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Prof. Bernard Goldman is all heart. Not only has he been one of Canada's leading cardiothoracic surgeons for decades, but now he wants to tell everyone how Israeli doctors save children with defective hearts in the developing world, and he suffered a fractured shoulder while defending Israel in his hometown of Toronto.
For many years chief of cardiovascular surgery in his city's Sunnybrook and Women's College Health Sciences Center, only now - three months before his 70th birthday - is he hanging up his scalpel and handing his open-heart operations to colleagues. Today a senior consultant at his hospital and editor-in-chief of the prestigious Journal of Cardiac Surgery, Goldman could have been head of cardiothoracic surgery at Jerusalem's Shaare Zedek Medical Center when the position became vacant in 1992. Yet he turned down Shaare Zedek director-general Prof. Jonathan Halevy's offer due to personal and family commitments in Canada, opening the post for the accomplished Prof. Dani Bitran.
But Goldman's heart remained with Israel. After learning on Pessah 2002 that Palestinian terrorists had blown up Netanya's Park Hotel, murdering 20 family members sitting at a Seder table and wounding over 100 more, Goldman happened to be in downtown Toronto when he saw a pro-Palestinian parade with marchers burning Israeli flags.
"Passersby kept their eyes to the ground," he recalled in an interview at Jerusalem's David's Citadel Hotel. "It must have been like that in Germany in the Thirties." When Goldman shouted at them: "Stop suicide bombings!!" he was attacked and suffered a broken shoulder. Today he says he would have "done it again."
GOLDMAN, WHO made his first visit here in 1967 after the Six Day War and has come about every two years since, has a wife, Frances, a choirmaster and French teacher who first saw Israel in 1959. They have four children, including the youngest, Sari, who is active in the "birthright" program to bring young people to visit.
Goldman has just completed a month here visiting Wolfson Medical Center in Holon and observing the work of Save A Child's Heart (www.saveachildsheart.com) - a unique voluntary organization established a decade ago by the late Dr. Amram ("Ami") Cohen. Since then, SACH doctors, nurses and paramedics have examined more than 3,000 children and performed free heart operations and catheterizations on some 1,400 born with life-threatening defects. Regardless of race, creed, color, sex or religion, patients have come from all corners of the world, including China, Congo, Ecuador, Eritrea, Ethiopia, Ghana, Ivory Coast, Jordan, Kazakhstan, Mauritania, Moldova, Nigeria, the Palestinian Authority, Romania, Russia, Somalia, Ukraine, Vietnam and Zanzibar (part of the Federation of Tanzania). Most of the operations were performed - with a 96% success rate - at Wolfson, while others were carried out in Third World countries while training local teams.
Cohen, a lieutenant colonel in the US Army Medical Corps reserves who set up a hospital in Saudi Arabia during the Gulf War, made aliya from Maryland and settled in Ra'anana with his family in 1992. He took up the post of chief of pediatric cardiac surgery and assistant head of cardiovascular surgery at Wolfson. Three years later, Cohen was contacted by an Ethiopian doctor about two African children who needed urgent heart surgery. Out of that first operation developed SACH, the world's largest foundation for providing heart surgery and follow-up care for children from developing countries. About 250 operations are now performed each year, thanks to the team's unpaid efforts, the Wolfson Medical Center's facilities, and donations from around the world. Transporting each child to Israel and covering expenses means $10,000 must be raised per patient.
Tragically, Cohen - whom Goldman met in Toronto - died four years ago at the age of 47 while climbing Mount Kilimanjaro, the highest peak in Africa. Accompanied by his daughter Tali, he had gone to Tanzania to help local children and was determined to climb it. He died on the slopes, apparently from a combination of altitude sickness and heart problems. But his SACH work is being carried on by Prof. Arie Schachner, chief of Wolfson's cardiac surgery department, Dr. Lior Sasson, head of its pediatric cardiac surgery unit and others.
"I WAS blown away by this project," says Goldman, who as a young cardiothoracic surgeon operated on children but then specialized in adults. "SACH is almost unknown abroad, and functions with no money for publicity. I had tears in my eyes when I saw what the operations did for the kids. I want to help spread the word. It is a really well-organized program. USAID should be supporting the project, and more well-off Israelis should be donating."
A reliable medical organization serves as a SACH partner in each of the various countries and prepares a pool of between 75 to 100 potential patients. A full medical history of each child is forwarded to Wolfson, and after examining the material, a medical team consisting of a pediatric surgeon assisted by a pediatric cardiologist and a member of the pediatric intensive care unit travel to the country to examine each child personally. Based on previous experience, SACH found that selecting children requires this double examination system.
Goldman, who knows many of Israel's cardiothoracic surgeons, says the level of heart surgery in this country is equal to that in the best centers in North America. He says he envies Sha'are Zedek Medical Center and Hadassah University Medical Center in Jerusalem for having all its cardiology srervices - from diagnosis through rehabilitation - on one floor.
"That's hard to do in facilities built before this comprehensive concept was developed."
He doesn't know exactly why he chose cardiothoracic surgery as a specialty. He was born in Toronto, and his father was a pharmacist who at one time was a business partner of the Canadians who set up Israel's Superpharm chain but dropped out because he worried it would hurt the independent pharmacists.
"I guess I became the doctor he dreamed of being. I loved studying the physiology of hearts and lungs, but the field of cardiac surgery was very limited in the Sixties."
After graduating from the University of Toronto, he went to Boston for more study and returned home when coronary bypass surgery was introduced. Angioplasty (balloon catheterization to open clogged coronary arteries) began in 1977. The introduction of stents (metallic mesh sleeves to hold weak-walled vessels open) came decades later, and drug-eluting stents to reduce the risk of restenosis (repeat clogging) followed in recent years. "What we used to do 20 years ago we don't do today," he notes.
Although heart disease is still the most common killer in the Western world, earlier diagnoses, improved medications and better treatments have reduced "business" for cardiothoracic surgeons. Goldman admits to considerable tension between interventional cardiologists (who perform diagnostic catheterizations, angioplasties and stent insertions) and cardiothoracic surgeons (who do open-heart surgery). In Canada, he adds, there is also much competition between suburban hospitals and those in big cities; the former are geographically closer to patients, while the major tertiary urban centers are farther away and more experienced but see fewer patients than before.
Israel, with about a dozen heart centers, has an "oversupply and they are incredibly competitive" says Goldman, noting that Ontario has only 11 centers for a population nearly twice as large.
THE LAST TIME he was in Israel (two years ago), Goldman recalls with some irony, he was walking up a hill between one Jerusalem hotel and another and felt breathless. "I didn't pay much attention, but when I came home I had a stress test and found my coronary arteries were partially blocked."
He underwent angioplasty and the insertion of several stents, getting a taste of his own medicine.
"I guess I have a lousy family history and a lot of stress," he explains. "My father was gone at 69," said Goldman, who is now exactly that age.
Having been on both sides of the stethoscope, Goldman says interventional cardiologists and heart surgeons should work as a team so patients get the most appropriate care, and not merely the first treatment suggested (which may be partially motivated by financial concerns). He recalls the case of a man who was rushed to hospital on a weekend with chest pains and was seen by an interventional cardiologist who diagnosed clogged arteries and inserted several stents.
"But while one location was fine, the other was near a branch and far from ideal. It may easily cause more problems in the future that could have been better resolved by open-heart surgery. The patient feels fine, but he doesn't know all this.
"While stents can be very effective, even the more expensive drug-eluting types have a 5% risk each of restenosis, which adds up if you have several inserted. Not enough time has passed to see the long-term results of such stents."
Virtual catheterization, in which a patient undergoes a non-invasive scan to find out how clear his coronary arteries are, has a great deal of potential, says Goldman, but actual catheterization is still the gold standard. "Eventually, a family doctor may be able to do it to see his patient's anatomy and serve as gatekeeper instead of just referring people to a cardiologist."
Robotically assisted coronary artery bypass surgery has already been used experimentally with stented angioplasty for treating extensive coronary artery disease. Robots are being used for bypass surgery in a dozen heart centers in New York alone, Goldman says, "but it took eight hours, which is a long time compared to surgery without robots. It will have to prove itself." Keyhole (laparoscopic) surgery is also tricky when used on the heart, and more suited to gynecological and general surgery.
Preventing heart disease by educating children and their parents and changing patient's lifestyles before they need catheterization should be the main goal, concludes the Canadian heart surgeon.
"Doctors don't have much time for explaining. Even complementary techniques for promoting relaxation are helpful. My heart tells me that a holistic approach is needed."
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