum much greater than simply adding up each part.
I challenge each of you to return after this meeting to your institution and make an appointment with your surgeon for five minutes. Explain to him or her what you saw, learned, or, even better, ask a question that you discovered here. Set up a journal club with not only the perfusion staff but also with the Intensive Care Unit caregivers and share the knowledge. Include in the meeting the nursing managers and nursing administration. Explain to them these are techniques or maneuvers that could someday be used during an emergency. Their involvement could make the vital difference between success and loss of a patient.
Take the lead, step forward, and show your courage, confidence, and strength. Become the “missing link,” which for so long has been invisible. Make the commitment to be the strongest link, and I assure you those who do not join will become the weakest link. Some will come. Note those individuals; they are genuinely ready to follow your example. Do not be deterred if only a few come the first time. Stay true to your commitment and others will follow.
Above all else remember the first law of chaos, “Each person has their own truth.” This is your truth. You are a perfusionist. You are the missing link.
In closing, I would like to share with you something I heard several years ago from an Academy member. It has been carried around in my heart all these years. The gentleman that made this profound statement was Richard Berryessa. Walking out of the Wharton Memorial Lecture that year just ahead of me, Mr. Berryessa spoke to the lady beside him saying, “For awhile now I have not felt as good about being a perfusionist. But today I really feel good about being a perfusionist.”
I hope that in some way, this lecture has instilled in you the pride and admiration each of you deserves. All of you are perfusionists by choice. You do not get the “Good job!” or “Well done” accolades you deserve everyday. But remember the old Charlie Reed quotation, “Any landing you walk away from is a good landing.” To that I add my own at this point, “Everyday you face death and battle as hard as you can for the patient is a day that you are a good perfusionist.”
- Foundation of Inner Peace. A course in miracles, second edition. Tiburon, CA: Foundation for Inner Peace, 1975.
- Sun-Tzu. The art of war. Indianapolis, IN: Book-of-the-Month Club, Inc., 2002.