Very soon, many of us will be descending upon the city of Bristol to celebrate the 40th anniversary of the creation of our Society. Before some bright spark alleges anything to the contrary, it should be firmly pointed out that your Editor was still very much a schoolboy in 1974 when the Society’s inaugural conference was staged in Dublin. Nevertheless, having commenced my training at the London Chest Hospital some six years later, I feel that the occasion of our landmark Congress this year offers an ideal opportunity to reflect upon at least 34 of the past 40 years and to attempt to identify some of the more significant changes that have occurred in the perfusionist’s clinical and professional life during that period.
In 1980, the Executive Committee of the Society of Perfusionists (as the organisation was then known) existed in a form that was very similar to what we have in place today, i.e., we had a Chairman, a Secretary, a Treasurer and a Registrar, plus a number of committee members whose role it was to attend to various facets of general Society business. However, as far as governance, education and regulatory mechanisms are concerned, it is fair to say that that is where similarities between the professional landscape then and now end. The accreditation process was still years away, and in its place we had an education system – one that was not necessarily bought into by the entirety of the perfusion community, it should be noted – where students were enrolled upon a day-release course at one of a number of technical colleges dotted around the country to study general physiology, anatomy, biology and a smattering of perfusion in the company of an assortment of physiological measurement technicians working in cardiology, respiratory function and audiology, to name just three of the groups with which perfusionists were loosely associated in many people’s minds in the 1980s. As was pointed out in the last edition of Perfusionist, the late Andy Pastellopoulos, a long-time Secretary of the Society with a passionate and enduring dedication to the ethos of education, was largely responsible for the evolution that took place during the late 1980s and 1990s that culminated in the creation of the bespoke degree course that exists for today’s trainees.
Education is not the only area where huge leaps have been made during the last 30 or 40 years. While the modern perfusionist continues to practise in the absence of statutory regulation, our College manages and regulates the profession – albeit in a manner that is associated with voluntary compliance – with a rigour that many would argue would be seriously diluted were we ever to be embraced by a nationally-recognised regulator, notwithstanding the myriad other benefits that would be conferred upon us by dint of recognition in this way. (On this note, elsewhere in this edition we publish an edited version of a letter recently sent by Steve Robins to the Health and Care Professions Council, in which he articulates the definitive case for statutory regulation for clinical perfusion.) The efficiency with which Valerie Campbell, our College and Society Administrator, coordinates all of our professional and regulatory activity is something of which she and we are justly proud. On the other hand, in 1980 there was not even a voluntary register, which perhaps explains why everyone in those days was vaguely aware of cardiac units where perfusionists who had received little or no formal education or training (see above) were employed as part of a misguided attempt to ease recruitment difficulties.
It is not just the existence of the present-day Society and College that characterises the stark contrast between today’s perfusion world and that of the 1980s. Technically, the operating theatre, and in particular, the heart/lung machine, are vastly different today to what I encountered when I first walked into Theatre 1 at the London Chest in December 1980. In no particular order of importance, these are the changes that I believe have made the most significant difference:
• In 1983, Cobe Laboratories introduced the Cobe Membrane Lung (CML), the first single-pump integrated membrane oxygenator to be made available in the UK. Prior to this, virtually all cardiac units utilised bubble oxygenators, devices whose trademarks were remarkable efficiency and a guaranteed capacity to produce clinically significant haemolysis when the bypass run exceeded two hours. Furthermore, despite the new device’s undoubted superior sophistication in terms of materials and performance, Cobe shrewdly chose to sell it at roughly the same price that units were already paying for their “bubblers”. In one fell swoop, the complications caused by the fact that the very equipment that one had to use to instigate cardiopulmonary bypass was partially responsible for influencing a patient’s prognosis in terms of blood damage were largely eradicated.
• Today’s market is dominated by the presence of hollow-fibre membrane oxygenators whose design and construction are constantly being modified in an attempt to mediate the pyrexial effects of bypass. The systemic inflammatory response syndrome (SIRS) has not gone away but it is a phenomenon that is mentioned much less frequently during clinical audit than was the case in the 1980s.
• It was not until well into the late 80s, and for some units, the 90s, that deployment of arterial line filters, level detectors and bubble sensors became standard practice during bypass. While it is true to say that identification of the clinically significant advantages of the deployment of these strategies is far from straightforward in terms of outcomes, the fact remains that accidents can happen, and the manner in which we practise today almost certainly renders them less likely.
• Transoesophageal echocardiography (TOE) dominates the peri-operative management of cardiac surgery in most units today, having become mainstream in the course of the last 10 to 15 years or so. We are not in possession of definitive evidence that indicates that this tool improves our outcomes, but it is impossible not to suspect that mortality and morbidity statistics in the 1980s and early 1990s would have been different had clinicians then been in a position to modify surgical and pharmacological management in the manner that they do today on the basis of what they infer from TOE images.
• Perioperative anaesthetic technique and intensive care medicine have continued to evolve over the years, particularly in terms of patient monitoring, such that it is increasingly rare for clinicians today to find themselves having to manage care when not in possession of a patient’s complete clinical profile.
All of the above must surely account in some way for the fact that Society for Cardiothoracic Surgery data show that predicted risk for cardiac surgical patients over the last 30 years has risen steadily, while actual mortality has steadily decreased. It is inconceivable that the significant developments that have occurred within perfusion during that period regarding techniques, governance and education have not had a profound influence in terms of this phenomenon becoming a reality.
See you in Bristol