The Development of Cardiac Surgery in South Australia

Paper presented by Dr Lesley Long, 23 February 2006 for the Celebration of 45 years of Cardiac Surgery at Royal Adelaide Hospital

I am very pleased to be here today to celebrate 45 years of cardiac surgery at Royal Adelaide Hospital. It is a privilege for me to have been asked to present the opening paper and to set the scene for this morning with an overview of the development of cardiac surgery in South Australia. It is a change for me to be able to say that I am too young to have been around when the Cardiac Service began, although it has consumed a large part of my life.

I have gleaned the information about its development from listening to the experiences of key individuals, from the Royal Adelaide Hospital Annual Reports, from the Escourt-Hughes and Forbes histories of Royal Adelaide Hospital and from the writings of D’Arcy Sutherland and Peter Hetzel. The original proposal that D’Arcy Sutherland and Peter Hetzel submitted to the Hospital Administration and Board in 1959 that went forward to the Government of the day is, however, the foundation of this presentation.

According to Mr Hamilton D’Arcy Sutherland (referred to as D’Arcy throughout the rest of this presentation):

during World War 2 civilian surgery remained static but in the armed forces rapid scientific advances were being made including the advent of penicillin. Organisations were evolving in which surgeons, physicians, scientists and nurses combined together in teams

It is clear to me that, even at this early stage, the concept of a team was important to D’Arcy. His ability to pull a talented team together and maintain it, I believe was an integral part of his leadership success and the strength of the Royal Adelaide Hospital Cardiac Surgical Unit.

Following World War 2, the rapid advances made in the armed forces were transferred to the civilian world. There were significant advances in endo-tracheal and endo-bronchial anaesthesia which together with antibiotics helped advance elective chest surgery. Significant advances had been made in the correction of acquired and congenital diseases of the heart and great vessels. This was due to the improvements in the physiological and clinical methods and advances in anaesthetic and surgical techniques.

In South Australia in 1946, no operations had been performed on the heart or great vessels, however, by the end of 1958, three hundred and twelve operations had been performed by D’Arcy Sutherland with Mr J.H Brown, better known as Howard Brown, as his assistant.

D’Arcy returned to Adelaide in 1949 after a two year stint at Harefield Chest Hospital in London. He returned as, in his own words:

a competent endoscopist with enough experience in both minor and major thoracic surgery to begin work once I had developed a team structure

John Stace was a senior registrar in anaesthesia and was invited to join the new thoracic team. The old theatre was vacant following the opening of the new theatre block and two theatres – a major and minor – and a twelve bed recovery area dedicated to the management of tuberculosis was allocated to the thoracic team. According to D’Arcy:

this building was equipped with some first class nurses and theatre staff all keen to be part of an exciting new adventure

Thoracic surgery continued to expand at Royal Adelaide Hospital in the early 1950’s and by the mid 1950’s some cardiac surgery was being undertaken. D’Arcy writes that – “from the middle 1950’s cardiac surgery was where it was all happening”.

D’Arcy took 3 months leave and went to the United States of new techniques. At the same time another South Australian was travelling down a parallel pathway and learning the physiological and non-surgical aspects of cardiac surgery at the Mayo Clinic in the United States of America and the Brompton Hospital in England. When D’Arcy’s path crossed with Peter Hetzel, history was made in Cardiac surgery in South Australia. These two dedicated individuals shared a vision and became the pioneers for the development of cardiac surgery in this state. The Royal Adelaide Hospital cardiac surgical unit under D’Arcy’s leadership became well respected both within Australia and internationally.

According to D’Arcy, the transition from thoracic surgery to cardiac surgery was made easier because of the strong team structure that they had developed. This was a time of rapid change with the team doing surgery that they had never seen before but had read about in journals or learned from a colleague interstate or overseas. The experimental nature of the surgery meant that there were times when the mortality rate was high – a situation that existed in all other cardiac surgical centres worldwide. D’Arcy acknowledges that this was a difficult time and that:

surgery was very much a team effort and while the surgeons could see where they were going, nurses, physiotherapists and others in the team found death hard to accept, let alone the patients and or their parents

This sensitivity to the feelings of the team and the patient and family was evident throughout D’Arcy’s time are leader of the Cardio-Thoracic Unit.

Towards the end of the 1950’s, over three hundred closed cardiac operations had been performed with acceptable results, and a small number of open heart operations under surface hypothermia and venous arrest had been performed. The number of operations performed was steadily increasing but the lack of facilities was constraining the expansion of surgery into more complicated cardiac abnormalities other than mitral, aortic and pulmonary stenosis and atrial septal defect. In the 1957 Royal Adelaide Hospital Annual Report Dr Gartrell, an Honorary Cardiologist predicted that:

with the development of heart surgery and the bloodless heart technique, the amount of work will soon increase five-fold

This prediction, of course, was very accurate.

In 1958, heart-lung bypass machines had already been in use in the United States of America for four years and other countries including Australia in Sydney and Melbourne. A proposal for the further development of cardiac surgery in South Australia was put forward in May 1959. The development of the heart lung bypass machine made it possible to correct the remaining fifty percent of the operable congenital heart disease cases.

In 1958, there were sixty-five paediatric cases and thirty adult cases awaiting surgery for congenital heart disease, with others yet to be diagnosed. Discussions were held at the time as to whether some of the urgent cases in South Australia should be referred to Melbourne or Sydney for surgery – a debate that still exists today for paediatric surgery. It was determined that Melbourne and Sydney would not have the capacity to undertake the additional work for South Australia. It was also considered that with the emerging new techniques more cases would come forward as the availability of the surgery became more widely known, which had been the experience in the USA. It was therefore decided that it was feasible for South Australia to have its own heart-lung bypass machine that would service the adult and paediatric needs of the whole state – both public and private.

In addition to the congenital cardiac surgical needs for the state, Peter Hetzel and D’Arcy Sutherland suggested that there would be more widespread use of the heart lung bypass machine into the other areas of heart disease and areas that had not yet been considered – and how right they were!

Congenital heart disease only accounted for about 1.5% to 2% of the cases suffering from heart disease with the majority balance being attributed to coronary heart disease, hypertension and rheumatic heart disease. Obviously rheumatic heart disease was more common at that time than it is now. Surgical techniques were being developed to perform surgery for rheumatic mitral incompetence and aortic incompetence that could not be performed without the support of the heart-lung bypass machine, particularly in the United States of America, thus furthering the argument for a heart lung bypass machine for South Australia.

The first part of the development of cardiac surgery in South Australia had now been completed – we had the Leader in D’Arcy ably assisted by Peter Hetzel -what was now needed was the Team. The personnel requirements for the Team were outlined in the May Proposal.

The Surgeon and Assistant Surgeon were already in place with D’Arcy and Howard Brown. D’Arcy had also already included John Stace in his early team, who was by this time, an Honorary Anaesthetist and D’Arcy attributes much of the surgical successes to John Stace. There was a need for a Senior Registrar to conduct the perfusion. Peter Hetzel suggested to D’Arcy that John Waddy (a colleague of Peter) might be interested in a career change. John Waddy had spent nine years in General Practice and recently passed his MRACP. D’Arcy approached John Waddy who agreed to join the team and John went to London to learn the techniques of perfusion and post-operative management. Two surgical technicians were also included in the team. A part time Physiologist was considered as necessary in the beginning stages of development, with the view that this need may decrease or be absorbed within a broader role. Peter Hetzel was eminently qualified to fill this role.

Lastly, the need for an additional theatre sister and 1 or 2 trainee nurses was identified. The team would then be complete, although at this stage the need for a dedicated post-operative recovery was not muted. Post-operative registered nurses were clearly added to the initial team as in 1962 D’Arcy et al write that:

the immediate post-operative nursing is in the hands of trained nursing staff appointed specifically for the purpose. They are responsible for the care of these patients for twenty-four hours of the day for the first three post-operative days or longer if complications make this necessary

It is also important to acknowledge the assistance and co-operation that D’Arcy and Peter received from the hospital administration of the day through Bernard Nicholson as Medical Administrator and Ron Hooper as a General Administrator. Bernard Nicholson’s role in supporting the 1959 proposal was considered to be significant. I will not discuss the individuals in the early Cardiac Surgical team or the contribution of nursing to the development of cardiac surgery, as I am sure that the speakers in the following presentations will do so.

By 1960, the proposal for further development of Cardiac Surgery in South Australia had been accepted by the government. Approval was given to establish the medical team and “for the purchase of specialised equipment required to perform the intricate and delicate heart operations”. Delivery of the heart-lung bypass machine was expected in mid 1960. The Government also provided funding for D’Arcy and Peter Hetzel to visit the United Kingdom and United States of America to study new cardiac techniques. The position of Senior Registrar for perfusion was formally created and John Waddy was appointed to the position in January 1960 and was promptly sent to study the new techniques at the Hammersmith Hospital in London.

By July 1960, a period of animal experimentation was conducted to test the equipment and develop team methods. The first operation using heart-lung bypass was performed in November 1960. At first, one operation a week was performed and from March 1961 this increased to two cases a week. From February 1962, three cases a week and incrementally increased over the next forty three years, as new surgical techniques and equipment became available.

Following a period of professional and political manoeuvring, a scheme for the re-building of Royal Adelaide Hospital was arrived at which included the building of the East Wing which would house the Cardiac Surgery Theatre, Recovery and Ward. This wing commenced occupation in 1961 and was fully completed in 1962 and remained the home of cardiac surgery at Royal Adelaide Hospital in its entirety until 2004 when the theatres transferred to the newly redeveloped area of the hospital and the recovery (now an Intensive Cardiac Care Unit) moved into a new wing of the hospital adjacent to the new theatres. Building and renovations continued throughout the 1960’s at the Royal Adelaide Hospital and the Cardio-Pulmonary Investigational Unit was transferred to new accommodation in the new North Wing in 1969.

It is at this point of the development of cardiac surgery in South Australia that I hand over to the rest of the mornings’ speakers whose presentations will include both the ongoing development of cardiac surgery in South Australia and at Royal Adelaide Hospital.

I feel by way of acknowledging the pioneers of cardiac surgery in South Australia that I would like to finish my presentation with a paraphrase from a quote from the paper that D’Arcy gave to the Royal Australasian College of Surgeons in 2002:

In Adelaide we were lucky – we had a strong team structure, we had competent medical, nursing and technical staff in every position, especially Peter Hetzel … we had John Waddy running our pump …an important part of our success… we had a health administration keen to get into the act … nation-wide we had nothing to be ashamed of with Australasian results all up to International standards … Two of our surgeons were made honorary fellows of the American College.