"Perfusion is a hands-on health profession involved in direct patient care, education and research," says Amanda Fernandez, Perfusion Clinical Coordinator/Educator with UHN Surgical Services. (Photo: UHN)

Growing up, Amanda Fernandez knew what a perfusionist did, even if she did not yet know it was the career for her.

An aunt, who is a perfusionist in Montreal, spoke with enjoyment and fulfillment about the profession, so it resonated with Amanda even if, as a teenager at the time, "I didn't fully comprehend the role."

It wasn't until after graduating in 2010 from York University with an honours bachelor of science in biology, and working as a research assistant in a laboratory focused on diabetes and cardiovascular disease, that Amanda realized she wanted to pursue something involving direct patient care.

Exploring options, Amanda reached out to the Perfusion Department at St. Michael's Hospital and the clinical coordinator helped arrange an observation day. She went. She was hooked.

"I realized perfusionists play a very large role in cardiac surgery and they get to save lives every day," says Amanda, who was accepted into the Advanced Diploma in Cardiovascular Perfusion Program at the Michener Institute of Education at UHN in 2011. She graduated in 2013, and has worked at UHN since.

"Perfusion is a hands-on health profession involved in direct patient care, education, and research," says Amanda, Perfusion Clinical Coordinator/Educator with UHN Surgical Services. "It's a diversified field that evolves with technological advances and research, and it has high job stability."

Perfusionists are key members of the surgical and critical care teams at UHN, specializing in the maintenance and operation of extracorporeal life-support (ECLS) devices. In the operating room (OR), they operate the heart-lung machine, which keeps a patient alive during cardiothoracic surgery. In the Intensive Care Unit (ICU), they are experts in the use of extracorporeal membrane oxygenation (ECMO) machines, widely used at Toronto General Hospital (TGH) during COVID-19.

Prior to a patient being wheeled into the operating room, Amanda sets up a heart-lung bypass machine, which will temporarily take over the function of the two vital organs so the surgical team can complete a heart valve replacement. (Photo: UHN)

They are affectionately known as "Pumpers" due to all the vital machines they set up and run. Increasingly, they have also become educators, teaching the multidisciplinary team at UHN to manage patients on advanced life-support devices.

Each of those three roles is a key component directly impacting patient care.

"It's an important surgical role that has grown and blossomed and been re-defined over the years," says Dr. Shaf Keshavjee, Surgeon-in-Chief of UHN's Sprott Department of Surgery. He's long been a champion of the profession, which traces its modern lineage to the invention of the first successful heart-lung machine in 1953 by Dr. John Gibbon and his wife, Mary, who in the 1970s was recognized by the American Society of Extracorporeal Technology with the honour of "first perfusionist."

Today, in a typical year, perfusionists at UHN are involved in more than 1600 heart surgeries, hundreds of lung, heart and liver transplants, dozens of thoracic surgeries and ventricular assist device (VAD) implants. And, during COVID-19, they have been integral to the care of nearly 150 patients on ECMO.

"A lot has changed since I began perfusion 27 years ago," says Cyril Serrick, Manager of Perfusion Services and ExVivo Therapies at UHN. "A perfusionist was really only involved with open heart surgery – transplantation was in its infancy and ECMO had such poor results it was rarely an option.

"However, today with technological and medical advancements, the perfusionists role and scope of practice has changed so much."

Cyril says that not only are perfusionists at UHN doing more complex open heart cardiac surgeries, they are also now involved in anything that may require extracorporeal support. And, he adds, their roles have expanded to thoracic surgeries; heart, lung and liver transplantation; ventricular assist device insertion and monitoring; ECMO in the MSICU, CVICU and cath labs; ex vivo organ perfusions of the lungs, liver, heart and kidneys.

"In fact, there is not a month that goes by I am not asked for our department's help with some new technique or procedure from the various surgical disciplines," says Cyril, who graduated from the Michener Institute's perfusion program in 1997 and sits on its Perfusion Advisory Committee. "It is quite rewarding to be working with such forward thinking individuals at UHN who recognize the potential that the Perfusion Department can bring."

"The surgeon is our eyes on the patient's heart and lungs, and we're the surgeon's eyes on the heart-lung machine," Amanda says of the relationship between the two during the procedure. "We work in unison, supporting each other's role." (Photo: UHN)

That expanding role for perfusionists has led to a shortage – across Ontario and Canada.

With an eye to helping meet that need, earlier this fall the Michener Institute received Ontario government approval to offer Canada's first Master of Science in Cardiovascular Perfusion. The inaugural cohort of students begin studies next September.

The school has offered an Advanced Diploma in Cardiovascular Perfusion for more than 40 years.

"The Masters will attract top candidates who want to study the science of perfusion," says Dr. Keshavjee, who is also Director of the Toronto Lung Transplant Program and Latner Thoracic Research Laboratories at UHN. "And, when they get to UHN, I'm confident they will realize there's no better place to be when it comes to the excitement and thrill of what they can do in their field.

"The sky's the limit."

For Amanda, it's the strength and support of her perfusion team and the professional autonomy and challenges arising throughout each day that she finds so rewarding.

"Our role is constantly evolving," she says. "There's never a dull moment."

In the OR, it might be recognizing – and fixing – a simple kink in the tube of the blood disposal unit on a heart-lung machine, to troubleshooting a major equipment malfunction; all before a patient is wheeled in for a valve replacement surgery. It's also about "the delicate balancing act" of providing the right blood flow, fluids, medication, and oxygen delivery throughout the procedure and until the patient is safely taken off the machine. It's continual communication with the surgeon and anesthesiologist.

"The success of open heart surgery is a reflection of the cooperation among all the disciplines in the OR," Amanda says.

"We almost have our own language," Amanda says of working with the lead surgeon during a procedure. "The surgeon is our eyes on the patient's heart and lungs and we're the surgeon's eyes on the heart-lung machine.

"We work in unison, supporting each other's role."

UHN perfusionists (L to R) Courtney Fischer, Sunpreet Takhar and Amanda Fernandez build an ex-vivo lung perfusion circuit, one example of the several types of extracorporeal life-support devices managed by the team. "Our program has survived on the compassion of our staff," Amanda says in reference to members working overtime and extra shifts due to the pandemic and staffing shortages. (Photo: UHN)

Like so many other departments across UHN, COVID-19 has transformed the work of perfusionists.

ECMO consists of a machine that oxygenates the blood outside the body. Set up and operated by perfusionists, it's normally used for transplant patients or those with severe heart or lung disease.

But during Wave One of the pandemic, the Medical Surgical Intensive Care Unit (MSICU) at TGH became a regional centre for ECMO, a last resort in an attempt to save some of the sickest COVID-19 patients. Led by members of UHN's Critical Care Medicine, Sprott Department of Surgery and Ajmera Transplant Centre teams, it's the largest and most comprehensive ECMO centre in Canada.

Most surgeries were shut down during Wave One, which meant the team of 20 UHN perfusionists could handle the increasing caseload of COVID patients in the Emergency Departments and ICUs. During the subsequent waves, with ORs back to full capacity, the team became particularly stretched.

"We just didn't have enough staff," says Cyril, noting that during Wave Three five perfusionists were brought in from other hospitals in the Greater Toronto Area and beyond to assist with ECMO patients.

At the peak of the Third Wave, there were up to 36 patients on ECMO at one time in the Toronto General MSICU. Prior to COVID-19 there would be one perfusionist on the unit, but their ranks swelled during the worst stretches last spring. Today, even as perfusionists from other hospitals have returned to their own sites, at least two members of the UHN team are on the MSICU daily.

"Our program has survived on the compassion of our staff," Amanda says in reference to members working overtime and extra shifts. "I'm not sure we would have survived if it wasn't for the team we have."

That strong team dynamic is evident when spending any time with UHN perfusionists. In their "pump room" – an office in the Sprott Department of Surgery on the second floor at TGH – there's an easy banter among colleagues coming and going throughout the day. They also continually check-in with each other – in person and via text – to see if anyone needs help with anything such as assembling a pump for an upcoming surgery, moving equipment or covering a lunch break.

"We all get along so well. We have genuine respect for each other and that really strengthens our team," says Courtney Fischer, who has been a perfusionist at UHN for three years.

Before completing her perfusion training at the Michener Institute, she was a registered nurse.

"Nursing allowed me to have some knowledge on a wide range of topics, but I became very motivated to become an expert in 'something,'" Courtney says of the difference between nursing and perfusion.

"I love being an expert in extracorporeal life support and its technologies."

Amanda teaching a session about a ventricular assist device (VAD) to a group of Cardiovascular Intensive Care Unit nurses, who are learning to monitor and trouble-shoot basic machine-related emergencies. (Photo: UHN)

In addition to clinical practice and research, perfusionists also play a large role in education.

UHN perfusionists give lectures on advanced perfusion practice, run lab-based simulation sessions and supervise clinical learners from the Michener Institute. They are also responsible for providing clinical education about extracorporeal life support devices for other disciplines across UHN, as well actively participating in national and international workshops and talks.

During a recent session organized by Yan Shao, an Advanced Practice Nurse Educator at the Peter Munk Cardiac Centre, Amanda spent several hours with seven Cardiovascular Intensive Care Unit nurses. She taught them about a ventricular assist device (VAD), an external blood pump connected to surgically implanted cannulas – small, flexible plastic tubes inserted into the heart – designed for short-term cardiopulmonary support in patients with heart failure.

Over the course of the session, Amanda stresses that the job of the nurses will be to monitor and troubleshoot basic machine-related emergencies, but not to set it up and change device settings.

She stresses more than once that help is only a phone call away.

Later, when asked what continues to excite her about her career choice, Amanda reflects.

"I like the professional autonomy of the profession," she says. "Perfusionists have a high level of authority to use professional knowledge and judgement to make decisions and take action to provide high quality care.

"It's a well-rounded profession – rewarding, impactful and diversified."

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