Master-Minding the Monster

by

Dr. Paul J. Friday, PhD


It is about to happen. It is finally going to happen. The patient Monster has decided to wait no longer and in two hours and 15 minutes you are going to have your first perfusion accident. Thirteen years of perfusion experience. Seven-thousand three-hundred and seventy-seven perfusion cases and nothing but minor flaws that have never truly contributed to the mortality or morbidity of a patient. You've even stopped counting. You're good. You have more letters after your name than you need. The esteem of your peers reinforces your conviction that there are few perfusionists who can do it better.

In an hour and 10 minutes you are going to put the tubing in backwards and pump air into the brain of a 45 year-old man. This will not be your fourth pump run of the day. It will not be an emergency stand-by from a failed angioplasty. It won't even be a Monday afternoon following a weekend of on-call after a 10 day stretch caused by the lack of staff perfusionists.

Your life is difficult. Your spouse didn't appreciate the dinner you cooked last night. Jim, your oldest son, got a 'D' in math and some idiot dented your fender in the hospital parking lot yesterday. At least the coffee tasted good and you'll be back for your third cigarette in an hour and a half. Dr. Seravangi is good and, even better, is fast, so you might get out early with just two SVGs scheduled, especially because the angiolab is down for renovation. Time to set up the pump. The checklist is completed. The sternum is cracked. Someone taps you on the shoulder-it's The Monster!

Last night your patient regained some of his faculties and he probably will live, but it is unknown how much damage has been done. How are you going to cope with the emotional ramifications of your perfusion accident?

If you are still reading this article, chances are that you have experienced one of the following three things:

  1. you've had an accident
  2. you know someone who has had an accident
  3. you fear The Monster

Whatever your relationship to the perfusion accident may be, it is important for you to understand two things before you attempt to cope with the situation.

First, the psychological effects of a perfusion accident are not based on the number of years of perfusion. It does not matter if the perfusionist is a student or a 15-year veteran of the OR. Rather, the effects of an accident on a perfusionist are more dependent on the variables of ego strength, tenacity and ability to learn and adapt.

Secondly, a perfusionist's reaction to an accident is much more a statement of the perfusionist than it is of the accident. The accident does not cause the reaction, rather, the reaction is reflective of the individual's self image and ability to cope. If the accident were responsible for the reaction, the reactions would be strikingly similar, which is not the case. I've witnessed an entire spectrum of reactions, from disillusionment at the lack of system-support which lead to a change of occupations, to a return to work the next day with little more than a mortality/morbidity conference with the Thoracic surgeon running the case.

Some perfusionists cannot reconcile the fact that they have made a mistake. When an accident occurs, the perfusionist has two choices: he can blame others for the failure-from manufacturer to surgeon and everyone and everything in between-or he can take responsibility for the event and become a better professional. The taking of responsibility of an event usually takes time, anywhere from six months to a year and a half based on my professional experience with perfusionists who have sought my help. Unfortunately, one of the results of a litigious society has been the tendency to force medical professionals into a defensive position. This often leads to a shifting of responsibility in an effort to protect them-selves. This reduces the level of 'open' learning, which is a non-defensive approach to change and growth. 'Closed' learning is more defensive and self-protecting in nature and tends to be less effective.

The perfusionist may require a period of adjustment before he or she can accept responsibility for the accident. During this period of adjustment a variety of behavioral changes may occur. The most severe surface from the moment of recognition of the event to 48 hours later. Few perfusionists who have had accidents who I have dealt with could sleep the night of the event, especially if the patient was still alive. This sleep deprivation accelerates and intensifies other emotional reactions, such as increased irritability, decreased appetite, forced or imagined isolation, rejection of emotional and physical support and a hesitancy to make decisions.

The rejection of support is both interesting and ironic. It is a form of self-punishment and is used psychologically to atone for a behavior that is ego dystonic. The person cannot align the behavior from his sense of self and therefore begins to punish himself for the behavior.

A perfusion accident not only affects the perfusionist, but also touches the people around him. Personal and domestic life is almost always affected by the accident. The perfusionist's spouse is often helpless in assisting the perfusionist in resolving the psychological effects of a perfusion accident. The emotional involvement almost always makes objectivity impossible. The rejection of support often alienates the perfusionist from his spouse, frequently causing a severe strain on the relationship.

Perfusionists often claim that their work is responsible for their alcoholism, marital discord, burnout and other life-stress responses. My therapeutic encouragement has always been to have the people with whom I talk take a hard look at themselves and to accept their behavior as statements of themselves and not their work. This 'owning' of responsibility is often difficult for all of us, but ultimately, I believe, our lives arc better for it.

A perfusionist who's had an accident may feel unable to cope with his psychological and emotional state alone. Frequently, there is the psychological sensation of isolation following an accident. Often, a visit to a psychologist for at least a couple of sessions following an accident is recommended to the perfusionists who contact me through the Crisis Intervention Program. It is the quickest and most efficient way that I have found to help a perfusionist to realign his sense of self following the incident. Everybody that knows the perfusionist is too emotionally close or distant from him to be objectively helpful. Their attempts at helping may actually hinder the coping process by inadvertently assisting the perfusionist in rationalizing the event. A psychologist who has been trained to deal with emotional problems has the skills to help the perfusionist gain perspective on the event and to place it within the larger context of the professional's life.

Counseling or therapy offered by a psychologist is usually a short term process. The length of time depends on the perfusionist and what he was like both before and following the accident. How the perfusionist deals with the accident immediately after the event can speed up the coping process. The following is a list of things a perfusionist can do if an accident has occurred:

  1. Write out in detail what occurred. For emotional reasons, it will help to keep perspective after rationalizing begins its natural flow. Your lawyer may also appreciate this exercise in objectivity.

  2. Find somebody objective to talk to. You don't need "should have" at this point. Those who love you will see your perspective and, ironically, you will unconsciously reject their support. Those who are neutral can be persuaded to your perspective. Those who have vested interests will be either for you or against you depending on what they have to gain. Your overwhelming sensation will be that you are alone.

  3. Get back into the OR sometime between 48 and 72 hours after the accident. You'll need some time for calming and perspective, but too much of a pause will help your guilt feed on your good qualities. Balance is the key and a strong sense of your own limits and capabilities will be your best guide. Of course, the sensitivity and level of paranoia of the system in which you operate may have a strong influence on the timing of your return to the OR.

  4. Don't rationalize. (See number 2 above.)

  5. Emote - alone and with others. Expressing emotion has both a physical and emotional benefit for the grieving. The loss of a perfusionist's invulnerability is surely the partial death of the ideal self and permitting emotion to flow will help the healing process.

  6. Wait for time to squeeze ever so slowly between you and the event.

  7. Attempt to place the accident into the context of the following three things:

  8. Don't think that you can ever get rid of The Monster - it comes with the territory.

Dr. Paul J. Friday is a licensed psychologist in Pennsylvania and is currently Chief of Clinical Psychology at Shadyside Hospital in Pittsburgh. Eleven years ago, Dr. Friday addressed his first AmSECT convention in Chicago. He has published numerous articles and has addressed medical societies throughout the country and abroad on a variety of psychology related subjects. Five years ago, Dr. Friday began his voluntary coordination of the Crisis Intervention program for AmSECT and has assisted numerous perfusionists in obtaining the help necessary to adjust to the stress of a perfusion accident.