 Hi there, my name is Chris Clay, I'm a 1976 graduate and still walking, still working actually in a lovely place in Tennessee. And I'm going to talk to you about some of the history of profusion that I experienced, and hopefully relate those experiences to the present, because I'm one of the living representatives of the past. I'm not filming this, are you? Oh yeah. Anyway, when I started, there were no safety devices, no alarms, no pressure monitoring, no ACTs, and no level sensors, none of that sort of stuff. So anyway, there was a three oxygenators. One was a hard shell called the Bentley Tentral and there were two bag oxygenators that looked like somebody had taken raincoat material and heat welded it with stainless steel sponges in it, and an aquarium that you could have bought at Woolworth's. I mean, seriously, we were dealing with aquarium air stones that cost $1.98. And so those were our three choices. The Bentley Tentral was so fragile because they didn't have the plasticizers right that if you hit it the wrong way with a clamp it would shatter like glass. I mean, it was just, you could break it with your hands. So that was a little scary. But anyway, I do remember one time the travel bag had a cuff above the air stone so that you could change the diameter of the oxygenating column. So you pumped up this cuff with a blood pressure thing, and the cuff would compress the oxygenating tube and make it bigger or smaller so you could increase the dwell time. So the blood would stay with the bubbles longer. Well, one time I was using that cuff and my cuff had a leak and I happened to be chewing some bubble gum. And so I took the bubble gum and plucked it on the outside of the cuff and pumped it up. And it looked great for about 30 seconds and then the bubble gum blew a bubble and popped and that was the end of that patch. So, we did a lot of that sort of stuff. I mean, talking about all these early days things, I mean I had an ant in the reservoir of my oxygenator once it was a sterile ant, but nevertheless when I primed it there was this black thing that was stuck in the plastic and it sort of floated up and I thought, what is that? Another time I had a piece of a stick that was also floating around because they used to glue the connectors onto these hard shell oxygenators. They weren't able to make injection molds that complicated. So literally they had people that they would pay to dip glue and stuff these things on so the arterial and the venus and the whatever. One day it takes us out all eight rooms were priming at the same time and we had a lot where the glue hadn't been put in. So we dumped the prime in and everybody's connections fell out and all the prime ran on the floor and there'd be ran in the middle and everybody was like, what? You know. So anyway, you have to imagine that kind of a life. We really, we really had it a little bit different. Oh, and by the way, Deb, my first yearly salary was 9,900. And Diane Clark was sent by Charlie Reed to give us a lecture and tell us, she told us with a straight face, do not take a job for less than $10,000 a year. And so we all sat there and okay, okay, I never let her forget that for 40 years I said, yeah, remember what you hired me at? 9,000. Anyway, but a serious moment. In 1979, you can look this up. It's an article that's easy to find. There was a 1979 survey done by a Dr. William Stoney, STO NEY. At that time he found that only 63% of the respondents used ACT. That means there's 37% of the people were just pumping and going. Yeah, winging it. And only 43% use level detectors. Not surprisingly, there were quite a few serious incidents, air embolism, clotting. I had a circuit clot completely on me. I was doing a tube, intermittently shaking it and sticking it in my underwear and shaking it, stopping timing it, you know, and I found out that my blood activated recalcification time was 164. And by that time, I heard this dreaded noise of the roller pump trying to pump clot. And that was the end of that. And even an open heart patient, it was a resuscitation effort. So there was massive blood loss. I mean, the blood was running off everywhere. And, you know, that's a situation that it took me three or four cases to realize that I had to compensate for the massive loss of heparin. Okay, you're thinking about the blood, the blood's all over and you see it, but you don't always necessarily think about losing your heparin at the same time. It's extremely important because as Jim said, our heparin is really not good quality. So if you experience a severe blood loss case, think about maybe grabbing your cell saver sucker and hooking it up and running at it flush. So in addition to the rate of one serious air embolism for 1000 cases, there were also nonpatient injury incidents in every three cases, every three cases there were some sort of ant in the reservoir stick, you know, whatever happened. I had one of those, I had one of those nonpatient injury episodes once I was sitting on a science heater cooler which you can Google it was a heater cooler that had a large, I don't know, basin part of it where you dump ice and it was a nice, it was a nice height for sitting on top of and watching students do this. So I was lounging because I had an advanced student and I was sitting on there, you know, watching her do this case and all of a sudden I had this kind of funny pinging coming from the heater cooler was like pinging pinging pinging weird noise. I started smelling hot wiring and I thought, well, this isn't very good. And then it really got loud and the electrical smell got really bad. And the heart long machine started looking like a pinball machine lights were like going off and then they're going on and the pump was stopping it was a roller pump. And it just was terrible. So I jumped off the burning heater cooler. My student was an advanced student so she grabbed the hand crank because back then we had zero batteries. I mean the batteries, there were no batteries. It was a hand crank. So she was a really good student and she grabbed her hand crank and started cranking the arterial knob for dear life which was somewhat difficult because when the power was off, the pump was designed to disengage the belt and so you could crank fairly easily. It was made to crank that way but when the power came back on she was like, you know, so Dr. Cooley looked over at that moment when she was going, and he said, get an orderly in here to crank the pump. And immediately I looked at him and I said, No, no orderly veto the orderly I can see him sucking the patient dry, going backwards, you know, just unimaginable things. So anyway, we finally figured that out and it was a typical problem in the early days to have very bad circuitry in the OR so we had the heater cooler and the pump plugged in the same circuit. Nowadays, I don't think any of you would even remotely think about doing that. It's one of the things you're taught. So one of the things you're immediately taught, you know, different circuits for everything. So we learned, we learned that. So these system failures taught us how to be creative. Okay, they taught us. And I think that's a hallmark of profusion as a profession and my colleagues that I know, they're the most creative people you can imagine. And they're always innovating. They're always, I can make that work. Sure. You know, just let me let me add it. I'll, I'll, I'll rig up something for you. You know, that's, I think our number one characteristic is that we're inventive and creative and we adapt and innovate. So, you know, there were a lot of really interesting things that we learned. For example, when we first started running membrane oxygenators the Cymed Colobos, we didn't have blenders. We just had these big tanks. And so we had to figure out, well, we don't have a blender what we don't want around 100% or two is too much, especially on babies. I mean we had, we had one membrane that was like a half of the little juice can it was the cutest little thing. So anyway, we learned that we could why and a room air pump head we can make a pump head and make it totally occlusive, and then why it into our oxygen tank source. And that would dilute it and then we could sit there and do the math and say okay we're at 60%, which is sometimes a little challenging because I'm not very good at math so, you know, so it was an interesting way to do it. And another thing that we learned is that a lot of the early cardioplegia sets had built in air chambers. Sarns made a cardioplegia set that had a little, you couldn't ever get the air out, it was supposed to be there and as you would pump. You can see what the pressure was even without looking at your pressure monitoring you could see by the compression of the air. You know. And so, if if I have an instance I hasn't happened in a long long time except on mission trips but if you have an instance where you don't have a pressure monitor, you can use a small air level. If the device will allow you to do that I wouldn't do that routinely but you know in an emergency or situation where you have no monitoring you can, you can tell how you're compressing your, your system. Another thing you can do is learn how to use your fingers, you know, make your own little wet lab and a clue to a fluid filled roller pump and learn to tell what the pressure is with your fingers. I mean when we had no pressure, we diagnosed dissections going on bypass by holding onto the arterial line and if it got stiff you were really in trouble somebody clamped it. You had a dissection so you know that that was a good way to do it so you know you have to get creative to overcome system failures. The other thing that I would tell you is if you have to do the improvisation that we all have to do sometimes or we think we have to do to make something better. Be sure that you consider all the aspects. This when we were running those SIMED membranes, we didn't get the result we wanted in terms of oxygenation so we called up Dr. Colobo. I mean who better to tell us how to run his membrane than the inventor so we called him up and he told us we should humidify the gases that that silicone membrane would function much better if we humidify the gases. What he didn't know is that we had an O2 filter in line between the gas source and where we're going to plug in the humidifier and there was also a safety valve on the actual bracket that held the SIMED that would pop off if there was excessive pressure. Well, so we humidified the gas everything looked like it was going great. You know Dr. Colobo was wonderful. And then I got ready to leave the hospital and I got this frantic call that the arterial lines turning black and I went running back up there. What happened is the O2 filter had got soaking wet because of the humidity and had over pressurized backwards and had popped off the safety valve and there was no gas. So we went from having some gas to having humidified gas which then ruined the whole situation. So yeah, you have to you have to consider all aspects when you're improvising something and one of my personal favorite perfusion stories had to do with the Slarnes heater cooler, which was the heater cooler that pumped 40 liters a minute. And then you could dump all kinds of ice in it. Well, Dr. Cooley was always always saying, can't you cool faster, you know, you're just too slow I think you all have heard all of this, many, many times. So I had what I thought was a brilliant idea. Sometimes I am brilliant on this occasion maybe not. I had this idea that if I wide into heater coolers, I'd still stay below the pressure limit, and everything would be wonderful I'd be pumping 80 liters a minute of ice water. Okay, so I filled them all up with ice. And then Dr. Cooley came in and it took up quite a bit of room with all the wise and the tubing and everything. He's like, what is this, you know, what is this? I said, oh, you're going to be so happy. It's just going to cool like the son of a gun. It's just going to be amazing. So I turned it on and sure enough I'm watching the patient's temperature going to do an arch aneurysm so we're going to like 15 degrees. I'm watching and boy those tents of a degree are just like, it looked like Las Vegas I mean they were just rolling around it was just like bing bing bing you know so anyway so I was so happy I just thought I was the queen of perfusion. I mean I was sitting there all puffed up just like, I'm so good. I heard this noise. And I thought, huh. And I turned around is this and I turned around just in time to see the lid from one heater cooler geyser ring off. And like a tidal wave coming towards me is this lid and this rush of water. And it hits the floor and there's water everywhere and the other machine is totally dry and going. It's like what is going on over there. And I'm like this literally tidal wave coming at me. And I was so embarrassed I had to shut the one off of course it was totally dry but I hadn't thought about the differential in the pump owners. It was brilliant, but this sound brilliant. So anyway, there I was with you know this one dry and for a whole rest of that semi long case I'm squishing around in the or on this water. Well it was really embarrassed. So anyway, I can keep you guys entertained with stories for hours. However, the main thing I would like to convey is. When you look at your older colleagues. Talk to them. Ask them for some of these silly stories that maybe will teach you something without having to go through the pain and the wetness of learning it yourself, you know, talk to talk to the old farts while they're still around and see what they have to say to you because there are some things that translate everywhere, you know, all these things that I learned that are just physical things, common sense things. You know they're great for mission trips, which I highly advise you all to do. I mean mission trips are the most wonderful thing in the world to do you get back to the reality of what you're actually doing. Life and when you go on a mission trip and you actually get to see somebody whose life is forever changed because you showed up. It's amazing. It's the best thing in the world. So congratulations to all of you that are going to graduate from the school it's a great place. It's, it's been amazing to be a tech Texas art graduate. I go around the room and I see people that I've known for decades and I'm really proud. I'm really proud to know all of you. So thank you very much. Thank you.