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the hole was miraculously closed and the heart repaired. This was a
momentous occasion in Irish cardiac surgery. After working in the
Royal Victoria Hospital, Belfast, and a two-year stint working in the
Hospital for Sick Children in Toronto, I returned to Ireland in 1983,
where the demand for cardiac surgery was huge. Mr Neligan and Mr
Shaw had begun coronary artery bypass (CAB) grafting in 1975 and
now it was gaining acceptance. In 1979, Mr Neligan had successfully
begun atrial redirection of transposition of great arteries, a complex
form of `blue baby syndrome' where newborn babies have cyanotic
heart defects, which up until then were all sent to the Royal
Brompton Hospital in London. Now the cardiac surgery service was
on the cusp of becoming a truly national service but performing to
international standards. By early 1985, the Mater was performing
850 heart operations yearly and Mr Neligan and I performed 220
operations in Crumlin. The scene was now set for change.
THE GATEWAY FOR TRANSPLANTATION
Dr Norman Shumway, who masterminded the reality of human
heart transplantation, had endured with it after it had fallen into
disrepute. Dr Shumway worked persistently in making continuous
improvements, so much so that, by late 1981, he was obtaining
a one-year survival rate of 85 per cent and a three-week hospital
stay. Long periods in isolation were no longer required. The main
advance was the introduction of a drug, cyclosporine, and the use of
myocardial biopsy.
Many units at this stage started to consider heart transplantation.
A hospital team was formed in OLCHC, where we focused on
consolidating the confidence of the nursing staff and building two
isolation rooms. At that stage, the surgery division, the Medical
Board and the Hospital CEO had all given their approval.
By March 1985, the isolation rooms were complete. We had spoken
with the city coroner, the donor coordinators, the renal transplant
surgeons, the blood bank, the Gardaí, the Air Corps, and all our
cardiology colleagues were also very supportive.
On September 10, 1985, a possible donor was identified in Wexford
General Hospital. The donor was a young man in his twenties who
had suffered severe brain damage after being knocked off his bicycle.
We proceeded with the transplant and the rest is history. Now, 28
years later, over 275 transplants have been performed, the longest
survivor being an 18-year-old orphan, who is now 27 years on from
his transplant, married with one child and working full-time.
Outcome data and audit was constantly collected to ensure that
we were achieving acceptable results and in 1987/88 we were able
to show that cytomegalovirus infection caused early death. We
initiated a treatment strategy of matching the donor to patient if
possible, or introducing antiviral treatment from day one. That
protocol is still in place today.
ESTABLISHING TRANSPLANT PROGRAMMES
In 1997, the then Minister for Health, Brian Cowen, initiated a
review to consider the establishment of a transplant programme
while acknowledging it would be an extremely complex and
difficult task. In preparing to introduce a lung and heart transplant
programme, the overriding objective was to ensure that the results
of such a programme would, at least, match international standards.
One of the critical factors in successful delivery was whether the
level of transplant activity was sufficient to maintain the level of
experience required to achieve successful outcomes.
It was decided to have a staged approach and, in May 2005, the
first lung transplant was performed and a double-lung transplant
followed in January 2006. In total, over 80 patients have been
transplanted to date.
A total of 16m has been invested in the programme to date,
supporting a range of initiatives including the setting up of a
pulmonary hypertension unit and the extension of intensive care,
as well as the provision of a cardiothoracic high-dependency unit
and a heart-lung ward. The lung transplantation programme also
provided the structure to set-up Extra Corporeal Life Support,
both in Crumlin for children and the Mater for adults. This proved
particularly timely for the swine flu pandemic.
GETTING TRAINING RIGHT
The Medical Council now has responsibility for training; there is
evidence that good training sites provide good outcomes. Within
the six years training I underwent in cardiothoracic surgery, I spent
some 40,000 hours on call, 8,000 hours operating and another 7,500
hours providing clinical care and education. Undoubtedly, this gave
me a level of clinical competence and confidence to be involved in
the developments I have outlined.
The question has to be asked, however, with the application of the
European Working Time Directive of the 48-hour week; can a
six-year training period, totalling 6,500 hours, produce surgeons
of similar experience? To do so, will require concentrated training
exposure in large, centralised, high-activity units/hospitals based
on a review of unit activity and outcomes and trainer activity. A
second question is, will the proposed changes in hospital structure/
organisation facilitate this? Currently, there are 47 hospitals in the
country as compared to 57 in 1968 (46 years ago).
The Medical Council, in association with the postgraduate bodies,
is focusing on training sites in its present term to ensure that Irish
graduates are trained to the best international standard in the
interest of the patient and the public alike. Excellent training and
training sites are more likely to attract back the brightest and best
of our graduates thus ensuring the sustainability of the medical
workforce.
A cardiothoracic surgeon, Professor Wood has
pioneered heart surgery and transplantation in
Ireland. From 1999 to 2010, he served as Director of
Heart and Lung Transplantation at the Mater Hospital,
where Ireland's first successful lung transplant was
carried out in 2005. He is currently in private practice,
and is a member of the RCSI Council.
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