Sterile cockpit or not: It's all about team and effective communication

Abstract

In the February 2010 issue of this Journal, an article appeared discussing the impact of protocol-driven communication during cardiopulmonary bypass. As the authors pointed out in their summary, the cardiac surgical operating room is an intense environment with significant complexity and a cadre of well-meaning, continuously multitasking individuals. Although the check and balance system designed for patient safety has proved its merit through the years, there is a difference in terms of effective reactive communication versus proactive communication for a surgical team. Therefore the ‘‘sterile cockpit’’ philosophy, although useful may not be broadly applicable to critical time rather than critical events. Of interest was the discussion after the article. In response to a question related to breakdowns in communication between surgeons and perfusionists, Dr Sundt relayed a recent experience involving activated clotting time management. As a perfusionist, I was pleased to read Dr Sundt’s reply, because it presented a reality that many of my peers have been concerned with for some time. As Dr Sundt digressed into their change in heparin administration protocol, it was recounted that after protocol change, initiation of cardiopulmonary bypass without even the administration of heparin had almost occurred several times. This being concern enough, what I found even more alarming was the perfusion response: ‘‘Well, Dr So-and-So goes on CPB without asking what the ACT is.’’ Further, Dr Sundt went on to say after questioning such perfusion conduct, ‘‘The perfusionists are not personally at fault—this is the culture in our institution.’’ That may be so, yet I find the perfusion response old, tired, an attempt to shift responsibility or defer responsibility, and not contemporaneous with what perfusion practice in 2010 should be. Likewise, I have experienced a situation when an eager young medical student was observing for the first time an open cardiac surgical procedure. With eyes wide, he asked the surgeon during cannulation ‘‘Is that the heart–lung machine behind you?’’ only to hear the following: ‘‘Mr Rosinski will tell you that it is extracorporeal circulation with artificial oxygenation involving systemic anticoagulation, myocardial arrest and reperfusion. But it’s just a pump.’’ Clearly more than operating a pump is occurring during bypass. There