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Journalist: Haleema Ahmed
Haleema: Hello everyone and welcome back to SciSection. I'm Haleema, one of your journalists, and this week, I got to speak to Dr. David Barron. He is the head of the division of Cardiovascular Surgery at SickKids hospital and a Professor of Surgery at the University of Toronto. In our lengthy conversation, we got to speak all about his work in surgery and at SickKids. Here is that conversation now:
And could you run us through the types of conditions and procedures that you commonly work on in your day-to-day? I understand there is probably a large diversity within that.
David: Yes, there is. Most of the conditions we deal with are in newborn babies and infants - conditions that used to be lethal with no treatment before the days of heart surgery. The most common things are conditions like holes in the heart where the heart doesn't quite function properly and has a hole within it, which causes heart failure and can damage the lungs very quickly in childhood. But also, there is an extraordinary range of different conditions, which we see in almost every aspect of the heart. So if you could imagine it, it can probably exist. Often in the great arteries- the arteries that go to your body and the lungs- can sometimes be the wrong way around and that needs to be corrected. Sometimes the veins joining the heart don't connect to the heart properly and we have to reroute to connect them. Sometimes you're only born with one artery instead of two so we have to make an additional one. Also, very commonly, you can get narrowings in the main arteries or the valves within the heart, even as a newborn, which can all be treated surgically through enlargement to make it back to normal. An important group of the children we treat is those who are only born with one functional ventricle. A normal, healthy heart has two ventricles; one to support the main circulation and one to support the lungs. But there are many situations where the heart may only have one useful ventricle. We have ways of using that one ventricle to supply both the body and the lungs. That often requires a whole series of surgeries during the first few years of life to not only enable these children to survive, but to give them a normal quality of life. As well as all of this, there is transplantation that we do here at SickKids; we have the biggest transplant program in Canada. We do both heart and lung transplants in children. We also have mechanical support systems to assist the failing heart, often in a condition called cardiomyopathy where the heart muscle is failing despite what is actually a structurally normal heart.
Haleema: And I think out of all of the different conditions that you described, heart transplants are incredibly interesting; even for somebody who may not know much about medicine. It is so cool to think that you can take somebody else's heart and place it in somebody else's body. Then do some kind of machinery and you can help that person live again. Could you describe what it is that happens during a heart transplant surgery from receiving the heart from the donor to getting it into the new person?
David: It is an extraordinary achievement that we're able to offer heart transplantation. Having said that, we always would much prefer to be able to do conventional surgery if possible – which we can do in the vast majority of children. However, when it's actually the heart muscle that is failing, that's when we have to really consider the option of transplantation. The sheer number of people involved and the level of expertise at so many levels is the real secret to the whole concept of transplantations. So you have to remember that it is not only the procedure itself, but it is the process of coordinating and organizing the surgery and all the management of immunosuppression which is the secret of success – so as to minimize that risk of rejection. The heart has been a very successful organ for transplantation in terms of being relatively free from the risk of rejection. It does seem that almost the younger you do it, often, the better the body will accept the new organ. However, it's a huge process of both assessing the patient from the outset and then making sure that they're truly appropriate [for transplantation]. There are so many things to take into account. A lot of it is, of course, looking at the family themselves and making sure the family- and if they're older children- that the children themselves understand what the implications and the consequences are; how their life is going to change, and if they can completely buy-in to that. But also then the actual process of being able to select the appropriately matched donors and then the logistics of doing the child’s surgery itself. As you can imagine, you need a whole separate team to be able to retrieve the organs and often they can be as far away as the far side of Canada. Sometimes we'll take hearts even as far away as BC or from the States. So we have to always be able to drop everything and organize the whole process if we get a call that a heart has become available. And then after that, the timing that's involved in making sure everything is then coordinated. It takes a lot of choreography to make sure everything happens at the right time. So it's a really big undertaking. It needs quite a big infrastructure to make sure that it works and it depends really on the commitment of a lot of very talented people.
Haleema: It definitely sounds far more complex than Grey's Anatomy and shows like that make it seem! They make it seem like it happens in an instant. Having completed over 3,500 cardiac surgeries yourself, what is the feeling like performing these kinds of procedures, oftentimes in very high-stress environments where you are working with children and babies who need these surgeries to survive?
David: Of course, it is a stressful job, but we all know that when we go into it. You have to also remember the rewards far outweigh those kinds of stresses and seeing the impact you can make on children's lives and for their families and so it is very rewarding. To some extent as a surgeon in any specialty, you do have to have some sort of ability to distance yourselves and the emotional issues because otherwise, it does become too stressful. I think what you rely on is a degree of confidence in your own ability -but also all the people you have around you to help share the load and share those stresses. You very much rely on a team ethic of all supporting each other and being there. We recognize that these can be stressful situations, but I think with all of this, the more experience you have, you get more comfortable with managing these sorts of stresses. I've often been amused over years when people come to me who maybe aren't medical and ask, “Who's the best surgeon to go and see? If I go and see a surgeon in his forties, they're at the peak of their career, or if I choose a surgeon in their fifties, are they getting a bit past it?" The bottom line is the more experienced you get, the better you get. There's no substitute for the kind of experience that you gain from more and more surgeries. You get more and more able to manage the kind of stresses and be able to manage those difficult situations. One of the many things I love about the job we do is that the more you do it, the more comfortable you feel in managing the stresses.
Haleema: Speaking of difficult situations, how has your work changed during COVID-19? Have you been conducting fewer surgeries or since they are life-changing procedures, how have the situations and the procedures surrounding them changed during COVID?
David: Of course, life has changed for all of us in an imaginable way. Having said that we have been incredibly lucky here in SickKids. I'm sure as you know, that on the whole, children have not suffered the bad spectrum of symptoms from the disease. They don't seem to get severe problems even if they do get impacted. So at SickKids, we've been very lucky mainly in terms of how it's impacted our work. We are functioning at completely normal, full capacity; we really have done so pretty well throughout the entire pandemic. It affects our day-to-day life because we all take our precautions extremely seriously. We all wear full PPE protective equipment for all surgeries and in all clinical areas. As I say, all of our patients are tested. I think the most disruptive thing for us is that all of our daily meetings, which are so much part of our daily life, are all done on Zoom or on Teams. Our human contact with each other as clinicians has been greatly reduced. I think that's the one thing that we really miss. But I say, fortunately, in terms of our activity, we're functioning at completely normal capacity which we're very grateful for.
Haleema: That is very nice to hear that children who need these procedures are able to get them despite all of the uncertainty right now. So going back to some of the work that you do, I know Hypoplastic Left Heart Syndrome is one of the main focuses in your research that I personally found particularly interesting. Could you run us through what this type of condition is and how you go about treating it?
David: So we touched on this earlier. It's a bit of a mouthful – the name of the condition - but what it means is you're really born without a left ventricle. The left ventricle is the main pumping chamber of your heart that supplies the body. So as you can imagine, the condition is lethal within the first few days of life without any intervention. Although it's obviously a very rare condition within the whole spectrum of all congenital heart diseases, it's still the single most common reason for neonatal death related to the heart if untreated. We've been able to devise a surgery over the last 30 years that has enabled children with this condition to survive. It involves quite a complicated operation as a newborn. We use the right ventricle, so the one healthy ventricle that the baby has, to really support not only the whole circulation but also to support the lungs as well. That surgery has really become progressively more and more successful over the past years. SickKids has the biggest program for this in Canada. So these children who used to have no prospect of survival, are now expecting somewhere between 85 to 90% survival. But it's not the end of the road. They need to do further planned surgeries as they grow up where you effectively bypass the one side of the heart completely. We use a passive circulation to supply the lungs. So it does mean that you can't have a completely normal circulation. But what we aim to do with these surgeries is to get these children to as close as normal as we can achieve. We really expect them to have a pretty normal quality of life although they don't have the same exercise capability as their peers might have at school. But it's been a remarkable story for the treatment of hypoplastic left heart. We've learned so much as a specialty for managing these most complex circulations, which has had a huge impact on almost all the other things that we do, particularly in neonatal cardiac surgery. So it's really been a passion of mine over the years. We've been able to develop some slightly different or newer techniques to try and improve and maximize the outcomes in the newborn age. We still have many challenges ahead with these children because still living with only one effective ventricle is a big challenge on the circulation. Many of these children may still come to need further support for their hearts when they are older.
Haleema: I think it was quite incredible that they went from a point where it was very little survival to 80, 85 and 90% survival. I'm interested to know how this increase in the success of these children with this condition came about. Was it through new innovations, machinery, research, or a combination of them all? How rapidly did that kind of innovation with this particular syndrome occur?
David: It comes from all of those things that you've mentioned. A lot of the changes come from true innovations through individuals who really pushed the boundaries of what we can do. But none of those changes are possible without the sort of background of the gradual improvements and advancements in technology and the abilities that we have which make these things sort of possible. But I think it is true that the real changes do depend on truly innovative individuals that drive these things forward. Then the new lines of research and application will come along to constantly push the whole thing forward. For example, at SickKids we’re looking at ways of using stem cell technology to help these hearts with only a single ventricle. We want to maximize the way that the heart and the muscle of the heart could improve and grow and strengthen to give its maximum potential future.
Haleema: I think a nice way for us to end off this interview is with some advice. I know a lot of the students who listened to this podcast are in undergrad or pursuing medical school or what have you. So being a surgeon requires incredible dedication and patients without a doubt, but most notably I think one skill that's really interesting is precision; a quality that many of us could adopt in our lives with our goals. How would you recommend people become not only more patient but more precise with the things that they pursue in their lives, be it medicine or anything else.
David: I think the most important thing when you’re going through med school or even when you are still in high school, is to try and keep an open mind and not try and second guess what you think you're going to be like in the future or what you think even want to do. Try and keep an open mind. Try and absorb as much information as you can. Take every opportunity you get to experience something that you think you might be interested in and grab it with both hands. I always tell medical students to try and see as much as they can and go to every specialty; get into the ORs, get into outpatient clinics, and really get a feel for what they think it's going to be like, because often what you're imagining in your head of what life will be like doing that as the career may be different when you actually spend a few weeks amongst the team and doing it. Try and see everything and keep your mind open. Don't necessarily label yourself too early on because your life will evolve; we all change and evolve as the years go by. There are so many different factors in your life that will dictate what you're going to enjoy doing rather than what you think you want to do. Try and find something that you really enjoy and that you are really interested in. Something that will keep you stimulated and interested for your whole career. But don't try and do something just because you think it sounds good or you think it is exciting. Your natural instincts will take you towards what you're really interested in.
Haleema: And on that note, thank you so much Dr. Barron for joining us today. That advice was incredible and I definitely need to take it myself! I don't want to take too much time from saving lives as that is definitely a priority right now. Thank you so much for joining us today!