The team has prepared a game plan for this day. The key players have anticipated what they may encounter and talked about how they will respond. Everyone has a role, a position to play. Each must execute to achieve success.
They move in a deliberate and coordinated way, relying on experience and depending on their teammates to handle their assignments. Precise execution is required.
A football team in the brink of a championship? No, this is a cardiac surgery team repairing a child’s heart.
“Very much so,” says James Quintessenza, M.D., when asked if the planning and coordination of a heart surgery team could be compared to the sort of teamwork more familiar to football fans.
Quintessenza has been in the game a long time, about 30 years. He has spent most of his career at Johns Hopkins All Children’s Hospital, where he currently serves as co-director of the Heart Institute and chief of pediatric cardiovascular surgery.
The key, Quintessenza says, is teamwork.
“The surgeon gets to be like the quarterback or the coach or whatever, but you have to be conversant with all different aspects,” he says. “The key is to pick your team well.
“I go into the operating room, and I know I have nurses and anesthesiologists and perfusionists and surgical assistants and the whole team that I know. It’s just a huge advantage for the patient because you can really focus on what you’re doing, and you know that everyone else is doing their job the right way.”
Let’s take a look at the team members and their roles:
Quintessenza is sometimes joined by a second surgeon, generally Awais Ashfaq, MBBS.
Physician assistant (PA)
Each procedure includes a PA, who assists the surgeon by holding open incisions, stopping bleeding, closing incisions and other technical tasks. The PA works alongside the surgeon throughout the patient’s care, before, during and after surgery. The PA may examine the child in the clinic, help formulate the treatment plan, document the patient’s progress and serve as a contact with the family throughout the child’s care.
This team is in action before the procedure begins and after it ends. It develops an anesthesia plan specifically for that child and monitors the child throughout the procedure. At the appropriate time, the anesthesia team brings the child back to consciousness. Johns Hopkins All Children’s team members are board-certified in pediatric anesthesiology with specialized training or experience in pediatric cardiac anesthesia. This training and experience helps in caring for children with heart conditions and provides a unique understanding of the needs of these patients.
“The thing is that when you work with someone for so many years there is a relationship that develops that is beyond knowledge,” says Gerson Rodriguez-Fazzi, M.D., a pediatric anesthesiologist who first worked with Quintessenza more than 20 years ago. “You develop a rhythm. A wordless communication. You become limbs that move without having to will it. That is the value of having a team that works together all the time.
“We know what the surgical part of the team needs. We prepare days before. We plan how to execute the procedure the best way. The day before we discuss the final script and include all the players, surgeons, nurses and other staff. On the day of the procedure, we know our roles, we have played the part before, and we are good at it. The focus is the patient and the family, our most important audience. That’s how we achieve excellence in our program.”
Unlike a quarterback who handles a ball on each play, a surgeon uses different tools. The scrub nurse stays a step ahead, anticipating what the surgeon will need next and handing him or her the proper instrument or suture.
“The keys as a scrub nurse are anticipation, concentration and focus, but the most important is teamwork and working with people who are passionate about what we do,” says Elisa Iles-Sabol, R.N., who started working with Quintessenza more than 20 years ago.
Cardiologist and sonographer
A cardiologist and sonographer are present to perform a transesophageal echocardiogram (TEE) when needed. The cardiologist inserts a thin tube down the patient’s throat, allowing the sonographer to use high-frequency sound waves to examine the heart without the ribs or lungs getting in the way. This allows the surgical team to assess whether there are any blood clots and if the heart valves are functioning properly.
During cardiac surgery, a heart-lung bypass machine is used to take over the functions of those organs. The perfusionists administer medication to stop the heart, so the surgical team can execute the repair, and later restart it when the procedure is complete. Perfusionists also regulate the patient’s temperature, often cooling the child significantly to slow the metabolic demand — the body’s need for oxygen — allowing more time to complete the procedure.
Johns Hopkins All Children’s has two perfusionists involved in each cardiac surgery to operate and monitor this equipment and the patient’s response. They work closely with the surgeon and the anesthesiology team, administering anesthesia and other drugs while the child is on bypass. The three perfusionists based at Johns Hopkins All Children’s all have a master’s degree in perfusion and specialize in pediatrics, which often can be more challenging than adult perfusion because of the range of heights and weights involved. One day the patient might be an infant and another a high school football player.
“Perfusion is a really small field, especially when you get into pediatrics,” says Jim O’Brien, a certified perfusionist who has been based at Johns Hopkins All Children’s for the past three years. “You have to really plan ahead because the amount of equipment you use in pediatrics depends so much on the size and weight of the child.”
These specialized nurses advocate for the safety of the patient. They prepare in advance for the procedure, continuously monitor the patient and staff while it takes place, and record the progress of the procedure, handle specimens and retrieve any instruments not already in place. They meet the family before the procedure and communicate updates to them about every one to two hours during the procedure. A circulating nurse coordinates the post-operative handoff to the cardiovascular intensive care unit and communicates with the family that it is complete.
“The role requires attention to detail, excellent communication and a high level of ability to focus in stressful situations,” says Laura McCool, R.N., a certified perioperative nurse who has worked as a circulating nurse for 20 years and joined the Johns Hopkins All Children’s staff full time in 2009. “Any patient that comes in to our operating room will get the very best possible care and attention that we can provide.”
Cardiac surgical team members depend upon one another for success. They each have their specialties, but by working together, they can achieve more than any of them could do on their own.
“Imagine you’re the quarterback, and you don’t have an offensive line,” Quintessenza says. “You can’t do squat. It’s so much the same here. Everybody’s got to be firing on all cylinders.
“We’ve got a really great team, and we’ll build on that. I think we’ve got a lot of great potential.”