HEART BEAT Maurice NeliganI have a simple point. We have a core problem in our health service. In my opinion, we should first solve that. We must get all our frontline patient-centred services running efficiently.
We will not do this by placing the shadows before the substance. Excessively providing for the shadows I might add. We cannot discredit common sense as a guide to our actions. We cannot be led unquestioningly by those who profess to know all, and assure us that adherence to whatever regimen that they favour will solve all our woes. "Convictions are greater enemies of truth than lies." - (Nietzsche).
Beware of the simple solutions for the problems of our health services. There are none.
Without further ado, I shall return to the past. I had been relieved of the necessity of undertaking casualty duty in the Mater for my surgical six months. This was because I was expected to be on call on the nights open heart surgery was performed. At that time this amounted to two to three operations a week. This was a far cry from the four to five procedures a day that later became the norm. This, however, was 1962 and the sub-specialty of cardiac surgery was in its infancy. The pioneering work of, among others, Gibbon, Liilehei and Kirklin, led to almost explosive progress in the development of heart surgery. This is not a history of cardiac surgery but rather one surgeon's personal experiences through this time of development and change.
The key to the progression was the development of a reliable heart-lung machine, which allowed the heart to be stopped and emptied while being repaired. This machine fulfilled the function of the heart and lungs mechanically, sustaining the patient during the period of repair.
This technique was rapidly replacing the use of hypothermia, in which the patient was placed in a bath of ice to reduce the body temperature to about 29 degrees.
As brain death in the absence of circulation occurs in three to four minutes at normal body temperature, such cooling allowed a brief period in which repair of heart defects could be undertaken without brain damage.
The problem was that there were few heart defects that could be fixed in the brief time-span thus provided. Another problem was that the heart (often very big) might arrest during the cooling process, before the chest had been opened and the operation begun.
Resuscitation in those circumstances was almost impossible and I well remember the feelings of frustration and inadequacy that pervaded the entire surgical team on those sad occasions.
Interestingly, this technique of hypothermia was again to come to the fore when used together with the heart-lung machine, in the surgery of babies and some major aneurysm surgery within the chest in adults. The faltering hesitant steps of hypothermia and the initial complex heart-lung machines enabled the surgeons to move forward and slowly but surely address the whole field of surgically treatable heart disease.
Pioneering work was going on all around us and discovery followed discovery providing new surgical techniques to alleviate previously lethal heart conditions, providing new hope to patients who had previously only faced the certainty of early death from acquired or congenital heart disease.
These were brave surgeons who took the process forward through unremitting toil and not infrequent disappointment. These were even braver patients who faced the dangers ahead and implicitly trusted those who were caring for them.
Many of the surgeons involved at the time were general surgeons, who had come to the evolving specialty through interest and involvement with one of the developing teams. Some were chest surgeons familiar with the ravages of tuberculosis and lung cancer, and who had experienced, by service in various armed forces, the dire consequences of warfare.
A team of other surgeons, anaesthetists, nurses, perfusionists (who ran the heart-lung machine) and NCHDs (non-consultant hospital doctors) provided the support, but the pinnacle, as I later found out, was a lonely spot.
At the time our pinnacle in the Mater Hospital was occupied by Prof Eoin O'Malley, whose intern I had the honour to be. Eoin O'Malley, a man of great intellect and ability, had unerringly picked the right pathway in the development of the specialty. He had seen clearly the benefits provided by what is called extra-corporeal circulation, ie use of the heart-lung machine as opposed to other methods then propounded.
He had established his team and then proceeded after the necessary laboratory work to bring the new techniques forward for patient benefit. He was a tenacious, hard working, determined man, seemingly tireless, and most certainly, as I came to appreciate over the years, somebody who never gave up. His vigour, surgical skills, intellectual depth and honesty founded the now National Cardiac Surgical Unit in the Mater, which properly bears his name.
Above all, he had the greatest attribute of a great surgeon and teacher; he was easy to work with.
I was then the lowest placed object on the totem pole, but with an awful amount of work to do.
Admitting and examining the patient, liaising with the family, supervising the signing of the consent form for surgery, explaining, in so far as you usefully could, what the operation would entail, and the risks and benefits that might attend.
In those early days there was a pool of very sick patients, previously untreatable, who had been steadily deteriorating over the years and who even today would be regarded as very high risk.
For most there was little option. This weighed more lightly on the junior members of the team, but for the responsible surgeon and anaesthetist, it was a heavy load.
Finally, all being checked and prepared, came the day of surgery, and what we were properly about.
mneligan@irish-times.ie
Maurice Neligan is a cardiac surgeon