On Becoming an Unassuming Perfusionist By Gary Grist RN CCP Emeritus

Definition: Assuming – supposing to be the case without supporting proof.

Definition: Unassuming – not pretentious or arrogant; modest. (In my context, unassuming means not to take anything for granted, but to question authority and speak up when things don’t seem correct. GG)

A NEW SOLUTION

In 1968, the heart surgeon at the hospital where I was working had just gotten his first powered pneumatic reciprocating saw (AKA rip saw). This was a new solution to a more efficient way of opening the sternum.  Prior to that, he used a Gigli saw to open most chests. (He occasionally used an even more barbaric tool; a Lebsche knife. Maybe to keep in practice? I don’t really know why.) Gigli saws and Lebsche knives are a lot of work, so the surgeon was thrilled to have the new saw.

CIVIL WAR TECHNOLOGY

On redo sternotomies especially, Gigli saws require a lengthy sub-sternal dissection from the xyphoid space to the sternal notch with Metzenbaum scissors that looked to be 2 feet long to me. Then, using a long tonsil clamp sub-sternally, one end of the Gigli wire saw blade is pulled under the sternum. The saw is composed of a wire blade with small chainsaw-style steel teeth and attached at either end by two handles. The handles are moved back and forth in a pulling motion to rasp through the sternum from the inside out. That is a lot of work for the surgeon, appears brutal in execution and there is a risk that the saw can damage sub-sternal structures. I recall another surgeon in that era calling the use of a Gigli saw “more carpentry than surgery”. Gigli saws are Civil War technology folks!

TIME OVERSEAS

Unless they have spent time at an overseas mission where Gigli saws are still used, I doubt that most American perfusionists today have ever seen a Gigli saw used on a virgin sternotomy let alone a redo. Oscillating saws are glorified cast saws that are safer than reciprocating saws and are used to safely open a redo sternotomy nowadays.

HE SHOULD HAVE KNOWN BETTER

This particular case was a redo sternotomy operation.  Several years before vein grafts became popular the patient had a Vineberg procedure where the internal mammary arteries were implanted directly into the myocardium of the left ventricle in an attempt to alleviate chest pain from myocardial ischemia. After removing the sternal wires the surgeon quickly unzipped the chest with the new rip saw. Nowadays, everybody knows not to rip open a redo sternotomy with a reciprocating saw.  I guess the surgeon did not know that back then. Powered sternal saws were new to the market and there weren’t very many patients who required a redo sternotomy. Little did he or I realize that this new solution was to cause a new, dangerous and unanticipated problem.

A BLOODY BLOB MONSTER

Blood suddenly welled up out of the open wound like lava from a volcano and began spilling onto the floor.  The surgeon ordered the suckers up to full speed and sucked the deluging blood into my pump.  The anesthesiologist hidden behind the linen drapes peered over the ether screen to see what was happening.  In the excitement of the situation he neglected to give the heparin.  With his first assistant shoving large lap sponges into the breach, the surgeon rapidly established femoral cannulation and went on CPB.  As I transfused the unheparinized shed blood that was captured in my cardiotomy/venous reservoir by the suckers (I did not realize it was not yet heparinized), I witnessed an ominous sight.  A huge clot had formed in the venous reservoir.  As the reservoir level dropped, the clot perched on a reservoir baffle and emerged into view like a bloody blob monster rising from a ghastly manmade swamp of stainless steel and glass. I quickly injected a full heparin dose into the venous reservoir system. I expected that either the venous blood coming into the pump would soon stop or that the clot would be pushed by the pump into the disk oxygenator, or further on into the rudimentary arterial filter we were using which could mean sudden death for the patient.

A VERY LUCKY PATIENT

Fortunately none of those things occurred to the degree that CPB was interrupted.  The patient survived the operation, but I had aged ten years! After things settled down the surgeon discovered that his new saw had severed both internal mammary arteries just above their implantation sites in the myocardium.  Luckily none of the vital cardiac structures had been breached which probably explains why the patient survived.

WHAT DID I KNOW…?

When it came to the new powered reciprocating sternal saw, I assumed the surgeon knew what he was doing….but what did I know?  I was only 19 years old.  I also assumed that the anesthesiologist had given the heparin when the suckers were placed in the chest. These were my first lessons in the old cliché; “Don’t assume anything, it makes an ass out of u and me!” From that time onward, I became a very “unassuming” perfusionist. Why did the surgeon back in 1968 not elect to put the patient on fem-fem CPB before attempting to open the redo chest? I don’t know.  Maybe he had successfully opened redo chests before with manual tools without resorting to fem-fem CPB first and thought the new powered saw would make the job easier. Perhaps if I were older, more experienced and less intimidated I might have suggested fem-fem CPB first. Hindsight is 20/20, as the saying goes.

IMA ASSUMING…OR NOT!

I told this story to another perfusionist many years ago and she, in turn, told me about her experience in making assumptions. (Sorry, Tammy, if I do not get the details exactly correct.) As a newly minted perfusionist, she was observing a case in orientation.  She studied the case before hand and knew that it was a simple, single internal mammary artery (IMA) to anterior descending coronary procedure. But when the patient was brought into the room, he was prepped for leg vein harvest. This was an experienced OR team and Tammy thought the prep must be precautionary incase the IMA did not work out. (Tammy did not say if there was a ‘time out’ at the beginning of the case.)

BECOMING AN UNASSUMING PERFUSIONIST

But as the case started the first assistant began taking leg vein. Tammy thought she should inquire why this was being done.  But as the least senior member of the team and a newbie to this hospital she did not want to interject and possibly make a fool of herself on her first day. In other words, she lacked confidence and was intimidated by her surroundings. This was a well-oiled cardiac surgery team and she assumed they knew their business. Even if the surgeons were not aware of their mistake, surely the scrub nurse or circulating nurse would speak up, she assumed. Only after the leg veins were taken and the surgeon was well into the case did he realize that the leg veins should not have been taken and had to be wasted.  The patient underwent an unnecessary vein harvest procedure which would be painful during recovery. But more importantly, the veins would no longer be available if needed for a future procedure.  At that moment, Tammy regretted her silence and vowed to never again make assumptions and to speak up if things do not seem spot-on. This was the moment when she became an “unassuming” perfusionist.

SO, WHO CAN YOU TRUST?

The short answer is “no one”. Even if you have worked with a surgeon or anesthesiologist for 20 years, they can have a bad day where their thinking is not spot-on. It’s your job to voice any concerns you may have. And your colleagues should be watching you closely as well.  That is why I recommend a “perfusion time out” just before going on CPB to make sure everyone is on the same page. My story shows how a new solution to one problem can sometimes cause a new problem, while Tammy’s story reminds us that routine can deaden our senses to a problem. It is important for teammates to watch out for each other’s individual foibles — and I suppose a perfusionist has a unique ability to do that in the operating room, paying some degree of attention to every aspect of the process; perfusion, anesthesia circulating, scrubbing and even the surgery. If you have an interesting story about becoming an “unassuming” perfusionist, I would like to hear it. Please contact me at garygrist@comcast.net .

ADDENDUM

After reading this article, Megan Roethle sent me the following email.  She tells a great story.

Hi Gary!

I just read your article on being an “unassuming” perfusionist on AmSECT’s website and wanted to share my story. I’ve been out of school for 3 years and am a perfusionist in Wisconsin.
I was doing a CABG with a locum surgeon about 2 months ago (it was only our second or third case with her), and a student CRNA was at the head of the table. There was an anesthesiologist with the student, but he was on his phone and not paying attention. The surgeon said, “Okay, we are ready for systemic heparinization.” The surgeon then looked at the student CRNA and said, “Can you let me know when it has been in for 2 minutes?” I watched the CRNA student grab her phone out of her pocket and start her timer. I thought to myself, “wow, that was quick.” Then, I looked at the back cart where I always put the loading dose to be given, and the syringe was still laying there. I spoke up immediately and said, “Wait, did you give the heparin?” The CRNA student then responded, “no, she is giving it” and pointed at the surgeon. I immediately spoke up and said there seems to be some confusion. Surgeons don’t give heparin (at least not that I’ve ever seen!). I’m very thankful I watched her, noticed the problem, and spoke up about it because we ended up needing to quickly convert to bypass because of the patient decompensating.
I recently taught a class of students in MSOE’s MSP program, and I told them, “If I can teach you one thing, it is to trust NO-ONE” just like your article talks about. 🙂 I told them to watch everyone and never assume!!!!!! I’m going to be sending them your article as well!!

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Perfusion Theory is an educational platform for the Oxygen Pressure Field Theory (OPFT). August Krogh’s theoretical concept of the oxygen pressure field is explained and then applied to clinical applications in perfusion practice.