I am indebted to Ian Johnson and his colleagues on the Safety Committee for providing the copy that makes up most of this edition of Perfusionist. Since its formation, the Committee has kept the perfusion community comprehensively updated in terms of safety alerts and good practice advice, and has consistently encouraged a culture of transparency and integrity regarding the identification and deconstruction of safety issues surrounding clinical perfusion practice.
For the small number of us who trained in the early 1980s and who are still practising today, it is very obvious that perfusion safety is an area that currently receives the kind of dedicated attention that did not exist in the same form when we were students. This is not to say that practices in those dim and distant days were associated with a plethora of untoward incidents, but merely to acknowledge that the sophisticated systems of today had not yet been developed and that risks that appeared trivial or acceptable then would come with the equivalent of a government health warning nowadays. Bear in mind the fact that this was the era of bubble oxygenators (Nescot students, I know that you have received exposure to these devices during your history lessons) – when arterialised blood was pumped directly from an arterial reservoir into the ascending aorta – and that most of us had yet to incorporate any form of level sensor, bubble detector or arterial filter into our circuits. Little wonder that one of my senior colleagues was moved to comment some years back that running a bypass in those days was akin to bareback horse-riding.
It is also interesting to recall that, in many respects, perfusionists’ attitudes towards risk-taking and onerous workloads in the 1980s were poles apart from the general state of mind that prevails today. This was encapsulated by a chapter contributed by Dereck Wheeldon to a volume entitled Towards Safer Cardiac Surgery (1981) – albeit a contribution that swam against the tide somewhat, in terms of its being critical of a kind of machismo that existed in some quarters at the time – in which he drew attention to the fact that some perfusionists were refusing to entertain the idea of including arterial filters in their systems on the grounds that such a “concession” would represent an undermining of the perfusionist’s “technical virility”. Whatever one thinks about the efficacy of arterial line filtration as far as its effect on neuropsychological outcomes is concerned, it is clear that attitudes such as this would be considered borderline Neanderthal by the majority of today’s practitioners.
A review of the above volume written by Ralph Sapsford in 1981 pointed out that “The literature [at this time]…is almost devoid of a comprehensive review of the dangers and the risks to the patient [associated with cardiac surgery and cardiopulmonary bypass].” The existence of the Society’s Safety Committee, for one thing, and the multiple safety systems inherent to all modern cardiopulmonary bypass systems, for another, serve as unequivocal evidence that we have come a long way in thirty-odd years in this respect. Yet there remains a suspicion amongst a few within our community that the infrastructure that promotes safety by way of technology and perfusion governance may not prevent some workers from being “conservative” when it comes to disseminating details of safety-related incidents within their own units to fellow professionals practising elsewhere in the UK. In a letter in this edition of Perfusionist, Martin Hargrove suggests as much, citing anecdotal evidence of perfusion incidents in some units that may not have been formally reported and documented. There is perhaps little to be said about this assertion that can come reinforced with any real authority, other than to comment that an inclination to protect the reputation of one’s institution by covering up what might be perceived as bad news, while debatably indefensible in terms of educating the wider perfusion community, is a state of affairs with which most of us can at least theoretically empathise, if we are to be completely honest with ourselves.
Discussing this issue brings to mind the subject of local incident reporting within individual units: depending upon where you work, it seems that sometimes you just can’t win. If you are a member of a department that rarely fills out incident reports because you are rarely involved with incidents that, in your opinion, warrant formal documentation, your Risk Management department may suspect a cover-up. On the other hand, if you resolve to report each and every occurrence that represents a deviation from strict protocol, no matter how minute that deviation may be, you run the risk of being subjected to unwanted and unnecessary scrutiny on the grounds that yours is a department that is not taking safety seriously. The answer, of course, is to identify a responsible and practicable middle ground, which is clearly not easy for anyone.
Perhaps one of the most important things to point out about the mechanisms that have been put in place by the Safety Committee is the fact that the release into the public domain of information from perfusionists regarding incidents and safety is characterised by strict anonymity, which should, in theory, be enough to quell fears regarding potential reputational repercussions. With this protective device reassuringly established, the way is clear for all of us to benefit from the advice and warnings that have been volunteered by our colleagues. Trainees, in particular, should be made aware of the Safety Committee’s postings on the Society website, mindful as they should be of how important it will be for them to demonstrate their proficiency in terms of safety during their practical examinations.