Expert Breakfast Report for 2 May 2018: Dr Jim Faed, Dept of Pathology and NZ Blood Service

Dr Faed is a Senior Lecturer with research interests in blood transfusion (blood donor health and donor selection) and stem cells for treatment of chronic health problems including spinal cord injury repair.

In addition to his undergraduate teaching, Dr Faed is the Blood Transfusion Specialist south of the Waitaki river, and is on call one day in seven for the whole country for medical calls about blood products and severe bleeding problems.

Dr Faed began by noting with pleasure that, although Health Science was well represented by the members present, there was a good sprinkling of other disciplines, such as Politics and Microbiology. He commented on the advantage of being able to mix with people with a variety of interests, and in particular how politics infiltrates everything, not least affecting how health professionals are able to do their work.

Born in the Waikato (Te Awamutu) and growing up on the outskirts of Auckland, he came to Otago to study Medicine, which was then the only medical school in the country. Medicine then was taught in the ‘classical’ way, in a series of labs and lectures, with no early exposure to clinical work at all. Until the clinical years, tutorials were not of the ‘modern’ type, as they involved virtually no student contribution.

In his clinical years of medical training, he discovered the usefulness of ‘being around’ rather than just turning up for scheduled sessions. This was illustrated with one of several anecdotes:

One day he and a fellow 4th-year student were ‘cruising around’ their surgery ward, and were invited to have a look at an acutely ill patient in a medical ward. She was a lady in her 80’s with a bowel obstruction requiring urgent treatment. He glanced through the case notes and noted a lab report that indicated a urinary infection. When the surgeon started to open the patient’s abdomen, he came across some ‘very strange greyish-yellow tissue where there should have been a white muscle sheath, he exclaimed, “I don’t know what I’m looking at. Has anyone got any ideas?” Jim, having seen the patient’s notes, said, “She’s got a urinary tract infection” which had been missed by the surgical team. The operation was immediately changed and a large kidney abscess drained giving the patient a chance of survival. The infected kidney had caused the bowel obstruction: learning occurs in all sorts of places and ways.

He emphasised the need to observe and think about what you see - no matter what sort of work you do - or you will miss many opportunities.

Dr Faed asked the members where they felt modern health care was moving currently. Robotics is certainly on the way, but is likely to be a tool used by the medical teams to improve patient outcomes, rather than replacing doctors. Jim’s observation is that more and more standardisation is creeping in, with set protocols for every medical situation. His description was very reminiscent of the “if-then-else” computing strategy. This is happening to minimise delays and mistakes, but he emphasised that this model cannot cover everything.

As an example, he mentioned a very recent case locally.The patient was releasing very large quantities of the natural anticoagulant - heparin - into their blood, with disastrous bleeding consequences. While heparin action can be counteracted using a medicine – an extract from herring sperm called protamine, this patient was producing such quantities and for so long that this treatment eventually failed, and he died. Over-production of heparin is not unknown, although the mechanism is not understood and no case involving this level of overproduction has ever been described in the medical literature. For perceived cultural reasons, no post-mortem was permitted, so exactly what caused the problem in his case will remain unknown. He linked this to another recent critically ill young male in Auckland over which he was consulted, in which he recognised that the problem was again due to heparin over-production. The blood test results indicated this, but the implications had not been recognised or correctly interpreted. He reiterated the importance of keeping your eyes open, and thinking about unexpected things that you see.

Dr Faed was one of the early pioneers of home-based treatment for people with haemophilia in NZ. The treatment involves the injection of a purified blood clotting protein (factor VIII). The problem for people with haemophilia is that frequent bleeding occurs into joints. Bleeding into joints results in serious damage for cartilage that covers the bone surface in joints and there is no way to repair the cartilage damage. If clotting factor treatment to stop bleeding is only provided at hospitals, there is inevitably a delay of several hours. With this recurring for several years, the joints become non-functional and young men with haemophilia are crippled by the age of 20 years! If a parent could be trained to give the injections at home when an incident occurs, or better still, every two or three days, bleeding can be prevented, almost completely! He gave a graphic description of training a parent to insert needles using their spouses veins for practice. Later he taught them how to move on to giving injections to their young child - so graphic that one of our members (not a Health Science student) was obliged to leave the room! Once the patient reaches the age of around 8-10 years, they learn to do the injections on themselves.Asking members present what they felt was the biggest advance in medicine last century, one person suggested ‘antibiotics’. Dr Faed agreed and treated us to an account of the discovery and first use of penicillin on a patient, again stressing the importance of keeping one’ s eyes open and thinking about what one observes.

Many laboratory workers who found a mould growing on a culture plate would have discarded the plate and thought it was just a nuisance, but Alexander Fleming looked more closely, and thought about what he was looking at. As a result the mould was grown and the antibiotic it produced was identified. The first patient was a policeman with a deep-seated bone infection. To try to produce quantities of penicillin during World War II in England, the staff developed the idea of growing the mould on blotting paper in Hospital bed-pans. When it came to providing the antibiotic for treatment, even though they were using only about one-fiftieth of the dose used today, the patient began to show significant improvement. Although they were producing more antibiotic as fast as they could, they were running out of penicillin. Someone had noticed that a good deal of penicillin was present in the patient’s urine, so this too was extracted and was purer than the original penicillin! Unfortunately, they eventually ran out before a cure was obtained, and the patient died. This was a complete failure for the patient and his family, but this case changed the course of infection treatment, aided no doubt by the pressing war casualty problems in many deaths from wound infections.

At the time, the antibiotic was described as ‘grown in bed-pans and purified in the local police force’. During this time, medical students at the hospital were recruited to patrol the Hospital grounds at night to detect any German spies trying to steal the penicillin secret. The medical students were armed with wooden clubs, but fortunately for all they were never needed. This anecdote raised one of the most concerning issues of today, developing strains of disease-causing bacteria and are resistant to antibiotic treatment.

A member also raised the problem of ‘anti-science, and the issue of ‘alternative truth’ as it applies to the anti-vaccination lobby. Dr. Faed then addressed the seriousness of the many viral and bacterial diseases that can be controlled or prevented by vaccination, especially Hepatitis B which is an important cause of liver cancer, quite apart from causing acute hepatitis.

A good deal of the discussion was about where the practice of medicine is likely to be in the future. Robotics and protocolisation of health treatments has already been touched on, but he also talked about the considerable impact that treatments which use human tissue stem cells is likely to have in the future. Stem cells are a tiny part of our tissues but have an essential role in slowly producing more cells which then rapidly divide to replace tissues such as skin, the bowel lining and blood cells, or are brought into action to repair tissue injuries such as cuts, bruises or fractures. After outlining the science of stem cells (including the use of a $300,000 3D printer to prepare a matrix of stem cells and synthetic gel), he briefly discussed how they might be used. Possible uses include regeneration of large tissue defects, stopping autoimmune diseases such as rheumatoid arthritis, multiple sclerosis, etc. Other possibilities include treating macular degeneration treatment which causes blindness in many older people.

As usual, there was so much more. You just had to be there!

Posted: Tuesday May 8, 2018