All-RN cardiac perfusion team
It was the search for a daytime job that prompted Donna Pratt to accept the job of cardiac perfusionist at New York University (NYU) Medical Center 8%years ago. Today, she heads a cardiac perfusion team of six registered nurses and works days, as well as evenings and nights. The concept of an all-RN cardiac perfusion team is unique in a field dominated by male technicians. The team a t NYU Medical Center may well be the only all-RN team in the country. “The hours,” Miss Pratt explains, “are subject to gross change. One reason is that we follow cases as opposed to shiftwork.” Speaking for other members on the team, Miss Pratt says, “Basically the flukey hours suit our personalities. We get bored by routine. Today, for example, I’m on second call and was scheduled to come in at 8:30 am. Last night we changed that to 11 am. A t 10 am, they said ‘take your time’ so I came in a t 11:30 am. Now, it’s possible we’ll be doing a total body washout on a patient with hepatitis a t Bellevue so we expect to go through the night as that is a lengthy procedure and requires three perfusionists.” Under a contractual agreement, the
cardiac perfusion team from NYU Medical Center, a private institution, also pumps for cases a t geographically adjacent Bellevue Hospital Center, a public city institution. In answer to the question, What can a nurse do that a technician can’t? Miss Pratt responded, “Our style of pumping is different than in a lot of places. Here, the perfusionist is responsible for medications so he or she has to be an RN. We give bolus doses of medications according to a written protocol or verbal orders. These may include Aramine, Thorazine, Regitine, vasodilators, or whatever else the patient’s blood pressure may require. We don’t just run so many cc’s per minute of blood going through the arterial pump head; we also give medications.” She explains that pump technicians are usually directed by a n anesthesiologist who is in charge of medications. “I also consider a n IV a medication,” Miss Pratt says, “and to keep a proper level in a n oxygenator requires that you continually add IV fluids.” She explains that the nurse also keeps a minute-by-minute record of the patient’s response during the case. “Many people say running a pump is routine, but I can tell you it isn’t,’’ Miss Pratt says. “Every patient reacts
AORN Journal, December 1975, V o l 2 2 , No 6
1025
Donna Prali heads an all-RN team of cardiac perfusionists at New York University Medical Center. Other members of the team are Roberta faden, Connie Bozic, Judith Brand, Mary Nizabeth Turner. and Dorothy Williams.
differently when you put them on a pump, and it’s anything but routine to hit the ideal situation for each patient. You don’t just say, ‘I want a mean arterial pressure of 70.’ You find out what the patient’s normal blood pressure is and apply everything you know t o achieve that.” In hiring a nurse perfusionist, Miss Pratt looks for someone with three to four years experience either in a coronary intensive care unit or cardiac operating room. Combined experience of her current staff includes coronary intensive care unit, supervision of open heart surgery, cardiac scrub nurse, hyperbaric nursing, and charge nurse of night surgery a t the NYU Medical Center . Basically, a member of the team is required to understand normal and pathological physiology of the cardiac patient and be able t o apply what they know about physiology and cardiovascular, pulmonary, and endocrine disease to what they are doing on the pump. Miss Pratt says, “They also have to know a lot about anesthesia and be strong on mechanical ability to
1026
understand the plumbing and electrical aspects of operating the pump.” The cardiac perfusionist also has to be aggressive. Miss Pratt says the person running the pump is basically keeping the patient alive while the surgeon is doing his “fancy stitching. If he doesn’t hear what you tell him you all may be heading for disaster. You can’t just sit there and say, ‘I’m sorry,’ because a patient’s life is a t stake. You have to be aggressive enough to say, ‘This is the way I see it, what’ll I do?’ or ‘You’ve got to help me out,’ or if the need arises, ‘Doctor, I comprehend things differently.’ ” Miss Pratt has never worked with a technician but has seen them work. In answer to the question, Are technicians, usually men, more aggressive than nurses? Miss Pratt concedes, “I suppose they are, they’ll say what they feel is right or wrong.” Training for Miss Pratt’s team is on-the-job, and it takes about six months for a perfusionist to be proficient to pump a n adult. “I don’t put them on call until they have been here for about a year,” Miss Pratt explains. “By then they can handle children, adults, and every kind of case. I re-
AORN Journal, December 1975, Vol 22, N o 6
quire this long period of supervision because I want them to react and do routine things, like filling the oxygenator, almost like a robot. It has to be this way because if the patient is a true emergency-subacute endocarditis and a blown out aortic valve, for example-and has something else wrong such as diabetes or hypertension, you have to be able to concentrate on that problem and do the routine things without really thinking too much about them.” Miss Pratt explains that when the patient goes on the pump, everything happens so fast. “An oxygenator, for example, can empty in 10 to 15 seconds depending on what your flow rate is.” When Miss Pratt began her career as a cardiac perfusionist in 1967, NYU Medical Center was doing about 125 open heart cases a year and had two RN perfusionists. In 1970, four more RNs were added. By 1974, the case load increased to about 800. In 1975, the team pumped for 1,000 cases, or a n average of three per day. “The increased load has forced us to schedule our time better,” Miss Pratt says as an understatement. The perfusion team is supervised by three persons: OR Director Catherine Smith for personnel and payroll matters; Clinical Director of Cardiovascular Surgery George Reed, MD, and Frank Cole Spencer, MD, chairman of the departments of surgery at NYU Medical Center, Bellevue, and Veterans Administration hospitals, for clinical or teaching matters and equipment procurement. The average age of a member on Miss Pratt’s team is 32 years. “We do our job because we like it,” she says, explaining that starting pay is comparable t o the salary of a n assistant head nurse in a private hospital in New York City. Team members take call for one week at a time and must
1028
live within 15 minutes of the hospital., Absenteeism on her team is almost nil except for bona fide illness. “I require they come in and let me see how sick they are before granting sick leave,” she quips. And the turnover? “We request they stay at least three years. If they last the first two months of training, they usually stay four to five years,” Miss Pratt explains.
Rose Marie Lee, RN Nurse editor
Lung control in open chest surgery A method of preventing collapse of lower
lungs and improving oxygen and blood flow during open chest surgery has been accomplished by University of North Carolina medical school researchers using a small system of tubes and valves that cause a positive pressure to be developed. David Brown, MD, and Virgil Roberson, MD, and their coworkers have developed and tested a device that enables anesthesiologists to give patients less than 100% oxygen during certain types of lung and heart surgery. Most often anesthesiologists must use 100% breathing oxygen to maintain levels high enough to prevent tissue damage. But the use of 100% oxygen limits the type of anesthesia that can be administered and the anesthesiologist’schoice of drugs. This might prevent some patients from having a needed operation. By enabling the anesthesiologist to breathe a patient with 40% to 50% oxygen during certain types of lung and heart surgery, a wider and safer range in choices of anesthetics and drugs is available. The Brown-Roberson selective PEEP (positive end-expiratory pressure) circuit is used to bring about a better distribution of blood and oxygen in the lungs and keep the levels normal. A double bore tube is inserted in the patient‘s windpipe. One opening goes to the upper lungs and the other to the lower lungs.
AORN Jortrnal, December 1975, Vol 22, No 6
It was the search for a daytime job that prompted Donna Pratt to accept the job of cardiac perfusionist at New York University (NYU) Medical Center 8%years ago. Today, she heads a cardiac perfusion team of six registered nurses and works days, as well as evenings and nights. The concept of an all-RN cardiac perfusion team is unique in a field dominated by male technicians. The team a t NYU Medical Center may well be the only all-RN team in the country. “The hours,” Miss Pratt explains, “are subject to gross change. One reason is that we follow cases as opposed to shiftwork.” Speaking for other members on the team, Miss Pratt says, “Basically the flukey hours suit our personalities. We get bored by routine. Today, for example, I’m on second call and was scheduled to come in at 8:30 am. Last night we changed that to 11 am. A t 10 am, they said ‘take your time’ so I came in a t 11:30 am. Now, it’s possible we’ll be doing a total body washout on a patient with hepatitis a t Bellevue so we expect to go through the night as that is a lengthy procedure and requires three perfusionists.” Under a contractual agreement, the
cardiac perfusion team from NYU Medical Center, a private institution, also pumps for cases a t geographically adjacent Bellevue Hospital Center, a public city institution. In answer to the question, What can a nurse do that a technician can’t? Miss Pratt responded, “Our style of pumping is different than in a lot of places. Here, the perfusionist is responsible for medications so he or she has to be an RN. We give bolus doses of medications according to a written protocol or verbal orders. These may include Aramine, Thorazine, Regitine, vasodilators, or whatever else the patient’s blood pressure may require. We don’t just run so many cc’s per minute of blood going through the arterial pump head; we also give medications.” She explains that pump technicians are usually directed by a n anesthesiologist who is in charge of medications. “I also consider a n IV a medication,” Miss Pratt says, “and to keep a proper level in a n oxygenator requires that you continually add IV fluids.” She explains that the nurse also keeps a minute-by-minute record of the patient’s response during the case. “Many people say running a pump is routine, but I can tell you it isn’t,’’ Miss Pratt says. “Every patient reacts
AORN Journal, December 1975, V o l 2 2 , No 6
1025
Donna Prali heads an all-RN team of cardiac perfusionists at New York University Medical Center. Other members of the team are Roberta faden, Connie Bozic, Judith Brand, Mary Nizabeth Turner. and Dorothy Williams.
differently when you put them on a pump, and it’s anything but routine to hit the ideal situation for each patient. You don’t just say, ‘I want a mean arterial pressure of 70.’ You find out what the patient’s normal blood pressure is and apply everything you know t o achieve that.” In hiring a nurse perfusionist, Miss Pratt looks for someone with three to four years experience either in a coronary intensive care unit or cardiac operating room. Combined experience of her current staff includes coronary intensive care unit, supervision of open heart surgery, cardiac scrub nurse, hyperbaric nursing, and charge nurse of night surgery a t the NYU Medical Center . Basically, a member of the team is required to understand normal and pathological physiology of the cardiac patient and be able t o apply what they know about physiology and cardiovascular, pulmonary, and endocrine disease to what they are doing on the pump. Miss Pratt says, “They also have to know a lot about anesthesia and be strong on mechanical ability to
1026
understand the plumbing and electrical aspects of operating the pump.” The cardiac perfusionist also has to be aggressive. Miss Pratt says the person running the pump is basically keeping the patient alive while the surgeon is doing his “fancy stitching. If he doesn’t hear what you tell him you all may be heading for disaster. You can’t just sit there and say, ‘I’m sorry,’ because a patient’s life is a t stake. You have to be aggressive enough to say, ‘This is the way I see it, what’ll I do?’ or ‘You’ve got to help me out,’ or if the need arises, ‘Doctor, I comprehend things differently.’ ” Miss Pratt has never worked with a technician but has seen them work. In answer to the question, Are technicians, usually men, more aggressive than nurses? Miss Pratt concedes, “I suppose they are, they’ll say what they feel is right or wrong.” Training for Miss Pratt’s team is on-the-job, and it takes about six months for a perfusionist to be proficient to pump a n adult. “I don’t put them on call until they have been here for about a year,” Miss Pratt explains. “By then they can handle children, adults, and every kind of case. I re-
AORN Journal, December 1975, Vol 22, N o 6
quire this long period of supervision because I want them to react and do routine things, like filling the oxygenator, almost like a robot. It has to be this way because if the patient is a true emergency-subacute endocarditis and a blown out aortic valve, for example-and has something else wrong such as diabetes or hypertension, you have to be able to concentrate on that problem and do the routine things without really thinking too much about them.” Miss Pratt explains that when the patient goes on the pump, everything happens so fast. “An oxygenator, for example, can empty in 10 to 15 seconds depending on what your flow rate is.” When Miss Pratt began her career as a cardiac perfusionist in 1967, NYU Medical Center was doing about 125 open heart cases a year and had two RN perfusionists. In 1970, four more RNs were added. By 1974, the case load increased to about 800. In 1975, the team pumped for 1,000 cases, or a n average of three per day. “The increased load has forced us to schedule our time better,” Miss Pratt says as an understatement. The perfusion team is supervised by three persons: OR Director Catherine Smith for personnel and payroll matters; Clinical Director of Cardiovascular Surgery George Reed, MD, and Frank Cole Spencer, MD, chairman of the departments of surgery at NYU Medical Center, Bellevue, and Veterans Administration hospitals, for clinical or teaching matters and equipment procurement. The average age of a member on Miss Pratt’s team is 32 years. “We do our job because we like it,” she says, explaining that starting pay is comparable t o the salary of a n assistant head nurse in a private hospital in New York City. Team members take call for one week at a time and must
1028
live within 15 minutes of the hospital., Absenteeism on her team is almost nil except for bona fide illness. “I require they come in and let me see how sick they are before granting sick leave,” she quips. And the turnover? “We request they stay at least three years. If they last the first two months of training, they usually stay four to five years,” Miss Pratt explains.
Rose Marie Lee, RN Nurse editor
Lung control in open chest surgery A method of preventing collapse of lower
lungs and improving oxygen and blood flow during open chest surgery has been accomplished by University of North Carolina medical school researchers using a small system of tubes and valves that cause a positive pressure to be developed. David Brown, MD, and Virgil Roberson, MD, and their coworkers have developed and tested a device that enables anesthesiologists to give patients less than 100% oxygen during certain types of lung and heart surgery. Most often anesthesiologists must use 100% breathing oxygen to maintain levels high enough to prevent tissue damage. But the use of 100% oxygen limits the type of anesthesia that can be administered and the anesthesiologist’schoice of drugs. This might prevent some patients from having a needed operation. By enabling the anesthesiologist to breathe a patient with 40% to 50% oxygen during certain types of lung and heart surgery, a wider and safer range in choices of anesthetics and drugs is available. The Brown-Roberson selective PEEP (positive end-expiratory pressure) circuit is used to bring about a better distribution of blood and oxygen in the lungs and keep the levels normal. A double bore tube is inserted in the patient‘s windpipe. One opening goes to the upper lungs and the other to the lower lungs.
AORN Jortrnal, December 1975, Vol 22, No 6
