Top cardiothoracic surgeons teach Port Elizabeth-based surgeons new skills

After initiating Zambia’s first cardiac service, Dr Jithan Koshy came to South Africa and coordinated the first public-private cardiac facility for state patients in Klerksdorp in 2015. Today, Dr Koshy’s work ethic is about to bear more life-saving fruit.

Head of the cardiothoracic unit at the Port Elizabeth Provincial Hospital alongside fellow consultant, Dr Jehron Pillay, he’s moved quickly to address the lack of advanced paediatric surgical skills and “thin anaesthetic support” in Port Elizabeth’s public hospitals.

To help achieve this, Dr Koshy applied for the Discovery Foundation Distinguished Visitor Award to bring two of South Africa’s top cardiothoracic surgeons to train Port Elizabeth surgeons to do heart surgery on children.

Specialists share their skills

While Dr Koshy’s and Dr Pillay’s cardiothoracic surgical skills can handle most adult heart operations, the complexity of corrective surgery for rheumatic heart disease and congenital heart conditions in children requires next-level dexterity and skill, which, with experience and help, they will eventually acquire.

This is why Dr Koshy invited two veteran cardiothoracic surgeons to train and upskill him and Dr Pillay for three years. The training will enable them to eventually handle all complex paediatric cases without referring them to the distant Groote Schuur and Red Cross Children’s War Memorial hospitals in Cape Town, where their new teachers Profs John Hewitson and Johan Brink are from.

The epitome of nationally scarce skills

Showing his hard-won adaptability, Dr Koshy contacted the Discovery Foundation to see whether he could invite an anaesthetist from the Red Cross Children’s War Memorial Hospital. Semi-retired anaesthetist, Dr Robert Nieuwveld will travel with Prof Brink and Prof Hewitson to allow the required training – and more surgery – to take place.

Dr Koshy wrote in his application that the paediatric cardiac surgery waiting list was growing at the rate of four patients a week. He explained; however, that the waiting list tally actually stays relatively stable because many patients simply return home or are lost to follow up. He’s unable to say whether this relative stability is due to any deaths. He explains that most patients who need emergency or elective surgery are referred to them from the nearby Dora Nginza Hospital’s paediatric cardiology ward.

“We prioritise emergency cases. We have a general paediatric ward where the paediatric cardiosurgery candidates are admitted,” he explains. Prof Hewitson and Prof Brink expressed surprise at the severity of the situation, saying that if the pair secure a full-time anaesthetist, they’d have the capacity to do “four to five paediatric operations a week”.

Overcoming adversity

Prof Brink, who trained Dr Koshy as a registrar, says the junior cardiothoracic duo inherited a difficult historical situation. “Prof Mervyn Williams built that cardiac unit into a top-class cardiothoracic surgery unit in the 1970s. It served the needs of the entire Eastern Cape without being attached to any university. However, since he retired more than 10 years ago, they’ve had challenges,” he says.

Dr Koshy says that before he and Dr Pillay joined the unit, the adult cardiac surgery waiting list stood at 150. “The hospital was using private sessional cardiothoracic surgeons. We’ve now got the adult waiting list down to about 45,” he adds proudly.

Drivers of paediatric heart disease

Dr Koshy says the dire need for paediatric cardiothoracic surgery is driven by a high burden of rheumatic fever in crowded, low-income settings where streptococcal throat infections (strep throat) are easily passed on. Studies have shown that 25% to 30% of rheumatic fever sufferers will need surgery due to long-term damage to the heart and its valves.

Prof Brink says the other driver of paediatric heart disease is congenital (inborn). Globally every 10 in 1 000 newborns develop a heart condition, regardless of income status. The global prevalence of coronary artery disease needing surgery in adults stood at about 100 for every 1 000 coronary angiograms. “A lot of people in emerging economies develop coronary artery disease as they adopt Western lifestyles, leading to obesity, diabetes, hypertension [high blood pressure] and hypercholesterolaemia [high cholesterol],” Prof Brink adds.

Meanwhile Dr Koshy, who grew up in Zambia after his teacher parents moved to Lusaka from Tanzania in 1984, says he has his mother to thank for his career in medicine and his wife to thank for his career in cardiothoracic surgery.

“My mother put all her savings into enrolling me in medicine in Lusaka. I started medicine reluctantly, but once I got going, I put everything I had into it and succeeded. I then started a career in cardiothoracic surgery as an unpaid supernumerary registrar with a Beit Scholarship at the University of Cape Town. This is where I met my wife who supported me through six years of my unpaid registrar training, while doing her internship, her registrar training in public health medicine and raising our daughter.”

“There’s very limited funding for healthcare and because of that, we’re struggling to provide an impactful service. The limitations create a lot of discouragement, which results in a brain drain to private,” adds Dr Koshy. He is doing everything in his power to mitigate that – and is slowly succeeding.

About the distinguished visitors

Prof Brink is the long-standing President of the College of Cardiothoracic Surgery within the Colleges of Medicine of South Africa, which sets standards, examines and certifies cardiothoracic surgery registrars. He has also chaired several other prestigious national and regional surgical bodies.

Prof Hewitson was section head of paediatric cardiothoracic surgery within the Chris Barnard Department at Red Cross Children’s War Memorial Hospital from 1993 until he retired in February 2019. He’s currently a member of the Governing Council of the World Society for Paediatric and Congenital Heart Surgery. His special interests include paediatric thoracic surgery, cardiac valve repair techniques, rheumatic heart disease, and infant congenital cardiac surgery.