Vital signs
Father and son heart doctors Alan and Andrew Kerr are two unsung heroes of New Zealand cardiac care. Donna Chisholm talks to them on the opening of an exhibition celebrating the pioneering work of Auckland’s Green Lane Hospital.
Heart doctors Alan and Andrew Kerr are two unsung heroes of cardiac care. Donna Chisholm talks to them on the opening of an exhibition celebrating the pioneering work of Auckland’s Green Lane Hospital.
Alan Kerr has never forgotten the three babies who changed his life. They were in separate cots in the corner of a ward in Dunedin Hospital, so blue they were almost black, so lethargic that even at about 18 months, they could barely move. They were waiting to die. Sending them to Auckland’s Green Lane Hospital for the then pioneering surgery to fix their hearts wasn’t an option, the paediatrician told him, because it would only “prolong the agony” for them and their parents.
Kerr was a 20-year-old medical student, who aspired to be a physician. Asked why he became a heart surgeon instead, he tells the story of those babies, the image still fresh in his mind 60-odd years on. “I was surprised that people hadn’t tried to do something for them, but that was how things were in those days.”
It was the first time he’d thought that instead of being a physician as he’d planned, becoming a surgeon might be a surer way to change lives and save lives.
Kerr has now retired, having done hundreds of operations of the type that would have saved those children, colloquially known as “blue babies”, who had the combination of congenital heart conditions called tetralogy of Fallot.
For most of his career, Kerr operated in the shadow of his dashing high-profile colleague Sir Brian Barratt-Boyes, but from the mid-1980s, it was Kerr who handled this country’s most challenging paediatric heart surgery.
Now 83, Kerr operated for the last time – in Gaza – three years ago. Since retiring, he has continued to be involved in voluntary work with Palestinian children, and he returned to the Middle East in March with a Kiwi team who operated on nine children with excellent results.
Recently, a new exhibition opened in Auckland that relives Green Lane’s glory years, and will acquaint a new generation with the hospital’s medical and surgical stars, including Barratt-Boyes, Sir Douglas Robb and cardiologist James Lowe, who took its heart unit to global renown in the 1960s and 70s.
Alan and his son Andrew, 55, are rare creatures in specialist medicine in that neither has worked in the private sector, despite the fact they could earn hundreds
of thousands of dollars more by doing so.
Alan Kerr says because he specialised in paediatric surgery for most of his career, going private wouldn’t have worked. “I always felt I needed to be in the same hospital with the kids, not just for the operation but looking after them afterwards. I knew I’d be very conflicted if I was operating for money at the Mercy [Hospital] and a baby was having a postoperative cardiac arrest at Green Lane, so I decided full-time [in public] was the way to go.”
Andrew says he can’t say he’d “never” go into private practice. “I’ve thought about it a few times, but I get well enough paid through the public health system. Often people go into private work to augment their income, and in Auckland’s housing market, I can understand why people might need to do that increasingly now. Most of my colleagues do. We’ve lived a slightly more modest lifestyle than some people in medicine would, but we’re perfectly comfortable and can do most of what we want.”
Andrew is principal investigator for a national research project, Anzacs QI
(the All New Zealand Acute Coronary
“I felt I needed to be in the same hospital with the kids, not just for the operation, but looking after them.”
Syndrome Quality Initiative), which he says is unifying the cardiac-medicine community. It has collected clinical data on more than 25,000 patients hospitalised with heart attacks and more than 50,000 referred for angiography and followed their outcomes. “Once you arrive in hospital, you get pretty similar treatment. The bigger postcode differences are because of problems in the community and maybe, increasingly and worryingly, the influence of the private versus public sectors.”
On the eve of the exhibition, the two men reflect on their careers in cardiac medicine, and how it’s changed over the decades. T ALAN KERR he exciting times were the new things we did. I don’t think we could do what we did at Green Lane in the 1960s and 70s in the current political climate. There isn’t the freedom to innovate now that there was in those days. That’s probably a good thing – things are more closely supervised. In a way, cardiac surgery was a last frontier really, because all the other specialties were far in advance. It wasn’t really possible to operate on the heart before heart-lung machines were developed, and that didn’t happen until after World War II.
I started at Green Lane in 1961 after I saw an ad for a research fellowship under a chap called Barratt-Boyes, who wasn’t well known at that stage. I’d heard of him vaguely but didn’t know much about him. He’d worked at Wellington a few years earlier and I asked people there about him. All the senior surgeons said they thought he was very bright and excellent technically but a bit of an upstart. I asked the nurses about him, and they recalled him playing the Moonlight Sonata on the piano at house surgeons’ Christmas parties. They were probably in love with him – I didn’t hear any bad accounts from the nurses.
It was a very exciting environment. The second day I was there, I was asked to help Brian do some cases. He had scheduled a mitral valvotomy [to open a narrowed valve]. In Wellington, that used to be a major performance that would take about six hours. Brian did it in 45 minutes. It was surgery of a quality I hadn’t seen before.
The first dramatic thing I was involved in was the first aortic homograft operation [using a valve from a cadaver]. He and I went down to the mortuary with sterile instruments – it was a pretty spooky place about 4am – and took out the aortic valve. Brian must have had permission from the pathologist, but he certainly wouldn’t have had permission from the relatives. It doesn’t come out in any of the books, but we lined up [the first] two middle-aged men with leaking aortic valves and in bad heart failure on successive Tuesday mornings. They both died with the anaesthetic induction and we couldn’t resuscitate them. I think the valves were probably wasted. You could say it was experimental, but there was no ethics committee to go through.
Iwent to the US for two and a half years in the late 60s. When I came back, Brian had done just one coronary-artery operation and he hated it, I think. He turned coronary-artery surgery over to me. He was never particularly good at it, to be honest. It was just a different type of surgery. I don’t think he had much confidence that it would be any good.
Green Lane was great until the mid-1970s. Up until then, people who had heart attacks were stuck in bed for two weeks and given anticlotting drugs. With the advent of coronary-artery surgery, the patients started flooding in. They became a huge part of our work.
We went from doing six operations a week to 20. We were constantly behind in terms of staff and resources and the waiting list grew. At one time, it was over 200, and one year we had 27 people die on the list, including quite young people with valve disease. It was a disaster. We were constantly overworked and that was about the time people started going privately, and the doctors weren’t always available for work at Green Lane. We were chronically understaffed.
There was a lot of argument in the late 1980s about where heart transplants should be done. Wellington and Dunedin wanted them. Everyone was keen to do the first few, but then the novelty wore off and that’s when I got involved – partly because others lost interest. The operation itself is fairly simple.
I retired in 2002, just before the move to Auckland City Hospital. That same year, there was a crisis about hearts that had been retained. Brian had earlier persuaded the coroner that all babies who died after surgery should have an autopsy. He did that to get the hearts to find out what had gone wrong. [Cardiologist] John Neutze and I had serious concerns about this process and talked to the coroner and said we didn’t feel all these babies required post-mortems because the cause of death was quite clear.
The really disturbing thing to me was that there had been an inquiry in Liverpool, where a pathologist had retained a lot of children’s organs, including hearts. We knew we had all these hearts collected and that sooner or later it was going to become public. We formed a committee to try to deal with this problem in the best possible way. We deliberately leaked the news, I think to the Herald, but they didn’t feature it at that stage. In the end, we contacted a TVNZ journalist to make an intelligent, compassionate documentary and I think it would have helped. But it came out at a hospital board meeting that this was in progress, and the reporters picked it up.
It’s all past history now, but I took the brunt of it, in a way. It was pretty ugly at the time. By then I was 67 and I was on a temporary contract. The upshot was that I was regarded as a medico-legal risk. I resigned. It wasn’t good at all.
Being involved in Palestine was part of the recovery. We’ve done 700 operations there and trained people, and the hospital [in Jerusalem] is now running independently.
A lot of my heart patients here keep in touch. I’ve probably operated on about 2000 children over the years, and the ones I see again tend to be those who have the most complex defects. But now, 80% of
the surgery is reasonably simple – one op and it’s fixed; goodbye, you don’t see them again. It’s great. Almost every condition is now operable – there’s only a handful that can’t be – and even in the most complex children’s operations, where once the mortality rate was about 30%, it’s now about 2%.
The Green Lane experience was a unique area of innovation in New Zealand. It wasn’t just the things that were done as firsts but the fact they were done well and done early and that we worked in a team. I don’t think it will easily be replicated. I ANDREW KERR ’ve always had a fairly conflicted feeling about following in Dad’s footsteps. I don’t think I was trying to. dropped out in my third year at medical school in Dunedin. The curriculum was worse than today – a lot of very basic science and no clinical stuff at all. It just about drove me mad. I spent a month tramping and climbing in the Southern Alps and a month in the Cook Islands. I was convinced I wasn’t going back to medicine – I even wrote to the medical school and said, “I’m not coming back.” I got very interested in psychology and philosophy and did a BA and then an MA at Auckland. I got progressively into the more scientific side. I found [Sigmund] Freud wasn’t for me, so I came back to the more practical stuff, and by then I’d figured out medicine seemed a pretty good and worthwhile thing to do.
I was going to be a neurologist, but there’s not as much you can do in neurology. There’s a lot of diagnostic work but less treatment. In acute cardiology, you have a problem in front of you and you can fix it and save someone’s life very quickly when they’re critically ill or almost dead.
I went to Boston to train in echocardiography in 1998-89. In the first year, I was diagnosed with Hodgkin’s lymphoma. The hospital effectively paid for all my treatment. It was worth a good $100,000 or so. It never occurred to me too much that I wouldn’t survive.
It did make me think, though, that ideally everyone in medicine should go through being a patient, because you take that with you into practice. From a simple, practical point of view, the most important thing is getting things done quickly.
Back in New Zealand, one of my main priorities has been trying to reduce waiting lists; making sure everyone gets access to investigations and treatments quickly. It seems such an obvious thing, but we’re so used to the idea of waiting lists here – there’s a waiting list for everything. In the US, I went to the doctor with a lump, had a biopsy the same day and started chemotherapy two days later. Only now in New Zealand have we set a target for starting treatment with chemo. For patients, there’s nothing worse than sitting around waiting.
In New Zealand, we’re trying to do the best we can with the resources we have. At Middlemore, where I was initially a cardiologist and then clinical head, the biggest thing I did was to argue with management that we needed more staff in sub-specialty areas, and I was able to appoint people I knew would be good. We started with three cardiologists and now we have a unit with 12, and it’s one of the best in the country.
We have achieved enormous efficiencies at Middlemore, but we are very close to the limit on a lot of things, and unless it eases up a bit, we’re going to run into trouble with keeping that up.
The biggest issue we have in cardiology is people presenting late. Maori and Pacific people are less likely to call an ambulance in the first place, they take a lot longer to get to hospital and they are more likely to die of a cardiac arrest.
Every day on the ward rounds, I see people who can’t afford their medicines or have two jobs and don’t have time to do any exercise. Or they have 20 people living in the house and everyone else is a priority but not them. They can’t afford
“Every day I see people who can’t afford their medicines or have two jobs and don’t have time to exercise.”
to call the ambulance, so someone drives them in.
The night before I was starting chemo in the US, I was offered jobs at both Middlemore and Green Lane. Green Lane already had so many good cardiologists and Counties Manukau had an enormous population which was way more poorly served than they are now. I really just wanted to improve their health outcomes and give people a better quality of life.
I was brought up thinking everyone is equal. It never occurred to me that people wouldn’t be equal or that you wouldn’t treat someone the same as anybody else, or they didn’t have the same rights as anybody else. Clearly that wasn’t happening in South Auckland at that stage, so for me it was, and has remained, important.
Brave Hearts: The New Zealand Cardiac Story, Auckland Museum of Transport and Technology (MOTAT), until December 31, 2017.