Middlemore Hospital's lifesaving legacy suffers

By ANGELA GREGORY

The spacious corridors in the original Middlemore Hospital are wide enough to drive a wartime Jeep through.

They were designed that way. The hospital was built on East Mangere farmland in the 1940s to take casualties from the Pacific campaign.

By the time it opened in 1947 the war had ended but the new facility was "as near-perfect for patients and staff as is possible" and "the shape of things to come".

For specialists in the rapidly developing field of plastic surgery, Middlemore offered exciting possibilities. New Zealand's top plastic surgeon, Sir William Manchester, moved from Christchurch to make Middlemore his base, bringing with him expertise in treating wartime burns.

By 1952 he had started a specialist plastic surgery unit, which was to gain an international reputation for its lip and palate work with children.

Burns victims made up a large part of the work and, as Middlemore's expertise grew, the unit began taking the most severe cases from throughout the country. It is now generally acknowledged as New Zealand's leading burns treatment centre.

But as the unit marks its 50th anniversary, the doctors in charge are in no mood for celebrating.

Two floors up from those wide wartime corridors, Dr Stephen Mills, clinical director of burns, looks around a cramped 24-bed ward and despairs.

Severely burned patients are not getting a good deal, he says. Some are even dying needlessly.

In most other Western countries, says Mills, hospitals decided as far back as 30 years ago to create special burns treatment units because of the highly specialised work and rapidly developing technology.

But at Middlemore it was thought burns patients could continue to be managed in the general plastic surgery ward.

Mills says a standalone site is needed urgently to ensure clinical safety. Patients need protection from infection, especially in light of the notorious superbugs sweeping through hospitals worldwide.

That means large and isolated rooms, multiple wash areas and patient baths, and good airflows.

Patients also need attention from a range of professionals, he says, but the space in which staff can manoeuvre is constricted.

Three beds had to be removed from a larger room recently to accommodate just one burns patient.

Mills argues for a dedicated burns unit to create a team approach to the physically and emotionally draining work.

He says staff have to cope with patients in pain and with disfiguring injuries.

"Sometimes the nurses need counselling as well as the patients and families."

Serious burns are treated at Middlemore, Hamilton, Lower Hutt and Christchurch, but it has long been argued that the country needs one major centre to deal with serious burns, which cover more than 30 to 40 per cent of the body.

Middlemore is the obvious choice.

Treatment is often a marathon exercise for patients and staff. It can require days of long and intensive surgery to remove dead tissue and cover wounds with artificial products.

That is followed by months of skin harvesting and grafting.

Patients come under the care of other professionals such as occupational nurses, physiotherapists, psychiatrists, psychologists and social workers.

The overall care has been compared with a jigsaw, but in this case one large piece is missing - a dedicated unit.

The Ministry of Health has indicated it is willing to partly or wholly finance a unit at Middlemore, at an estimated cost of $4.2 million.

The hospital had hoped to see this happen within two years, although burns specialists maintained that even this delay was unacceptable.

But now, with major hospital construction underway or soon to start throughout the country, the ministry cannot say when that money will become available.

Dr Colin Feek, deputy director-general of clinical services, says the ministry recognises that a national burns unit is needed but is still working through a proposal - possibly with an unnamed third party - to provide one.

He says that because New Zealand's population is thinly spread, there have been questions about transferring burned patients long distances to one national centre. Other district health boards will have to agree to any proposal.

Mills says his staff are running out of patience.

"It's morale-destroying. We're flogging a dead horse."

Some clinicians are at the point of walking away. Mills' co-director at the burns and plastics unit, Australian Michael Muller, told the Herald he is not used to getting such "poor results".

He plans to leave when his two-year contract expires in January.

Hospital managers worry that with a worldwide shortage of burns surgeons, departing staff will not be replaced easily.

They believe the burns unit could lose its capability by default - a sad comedown from the days when New Zealanders pioneered plastic surgery techniques in Britain between the two world wars.

Their father figure was Otago-born Sir Harold Gillies, who developed innovative plastic surgery techniques to repair the casualties of trench warfare in World War I.

Sir Harold, who specialised in reshaping and remaking mangled faces, was regarded as the finest plastic surgeon in the world.

He trained compatriot Sir Archibald McIndoe, who earned his reputation and the undying gratitude of badly burned airmen during World War II.

As a consultant surgeon to the Royal Air Force, Sir Archie revolutionised the treatment of extreme burns, making plastic surgery history.

He controlled the Queen Victoria Maxillo-Facial Hospital in East Grinstead, Sussex, which became a haven for injured airmen. More than 600 came under Sir Archie's care, many burned beyond recognition and afraid to face the world.

They were without eyelids, eyebrows, noses, lips or hair, and some just wanted to be left to die.

But after intensive surgery - perhaps 30 to 40 operations over four years - Sir Archie would give them back their faces.

Recognising the psychological barriers to their return to civilian life, he sent many patients at his own expense to London to see shows, or ordered them down the road to the local pub for a drink with the villagers.

The airmen later formed the Guinea Pig Club and made Sir Archie their president.

In 1940, Sir William Manchester, founder of the Middlemore unit, trained under Sir Archie and Sir Harold in Britain.

During the war Sir William ran a plastic surgical unit in Egypt. On his return to New Zealand, he headed a burns and plastic unit at Burwood Hospital in Christchurch.

When Middlemore Hospital opened in May 1947, it was immediately seen as a good site for a plastic surgical service.

The first operations - cleft lip and palate surgery - were performed on Saturdays by a military surgeon who travelled by train from Wellington.

But in 1950 Sir William was appointed as Middlemore's first resident plastic surgeon and invited to establish a unit. He wanted one similar to those he had worked in during the war - collecting all the skilled staff and disciplines under one roof.

Over 29 years he built up the unit to 72 beds handling 3200 operations and 19,000 outpatients every year.

Sir William retired in 1979 and died on Christmas Day last year. He was replaced as chair of plastic surgery at Auckland Medical School by Professor Donald Liggins, who praised the unit's work in a speech marking the 50th anniversary this year.

He mentioned the development of a skin bank and tissue culture facility as two of the many advances in treating life-threatening burns.

But Liggins also wants to see a standalone burns unit in New Zealand so treatment can continue to advance.

"The management of burns is getting more difficult," he says. "We are saving people who used to die, and that means we must keep trying harder and harder, and can't stand still."

nzherald.co.nz/hospitals