E122 Bill Wall on Liver Transplantation in Canada

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Chad Ball  00:12

Welcome to the Cold Steel podcast hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only masterclasses on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human. Welcome to a special episode of Cold Steel. Dr. Bill Wall was a transplantation surgeon at Western University in London, Ontario for the better part of four decades. He was not only a globally renowned HPB and transplantation surgeon, but he meets the very definition of a pioneer. Dr. Wall talks to us about introducing hepatic transplantation in Canada, about developing a transplant program in the early challenging days, as well as the importance of both institutional and colleagues' support during this process. Dr. Wall is truly a 1.0 original icon in Canadian surgery, and we were absolutely thrilled to hear his perspective on an amazing life lived.

Ameer Farooq  01:20

For the one listener who may not know your name and your legacy and your history and the work that you've done in our country, can you please talk about where you grew up and what your training pathway was?

Dr. Bill Wall  01:31

I grew up in a small town in southwestern Ontario, the population was only about 1500 people. There were no doctors in our family. But we did have a very good family physician who was held in high regard by people in the community, including my parents. It was such a small community, the doctor was, of course, more than just a doctor, he became a personal friend of his patients. And that was true with our family. And I think because of that, and my parents had some thought that I might enter medicine, they arranged for him to invite me to his operating room to witness a tonsillectomy. And this was when I was still a teenager. And it was a time when family physicians were still doing surgeries of that nature. So I did attend. And this was in the days of facemask, ether and the odor in the room and the clanging of instruments and noise from the suction kind of got to me at one point. I had to go and sit on the floor in the corner of the room. I put my head between my hands, so I wouldn't faint. So that was my first introduction, but it didn't deter me. And in fact, it stimulated me more. So by the time I was ready for university, I had pretty much decided that I wanted to be a physician. And I enrolled in science at Western and applied to the medical school and managed to get accepted. I don't think I'd get accepted today. Actually, the competition is so fierce and the students are so accomplished that I probably wouldn't have a chance. But anyway, it was easier back then. And then the summer after my first year of medical school, I got a job working in the operating room in one of the hospitals in Windsor. And that again was arranged to our family physician. And it was very revealing. The nurses taught me how to scrub and gown and glove and they taught me the instruments. And by the end of the summer, I was pretty much working as a scrub nurse. And after my second year of medicine, I went back to the same OR to do the same thing again. And the surgeons were very good at showing me the anatomy and the pathology and quizzing went back and forth. And by the end of that second summer, I knew that I wanted to be a surgeon, to use my hands and tools to treat disease. So the path was set then, and when I finished medical school I applied to Dr. McLachlan's training program in London. It was a hard school to be sure, he had high expectations of his trainees. But I received an excellent education and the principles in practice of surgery and obtained my fellowship in 1974. So that was my path to medicine and surgery. And it was a very direct route. In fact, one could say it was even a straight line.

Ameer Farooq  04:34

Dr. Wall that's a fascinating story about the way that you kind of got interested in surgery and I'm particularly amazed by the fact - and I think it happens to a lot of us - that our first experiences in the OR are actually ones of nausea - like no one goes into the operating room and isn't affected in some way by something that's kind of unnatural if you really think about it, so that's kind of amazing. Dr. Wall, obviously you're the grandfather of hepatic transplantation in Canada. Tell us about those early days of liver transplantation. What were those days? How much of what you were doing was kind of trial and error? You know how much was sordid? Tell us about those early days.

Dr. Bill Wall  05:17

Well, the early days were hard. They were tough. I had done my transplant training in Cambridge, England. That was a bit of a straight line, too. When I finished my surgery residency, I thought I had an aptitude for academic surgery. And I went to John Duff, who was our chief at the time and expressed my thought that I had a plan that I could enter academic surgery. He was great role model, and I had several role models to go by. And I recall the meeting well. I told him that I thought I wanted to do vascular surgery. And he listened to what I said. And then he said, "No, I don't think so. I think you should do liver transplant surgery. We want to send you away to England to Cambridge, and you'll learn liver transplantation and come back to University Hospital and start a program." I can tell you, I had just finished taking the fellowship examination. And there were no questions on liver transplantation. And I know for certain that we didn't study liver transplantation and preparation for the exam. But the meeting ended; he had to go off to something, we planned to meet again at the end of the week. So I went immediately to the literature and looked up liver transplantation and came across Tom Starzl's first report some years previously, and he recorded five cases. And these were the first experience in the world all done by hand. The average survival was 11 days, and the longest survival was 23 days. Now understand at the same time, a moratorium had just been called on heart transplantation worldwide because of the dreadful results. It was the inadequacy of immunosuppression, and the control of rejection. The year was 1970. This was just a few years after Barnard had done the first heart transplant. Tom Starzl had done the first liver in 1963. But after the first heart transplant, it garnered worldwide attention and attention from all cardiac surgeons who suddenly wanted to be involved in this glamorous undertaking. And about 100 heart transplants were done in the year right after Barnard had done his first. But most of those surgeons didn't know about rejection or the drugs to try and control it. And the results were so abysmally poor that a worldwide moratorium was forced on the transplant community to stop doing liver transplants. Well, the year before that, Neil Armstrong walked on the moon. So it was possible to send astronauts to the moon and back, but it wasn't possible to reliably transplant a human heart with any real prospect of success and liver transplantation could fit into that same category. The general feeling was that it was a questionable undertaking, recognizing the deficiencies of immunosuppression. So, I met later in the week with John Duff for a second meeting to talk about transplantation. You can understand that I wasn't particularly enthusiastic about it. But John Duff was a visionary. And most important things in life, I think, come down to circumstances and people and I was very lucky on both fronts. The circumstance was, as I describe it, an undertaking, it looked like it had no future. But the people and John Duff was one of the important ones. And Calvin Stiller, who was trying to get kidney transplantation off the ground at London were visionary and they knew that someday this obstacle of rejection would be overcome. And not only renal transplants would be successful but not just renal transplants, but transplants of other non-renal organs, too. So I was lucky on both fronts and here's another bit of serendipity. John Duff had a colleague in Montreal, a British surgeon, who had gone back to Cambridge to work with Professor Roy Cohn and Professor Cohn and Tom Starzl were the only two surgeons in the world who were persisting with their efforts at liver transplantation; and, it was because of that connection, that the decision was made for me to go to Cambridge. And it took one phone call only by John Duff to Roy, and Roy Cohn's response was "Sure have him come." So when I arrived in Cambridge, we got there on the weekend, I recall this very vividly, we got there on a weekend, and I went to the hospital on the Sunday night, just to case the joint as it were, familiarize myself with the surroundings and get ready for the next day's work - my first day at work. And when I was leaving, I went to the tuck shop in the lobby. And there was a gentleman in front of me, who was obviously a patient, and he was dressed in a hospital gown and bathrobe and slippers, and he didn't look sick. But I could tell there was just a slight bit of [inaudible], a little bit of jaundice in his skin. I didn't think much of it. So the next day, I went on ward rounds after meeting Professor Cohn. And as we were going through the room - this was the big Nightingale ward with 12 patient beds, 6 on one wall and 6 on the other - and as we got to the final patient to the registrar, who was giving the story, I looked at this patient, and it was the gentleman I'd seen in the tuckshop the evening before. And the registrar proceeded to say how Mr. So and So was now two and a half weeks after his liver transplant. And my eyes remained transfixed on him. And I knew right then that this was something that was possible. And it also made me immediately aware of what my burden was to learn everything that could be learned about liver transplantation and come back to University Hospital and start a program. My time in Cambridge was valuable. But I can tell you, it was a hard, hard time in liver transplantation, especially in patients with end-stage cirrhosis and bleeding diathesis, bellies full of fluid, renal insufficiency secondary to their liver disease. And as you would expect with procedures that were of an experimental nature, you didn't get good candidates to operate on, but you received poor candidates to operate on - very high risk candidates. And that in combination with the primitive use of immunosuppression as it existed at the time, and that, in fact, most patients were not going to survive. I'll give you an example of difficulties and the primitive time, there was one case in Cambridge, after we'd operated all night and most of the next day and the gentleman with end-stage cirrhosis, and we couldn't get the bleeding stopped and we put packs in the abdomen. And this was before modern blood component therapy. And after getting a few hours of sleep, we went back to the hospital with Professor Cohn. And he always left three drains and one above the liver, one below the liver on the right, one in the left upper quadrant. And the blood was just streaming out of these drains, just dripping. And he instructed the ward sister to go to the warm cupboard, where they kept the warm blankets for patients, and get a bottle of hot saline. And he took a bulb syringe and he proceeded to inject these drains with saline and attempt to try and get some thermal coagulation of the bleeding. And of course, it didn't work and that patient did not survive. But that was the status of it at the time. And it was really hard surgery, was hard to get survivals; it was before there was modern monitoring for rejection, rejection of liver histology had not yet been developed. And so it was a primitive time. But looking back on it, it was a good time to be there. Because when you learn something when it's really hard, when it becomes easier, it's much much easier. So it was a valuable time I had Cambridge and that was the status of it at the time before cyclosporin.

Chad Ball  14:33

An unbelievable story and unbelievable history. What was the sort of the timeframe and the evolution of immunosuppression, cyclosporine and so on in that era? How fast did that come on globally, and in particular for you here in Canada, and change things?

Dr. Bill Wall  15:10

Well,  I was very lucky to go to Cambridge and be with Professor Cohn. Years previously, he was the individual who showed the effectiveness of azathioprine in renal transplantation. And that drug in combination with steroids would become the cornerstone of immunosuppression for the next 20 years. So that what was being used. Cyclosporine came on the scene about a year after I left Cambridge, and it transformed transplantation worldwide. It was discovered by Jean Borel. And this was part of the process where pharmaceutical companies looked for agents and soils. And they were particularly looking for fungi that produced antibiotics. And in this particular soil sample from Norway, they found a fungus which produced something that will later be called cyclosporine. And he identified in the laboratory of Sandoz pharmaceuticals, that it had some immunosuppressive properties that interfered with the mixed lymphocyte culture reaction. And it seemed to have some minimal prolongation of skin graft survival in rats. And he didn't have a facility to pursue it any further than that. But Sir Roy Cohn and his colleague, David White, who was working in immunology in his laboratory, became aware of this immediately. And they approached Jean Borel and Sandoz and secured the drug for Cambridge. And Professor Cohn had a very sophisticated experimental laboratory and he immediately went to work with the drug - first in rodents and then in large animal models of heart and kidney transplantation. That was in 1976-1977. And he showed that it was far superior, this drug was far superior to any other that had ever been shown in transplantation. And he immediately adopted it for the clinic, and used it in recipients of heart, liver, kidney, pancreas transplants and reported on that 1978. And it was a different immunosuppressant. Of course it was selective, and affected just the T cells that were responsible for rejection through interference with interleukin 2. And it transformed the whole field of organ transplantation, everyone wanted to get cyclosporine. And it made possible the transplantation of not only kidneys with a high degree of success, but opened up the entire field for the transplantation of other organs. So I was fortunate to have been exposed to Sir Roy Cohn and to spend time in Cambridge, partly because of that, and because of the vision of Calvin Stiller, we were able to secure a cyclosporine for our program in London, before other centres in Canada, in fact, before most other centers in the world,

Chad Ball  18:29

That's fascinating. You know, you touched on something earlier that I think is particularly interesting. You mentioned Neil Armstrong, and in aerospace medicine, we talk a lot about those decades and that era, you know, having set land speed records, gone to the moon, depth records in the ocean, all of these really extreme voyaging endeavours. I think, really probably reflected society's tolerance for risk. And then we start to come ahead, and we compare that to now where there's very little tolerance of risk, whether that's aerospace or really anything else. So I'm curious, obviously, Dr. Duff and Dr. Stiller were so instrumental, as you comment, in London and in supporting you, but what was the general outlook from your colleagues beyond some of the immediate support that you had and were they skeptical? Was that hard? Because I can't imagine taking your experience and transplanting it - pun intended - into today's day and age.

Dr. Bill Wall  19:38

Well, you're quite right that there was very little support when we started our liver program before cyclosporine was available to us. And I remember those first three cases, like it was yesterday. We started in 1977. And we failed three times. They recovered from the surgery but they died of a fatal infection with in two to three months, and that made it really hard. When cyclosporin became available, we secured it for laboratory experiments because of our connection with Cambridge. You mentioned aerospace. That reminds me of a story. In 1978, David White, who I mentioned was coming to Canada. And we said, "Please bring some cyclosporine with you. We want to try it in the laboratory and learn what we can before we use it clinically." It wasn't available clinically until years, years later, at least until it was approved. So he came to Canada and it was the winter of 1978 and I pick him up at the Toronto Airport. And almost after making introductions, I said to him, "Did you bring the cyclosporine?" And he smiled and reached into his shirt pocket, and he pulled out a vial of the magic white powder. And I smiled too. But can you imagine today trying to board an aircraft with a vial of white powder in your shirt pocket? But that was a different time. And when we got the drug, we looked at it experimentally in the laboratory. And the time was right, because Calvin Stiller was looking at immunological monitoring of transplant patients. So it was natural to look at the immune monitoring that could be applied to cyclosporine or cyclosporine drug levels and therapeutic levels and what was the best way to manage it and what therapeutic levels should be obtained. So we had a leg up there. And clinically, we began to use it. Again, you mentioned about a different time, when we first gave it to our liver patients, this was before it was licensed for use, I went to them and I said to them, "We've got this new drug. We think it's better than anything that's ever been described; we'd like you to have it when we do your transplant." And, of course, they agreed; there was no special consent that was formed. They signed the same surgical consent that they'd signed for an inguinal hernia repair. And it was to the great benefit of patients. So we had those three deaths. And then we had three survivors, all young women between 1982 and 1983. They're alive today. They are Canada's longest surviving liver transplants. Between the three of them, they've got about 120 years now of post-transplant survival, and each one of them is and looks perfectly well. So there was a transformation. It was hard early - few supporters. And then when transplant changed everything we hit the ground running because we'd already been trying and working things out in the laboratory. And one way that you know when you want people over is when they come to you and want to borrow your slides. People who were not enthusiastic about transplantation, but because of the profile, man, and the success of it, they wanted to join the bandwagon. Of course, that was just great for that to happen. But it was slow. It was a slow transition. And to be sure there were a lot of naysayers at the beginning and then an enthusiastic response. And I give credit to our administration of our hospital, too, because they fully backed what we were doing. But in truth, John Duff, Charlie Drake, Calvin Stiller, they were the visionaries, and that made all the difference. Circumstances and people made all the difference.

Ameer Farooq  23:55

Well, Dr. Wall, you may have won people's support eventually, but it didn't change the fact that you were in one of, arguably, the most demanding surgical specialties, certainly then and even now, but I think even more so then. And you were going out, you were doing the procurements, you were doing the transplantations. Tell us about what that experience was like - just being in such a demanding grueling lifestyle and specialty. What got you through those tough times? And what were some moments that really stand out to you?

Dr. Bill Wall  24:31

While you're quite correct, in that the decade of the 80s and the 90s is actually it's much of a blur for me, personally You're correct. It was exhausting work. We were the first program in Canada to become successful and one of the first in North America, the first to use cyclosporine and what that meant was we were serving Canada in terms of transplants. We had patients coming from everywhere. We frequently went to the United States for donor organs because there weren't that many transplant programs developed at that time. And we took a very liberal approach to the use of donors and in particular older donors. So we got a reputation for transplantation and organ donation. It meant just what you say: many trips, almost always at night and on the weekends to institutions to retrieve donor organs and bring them back to London for transplantation. I can't say enough about the team and the teamwork. Our medical students, our residents - then at a later time - our fellows, everybody worked beyond mental and physical exhaustion, and they performed so admirably. Of course, it was for patient care and that was the stimulus. And the rewards were great, but it was grueling work. I remember a particular case, Michael Block, we just said one donor coordinator for the first couple of decades, and we carried beepers all the time. And we had done a couple of transplants that week. We'd been out west a couple of times for the donor organs. And I was exhausted. He called me about nine o'clock on a Friday night, and I was already asleep, to tell me about another donor. And I said "Michael, I'm really tired, this has been a grueling week." "Yes," he said, "but you know, this is a pediatric donor." And I said, "Oh, and you know, we've had a dry run with her once." And as he and I both knew that pediatric donors were uncommon, and one did not want to pass up the opportunity of doing a transplant, no matter how tired we were. There were some pauses back and forth. So this was a donor, and it was either Newfoundland or Nova Scotia. And I said, "Okay, Michael, let's go, let's do it." It was just he and I, and we flew to a smaller community hospital. And I'll never forget this. Almost always the donor procedure gets delayed, for some reason or other. And we were getting up just a little bit of sleep and an antichamber to the operating room. We were nodding off and there was an autoclave in a corner, every 15 minutes there would be [makes swooshing noise] and he and I would have a sleep start, restart. And then we'd nod off again. And that's what it was like. But, you know, you just reach back for the strength and the energy to do it. And then we did and did that transplant successfully. I think what keeps you going, and what kept us going, was the rewards to patients. They're facing certain death from liver disease and liver failure, and to see their lives saved and transformed, it was a privilege for all of us to be part of it. And I think that, more than anything, was the stimulus that that kept us going through those really, really busy times and exhausting times. It was a wonderful experience.

Chad Ball  28:33

You touched on the lack of donors and donorship, Dr. Wall. I'm curious what your panoramic historical view is on recruitment, maybe on DCD [Donation after Circulatory Death] and sort of the other thoughts of how to increase the potential donor pool in general, both then and now.

Dr. Bill Wall  28:56

Well, early on in our liver transplant experience, we liberalized all the indications for liver donation, age had been a big barrier. And the age that was thought to be the upper limit was 45 years of age. Well, in fact, our very first liver transplant was with a donor who was 60 years of age, and the liver worked perfectly after the transplant although the patient ultimately died from infection. But we knew from that one experience, that an age restriction of 45 was too arbitrary and not necessary. So we did laboratory experiments to look at that and the susceptibility of the liver to preservation entry, to liberalize the availability of donor organs. So there's that one scientific way of doing it. You mentioned donation after cardiac death, which is another way and I think that's been largely responsible for the modest increase in the number of transplanted organs over the past 10 or 12 years. But in the broad scheme, if we look coast to coast in Canada, and look at transplantation services to the population, Canada is well served with transplantation in terms of expertise, and outcomes, and we can be proud of that. But we can't be as proud as we would like about our organ donation rate; we've been mediocre for quite a long period of time. And if you look at polls of the general public about their thoughts and views about donation and transplantation, the figures are always the same. 90% of them say, "Yes, I'm supportive of it." And you ask the second question, "Well, have you registered to be a donor? Have you talked to your family about your wishes, that if you should die, your organs could be donated?" And the figure drops down to 30%. So there's this enormous gap between what people say and what they do. And I think it's the apathy that is mainly responsible for that gap. Although people have some misconceptions about transplantation and need to be educated. My personal view is that if we're going to really capitalize on this, we need to educate people. And that was a major reason why we started a high school curriculum project many years ago, to educate secondary school students on this particular subject. They're reaching the age of consent, they're making serious decisions about life and lifestyle. And we wanted to present them with the facts of donation and transplantation. And we had a conviction that if they knew the facts, and the benefits of it, that the majority of them would agree to it, and the numbers of donors would be increased in that way. So we developed this curriculum for that. And we didn't really earmark it at the time, but the students went home and talked to their parents about this. And of course, the parents became a second target audience as it were and they were educated in the same way. We were impressed by the enthusiasm of these students, I must say. It started with them coming into the transplant program as part of a co-op. And they were bright and energetic, and they asked hard questions. And they invited us to go back to their individual schools and take their school assemblies. And it was always the same: at the end of our presentation, the students were lined up at the microphones, with more questions than we had time to answer. So, we thought we should take this into the school, have teachers teach the students, and we started just with physical health and education. And then we expanded that into other disciplines as well under subjects: civics and religious studies and science, and put it all together. And I think that is a way - I am not saying it is the way - but I think by educating young people on the importance of this subject - over time - we can change the fabric of Canadian society and have individuals grow up knowing and understanding that donation and transplantation are good. The presumed consent legislation that was passed last year in Nova Scotia, I think, is a positive thing. And hopefully, that will prove to be the case there and will be disseminated throughout Canada. I think though, unless you have an educated person making the decision, they can still opt out of a system like that, of course. So, my preference would be education over legislation, but I think it has to be a combined approach.

Ameer Farooq  34:00

Dr. Wall, your story about educating high school students is such a neat one, it really speaks to your thought process around transplantation from really all of the angles not just what happens in the operating room, but really what goes into building a system around transplantation. And we want to come back to the children's book that you just wrote, as well, just later in the podcast. I think that again is another example of that type of thinking. Dr. Wall, a lot of nonsurgeons also listen to this podcast, and maybe you can give a brief synopsis for our nonsurgeon listeners as well. Really, what is a liver transplant and how does that happen?  What are the broad overview steps of a liver transplant?

Dr. Bill Wall  34:49

One of the major problems is removing a diseased liver. These generally are patients with scarring in the liver, cirrhosis of the liver, and all the things that go along with it, but horrible hypertension, swollen veins, blood counts that are abnormal and their blood won't coagulate normally. So, removing the diseased liver is difficult. And it's tricky, it's hard. The new liver has to go in the exact same location, what we call "orthotopic transplant" in the same location. And the liver has a number of vascular attachments to it. It's got a bile duct, it's complex. And during the surgical procedure, one has to occlude major blood vessels around the liver, that produces a strain on the heart, difficulties for the anesthesiologist and maintaining the patient. So it's a very unphysiologic operation in the sense of the abnormalities that are created in the maneuvers that's necessary to do the procedure. And of course, the liver is like a heart transplant, it's got to work immediately once the blood flow to it is restored. And it's a time during the surgery that's been referred to as "the moment of truth" when the clamps come off, and you watch the organ fill with blood and you see bile start to be produced from a bile duct, and those are all good, good signs. And, when it's successful, it's usually very, very successful. The selection of patients for the procedure is something that is continues to be defined. One of the advantages of cyclosporine, especially for the liver, is that these potential recipients are sick to begin with, and they're at great risk of infection, independent of anything else. So, cyclosporin provides them with that big advantage. But what it also has done, is allowed the other branches of transplantation to develop, too. Who are the best patients to get a transplant, who are the best candidates, what are the contraindications to the procedure? With good immunosuppression and the expectation of survival that allowed us to study organ preservation, that are means to preserve the liver so that it would function better and function immediately after transplantation. So cyclosporine is effect was disseminated amongst these other disciplines. And I should mention two people here, Judy Cut was our anesthesiologist. Anesthesia for this is very tricky. And she began with us in the laboratory and clinically, and she gave every liver anesthetic for maybe our first 300 cases. It was a tremendous commitment. And we trusted her and she did a marvelous job. It's tricky - anesthesia or fluid replacement - and a lot of other things that go along with the operation. She was marvelous. And the other person was Cameron Ghent. We mentioned serendipity and circumstances and people - when I went away to study liver transplantation in Cambridge, Cam Ghent who was a classmate of mine, without my knowledge, he went to Yale University to develop hepatology. This was a spin off from gastroenterology. And while he was there studying in Yale, I was studying in Cambridge. Neither one of us knew what the other was doing. But we were both recruited back to University Hospital. And we came together and he became the hepatologist to manage our transplant program, our transplant patients, and I was his counterpart in surgery. And it was a marvelous, marvelous association that we had for four decades together, but it comes to teamwork. You talk about success. And it's a lot of people, like-minded people working hard, working together. And that, to my thinking, in addition to immunosuppression, is a large, large factor in success.

Ameer Farooq  39:15

Dr. Wall, you've performed 1885 transplants in your career, and that is just an astounding number. You've talked to us a little bit about your memories of the early transplants, but are there any transplants that stand out in your mind over that long and brilliant career that you'd like to share with us in the podcast?

Dr. Bill Wall  39:37

I should clarify about the number 1885. That was the total number of liver transplants during the 40 years or so that I was working in the transplant program at University Hospital. I was the only surgeon for the first group but then we have recruitments of other individuals, additional surgeons. So really that's the gathered experience. Now, each of us individually participated in the care of virtually every aspect of some part of these patients' course in hospital, selection, post-operative care, donor operation, recipient operation, helping one another, and so forth. I guess in the scheme of things, if you'd looked at the numbers carefully, maybe I was the surgeon of record for 700 or 800. But, the number doesn't matter; what matters is that it was a team effort by a lot of like-minded individuals, and the support we had for one another. Do I remember some more than the other? Absolutely. The first three will always remain clear in my mind, where we failed. And I can see them in front of me right now. And I can see the next three in front of me, too. They were done in 1982/1983. And each of them is alive today. And they are Canada's longest survivors and are part of a small group that are the longest survivors in the world, actually, after liver transplantation and between the three of them, that's 120 years of post-transplant survival. So yes, there are some that stand out more than the others. And, they serve as an inspiration to us. You know, we talked about pioneers and pioneering efforts and the roles of doctors and so forth, but we shouldn't forget about the patients who are pioneers, too. They put their trust in us - at a still an uncertain time in transplantation - even when we had cyclosporine and we were learning a lot about it and how to monitor the doses and adjust the doses and defining rejection. We were learning as we went, but these patients trusted us; they put their faith in us. And they were pioneers in their own right. So yes, those are the ones that stand out to me and I remember more than anything.

Chad Ball  42:29

At a time when stress was so high, and I'm sure there was anxiety on the part of your transplant team in the initial days in particular. Many of us take that stress home. And I'm curious, you know, you've talked a bit about the support you had, again from Dr. Stiller and Dr. Duff and a whole bunch of other folks at work. Where did your support come from outside of the hospital and how relevant was that to you in allowing you to do this, this iconic pioneering work - to use your term - which is certainly accurate over your 40-year career?

Dr. Bill Wall  43:13

Well, I was lucky. A wonderful wife, Diane, two boys, Brian and Graham. What you say is exactly right about family support. And I only give my sons two pieces of advice, real advice. I say number one, pick the right partner, or be picked by the right partner. And number two, have a job or get a job where you are happy going to work every day. And both were true for me. Diane has been a wonderful, wonderful support. I think about the times I abandoned them on so many occasions because of hospital-related duties or transplant activities. And they were marvelous. The support at home is, I think, crucial. There were no issues at home that I took to the hospital and that really is beneficial. You want the home environment to be ideal. At the same time you have the trials and tribulations that you inevitably face with this kind of undertaking at the hospital. And you don't want to bring that home with you. You leave it there, deposit there and come back home and enjoy that separate life that you have. I don't know that there's a magic formula to it. But I think the ingredients to the formula are what I've said, having the right partner in life and number two, having a job where you are happy going to work every day. The barometer of the ladder is enjoying your colleagues. And I can honestly say that I would look forward to going to the hospital to see my colleagues and to discuss something with them at a particular time of day or night. We enjoyed one another's company and the camaraderie and the team spirit to team effort. So, we had that and we had the support, as I said earlier, of the administration and doing what we were doing. And it was a wonderful time really; it was a privilege to be part of it for such a long period.

Ameer Farooq  45:30

Dr. Wall, as we mentioned earlier in the show, you've written a children's book that talks about transplantation. Can you talk to us a little bit about what the impetus was for writing that children's book and a little bit about the book itself?

Dr. Bill Wall  45:44

Well, I mentioned earlier, about the One Life…Many Gifts to educate secondary school students. And over time, and after becoming a grandparent, I've come to understand that young children can learn complex subjects at an early age if it's presented to them in the right way. And when I was reading stories to my grandchildren, Ruby and Dexter at ages four to eight, I was impressed by what they could understand and what they could absorb. So it took a couple of years of thinking about it but then I finally said, "Well, maybe a children's picture book story could be written, that would take the subject of donation and transplantation and put it to them in an interesting way, in a straightforward way that they could understand, with a broad objective of having them grow up knowing and understanding that transplantation and donation are inherently good, and if that happens, then life will ultimately be saved and society will benefit." So I wrote this little children's picture book story; I can't tell you too, too much about it, otherwise, they probably sure would get annoyed with me for pre-empting things. I hope it gets published this summer. But I hope it's going to fulfill a need so that school children can be educated on the subject, too. Just think - they're being educated about climate change and the environment. I think they can absorb it and understand it. And I'll make sure I send a copy to you, Chad and Ameer as soon as it's published.

Chad Ball  47:46

We'd love that so much. And we'll be sure to link to the publisher website once it's out. So let us know. That's a remarkable endeavor. And I agree with you entirely. I think our kids are capable of understanding so much and the earlier the better. The last question we wanted to ask you, Dr. Wall, in closing, our last question really is if you could go back in time and give your younger self some early advice, either clinical or personal or really anything, what would that be? What would you touch on?

Dr. Bill Wall  48:24

Well, as I've emphasized, the importance of my training and people in my training and in subsequent careers has been enormous, and I had exposure to find individuals. And Sir Roy Cohn, I've mentioned, he was a superb surgeon/scientist, an intellectual, widely read, avid sportsperson, a prolific painter, he was everything. And I think few people can aspire to that. But yet, we all have these role models that you want to emulate. And I had lots of them. And I was very, very lucky in that regard. So I look back over my career, and say, what advice would you give yourself? That's a hard thing to do, I think. And it was a privilege to be part of what was an amazing experience from my perspective and amazing people, amazing patients and colleagues, and it was a privilege to be part of it. You know, I look back on it, they say what would you have done differently? I would have said to myself, "Well, look, take a bit more time to smell the roses." It's easy to be overcome with work and work schedules and you get into a mode where work just dominates over everything else. And if you have the ability to differentiate a little bit and sort out the more important things from the less important things - to not be at the hospital every Sunday morning for a few hours just to get another paper written, or to read another brief or to attend another meeting - to try and leave some of that more at the hospital and attend more soccer games and basketball games played by your children and be home for anniversaries and birthdays. I think today, young people have a clear understanding of this in medicine and surgery, they have a more appropriate work-life balance and good for them because that's what's needed. It was a great ride to be absolutely sure and I wouldn't have changed a day. But looking back on it, I would have just said, "Well, just take a bit more time to smell the roses."

Ameer Farooq  51:05

You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your thoughts, comments or feedback. Send us an email at [email protected] or tweet at us @CanJSurg. Thanks.