I am writing a book on an inside perspective on Heart Surgery in America. I decided that I would release portions of this story as I am telling it- to see what you think. We all have our stories about how we got here 🙂
It is in chronological order, so some of the passages will relate to the story of a man, and his journey to get into the surgical arena, and become a perfusionist.
Let’s see how it goes, and I look forward to any suggestions or comments. Plz remember, this is a somewhat rough draft, but based on real events as they happened. 🙂
Yahoo’s, Cowboy’s, and Heart Surgeons
An Inside Look at Cardiac Surgery in America
By Frank Aprile
So who is in charge running this ship?
There is no particular hierarchy here, certainly the surgeon is the captain of the ship, and if that is the case, allegorically, we would be the masts for the sails that capture the wind and in this case- the patient’s repository of blood, to maintain a steady course for the cardiac surgical patient so that the cardiac surgeon may operate on a still, unbeating heart. We accomplish this using the heart- lung machine, as well as its associated components consisting of an oxygenator, filters, reservoirs and tubing. We are totally responsible for the management of circulatory and respiratory functions of the patient allowing the cardiac surgeon to focus on the actual surgical procedure and less on the immediate life supporting needs of the patient.
Who are we and what are we made of? Nobody else really knows the who, what, when, where, and why about us. It does get confusing (I have no idea how often I have had to explain what a perfusionist is- and does- to somebody).
As perfusionists we examine on a daily basis, clinical questions that knock on the door of the medical decision making process. We confront the medical license on every pump run in terms of how our decisions impact patient outcomes. Our spouses are typically unaware of our day, and more significantly, are usually more dedicated to navigating around the “work” that we tend to put to task on a daily basis.
Well the easy answer (to the question of “why we are?”) is that anyone who has been in the profession for a period of time, has clearly dedicated themselves to a cause. In terms of exposure to colleagues (other perfusionists), the work environment is most often in numbers of 2’s and 3’s, sometimes 6 or more, but rarely exceeding 10. We work in professional triangles, yet express ourselves as individual clinicians. Our relationships tend towards geography and family, and our loyalties to the programs we represent.
We have different motivations, yet a common sense of urgency… that is who we are.
Most of your more experienced perfusionists had probably worked in another healthcare related field for quite a bit of time before earning a ticket or entrance into a perfusion program/school. High school grads didn’t just sign up for a perfusion major and suddenly start putting people on bypass at the age of 22 or 23.
Becoming a perfusionist wasn’t a reflection of education as much as it was an investment in experience. The raw ability to think on your feet when under the gun isn’t in any college curriculum, it comes from a combination of academic preparation, critical thinking, and the confidence to make the right choice. Repetition helps, ask any resident.
What separates the perfusionist from the pack, is the need for speed. Not how fast you move- as opposed to the clarity of thought that gets you from point A to point B. Windows of opportunities are very narrow for us to identify a problem / mistake, find a solution, create a fix, or whatever, and engage it. Patient survival is measured in the minutes it takes for cellular death to occur due to ischemia. So it’s a one shot deal. You either have it or you don’t.
But if you have it, most likely you have it due to the rigors you encountered from experience you gained doing whatever you did before. Basically? You are only as good as your last case. That comes with the turf if you are a perfusionist.
Precision baby- precision…
Well we are THAT guy (or girl). That person behind the scene. right behind all those magnificent rolling machines that pump red blood in countless directions and circles to their final destination- the heart and lungs of your loved ones, yourself, your children, or total strangers that you read about that are “miracles of medical science”.
Perfusion is not a pretty life.
In the profession, you make some serious decisions. They need to be quick, incisive- AND decisive. Anyone that second guesses will kill a patient, anyone that hesitates or defers- won’t last.
Surgeons expect us to be proactive- not reactive. They expect us to care, and to be prepared. There are no excuses. A mistake happens in a split second, inaction kills people, and your ability to fix the problem needs to be faster than holding your breath.
Put a marble in your mouth and inhale. That should give you a pretty good idea of how fast you have to be to first of all- make the decision- and then take action and implement that, in order to change out an oxygenator. (This is assuming of course, that you made the correct choice to begin with).
And I mean that. Any major fix has the same timeline as brain-death occurring to a non-resuscitated patient- 4-6 minutes by American Heart Association standards. Death in this field is quick and unexpected. No one puts a patient on bypass figuring they will die- and if the situation is so critical and emergent- the focus is always to stay ahead of the game- or to catch up if it’s really that bad.
The caliber of a Perfusionist is measured in seconds. There is an instant, a visceral moment when you have launched on bypass, and your evaluation sees things that you may not understand, but your gut instinct knows something is OFF or not RIGHT and several things occur at the same moment: You temper the following questions:
Am I seeing what I am seeing? In other words, is it real?
Continuing your scan and verifying. Have you ever seen this before? Do efforts to correct the problem work, or is it still undefined? Have I made a critical error in my setup? Is the pump functioning appropriately no mechanical errors? No it’s not, but I don’t know why? Eliminate the crucial suspects: Lines reversed, power cords are not connected, lines are kinked or clamped, O2 Hooked up? Clot Free? No Aortic Dissection? Forward flow (are you are generating a cardiac output)? This is your moment to succeed or fail. This is when you find out what you are made of. Are you honest? Can you be humble and accept a mistake for what it is and not what it isn’t? Will you be decisive and make a choice for the patient regardless of further ramifications external to what is in front of you now? A patient’s life rests in your hands. Will you ask for help if you need it? Are you bold enough to make a quick decision and take charge of your side of the equation? Whatever you decide will be the fate of the patient as well as your unclaimed doorstep to the future you dreamed of.
It takes a few seconds to miscalculate and kill, and a lifetime to reconcile it.
If you have the same heart- as the courage the patient demonstrated to allow you to be a part of saving their life, and possess the honesty and the moral strength to appear weak when making a strong move to salvage a potentially lethal event, well that is when you can call yourself a perfusionist.
It’s called tunnel vision for a reason. A narrowing of cognition when fear implodes instinct and what you would normally do becomes abnormal and your choices change based on the relationship you have with yourself, the surgeon, and the team. If for a second you make decisions based on your anticipated fear of failure, rejection, or down-the-line criticism, then you have failed yourself, the team, and most importantly the patient.
Failure to vocalize or communicate or take the initiative is a fatal flaw on many levels. It means you shouldn’t be doing what you are doing in this profession. If it’s out of your control that is one thing, if you let it get out of control for whatever personal misgivings or insecurity well, ADIOS cowboy! This isn’t Sunday NFL. This is someone’s life in less time than it takes to “split to a commercial”. Just a thought…
You are expected to catch up.
There is no CEO, CFO, Cardiologist, OR director, or chief pharmacist sitting right there to give you a hand when things really suck. No one to do an internet search when you are in the middle of a world of woeful hell, that no one can deal with but yourself. Your best friend is your surgeon and anesthesiologist- that is- if you have things “right” with them. You worst enemy is yourself- if you start second guessing, doubting yourself, or allow politics and protocols to inhibit your native instincts to do your job.
There was a reason for your Oral Boards…
It was to find out how far you would bend. it wasn’t a didactic examination- you had already passed that to get to the Orals. It was to determine one thing, and one thing only. Who you were going to bat for. And if you weren’t up to the task- who you would ask for help from. That was why you took the boards. To see if you would cave in- or bullshit your way through… or allow other people to bully you into decisions you knew were intrinsically bad for the patient.
Basically it was your position statement.
And just so you know… Those board questions don’t go away. Every case you do is the same as taking those boards again. Who are you going to bat for? It’s always gotta be the patient 1st
Some people will read this story because they can relate to what it is that we put down here. This book represents a straight forward look at the profession, albeit with a little salt from my perspective. It’s a scary thing we do, but when it boils down to it, it’s all about the shoes…
“People in Iraq- leave their children’s shoes outside of the doors of the operating room so that after surgery, their children will find their way back”.