Cardiology – Dr Richard Luke

[Talking in background]

Joyce Barry: The Heart: terribly symbolic; romantic … you just name it, it’s everything. It’s basically just a pump, isn’t it, Richard? And it’s a very complex pump, but that’s all it is really; but it’s huge, ’cause it does keep us ticking over. In 1969 when Professor Christiaan Barnard arrived and they made this terrible big fuss about him and he strut [strutted] round the hospital, I know the late Michael Bostock said he’d never seen so many nurses attend; and [chuckles] he said, “Every time I want one I can never get one.” [Chuckles] But anyway, I don’t know if you had that effect, Richard, did you?

Richard Luke: Not at all.

Joyce: No, [chuckles] okay. But anyway, it’s a great joy to have Richard; he’s on the cusp of retirement. He’s had extensive decades of cardiology in Hawke’s Bay, and I think also through a period of great change in cardiology, which he’ll explain tonight. Welcome, Richard – it’s over to you. Thank you.

Richard: Well good evening. I’m not sure how long this is going to take, and if I talk too fast, tell me. If you get bored I will stop. But when Joyce Barry coerced me into giving this valedictory speech before I head off into the sunset and travel at taxpayers’ expense, [chuckles] I thought there might be a handful of people here. I’m not sure if I should be flattered or horrified by [chuckle] this enormous room.

So I wasn’t quite sure what to talk about; what I thought I would do is to go through a series of topics firstly, at some length; and going back into history – ‘cause this is a historical group – to talk about where I came from and perhaps to understand where the medicine in me came from; look at training for me which was a very long period from university entry to arriving here to replace Michael Bostock, who, looking at the crowd, most of you will probably remember – he was a very interesting man actually, I had a lot of time for him, but he was sort of polarising in his way; talk about the changes that have happened in my thirty-two years in Hawke’s Bay since I came here in 1987; not all has progressed – I’ll try not to be political about this, but there’s certainly some bad tidings on the horizon I think, for health care in this country, and that’s in part due to some of these things; looking at societal change; epidemiology of heart disease. I’ll talk through a little bit about some of the diagnostic changes that have occurred in my lifetime; about a handful of drugs which I think are significant that have arisen since I started practise here; and some procedural issues, but while that won’t be particularly detailed, you can ask questions at the end.

So I thought I’d go right back and tell you where I came from. And unfortunately I tend to be patriarchal, so this is the Lukes. [Showing slides] This is the family who came to Wellington and landed in Petone in 1874; so Samuel in the middle there, his wife and ten children – I think one actually might be a wife; I might’ve got that wrong, she might be the wife of this fellow at the back. So, bearded Cornwall men who were all metal workers when they arrived – the older ones were. Samuel, the patriarch, was born in 1831, and I’ll [chuckle] show you the story of his death, which is quite important as far as cardiac disease is concerned.

So [the] Lukes arrived in Wellington as metal workers … calloused hand[s], Primitive Methodists – I’ll talk about them in just a moment – and they set up a foundry which lay beside where the Opera House is. [Te Aro] There is still Lukes Lane there, which was famous recently in the earthquake [which] I think shattered some of the structures around it. So apparently that was in Manners Street, and they built a variety of things including the Castlepoint Lighthouse here, which I think had its centenary quite recently; boilers, coal ranges, and they built a couple of ships, both of which sank in short order. [Chuckles] Didn’t last very long. And this group were Primitive Methodists, and that’s important for some of the little tidbits that I’ll point out as I go along.

And of course in those days, Victorians were used to death; we aren’t nearly as used to it as they were. So within probably ten or fifteen years, half of the family had died, so the mother, three sons and two daughters. And if you look at the death certificates, a lot of them died of phthisis which was the original name, or the traditional name, for TB. [Tuberculosis] I’m not certain how the diagnosis was made in those days, so probably pneumonia of various causes was attributed to TB.

So this was interesting; I’m not quite sure when this was written – so ‘Sam, who is the oldest, is still with us, and enjoys a green old age’. It was a term I’d never heard before – does anyone know what a ‘green old age’ is? Quite a quaint term. And this is important too; the family were Primitive Methodists, and as part of their sort of beliefs, temperance and social reform were strongly pushed; and that’s important when I come to talk about John Luke in the early 1900s. So there’s a green old age, so that’s where it comes from; I guess it means growing old in style, really, but ‘old’ in those days is [of] course not what ‘old’ is now. There’s the term ‘a green old age’, which I thought was quite quaint.

So here’s Sam, and here’s his death, which is a lovely description of sudden cardiac death – I’ve highlighted it for you there. [Chuckle] So ‘he walked up a hill, gasped for breath, fell forward and expired’. So [chuckles] he had a cardiac arrest at sixty-nine, and somewhere I think, it says there he’d been retired for some time; so again, things have changed. So he was in retired life for many years before dying at sixty-nine; that’s also evidence of significant change over a number of years.

So left behind were the two eldest sons; Charles Manley was my great grandfather; and his brother, John, both of whom became mayors of Wellington – Charles in 1895 for one year, [cough] and JP [John Pearce] for a longer period from 1913 to 1921. And here was a problem; and I’ll show you in just a moment, is that John Luke, the mayor of Wellington, was a temperance man – a prohibitionist – so the devil whisky was not on his list. Unfortunately, during his tenure the Spanish flu broke out. The Spanish flu, which was not really the Spanish flu, apparently arose … and someone researched this about twenty years ago … in a military camp in Étaples in France in January of 1918. The reason it was called the Spanish Flu was there was censorship then, and the fact of all the deaths was not made public. In Spain, where censorship wasn’t applied, there was this list of all these people that had died; so it became known as the ‘Spanish flu’. So in New Zealand it killed [cough] close to nine thousand people; it actually killed fewer than had died in the war, but world wide there was a huge death toll; far more died of the flu than of military action.

So here is poor John Luke, in Wellington and a temperance man who thought that ‘wine was a mocker; strong drink was raging, and whosoever is deceived thereby is not wise.’ [Proverbs 20:1] Because the only treatment for the flu in those days was whisky and carbolic. [Chuckles] Carbolic acid was sprayed in the place, and you can see there’s pictures of people sort of walking past the guy with his puffer machine blowing carbolic acid out. They’d then have a slug of whisky afterwards, so I’m sure that John was troubled by the difficulty of treating these people with the therapy of the day.

So I thought I should share my mother’s side a little bit; this sort of echoes the same thing. This is a picture I had at home of my grandfather, Alan Brown, who was on a troop ship in 1918, off to the war; and a bit late in fact, to get there to do anything useful. But here’s a story of the flu breaking out on the ship, so in August of that year the flu broke out, and they lost eighty people on that boat on the way to Europe. And by the time they got there, those who survived were too weak to serve, and of course after that the war was over. But Alan Brown’s claim to fame was that he was the Crown Prosecutor in the Parker and Hulme murder case – the ‘Heavenly Creatures’ case which … I grew up with that story. And he was manic-depressive, I’m told; but that case actually did very bad things to his mental health.

So we’ll come next to my grandfather … fine-looking man; here is off to the First World War. He was the city engineer of Wellington – as you might expect from his parentage, there was [were] engineers throughout the family – city engineer for that period there. I did then find in that generation his youngest brother who was a surgeon, and there is a local connection to this. So Eric Luke, who I met a number of times who died not that long ago, was a thoracic surgeon. He used to visit Pukeora and Waipukurau Hospital, and in my early days here I would meet patients who had been seen by him. The treatment then for TB was collapsing the chest to deprive the tuberculosis infection of oxygen, and thereby to effect cure. So there were people around – I’m sure there’s some I’ve met now who had very deformed chests from this procedure, which was the only way in the pre-antibiotic days that they could actually treat TB.

They’re my parents, [showing slides] and there’s the doctors; both of them were doctors. I couldn’t [coughing] find a picture of my mother in a white coat ‘cause she never actually wore one. My father who was a physician at Wellington Hospital with an interest in cardiology; my mother in later years gave anaesthetics in the days when it was ‘see one, do one, teach one’, which you would never get away with now. So very ‘seat of your pants’ anaesthetics. There’s one lovely anecdote from my mother’s days; she had a few little [cough] stories of operating here in Wellington, noticing that the orderly would always leave the room very quickly when the patient arrived. So one day she asked the surgeon why George disappeared so quickly; the surgeon said, “Well he doesn’t like the sight of blood – he’s squeamish, that’s why he gets out of the room so quick.” My mother turned to a little nurse standing next to her and said, “Dear, are you squeamish?” She said, “No, I’m Norwegian.” [Laughter]

So this is quite interesting too – this is the fifth-year medical class in 1948, and I’ve flagged my father hiding at the back; my mother down the front. So I think twelve women in the class; what’s the other thing you notice about them? They’re all Caucasian. And that’s just a totally different demographic to the medical school of today – probably two-thirds female; of the class, I would guess probably more than half would be non-Caucasian. Things change substantially over time.

So here is my training pathway from university entry in 1972, to starting work in Hawke’s Bay in 1987; so fifteen years of work apart from one year off in the middle where I took off with a pack on my back, and saw the world. There’s the pathway there, so starting at Victoria University for my Intermediate; a time at Otago University before I decamped and travelled the world; returning to Otago, and then to Wellington for my training intern year in 1978; my degree at the end of that year; a house surgeon year in Waikato, where I was entranced by Canadian house surgeons … in those days we used to have a lot of Canadian house surgeons coming to New Zealand. They stopped coming ‘cause the pay was inferior. But I followed some of them back to Vancouver and spent two years there in medicine, before returning to Greenlane for my advanced training. With my specialist qualification in 1986 I went to London and worked at the Brompton Hospital for a year, and then returned with our first child, who’d been five months old when we left, to Hawke’s Bay in 1987.

So what have we seen over that thirty-two years? There’s been a lot of things go on, [cough] a lot of which you will know about. Health services in Hawke’s Bay clearly underwent major change in my time; there was an attempt I think in the 1970s to rationalise the hospital system in Hawke’s Bay, but that didn’t occur; so there was a move from two hospitals to one hospital, of course. The other thing, and I’ll come back to more than once, is the fact that the population has aged substantially. Half these patients are doing better for a variety of reasons; some good news on that front in terms of lifestyle. There’s some bad news; and there’ve certainly been very significant advances in treatment over the period I’ve been here.

So what we’re seeing is increasing life expectancy; this is Britain in quite a tangible short timeframe, of the increase in life expectancy from birth going up by a number of years; and that’s mirrored in New Zealand as well, just a longer period. You’ll see for a male born around the time I was born, [coughing] expectancy of sixty-eight; if you’re born in 2010 you can expect to live to eighty, so a remarkable increase in life expectancy, both because of improvement at the end of life, and of course because of an improvement in health at the beginning of life. And the consequence of that is what I’ll call the ‘grey tsunami’. [Chuckles] And here we come, I mean we’re right there, where the aging population is increasing at a horrifying rate. And not just that, the very elderly too, are going up hugely. This is quite a long time frame, but the over sixty-fives go from seven hundred and fifty thousand around now, to 1.3 million in … what, twenty years’ time; and the very elderly population’s increasing as well, so over eighty-fives … a vast number are more in that [coughing] demographic as the years go by. So for Hastings – this is quite old data – the same thing’s happening, so we’re going up substantially in quite a short time frame in terms of percentage in the population over the age of sixty-five.

What that doesn’t necessarily mean is quality of life, and here’s a graph which shows you health expectancy, so you’ll see whereas life expectancy is well into the eighties for both males and females, in 2006 a healthy life is not as great as that. So time on this earth is not necessarily quality. And the other problem of course we have, which again I will come back to, is the fact that looking after old people is very expensive, so most of the health expenditure for us comes in the last years of life. And as that group grows there’s going to be huge pressure on our health system.

So the good news: smoking in New Zealand is declining, certainly in Caucasian populations, and death rates are going down – I’ve jumped ahead of myself there – but this is deaths from heart disease in New Zealand. And particularly for males there’s been a substantial decline since the late sixties in deaths from heart disease, which means there’s more people out there who’ve got the condition, but they don’t die from it as they used to. Smoking, good news; so in the last health survey less than twenty percent of New Zealanders in total smoked, but for Maori and Pasifika the numbers are much less encouraging; so a lot of smoking still in Maori women, but for most of us smoking is far less prevalent.

And here’s the bad news: obesity is going to potentially turn around that decline in death rate we’ve seen since the late sixties, because obesity is becoming more and more of a problem. And what you can find is your wonderful fat map; this is the USA – looking between 1985 and 2010 – at the percent of the population who are overweight. So the more [?] you are the fatter you are; and you see how you’ve gone from the states of the US, where obesity rates are down around ten to fifteen percent of less to states now, where a prevalence over twenty-five percent is increasing hugely. And if you split it up even more, you’ll see how that’s progressively got worse; from 1985 through to 2014, a huge increase in obesity in the US.

And the same is true for New Zealand, and we’re getting worse, so people in this country are getting fatter, and by world standards we don’t rank very well, so we’re among the ten most obese populations in the world. I’m sure if you [?saw?] some of the small islands in the Pacific you’d find fatter ones than us, but New Zealand doesn’t feature well in these statistics. And with that goes increased cardiovascular risk factors; so blood pressure, diabetes go up, and heart disease goes up. So [cough] the fatter we get the more heart disease we will see.

So in terms of the changes in my working career, there are some simple things that’re actually quite significant. When I first came here we had these terrible things to find us; so this thing would go off in your pocket, and you’d have to rush and find a telephone and phone in to see why you were wanted; next you’d ring the hospital and they could tell you where to go to. We’ve progressively gone through this sort of technological evolution to where the smart phone now is the prime communicator, and also the resource for information in our work. So a big shift there – I remember when I first came here, fax machines had just sort of come into vogue, and we don’t use those any more; but when I first [coughing] came here they were wonderful things for transmitting documents between doctors and hospitals.

The other thing that’s changed is education. When I came the textbook was the lord, and this was finding journal articles in the library – we had to go and look at these things called Index Medicus, where all the journals were listed, and you’d have to find the reference and then go and find the journal. These days it’s pretty much all online, and I would suggest that many doctors in training now would have very few textbooks – certainly fewer than we had. Now there’s free access to journal articles, to textbooks; and we have a wonderful sort of online textbook which is available in hospital, that’s updated regularly.

I thought I’d go briefly through some of the drugs which I think have made a difference [coughing] to what we do. And the other thing that’s changed too, is that everything we do now is very focused on evidence-base, so if we use a treatment, it has been tested and has been shown to be effective. There’s always this mantra of evidence-based treatment.

Drug therapies: most of the significant ones as far as I’m concerned are these several: ace inhibitors, which is a drug that blocks an enzyme that generates a very powerful blood vessel constrictor. The inhibitor was actually isolated from the venom of the Brazilian pit viper, so this drug development comes from snake venom [whispering in background] – it’s the work done with snake venom that has been useful to medicine. So that’s the Brazilian pit viper, and the product of that is these drugs … some of you will know these drugs and some of you will probably be on them. Introduced to New Zealand as Capril in 1982, so a bit before my time, and have been very important treatments for a variety of conditions; very good medications for blood pressure control, and a very important medication for patients with heart failure. [Showing slides] And this shows the reduction in death rates from heart failure where the pump’s not working properly, from drugs like ace inhibitors. There are other drugs we use which have been around for a long [time] which are also useful, but ace inhibitors can improve survival in patients with heart failure.

The other one, and there may be some in the room who think these drugs are terrible poisons, [coughing] is statins; introduced to New Zealand in the 1990s, and initially very hard to access. We used to have to fill in forms to justify the prescription; a form called a Section 99, which was a pain in the neck; but basically now freely available, in part because drugs are now generic, so that the companies that develop them now no longer hold the patent. These drugs are produced very cheaply, often in places like India and cost very little, so there’s no cost issue in terms of prescribing them. So drugs which lower cholesterol better than any other freely available drugs that we have at the moment; LDL or bad cholesterol dropped by up to fifty percent with statins; and very consistent [coughing] evidence for benefit in terms of improving outcomes. And this [slide] is looking at second prevention – this is people after heart attack given these drugs, showing – unfortunately in American units – the fall in bad cholesterol in [coughing] various studies, and showing a consistent and linear decline in the event rates as cholesterol is driven lower and lower. So no doubt that these drugs are very helpful for reducing risk after heart attack, and improved survival.

The other one I’ve chosen to mention is the new blood thinners which have been around for a period. These drugs are mainly used in patients with a very common rhythm called atrial fibrillation. There will be a number in this room who have or have had that rhythm. And they’re a very good alternative to Warfarin, which is a drug that raises eyebrows when you mention it to patients. The drug’s been around for a long, long time, and is a very powerful thinner of bloods, and protection against stroke and atrial fibrillation. [Coughing] These newer drugs are safer, are much easier to take, and you don’t have to do blood test monitoring to use them.

The other one I’ll mention because it’s just [coughing] been released in New Zealand, is a new group of drugs which are injectible cholesterol lowerers – very powerful agents to lower blood cholesterol, and they’re given, like insulin, subcutaneously once every two or three weeks. [?Alorusamab?] which is this one here has been approved for use in New Zealand as of the last few months; it costs $850 a month, which is two doses, and it’s not [cough] yet funded – I think it will come – but drugs that have the potential to lower cholesterol over and above what we get in statins, and potentially to reduce further event rates after heart attacks may be something to watch out for. There may be some in this room who can’t take statins, and some can’t because of muscle side effects, and this drug group will be a very useful alternative for those people.

So a few things about technology. When I first came Michael Bostock had bought an echo machine, I think in about 1982, which looked something like this. I wish we’d kept it; it looked like a 747 cockpit [chuckles] and all it produced was [were] the images I’ll show you in a moment. We moved on then, and this is a much later machine, to when I first came to large frame ultrasound machines to get path images; we now have hand-held appliances which a lot of doctors carry in their pockets which can provide very good images of the heart. This is actually an echo picture from 1987, the year I arrived. The earlier machine gave these sorts of images, which were basically squiggly lines that you had to interpret – not easy to interpret, often. The newer machines gave wonderful two dimensionally pictures of the heart – this is shown here, the big pumping chamber; [coughing] the inward valve, the outward valve; the heart chamber in cross-section; and what’s good, four chamber views showing all four heart chambers and the two valves, left and right there. And these pictures move in real times, so you can actually look at the images. [Cough]

And we also have the capacity to look at blood flow in the heart; this is what’s called colour[?], so blood flow is shown directionally by colour, and that’s showing a very severe leak in the inlet to the mitral valve. And next we have 3D echo, so here’s a picture in 3D from a modern machine of the outward valve of the heart, opening and closing. So very stunning technology; so you can see the three leaflet aortic valve there. And we’ll talk again in a moment about the aortic valve in another context.

The other thing that’s come in my time, and I learnt this once I arrived here, was the ability to pass a probe down the throat and with local anaesthetic and take ultrasound pictures of the heart from behind, which has the advantage of avoiding having to get the ultrasound beam through sort of lung tissue. If you come down from behind you get these wonderful images, and here’s a picture of the two reservoir chambers of the heart, the left atrium and the right, showing a hole between those chambers; and this is what’s called an atrial septal defect, which is not an uncommon congenital condition, and showing here in colour flow from the high pressure left side across to the right side. And these days these holes can be closed percutaneously with the wires that sort of open up like a little mushroom across the hole, and close it.

The other thing we have here now which we started doing in 2014, is doing coronary angiograms with CT. [Computerised tomography] So this is a picture – conventional angiogram of the right coronary artery with a catheter – you can just see it coming in here injecting an x-ray contrast iodine containing material into the artery, and taking x-ray pictures. This is showing the right coronary [artery] with a blockage just here; the artery’s actually blocked – that should continue on – and this is the image that came with CT, so non-invasive intravenous injection; very low risk. And in selected patients with good preparation you can get images which are very comparable to the invasive image. So a great advance; and we’re doing … unfortunately not very many of those – we do about four a fortnight. We have a waiting list now which probably is stretching out to four or five months. And I’ll come back to my [???] later, ‘cause everything here is stretching out now for months and months in terms of waiting times.

So I’ll go through rather quickly some of these procedures which have developed and advanced in the time I’ve been here. Angioplasty is now a very important part of managing coronary artery disease, and many of you will know about that, or will have had it done; quite an exciting development is the ability to replace valves without having to open the chest – that’s called transarterial valve replacement or valve implantation; there’re now quite effective techniques for fixing some heart rhythm problems by using wires and high frequency radio signals to damage or knock out heart electrical tissue; as I said before you can close holes in the heart without having to open the chest; [there’s] been a lot of advances in pacemaker technology which I’ll show you in just a moment; and also devices such as defibrillators which can save people who are at risk for sudden death.

So for angioplasty, and most of you will know about this – this is where a small catheter with a balloon on the end of it is passed across a narrowed artery, which is shown there, and then inflated under high pressure with a little expandable stainless steel cage around the balloon which opens up and struts the artery and stents it open. Here’s a patient with a very severe narrowing of the right coronary artery, before the procedure and afterwards; so basically you can restore the vessel pipe diameter to normal, a very effective management for angina, and also for patients with heart attack. What you’ll see here and in the UK [United Kingdom] is the way that this has grown, certainly in the time I’ve been here, so a huge increase in the number of angioplasty procedures worldwide, over that period there. At the same time, probably coronary cardiac surgery’s gone down a bit in terms of its frequency.

For heart attack treatment there’ve been major advances; so heart attack is due to a blood clot forming in a narrowed artery and completely obstructing the path of blood flow. [Further slides being shown] And here’s an artery that’s been blocked, and the way that was developed to deal with this in the early eighties, was to give a very strong medication to dissolve the blood clot and restore flow down that pipe. And this is a trial from those early days when I was here looking at one of these agents, either by itself or with aspirin, showing a substantial reduction in death rate from using this drug called streptokinase, a clot-dissolving agent, with aspirin. And more recently, what is favoured now – and unfortunately for you guys in Hawke’s Bay, you can’t get access to this, ‘cause you need to get to a facility very quickly where they can do it – is that people get in with a balloon and open up the artery with a device rather than drugs; you do better. So here you can see that mortality reduced further, from round the seven or eight percent level with this drug, down to five percent with the use of an angioplasty balloon, early. The good news is that angioplasty, I think, will come here; when it will come I do not know, but if you’re going to have a heart attack you’d be better to do it in Wellington. [Chuckles]

TAVI, which is this valve replacement about opening the chest is dear to my heart ‘cause my mother had it done when she was I think eighty-eight, and it gave her probably one year of very good quality life before she died of cancer. So this involves passing a rather large catheter or tube from the artery in the groin; [coughing] it requires a cut down onto the vessel ‘cause it’s a big device. On the end of that catheter there is a balloon, around which is crimped a [an] artificial valve, usually made of beef pericardial tissue, and it has a metal sort of strap around it. That’s opened up across the point where the valve is narrowed; the catheter’s then removed and the new valve remains in position. So it’s a way of replacing a very narrow valve. And there’s an aortic valve which is normal, so a 3D structure as you saw on that echo picture before; and here one which is very heavily calcified and narrow. This procedure is increasing exponentially in use; it’s still not readily available in the public system here, you have to sort of jump through hoops to get it, but worldwide the number of transarterial valve replacements here is increasing as surgical valve replacement goes down. And what’s come out … and this is very recent, just this year … from the American College of Cardiology meeting is data from a trial which was applied to patients with low surgical risk. So initially this was applied to patients who weren’t going to do well – so if you cracked their chest – so elderly, frail people; that’s where it’s seen at its best use. This study looked at low-risk patients, and basically showed here that event rates for those with transarterial valve, in the blue, were substantially less than those who had surgical valve replacement, so showing that even in a low surgical population this was a good treatment to have. The only concern might be durability of these valves, but it’s looking pretty good at the moment.

Heart transplantation I thought I’d mention briefly; so that’s been going since the early eighties, or sorry, the mid-eighties, and patients with end-stage heart failure who would probably be dead within six months can now expect on average, fourteen years of good quality life after cardiac transplantation. Some of those patients will live a lot longer. [Cough] And they’re the New Zealand numbers from the time I arrived through to now … so this is up to 2017. So the numbers have been, I guess, up and down – the major issue there of course is donors, it’s not patients who need it; just that the donor population is not large and there’s often problems getting donor hearts.

ICDs [implantable cardioverter defibrillators] are an implantable device a bit like a pacemaker, which sits high up in the chest and is designed to deal with this condition here, which is ventricular fibrillation, which is the cause of sudden cardiac death. And I’m sure you will know people who’ve dropped dead on the golf course or in other places, and this is what they die of. [??] usually they die of a massive heart attack; well unfortunately, you don’t have to have a massive heart attack to develop this electrical chaos. If that develops in the context of a heart attack, it doesn’t have to be a big heart attack, and if you’re not treated promptly with a shock to the chest, then you won’t survive. These devices are implanted in patients at risk either because they’ve survived an event or have very damaged hearts, and has the potential to substantially reduce the risk of sudden death; so very effective in saving these patients. And here’s a rather unusual patient that’s been saved by the defibrillator that stopped a bullet – that’s a slug that’s impacted upon the defibrillator and [murmurs] and as he had six shots fired at him it probably saved his life.

So what is there in the future? Hawke’s Bay is supposed to be becoming an interventional centre, probably for at least eight or nine years. There’s been numerous discussions, and there’s been people working on business cases. I don’t know when that’s going to become a reality, but the hope is that in the foreseeable future we’ll have access here to angioplasty so those who presently have to go to Wellington to have balloons blown up in their coronary arteries, both for [?] angina and heart attack, hopefully will be able to have that done here. I don’t think it’s going to happen in the next two years … lot of money, lot of staff, and we need support from Wellington, who aren’t particularly happy about us taking that work away from them. So there’s some politics involved as well.

Increasingly procedures are less invasive to treat heart disease, so there’ll definitely be more use of those implantable valves on the end of a catheter. People overseas are now working on replacing the larger valve on this side of the heart, the mitral valve; that’s a bit more tricky. Certainly catheter or wire direct interventions for rhythm problems will become more widespread and active. Digital health’s a new area where you’ll be reminded by your smart phone to take your pills and come to appointments and [murmurs] to comment on your mental health – it’s a big issue on the news at the moment. Pacemakers are getting much better; so this is an old pacemaker here, this is a current pacemaker. We now have these leadless pacemakers which are miniaturised, and which don’t have a wire; they’re simply implanted in the heart and will function without the need for a device on the left side of your chest and a big wire. There’s been a few of those put into New Zealand. I’m not quite sure what the battery life is like; eventually we’ll have devices that can be recharged across the chest wall.

So we’ll come back to my big worry, which I think has the potential to completely cripple the country’s economy, and the same is true worldwide. And here we come … ‘cause I can say this ‘cause this is me [chuckle] … is the over sixty-fives are going to increase in number hugely, and with that, as I’ve shown on this graph before, so will the health care costs. So there’s going to be huge change … either increased rationing, increased taxes. I don’t quite know how the country’s going to deal with it; I’m not certain that the politicians are actually taking this as seriously as they should. And of course the other thing that will have to go is National Super – I’ve told my kids they won’t get it. I can’t quite understand why governments are so resistant to raising the age; don’t like a sensitive topic.

So health will get more expensive, and as far as Hawke’s Bay … and I’ve only got one more slide after this … I think there are big problems in our environment; this is my political speech – we’re horribly under-resourced. At the moment we’re functioning with two full time cardiologists, a locum and myself working part time; the waiting lists are huge, and the referrals to the service are going up and up, so people are waiting too long to be seen. We don’t have easy access to investigations that people need. So I don’t think that certain cardiac care in Hawke’s Bay is in good health; a working case was put together two years ago; we had a visitor from Auckland come down and review the service who suggested we needed four to five cardiologists for the Hawke’s Bay population, which I think is realistic; and nothing’s happened. So we’re often having to apologise to patients who are waiting a long time to be seen, and that’s not very good when you’re working in the system.

So finally, here’s my legacy: I’ve got three large sons – I’ve got a dentist here who’s in Singapore, an engineer who’s in Auckland, and a banker who’s presently in London. And here’s the key person in my life, my wife, Jill, who’s always been hugely supportive of my work and has never complained about my coming home late [if] I’ve been working in the middle of the night, which fortunately didn’t happen that often in my career. And these are two daughter-in-laws [daughters-in-law] in waiting; we haven’t had any weddings in our family, [laughter] but Jill is ever hopeful. [Chuckles] So a good wife is very important to one’s work, and Jill’s been a stalwart throughout my career, and extremely supportive. Didn’t mind me heading off to meetings overseas, and in fact encouraged me to go – I think she enjoyed the peace and quiet, actually. [Chuckles]

So I’m very open to answering any questions.

Question: I’m John to most of the people in the room; been here forty-eight years in the Bay. I’m just wondering, those procedures you mentioned, Dr Luke, are they predominantly available privately or publicly?

Richard: The short answer is all of them are available in both sectors. If you wanted to have a transarterial valve replacement today, you’d be able to access that easier if you had health insurance. At the moment in New Zealand they’re tending to favour frail patients for that type of operation. That won’t be the case long-term. In terms of coronary angiography, we’ve had that … diagnostic angiography … in Hawke’s Bay since 1971, so one of the early places to get that. That system’s been replaced twice in the time I’ve been here – I remember the first angiogram suite we had in Napier; the patient had to rotate on the table so there was a cradle the patient was strapped into, and we took the patient for [??] off their side to get the sideways image. And one day that table actually jammed, and we had this patient [chuckles] on their side; and we had to abandon the procedure and sort of get him out onto a bed. So those facilities have improved in Hawke’s Bay. Echo – we have good echo; we don’t have enough echo techs, [technicians] so [?] ultrasound. We’ve had one of our techs resign in the last two months but he’s not been replaced. Pacemakers, you go to Wellington; that should be available here, but it’s not. So for a reasonably large centre, we don’t have good access to reasonably simple treatments that we should.

Joyce: Richard, when it comes to surgeries and procedures, sometimes the patient’s condition [is] that it really does need intensive care options afterwards; does that limit anyone thinking privately in some procedures?

Richard: Well open chest cardiac surgery we will never have in Hawke’s Bay, ‘cause of the complexities, the cost, and the intensive care. So we’ve got Auckland, Hamilton, Wellington, Christchurch and Dunedin, and that will be it. I don’t think there’s any expectation that cardiac surgery, that is bypass surgery or valve replacement, open chest, will ever come to Hawke’s Bay. And it shouldn’t; I mean, it’s a bit like Napier and Hastings hospitals, [chuckles] you need to have one centre of excellence rather than dozens of half-pie centres.

Comment: [Microphone interference, 1-2 words deleted deleted] Referencing your article, to green …

Richard: A green old age?

Comment: Should’ve been in the greenfield, between the two cities. [Chuckles]

Joyce: A greenfields hospital.

Richard: We’ve got some Napier people here. Many of you’ll know Jill Lewis who was a very strong supporter of the Napier Hospital plan, and was very unhappy when it came to Hastings.

Question: Thank you for your talk, Richard, from a layman’s point of view it was excellent. Is our main problem cost or technicians?

Richard: You mean for personnel, is it money? I think they’re the same thing. I mean there’s a great reluctance to spend more on health care; in fact I was told by one of our managers – this is probably a secret. Recently, when told that we needed more cardiology staff, that yes you could do it; but you had to do it with an existing budget, which is the sort of government response [cough] we get into about spending money. So there needs to be a huge injection of funding to health care, and the same is true across all specialties. And some of you may know that there was a senior staff meeting this year where the Director-General of Health was there; and there was universal concern about underfunding of health services across all specialties. So people waiting for joint replacements are waiting far too long; a cataract’s waiting far too long. But the problem is we expect a Rolls Royce service when we’re a sort of a … really a Mickey Mouse economy – we just can’t afford it. So I think it’s going to be a very difficult time to be in health in the next twenty years; I think there’ll be huge issues in terms of providing adequate service at a huge cost. Don’t know how the country’s going to do it; so higher taxes perhaps?

Comment: Euthanasia. [Chuckles]

Richard: No, most of you are too young for that. [Chuckles]

Question: Wondering if you’ve been involved with heart transplants at all?

Richard: Not closely; I’ve had maybe three or four of my patients transplanted in the time that I’ve been here. I think there has been someone in Hawke’s Bay done recently. What’s of course happened – the early days of transplant here was very public … just remember Billy T James getting his heart and then doing badly; so I think they decided that the fanfare of a cardiac transplant patient, then a bad outcome, was not good PR, [public relations] so … In the early days it was front page news, you know, ‘someone’s going to have a heart transplant in Auckland’ and ra-de-ra; but then they changed that view, so it’s now quite private; you won’t read about it in the papers. I think it’s a pretty tough road to follow, there’s lots of immune suppressing drugs required which carry a risk of infection and cancers. So it’s not an easy path, and you need to be pretty robust to go through it; but for those who do, and they’re a very selected population … interesting, they’re getting a lot older. In the early days [coughing] fifty-five was sort of the cut [off] point, [deleted two words, coughing] transplant patients going up and I don’t think there actually is a defined upper age limit, but I think you’d have trouble getting accepted if you were in your eighties. It is increasing, but the donor supply is the big problem … same for kidney transplants. Hope you’ve all got it on your licence that your heart’s available; in fact for some [??] you probably wouldn’t want it, but … [Laughter]

Question: Have they done any study on how long people survive after? We had a family member who had a heart transplant back in ‘97; he was given sixteen years. I just wondered …

Richard: Fourteen years is the average expectation at the moment, and some beyond twenty years. And that’s good quality of life too, you know; people who can’t breathe and have swollen legs all the time – it’s a very traumatic treatment option for selected people.

Question: Richard, if there was money are there cardiologists available?

Richard: That’s a good question; people don’t seem to want to come to Hawke’s Bay. I don’t quite understand that. So if you look right across medicine, actually, most of the appointees in the last five or ten years have been from overseas. It’s very hard to get Kiwi-trained people to come here, and I don’t know why. I think probably in cardiology, because cardiology’s become so specialised, so the old fart like me who tries to do a bit of everything is a rarity now. So cardiologists get trained, then they specialise – in balloons, and wires to treat rhythm problems, and valves, in very specialised areas, and they focus on a very narrow block. And they wouldn’t want to come here ‘cause we don’t need super specialists in Hawke’s Bay. So it’s hard to find the right people, but yes, I think there will be a problem appointing them when the time comes.

Question: I mean, are we advertising?

Richard: Nope. Well I suppose … we had one person here [???] called Bob Hurber who was here for twelve months on a sabbatical appointment, who’s now not in the public hospital but is still working in private practice at the weekends, I think, in Canning Road. He’s being replaced in November by another fellow from Britain, who I think’s end of career, and is here for a year. So they’re all sort of stop-gap appointments, in part because they want to sort of hold off until angioplasty is developed in Hawke’s Bay so they can get the right people. But that means there’s going to need to be a big injection of funding, ‘cause they’ll need more than one. I just don’t see it happening in the next two years, so temporary appointments; there’s locums – we’ve had a continuation of locums through this year, which means you come to see a different person every time you come, and things get sort of left between doctors, and no continuity, so it’s very patchy at the moment.

But yes, appointing people is hard; the technicians – I think they’ve just had approval to get three cardio/ultrasound or echo technicians in Hawke’s Bay. They’ll be very hard to find; I think there’s probably five or ten vacancies in New Zealand for that. I mean, you’d think people would want to come to Hawke’s Bay, and it’s not easy to attract them. Has that always been the case, David?

Dr David Barry: Well for somebody who … like us, who worked in London, we thought, ‘Well, the reason we work in London is we can go to any sort of place.’ So if you’re used to what the big city offers, and then come out of the big city and decide to go somewhere else, I think you’re more likely to come to a smaller town. I got the impression that if you come to New Zealand very often, New Zealand graduates will want to go to [cough] Auckland, Wellington, Christchurch or Dunedin. That’s …

Richard: And super specialise. Well we were in London for a year; it was the cold that drove us to Hawke’s Bay. [Chuckles]

Joyce: I think he deserves a huge round of thanks … [Applause]

Dr Barry: Richard, I just wanted to comment about your extraordinary availability to come out and examine and do echoes on small babies when you first started here, when we [coughing] were making huge decisions on whether to send them to Greenlane or not; and that was a wonderful effort for an adult cardiologist to come in and examine newborn babies, which I don’t think you were all that comfortable with for a while, but you always got the right answer, and we always hoped …

Richard: So I was right all the times out of ten, wasn’t I? [Chuckles]

Dr Barry: That’s very good.

Richard: That’s a mark of the time – so when I came here I did all the hard ultrasounds. Brisbane had two full time technologists; but in the old days it was me, and I don’t know how we got through it. But probably if you have a service you get more and more demand – that’s sort of part of life, really; if you provide a service demand always goes up.

Joyce: It’s been fantastic – do you all know a wee bit more than when you came? I just think it’s been wonderful; ’cause it’s just grabbing these doctors and professionals as they get towards the end of their career[s], ’cause they do focus and they give us tremendous service. We’ve covered most bits of the body; there’s a few bits still hanging around [laughter] so we’ll keep an eye out for the next lot to retire. Thank you so much, Richard, it’s been fantastic.