 I'm proud to be welcomed back to the Texas Heart Institute profusion conference again this year and want to thank everyone affiliated with the program who extended me that invitation and before I get started with my presentation I want to make certain everyone is aware I have no declarations, no conflicts of interest and no disclosures. The topic that I'm speaking on is the microbial world, essentially dust to dust. I invoke the term dust to dust since it is relevant to the soil microbiologists who were approached in the 1930s through the 50s to develop a antibacterial agent that can treat tuberculosis and they felt like if you wanted to understand the tuberculin bacilli you had to go to where it lived in the soil and they felt like you would better understand the microorganism if you researched it in its world as opposed to in a Petri dish of broth or what have you or attest to. Salman Wachsman was one of the great scientists at Rutgers University who researched the soil bacteria for these various disciplines in science. He invoked the term Ecclesiastes scripture that stated the Lord have created medicines out of the earth and he that is wise will not abhorred them and Salman Wachsman went on to win the Nobel Prize in medicine for the discovery of streptomycin just so you know and he wrote a wonderful book if you haven't read it my life with the microbes it's a fantastic read if you have an interest in the history of the treatment of microorganism. The title of his poem here a speck of dust is at the end of the book there's several verses but I utilize the last verse which reads I am that speck from the beginning of time to the end of time that tiny speck in eons of time that flicker of life that has let left its trace upon the course of life the significance of which in this universe of time it's still to be unraveled and so that sets the tone for the modern pandemic that we're in there's much we don't know and much we still need to know and I feel like this slide represents the mood of the nation today when you look at the devastating reality and our fallen heroes both medical professionals and our fellow citizens and there's no hospital administration no medical staff no first responders that were prepared for what the scene is in the upper left where the streets of Brooklyn right outside the hospital in New York were just congested with ambulances and if you look at the picture on the left sadly 88 nurses that I know of have succumbed to the coronavirus and I think the image on the right where the healthcare providers are now in prayer invoking all the arsenal that they have available to them from the medical treatments and therapeutics to protection to prayer in their battle against this horrible disease 1.7 million today have been infected they're now we're now approaching 100,000 deaths and if you feel sometimes you don't have friends think again you have trillions although you also have trillions that potentially can harm you but our world is dominated by microbes the microbial cells on earth number around a no-nillion outstripping the imagination of our minds and exceeding the estimated stars in the universe they outnumber human cells 10 to 1 and up around 2 pounds of our total weight and if you look at the greater understanding we have today than when I took microbiology bacteriology and all the last science courses they understand the human very own today much better and these images the one on the left is an Impressionist art poster that shows us basically as a walking Petri dish with broth in our body or a test tube carrying all these microorganisms that are both advantageous and disadvantageous to us and we all know they live in in us and on us they live on the skin in the blood and then of course in our respiratory tract and gastrointestinal track and we're learning much more every day of the relevance in cardiac surgery and other health care considerations about the gut and how important it is and related to the brain we have good the bad and the ugly and there's no more impression of a slide than the one on the right the Corona alert with the Corona cells floating in their space their world and the emphasis on PPE and protecting oneself and then the bacteria we have good and bad and we wouldn't have wine cheese or bread to enjoy if it wasn't for the good bacteria and the human microbiome and this slide on the right it reveals numerous species of microorganisms that reside in our bomb in our major organ systems and then on the left you see a slide emphasizing the microorganisms that can be both deleterious and beneficial to the human. We're presently in a state where I feel like we're transitioning from the multi-decade focus of killing all bacteria with soaps detergents antibiotics and heart sanitizer how many times were you called to the dinner table and first instructed to wash your hands and then we try to create a environment where we feel like we're free of microorganisms and yet I'm not so sure that's the total direction to go some good some bad but we're shifting into maybe what might be a greater understanding of this antibacterial obsession we encountered into a world where we understand more greatly the microbial ecosystem and it is now linked to allergies of obesity coronary artery disease and so our microbial world we have a lot of room and work to improve bone in terms of understanding and life in a world without microbes was a question posed to Louis Pasteur and Louis Pasteur answered this query life would not long remain in the absence of microbes and of course Natal and Thurfelder and others wanted to try and prove him wrong with the no-toe biotic life and I call it that gut feeling what happened is they proved that you could take guinea pigs and place them in a microorganism free environment and they would survive but yet there was a myriad of problems in mental health and other interactions with the gut microbiome and neuro physiological health that manifested itself as a consequence of that environment and it connects the dots between your gut bacteria and the mood you're in it influences how we feel thinking are we having a good day bad day or good encounter bad encounter or whatever and so the area that I think we really need to gain more knowledge of is actually in the gut and I've done some studies on that in cardiopulmonary bypass and cardiac surgery and the inflammatory processes that mediate because of the poor perfusion to the gut at times so it's a very important topic then Lee and how discovered the microscope in 1675 he was a draper researching threads materials dyes and other components that made up his vocational world and one day out of curiosity after he had developed his microscope pictured on the right there and I have a replica of this microscope and I can't hardly see through it I don't know how he did he he observed tiny bacteria through this device so it's just amazing what his eyes were able to see and then I'm both this slide into the presentation innovation beyond the microscope the tank respirator or what you might more commonly know as the iron lung fill up drinker senior develop this system utilizing an electric motor and two vacuum cleaners to control the pressure in an airtight environment for the purpose of treating individuals afflicted with the polio virus more more prominently children but adults as well I had the experience with working with these systems in the 1970 and you see emerson's improvement in the top left photograph of working with the iron lung it had window portals and things like this that could allow the health care professionals to interact with the patient while they were in there providing them comfort and care and then he's pictured on the right with his son Phil drinker junior who was very prominent working with Robert Bartlett to develop at most systems developing a silicon polymer membrane and just for a brief borrow inside 2,500 years experience the plague of Athens took the lives of 100,000 people the citadies wrote the principal reaction of the people was fair and despair such that most of the in afflicted died in isolation alone and uncared for you strike alone and uncared for in today's pandemic and yet we hear quite a few prominent complaints from the public and understandably that they can't be with their loved one who is isolated and it makes an emotional impact on them looking at the Antoine small catpox pandemic and the plague of justinian and black death plague millions and millions and hundreds of millions of people died in a period where they didn't understand the diseases isolation they didn't have medications and so on and so forth and if you look back in the history of humanity most escape a great example in the town moved after the exodus when he probably could be considered the first public health official and microbiologists he taught his people how to live and live cleanly and freely and then the first human virus discovered was the yellow fever in 1901 it was confirmed in 1901 although Carlos Finlay proposed the concept that a vector in the form of a mosquito was transmitting this virus to humans and researchers at Columbia University Medical Center confirmed his suspicion about 21 years later and if you look at hepatitis B though it's a human virus 1967 it was discovered DNA extracted from a prehistoric human tooth revealed that hepatitis B has been infecting humans for at least 7,000 years or more and it's the oldest human virus to be sequenced and today 800,000 people died annually and there are 250 million infected with the virus today as we speak and you see on the map on the left this is where the discovery of all the oldest human research sites took place in archaeology and isolated the virus in ancient bones our list just keeps growing and growing in the microbial world you see the Marburg virus Ebola HIV influenza and all of us are familiar with the SARS and MERS and H1N1 it has impacted our profession greatly and what I want to emphasize here every generation of perfusionist understands their role their place in time in history and the fact of the matter is these people today the younger generation are making their mark and they will never forget this experience and you cannot overemphasize the topic of transmission by other direct or indirect contact large droplet sprays measure about 100 microns and carry enough sufficient momentum to deliver a direct hit on the respiratory mucosa and if you look in the bottom left you see the particle sizes that can A be inhalable and enter the lungs B respirable penetrating deep into the lungs and then the bottom particle the one micron size can penetrate all the way to the alveoli so aerosols for the remainder of this presentation will be a great emphasis that I emphasize in the control of these viral containing containing droplets and in relevant to our present coronavirus June Almeida actually discovered the coronavirus in 1964 she was a high school dropout at the age of 16 but went on to become one of the world's greatest electron microscopic examiners and she described a round grey dot covered in tiny spokes and noted that the pegs form the halo around the virus much like the sun's corona and how corona spread in a single restaurant before we learn the social distance if you look at the table setting on the left there's a yellow dot with a red circle red that's the first known to infect anyone in a public place in a restaurant and you see all the others that were infected we can't forget Legionnaires disease non tuberculin Michael bacteria all these other vehicles of disease that have affected us in our lifetime and the heater cooler incident where non tuberculin Michael bacteria was exposed to patients undergoing cardiac surgery unknowingly and in the exhaust system so aerosolization is very important PPE as far as the armature of safety and precautions is critical but in periods where intubation broncholavage bronchoscopy mechanical ventilation exhaust gas oxygenator exhaust gas endotracheal suction those are key periods where you're most predisposed to the risk of exposure to aerosol borrow micro organisms and of course transporting in a setting of whatever the case may be in house rotary fixed wing whatever and then quarantining hardware after deep cleaning for 30 days so those periods are very critical for us to understand and I want you to think about this slide as I begin to conclude COVID-19 around the world has experienced 966 patients place on ECMO in the United States 380 with 51% survivors that's pretty impressive because ECMO at first was considered a contraindication to use for treatment of COVID-19 because a group in Japan had experienced aerosolization in their institution and knowing what we now know I don't think this coming Valentine's Day is going to be like we've experienced in our life up to now there's not going to be any hugs and kisses are going to be the shields place that our culture is going to transition to a new environmental safety program that will probably decline kissing as a practice you won't see George Mendoza or Greta Friedman kissing in the streets of New York he grabbed her thinking she was a military nurse she was just a dental hygienist walking home and he grabbed her and planted a great big kiss on her it's the iconic image of the Japanese surrender during World War two and I don't want to get to the point where our famous artists have to place masks on such figures like the Mona Lisa's of the future and then that touchy feely thing we may want to rethink Lala given in 1929 wrote up a paper that pervade the message that hands are agents of bacterial transfer and she promoted the concept of shaking hands like the Chinese did but putting their two hands together and motioning and jashers of welcome kissing has been around since the 14th and 15th century BC handshaking has been around at least since the period of Homer in the Elliott and the Odyssey where he made numerous references to handshakes and at this moment this concludes my microbial world presentation and I look forward to any questions anyone may have in the future and what I would like to do summing up is recognize a dear friend of mine in memory of Sal Garico. Sal was at the Academy meeting this past year and I asked him point blank how are you feeling how are you doing and man he made me impressed that he was feeling great and we actually inducted him into the American Academy as an honorary fellow this past year he didn't know that we were going to surprise him at our next meeting and one thing Sal did emphasize to me he was so thrilled that David and Michael Duncan who are both retired now as surgeons from Texas Art reached out to him carried him to lunch and it just boosted his moral his morale and spirit very greatly he told me he thought it was a wonderful experience and then lastly how did I honor Terry Crane Terry made the impression on me of the great instructor teacher engineer and safety expert that he is from the very moment I met him and I met him in 1981 Terry is pictured here with his wife Marilyn and of course his daughter Jessica is a profusionist in San Antonio and her child with Dr. Cooley I wish Terry all the best in his retirement hope he enjoys life to the fullest with all this great family and the other thing I want to say Terry don't you dare become absent from our profession we still need you you step back and come in anytime and share your wonderful knowledge and life with us thank you