Speaker 1: Bringing you conversations with leaders within the operating room and health care community, this is Scrubbing In.

Todd Schlosser: Hello! And welcome to this episode of Scrubbing In, a podcast powered by Specialty Care. I’m Todd Schlosser, and today my guest is Charles Yarnall, national clinical specialist of perfusion, and chief perfusionist at Abington Hospital Jefferson Health. In this conversation, Charles and I discuss how he began his career in perfusion, how to manage stress during high stakes surgery and how vital trust and communication is in an operating room, enjoy the conversation.

Thank you so much for joining us on Scrubbing In, I am Todd Schlosser, your host and joining me today, is Charles Yarnall, who is our national, clinical specialist. And chief perfusionist at Abington Rural Hospital, for the first time.

Charles Yarnall: Nice to be here Todd.

Todd Schlosser: Thank you very much for joining us today, I really appreciative it.

Charles Yarnall: You’re welcome.

Todd Schlosser: So I wanted to talk to you today, a little bit about your background and what led you into where you are now, and also some unique relationships that develop because of your position, but I wanted to start out with, what got you into the medical field, what was it that drew you to that as a career choice?

Charles Yarnall: Well, actually more than 25 years ago, I was actually interested in going into nursing program, at the time. I was actually at Temple University, I was putting in my time, learning my dietetics, and at that time, just when clinicals were gonna be coming up, I was actually, just by chance, introduced to the term perfusionist, and there just happened to be a friend of mine who’s husband was a perfusionist who just graduated who’s working over at Saint Christopher’s Hospital, his name was Chuck. He actually still works with Specialty Care, he had come on a number of years ago. He said, “Well, Charles, if you’re willing to take on what might be the most interesting career of your life, I’ll have you come in here as a pager, and when I call it, give me a call, we’ll set you up, get you to look at what actual open heart surgery is.”

Todd Schlosser: If it was a pager, it had to have been mid-90s?

Charles Yarnall: It was, yeah, that’s right. In the very early 90s.

Todd Schlosser: So, is that when you graduated? Did you graduate from Temple?

Charles Yarnall: Actually, at this point, I had my Associates which is what you needed to get into a school of perfusion, so at this point I was like, “Oh okay, gosh I might have the credits if I decide to make this a career choice.” And after watching this case with Chuck, at Saint Christopher’s on a new born child that had to go open heart surgery, and actually it was a transplant that occurred and the other perfusionist went with one of the other surgeons acquired the heart and brought it back, I got there six o’clock in the afternoon, I didn’t leave until six o’clock the next morning, at that point I was just sealed at perfusion, was what I wanted to have as a career choice.

Todd Schlosser: Wow, okay, so just to make sure I understand what you said. You’re first time ever seeing perfusion as a job, not necessarily as a perfusionist, but sort of witnessing it?

Charles Yarnall: Witnessing it.

Todd Schlosser: You saw it on a new born child doing a heart transplant?

Charles Yarnall: That’s right.

Todd Schlosser: I can’t think of a no higher stakes situation for you too.

Charles Yarnall: That’s right.

Todd Schlosser: And, now I realize you weren’t actually doing the perfusion job at that point, you were just observing.

Charles Yarnall: I was not, I was observing.

Todd Schlosser: But, that seems … Oh man, so that solidified that moment solidified your desire to go into perfusion school?

Charles Yarnall: Yes, it did.

Todd Schlosser: And then that perfusion school took two years?

Charles Yarnall: It took two years.

Todd Schlosser: And, that was from 94 and 96.

Charles Yarnall: That’s right.

Todd Schlosser: So, when you leave perfusion school, where did you end up?

Charles Yarnall: Actually, I was hired by the university, I was at the school of perfusion which was Hahnemann University, and they asked me, when I graduated, to come there and be a part of their team. And actually, it was one of the largest heart programs in the area, it was at Hahnemann University was doing routinely 1800, 1900 we were scratching the ceiling with almost doing 2000 hearts that year, that I graduated.

Todd Schlosser: That’s just out of one hospital, one university hospital?

Charles Yarnall: One hospital, one hospital was doing about 2000 hearts back in 1996.

Todd Schlosser: That seems like a lot.

Charles Yarnall: It is a lot.

Todd Schlosser: A lot of a workload. So, there must have been quite a few on staff perfusionists and on staff doctors, there?

Charles Yarnall: There were. There were about a dozen surgeons there was about 13 cardiovascular perfusionists working there. And there was a school of perfusion there, so there was about 12 students rotating through there, each one was seeing hundreds of cases.

Todd Schlosser: And that’s sort of setting, and I realize in your situation now, you work primarily with one surgeon, is that the case?

Charles Yarnall: Actually, about three surgeons.

Todd Schlosser: Okay, so it’s still a tighter knit community, if you will.

Charles Yarnall: Yes, mm-hmm (affirmative).

Todd Schlosser: Than when you’re doing 2000 hearts out of one hospital.

Charles Yarnall: Right.

Todd Schlosser: And one of the things I wanted to talk to you about is sort of team work and building a team.

Charles Yarnall: Mm-hmm (affirmative).

Todd Schlosser: So, when you have that many surgeons and that many perfusionists and other scrub nurses and other people who are in the OR kind of on that surgeons team, trying to get the surgery completed with successful outcomes, is it hard to develop a work rapport with that big group of people? I’d imagine those types of relationships form easier in smaller groups.

Charles Yarnall: Yeah, you’re obviously right, the smaller the group the easier, the larger, the more difficult it is, but there’s a unique bond that occurs between a perfusionist and a CT surgeon, because they understand that you’re proving the life support keeping that patient intact so that all the work that they do on that patient at that time, that they’re still gonna be completely intact because of your efforts behind the pump, because when you put them on pump, you turn off their heart, you stop the ability for the anesthesiologist to do any meaningful respirations or to actuate the blood, it’s all in your machine. So, even through there is 13 different cardiovascular perfusionists, and 13 different surgeons there, we all knew each other on a first name basis.

Todd Schlosser: Oh I’m sure.

Charles Yarnall: And, work very well together. There was about a handful of nurses, a dozen nurses and a CT specifically trained CTM, [inaudible]. Even though we were so busy because we were there for long hours, we became quite intimate. But, where I’m at right now, with a smaller group and a tighter group. There’s an even a more intimate relationship when it comes down to. I actually know some of the people’s favorite colors. I can tell you in Hahnemann, that never came up, it was always like, “What are you going to do when you get out of here? Sleep.” “Yes-

Todd Schlosser: Yeah, sleep, yeah me too. [crosstalk].

My father was a huge baseball fan and it seems like … ‘Cause he would always talk about how a certain pitcher plays better when he’s throwing to a certain catcher, and I’d imagine that that’s somewhat similar in … And maybe not throws better in a sense of does better surgery, but I’d imagine there are some non-verbal communication that forms between a perfusionist and a surgeon, when you’ve worked with someone so long.

Charles Yarnall: There are, and some people say, some things go unspoken and done and stuff like that, and in the past I can say, yeah you did things because you know that’s what the surgeon wanted, but now in today’s surgical environment, is what you now know what to do, is not to do things without it being spoken, but know when to speak up, know when things are supposed to happen, so actually being familiar with a surgeon and an anesthesiologist, you know that when things don’t flow in the normal manner that they do, to speak up, to say your piece, to communicate the variable that is occurring so that the correction can happen quickly, so that familiarity happens so that you can communicate even better.

The problem you have new people who haven’t worked together, is that you worry, “Should you speak? Should you speak?” Not, whether you should speak but how much you should say and what will they understand and what words are they using that you can get their attention with.

Todd Schlosser: Yeah, and I imagine, just like in any relationship, communication is being sort of a vital piece of that in the allure of such a high stakes environment, that, that is even more so and important. Is it? Is it difficult coming into a new situation or a new surgeon or if you step into a new role in the hospital with a a new team, is it difficult to be able to speak up?

Charles Yarnall: It could be. But it doesn’t have to be it all depends on what you’re willing to do, and what I mentor every perfusionist that I’ve trained that has been a student underneath me, is I try to make sure that they are very comfortable with communicating to that surgeon, that when you speak you, speak up, you make sure that what you say is heard the first time. Not that the first time you speak to the surgeon should be when he’s on one side the operating table and you’re behind the pump. You should speak to the surgeon before getting into that situation, you should say, “Hi, my name is Robert, Joey, whatever.”

Todd Schlosser: Before surgery.

Charles Yarnall: A rapport and just, “So, I hear that from the other perfusionist who I was watching who was pumping your case the last time, who is orienting me to you, that you like to cool to this, you like to keep your pressures abut here, and so on.” And then he says, “Yes, yes, that’s correct.” And then he might even direct you, “If there’s any deviation, or something like this, make sure you speak up, the only wrong question is the one that you don’t ask me, because I don’t like any surprises. I wanna make sure you do your job as you were helping me do mine.”

Those are the kind of surgeons, and anesthesiologists that I find in the field nowadays, which is just fantastic. It’s really a great time to be a perfusionist, if you don’t mind me saying.

Todd Schlosser: No, I definitely don’t mind you saying, and I do understand that there is sort of a perfusionist crunch going on because there aren’t as many perfusionists as there is a need for them.

Charles Yarnall: That is right, I believe that the statistics out there, right now is at over 50% of the perfusionists out there are over 50.

Todd Schlosser: Yeah.

Charles Yarnall: I happen to be on of them.

Todd Schlosser: I don’t want to place a-

Charles Yarnall: Yeah, I won’t give you a number, but I will say I am over 50. There used to be over 20 schools of perfusion out there when I was in perfusion school, and now there’s somewhere arguably between 10 and a dozen schools out there, that’s it in putting out perfusionists. And matter of fact, because I’m lucky enough to work with a CT surgeon, Dr. Riscio Grido and Dr. Rohenta Morris, and they saw the need as these schools were drying up to help foster another school. They actually put their full weight behind opening a school of perfusion at Jefferson School of Perfusion in Philadelphia, and with no short help of Specialty Care to help it get up and running. It’s completely independent, the Specialty Care, but they helped facilitate some of the materials that we needed, and equipment so that we can have a simulation lab that we have, I would say is one of the best schools of perfusion that are putting out phenomenal graduates.

Matter of fact, our first year that we had, which was a year ago, the graduates, we hired three out of the six graduates, and they were just top-notch graduates that are now about to take their boards and become nationally certified as a cardiovascular perfusionist. We have people that are training them that I’ve known for years, worked with that have the highest quality in mind, in doing that and so there is hope for perfusion.

Todd Schlosser: I hope so, it’s a vital part of surgery.
Charles Yarnall: Absolutely.

Todd Schlosser: Any time the surgeon has to go in there and operate on the heart, you guys have to be there to keep the patient going during that time, because there’s no way to do that without.

Charles Yarnall: That’s right, no one else stops the heart but the perfusionist, with the cardioplegia that we give, cardioplegia cardio, heart and plegia paralyzing heart, and then once that happens you better have a machine that can take over to function the heart and the lungs to keep that patient going.

Todd Schlosser: Yeah, gonna oxygenate that blood.

Charles Yarnall: Oxygenate that blood, remove that Co2, keep the pressures where they need to be, keep all the organs happy, prevent acute kidney injury, keep mental status the way it was pre-operation. It’s a lot of balls in the air but satisfying as a job as I’ve ever known.

Todd Schlosser: I’ve talked to quite a few perfusionists through Scrubbing In, the podcast, but also just in the halls here, at Specialty Care, and the amount of things they have to account for always sort of blows me away, ’cause all the things you just mentioned. It’s not just blood volume and levels, it’s how are the organs doing, how much oxygen is in the blood and is it getting passed through the body correctly, and also brain function, and stuff like that, has to be a concern. So, when you’re in a job where if you’re not at the top of your game and things go wrong, the worst can happen.

Charles Yarnall: Yes.

Todd Schlosser: How stressful is that, and I’d imagine you’ve been doing it so long that it may not be as stressful as it was on day one for you, but it’s gotta still be stressful.

Charles Yarnall: Yeah, and as I was saying this is one of the best times in the [inaudible] perfusion to be a perfusionist is because back in the day, back in the 1980s, 1990s, there wasn’t things that we have now which we take for granted. Such as cebryox symmetry monitoring which actually measures the saturation of the frontal lobes of the brain which can actually tell you how you’re doing and your objective as a perfusionist. Perfusion being the organs and the body such as the brain. We now have data which can be fed back to us live, real time that we can use to manage how we are doing our job, whether we need to increase our flows, increase our pressure and stuff like that. There are many devices out there that can give us immediate feedback in what we need to do. We have blood gas analyzers which are now directly on the heart and lung machine that we can run a blood gas, we can see if we’re building up lactic acid, we can see if the Co2 is building up. We actually have many axillae devices which are at the finger tip of the perfusionist to let us and help us do our jobs.

And, of course, one perfusionist being a lone ranger, not being backed up by others, is something that has basically fallen by the wayside, we have backup and we have teams, and you have your wing man, if you would, that are there that can help manage any kind of situation which could arise, matter of fact, building the team is something that, if you don’t mind me saying, Specialty Care has facilitated that we’ve been able to do even better than other times with working with any other previous companies and entities. And I’ve used that to help give better care that is seen, not just by the perfusionist, that don’t feel like they’re alone, but the surgeon and the anesthesiologist are like, “Hey Charles, it’s you, who’s coming in to vacuum?” I’m like, “It’s Derek, it’s Dan, it’s Megan, it’s Mark or someone.” They’re all on their way because we have that second tier always set up in case of emergencies.

Todd Schlosser: And that’s actually in the OR with you-

Charles Yarnall: In the OR with me.

Todd Schlosser: … you have two perfusionists in the OR with you at all times?

Charles Yarnall: They don’t have to sit next to me, but they have to be able to come within a moment’s notice, which is like two minutes. So, they’re not in another part of the hospital.

Todd Schlosser: Sure, so if you’re having some issues, or just questions that you need a second set of eyes on, you say, “Hey, can you come in and take a look at this?” And you have another set of hands, another set of eyes, another brain there to help you out.

Charles Yarnall: That’s right, and there’s always people like, you know, when you talk about team, you have nursing, nursing can be a great deal of assistance to the perfusionist, with Karen Rachel who is our director, in with a CT surgery, it’s fantastic, but when it comes down to where you need a perfusionist who knows the ins and outs of your heart lung machine has the experience, it’s nothing like having another perfusionist there, and that has just been … It’s made doing this job for as long as I’ve done it that much more enjoyable.

Todd Schlosser: Yeah. One final question, maybe a few more, it depends on how you answer it.

Charles Yarnall: What’s the quick out, no I’m just kidding.

Todd Schlosser: So, one follow-up question, when you’re in that atmosphere in the OR, I imagine trust is very important.

Charles Yarnall: Yes.

Todd Schlosser: And not just a trust that you know how to do your job, but trust that other people know how to do their job as well, because you can only handle the heart and lung machine as the perfusionist can handle that, but you gotta trust that surgeon knows what he’s doing, you gotta trust the anesthesiologist, to know what they’re doing. So, is that a frustrating dynamic, sometimes, or is it-

Charles Yarnall: Yes. Yeah, and here’s the thing I know what you’re looking for, and actually that is a key point that I actually make to every perfusionist I work with and every student that I’m training. Is that, you through the patient are connected to every other modality in the operation room, the anesthesiologist who is running vasor pressers or vasodilation agents, before going on bypass [inaudible] and they keep them running and it’s affecting your blood pressure, you can’t get the blood pressure down, or you can’t get it up, and it’s because something you’re working, the nursing that’s at the surgical table, what comes back to your pump through the sucker which goes into the chest of the patient can either bring stuff you do want or stuff you don’t want, depending on what you’re sucking, or stuff can sit there that should come back to the pump that isn’t because you need them to actually go and bring that fluid back to the pump, before it ends up sitting in the patient. The surgeon places the actual venous canubla that brings the blood back to the pump, so you have every other modality in the room directly affects what you can do to sustain that patient, so you have to have that rapport, you have to have those lines of communication and you have to develop that, and that should be something you focus on, on a daily basis.

Having a good rapport, having familiarity with the people in the room is key and paramount. Because of the many initiatives which have been put forth, not just by perfusion but through nursing and anesthesia to bring these teams together, it just has made in the last several years of my life as a perfusionist have been just that much better because everyone has been focusing on safety and communication.

Todd Schlosser: Excellent, so a great way to answer the question. Because I like to focus on that because you are only control of what you’re in control of, but there are things that impact you that you don’t have control of, but you have roll with.

Charles Yarnall: Right.

Todd Schlosser: I’d imagine, even if you have trust in those people, to be able to communicate in a way that is professional, but also-

Charles Yarnall: It’s gotta get done.

Todd Schlosser: Yeah, it’s gotta get done.

Charles Yarnall: You gotta help me, you know, that’s right.

Todd Schlosser: Not aggressive is not the word I’m looking for.

Charles Yarnall: No.

Todd Schlosser: But definitive-

Charles Yarnall: Definitive.

Todd Schlosser: Yes.

Charles Yarnall: It needs to be precise to the point, non-distracting and clear, and those points to be made on communication, which is actually what we were speaking at earlier today, Dr. Roriscio and Grido and I, at a meeting, and we were talking about communication and collaboration and what we’ve learned about working with each other for seven plus years.

Todd Schlosser: Yeah, let me ask you one final question, I just thought of this, since you’ve been in the industry for so long, what would you tell-

Charles Yarnall: Other people have been in there longer than me. There’s older perfusionists than me out there.

Todd Schlosser: Oh, I’m sure. Yeah, it is an aging population, and Specialty Care does focus on trying to get more people to enter that realm, so what are some things that you would tell people who are looking to … Like, they just graduated nursing school or maybe a bio science degree on some level, what would you tell them in order to maybe confine them, or just if they had general questions about perfusion, what would be a good starting place for them to start looking into? Maybe this is what is for me, ’cause not everyone’s gonna have the chance to go witness a heart surgery of a new born child.

Charles Yarnall: Right, right, well. There are the schools of perfusion that are out there, all have, and again, because of the web, there are webpages out there, you can Google the American Board of Cardiovascular Perfusion which actually lists all the active perfusion schools that are out there, that will direct you to the individual websites of the schools that are out there. And you should be a person who can juggle several things at the same time. Someone who can deal with stress, someone who is looking for a challenging environment to work in, someone who wants to go home knowing that you’ve made a difference in someone’s life every single day.

There’s something to be said for balancing a check book for balancing the budget plan for an institution and stuff like that, and they’re all very rewarding, but on a daily basis you have people in the worst point of their life who need to undergo open heart surgery to be put on a life support device and maintain in a way that they come out as good as they came in, that if you don’t have good people there, good things don’t happen and getting good people who wanna come out and know that they made a difference in a team that has the exact same viewpoints as you on having the best outcome for a patient, is just rewarding beyond compare. I just think about some of the options that I had that would have been great but I never would have hit the same highs of satisfaction that I have now, being a perfusionist for as long as I have and actually being privileged enough to be a part of a school of perfusion and to have taught people and have students come back to me and say thank you and also thanks for direction, thanks for the discipline, thanks for making a difference, and stuff like that.

And, they’re going out there, ’cause see, there’s a chance I’m might develop [inaudible] disease, there’s a chance I might end up on a table one day, and I would love to have the privilege of looking up and seeing my best student behind a pump who has graduated and truly, maybe even become a chief perfusionist somewhere say, “Charles, you rest assured, I got this, you’re gonna do fine.” Because, some of my friends have had that exact scenario happen, and they said, “Boy, I’m glad we have all this technology right now that records what we do behind pump, because I can review my own [inaudible], they did such a great job, and I feel fine.” So, they believe in the system you live the system you have great outcomes.

Being a part of a system that emphasizes protocol and like we have here at Specialty Care and outcomes based medicine, it just goes hand in hand. It’s been very happy and very rewarding.

Todd Schlosser: Well, thank you very much, I can’t think of a better answer to end on, but Charles Yarnall, thank you so much for coming and having this conversation with us, we appreciate it.

Charles Yarnall: Thank you very much, it’s been my privilege to be here.

Todd Schlosser: Thanks for listening to Scrubbing In, please take a second to give us a rating on your podcast app and subscribe so you won’t miss out on what we have coming up, see you next time.