King of hearts: Dr. Tirone David
No rest for the weary. Dr. Tirone David, Head of Cardiovascular Surgery at The Toronto Hospital (TTH), General Division, has barely settled into his chair when an overseas call is routed through: A surgeon in Israel has a problem, and he’s looking for help.
“They have a patient they don’t know how to handle,” David later explains, “so they’re going to fly him here for us to fix. It’s an unusual pathology. “Poor guys, they have no idea what they’re looking at, but we’ve had a dozen or two, so we know how to fix it.”
Ten years ago, the Israeli’s case would have stumped David, too. “We are much bolder now because we have better techniques,” he says, in his soft Brazilian accent. Still, the challenges sent to them from around the world can be daunting. All are complex, unusual pathologies or patients who’ve had so many previous operations that most surgeons would say nothing more can be done.
Their success at TTH, David says, is due to a number of things – what they’ve learned, for example, about keeping a patient’s heart and brain alive during an operation, as in the case of the Israeli patient. His doctors didn’t want to operate, David says, “because they believed they cafix the heart, but they’re afraid the patient will be brain dead. We have the technology to protect the brain during operations now. So, the combination of these new developments allows us to venture ourselves – responsibly, I should say – in new areas that we would not pass before.”
Their success, a great many say, is also due to David himself. A typical example: David performed an operation on a Chilean woman who came to Toronto “after her doctors concluded that David was the only person in the world who could save her,” wrote Leslie Papp in a 1995 Toronto Star article. The woman’s Chilean surgeon, Dr. Miguel Berr, told Papp that “‘Dr. David has unique skills. The patient would have died in any other hands. He’s the most brilliant surgeon I’ve ever met, and I’ve been a lot of places’.”
David works fast, for one thing, which gives his patients an edge: The less time they spend in the trauma of surgery, the better their chances of recovery. At his previous appointment, Toronto’s Western Hospital, where he performed about 400 of the unit’s annual 700 heart operations, David helped reduce the hospital’s mortality rate to among the lowest in North America. “He can do magic, he has such great surgical skills,” says one colleague. “He’s just a very talented man,” says another, “fast, confident and precise.”
What really sets David apart, though, is his creativity. There are surgeons as deft with a scalpel, but few are as brilliantly innovative. On more than one occasion, David has leaped off the beaten path, so to speak, in mid operation, devising an ad hoc solution to a unique puzzle in a patient’s wounded flesh – spontaneously inventing a technique that his peers around the world will soon be copying. Sometimes, it’s not breakthrough innovation – just decisive action. In one memorable operation, David concluded that his patient’s bleeding was so profuse he couldn’t wait for a delivery from the blood bank, so he called for on the spot donations from the operating team, himself included. Blood type matches were infused, and 20 critical minutes – and the patient’s life – were saved.
David has admitted he can be “too cocky,” too confident, for his own good. When you’re dealing with people’s lives, that can be a bit like “trying to play God,” he says. More than once he has pushed the limits of his abilities, of existing technology, of current surgical and medical understanding, in an attempt to save someone colleagues had argued was inoperable. Sometimes that person died on the table. Those are the patients that remain with him, lodged in the dark creases of memory, unassuaged by the knowledge that if he hadn’t tried, those patients would have died anyway. And sometimes, against all odds, those patients do survive; sometimes a daring procedure has given someone back a little more life. The urge to prolong life is something David clearly identifies with: “Something I have learned is that the dying patient doesn’t want to die. We are this way. The moment you turn into a patient, you realize life is precious, and it’s too early to leave. It’s not so much for the patient as his family and loved ones – they’re going to ask you to do everything possible to keep them alive.”
David almost missed any chance he might have had to gather that insight, when he accidentally pricked himself with an infected needle during an operation in the ’70s. He developed hepatitis, lapsed into a coma and, for the better part of two weeks, hovered between life and death. That episode left him with a permanently damaged liver and a sense of casual fatalism about the risks of surgery – of which he’s regularly reminded with every nick and cut he sustains in the course of his work.
David was raised in a small town in southern Brazil, where his mother juggled the competing demands of young Tirone and his five siblings, a crowd big enough to sideline David Senior’s own medical aspirations in lieu of more immediate prospects in business. He tried to convey his enthusiasm for the medical profession to his children, but only Tirone caught the bug. It was a high school project on Albert Schweitzer – whose medical missionary work in French Equatorial Africa earned him a Nobel Peace Prize in 1952 – that set David’s course in life. After completing his research on Schweitzer, David wanted to go to Africa, too. “What a great man,” he thought, “what a giving soul!” He, too – Tirone David – would become a priest and go to Africa to heal the sick.
Alas, the priestly intentions were doomed: “Of course,” says David, laughing, “I like women, too.” The medical part of the plan seemed like a good compromise, though, despite a marked distaste for the sight of blood – an ironic sensitivity in someone destined to be a heart surgeon. But cardiac surgery was taking an interesting turn just about the time David was finishing his medical training: In December 1967, Dr. Christiaan Barnard made medical history in Cape Town, South Africa, with the first “successful” human heart transplant (the recipient died 18 days later). That eventually led David to some surprising observations about his chosen profession. The average (or even better than average) heart surgeon, he found, could expect to do no more than one or two operations a week requiring more craftsmanship than a plumber: “That’s basically what it is – changing valves. After the musculoskeletal system, the heart is the most mechanical part of the body. It doesn’t do anything but pump blood.”
Despite that reductionist conclusion, David had to admit that the simplicity of the fist sized pump and surgery on it appealed to his logical mind. And if, as he once claimed with self deprecating honesty, he’s “not very good at philosophy or abstraction,” it soon became clear he had the qualities essential to surgical success in spades. Chief amongst those, David says, are dexterity and inquisitiveness: “You should be keen enough to find the answers, to ask the whys, and, if there is no answer yet, to look for alternatives.”
You don’t have to be a genius to be a good doctor, he says: “In fact, geniuses don’t make good doctors; they’re too scientifically minded, too much the medical professor type. A more human type, an average human being probably makes a better doctor, perhaps because medicine is not a science yet. We are far from a science. We use scientific approaches to deal with clinical or medical problems, but it’s not like science, not like engineering problems or going to the moon. For me, it’s a mixture of art and science.”
David earned his M.D. in Brazil before heading Stateside for further training, first in New York, then Cleveland, where he met his wife to be, Jacqueline, who was head nurse in the cardiac unit at the prestigious Cleveland Clinic. Toronto’s Western Hospital beckoned, and the couple packed their stethoscopes and moved north, where Jacqueline set her own career aside to raise their three daughters.
The girls, collectively, are a major reason why David has never succumbed to American entreaties to migrate south, where, his temptors say, he could make a zillion dollars a year. David likes living in Canada, but he’s also been loath to uproot his daughters from their friends and schools.
There are also professional considerations: The big money at a major American hospital would mean a very different workload – five or six hundred “ordinary” heart operations annually, instead of a mix of 300 ordinary and challenging procedures – the kind of mix that’s helped to establish David as one of the world’s top cardiac surgeons.
His work has made him the expert in a number of highly specialized areas, including complex heart valve disease; heart reconstruction, or “remodelling,” to reduce the size of an organ enlarged and weakened by congestive heart failure; as well as repairing aneurysms (bulges in vessel walls) in the aorta of the heart, for which he developed operations that preserve the aortic valve while repairing the faults.
Where is cardiac surgery headed? Transplants are routine these days, he says; finding donors is the hard part. David performs only about 25 transplants a year, though “there must be at least two or three times more donors out there, based on the American experience. Americans get about two and a half, three times more donors per 100,000 people than we get in Canada.” There is “some light at the end of the tunnel,” he says. “There is now a totally implantable mechanical heart that’s very successful, so successful that many patients who have had it implanted as a bridge [while waiting] for transplants, many of them say, ‘Thank you very much. I’m going home on my battery instead.’ They feel so great, so why transplant?”
Unfortunately, the artificial hearts are still considered experimental and aren’t widely available, David says, “but that’s how it starts.”
Another promising initiative is genetic engineering, as scientists modify animal genes to make them compatible to humans. A group in Boston, for instance, has been modifying the DNA of pigs in an effort to make the pigs’ hearts human ready: “The pig heart has the best anatomy for implantation in humans,” David says, noting that pig heart valves have been used in humans for years: “These guys are changing the DNA in such a way to be easier to immunosuppress, easier to prevent the rejection. It would never be identical – perhaps one day, but not in my lifetime – and you’re still going to require anti rejection drugs, but to a much lesser degree.”
Immunology has progressed in leaps and bounds in recent years, David says, “way beyond my comprehension, to be quite honest.” The science of immunology, rooted in highly complex molecular biology, is almost a foreign country, with its own language and issues, but, says David admiringly, “this is science, its essence, what we are made of.”
Eminently practical man that he is, David will turn that essence into a saving grace, for what matters most when he replaces a heart or repairs a valve isn’t decoding the mysteries of science, but preserving the mystery of his patient’s life.