Fast Confession – surgeon Robert Lischke: The mortality of our COVID patients is huge
Professor Robert Lischke is the head of III. surgical clinic of the 1st Medical Faculty of Charles University and the Motol University Hospital, which he took over in 2010 from the legendary professor Pafko. It is also the only workplace in the Czech Republic performing lung transplantation, which is one of the main topics of his interview with LP-Life.com. Moreover, leading thoracic surgeon Robert Lischke also openly expressed his views on the coronavirus and described its severe effects on lung transplant patients.
Professor Lischke, you, together with Professor Pafko, were involved in the first lung transplant in our country, which took place in 1997. How do you remember it?
It's been over 20 years, but I remember almost every detail, as it was such an important moment filled with a lot of tension for us, especially for Professor Pafko, who was responsible for everything. I even remember the cold, since we had to pick up our lungs in a hospital in České Budějovice, we were driving in a terrible blizzard and could not go faster than 40 km/h on our way back. We expected our teacher, Professor Klepetko from Vienna, to help us with the transplant, but his flight was interrupted in Brno due to the weather and he arrived only at the end of the surgery, which, fortunately, was a success.
You usually perform lung transplants at night. Why is that?
That’s because the donor identification process usually starts in the morning, when somewhere at the anesthesiology and resuscitation department of a hospital it is decided that, unfortunately, a certain patient likely is brain dead, which has to be confirmed first by two neurologists and then with imaging. This confirmation takes several hours, and if the brain death is confirmed and the patient becomes a potential organ donor, a series of examinations of other organs need to be completed to see if the transplant can be accepted, and this process ends sometime in the afternoon or evening. Then the individual transplant teams agree on the time of procurement, which is usually in the evening. Organs such as the lungs or heart need to be implanted immediately – you essentially perform both surgeries simultaneously, so that two teams operate at the same time, one procuring the organ and the other operating the recipient.
What do the lungs you take out of a patient's chest look like?
In the vast majority of cases, these are macroscopically and visibly altered by the pathological process, so they are not nice. They are either wrinkled or full of transparent bullae, and it is usually obvious at first glance that the lungs are diseased.
Which lung disease is the most dangerous?
That is hard to say. There are about two major groups of diseases that we encounter, and these are diseases that lead to dramatic lung dysfunction and respiratory insufficiency, i.e. inability to breathe and the need for oxygen inhalation. These are patients with chronic obstructive pulmonary disease and patients with cystic fibrosis. Then there is a huge group of patients with lung cancer, which is one of the most common diseases, often diagnosed late and difficult to treat.
Do you perform lung transplants on cancer patients as well?
No, because most of the time, the malignant tumour is already generalized to the lymph nodes and outside the lungs. It has been shown that if we were to perform a lung transplant and administer immunosuppressants to the patient, which we have to, as it inhibits the immune system, then this muted immune response would affect his ability to deal with cancer. It simply can't be done, because the disease would progress and the patient would still die, and more likely the immunosuppressive therapy would only speed up the process.
Who are the most common lung donors?
The ratio of men and women is equal, and they are most often patients who have had a stroke or who suffered some kind of isolated head trauma.
And what about people who tragically died in a car accident?
If someone dies during a car accident today, then with the current quality of cars they usually do not become a donor because their body is so damaged that it’s not possible.
How long, on average, does a patient wait for new lungs?
On average it’s about 3 to 4 months, but it is extremely individual based on their blood type, and especially on the size of the lungs and the patient himself. So when a patient comes to us and we put him on the waiting list, we know that it shall happen very soon. On the other hand, mainly patients with small lungs, either due to their small stature or due to their disease, which significantly reduces the size of the chest cavity (cystic fibrosis), need to be put on the list very soon, because they have to wait over a year.
How long do people live after a lung transplant?
The results are very carefully registered both throughout the world and, of course, in our centre. In those registers, one-year, five-year and ten-year survival are reported. One-year survival is above 80%, five-year survival around 60% and ten-year survival around 30%. Of course, you can also become one of the patients who live 20 years or more – you never know in advance. Overall, the survival rates are much better than, for example, with cancer.
How old was your youngest patient and what was the specific case? Is this patient still alive?
That was an eight-year-old boy with cystic fibrosis, permanently hospitalized on a ventilator here in the children's ward in Motol, so he was in really very serious condition. We got a child donor for him, which is usually incredibly difficult.
Is this patient still alive?
Yes, he is. 5 or 6 years after the surgery he’s still doing very well, which makes me really happy. He attends school just like other children, of course not now during the pandemic.
These surgeries must be very mentally taxing, both for the patients and for you. How do you cope with that?
The only way to deal with it is to perform transplants as often as possible. This means the sheer number of transplants is important for your whole team – anything you do often enough you eventually start doing better and it becomes a routine method for you.
Would you undergo a transplant yourself?
That’s a difficult question. It’s a rocky road indeed, and our patients share a sombre and very frustrating fate. I really admire those patients and their bravery, I observe them with great respect. If I were in a condition like our patients are before the transplant, I would be very aware that I have no other choice and I would of course have my lungs transplanted. It is important to realize that these patients are virtually suffocating before the transplant, and shortness of breath is known to be one of the greatest sufferings a person can face.
What do you consider being the most beautiful moment in a lung transplant?
The best moment is when we restore circulation in the lungs and the lungs begin to breathe. On the one hand, it is a nice sight that we never tire of, and at the same time, it is associated with relief, because at that moment you feel that the lung implantation has succeeded and it will probably work well. The end of the operation is approaching, and it is simply a euphoric moment.
Do you share an empathic connection with every patient, then?
Absolutely – I believe this is extremely important to prevent the burnout syndrome. It is essential to be in touch with patients, to perceive what we are doing for them and what the point is in all of this. Sometimes we have more successful periods, sometimes less successful ones, so being with those patients and rejoicing in those successes is a way to maintain mental health.
We have been facing a coronavirus pandemic for a year. How does coronavirus affect your work?
We see an impact on many levels. Purely from the perspective of a surgical clinic, in both the spring and autumn waves, we naturally had to limit our planned procedures. That means we got into a situation where we were forced to make a certain selection, which in itself is very problematic, both ethically and logistically, but we simply had no choice, because our capacities were not and still are not on the level we are used to.
Then there is another point of view, because everyone who has to undergo surgery must be tested for COVID, which is extremely complicated in terms of organization.
Another level is the use of protective equipment, being in contact with a huge number of patients and colleagues with the fear that we might get infected, that we could infect our colleagues, since many doctors and nurses have indeed become infected.
In the context of transplant programs, there is a shortage of donors. Also, our post-transplant patients have contracted COVID and have a huge mortality rate that is close to 30%, which makes sense, as the target organ for covid-19 is the lungs.
Would you say patients after lung transplant are the most high-risk group, then?
In the spring, when the first wave came, we were very worried, because we knew nothing about the disease. It was with great relief that we found out that no patient of ours became infected. Unfortunately, in the second wave, we had about 30 patients infected, a third of which died, so even though we consistently urged patients to follow sanitary measures as much as possible, to isolate themselves and to use protective equipment, some patients became ill and subsequently died anyway.
What’s your stance on the coronavirus?
I guess it’s based on the situation I see here. It is an extremely serious infection with an unpredictable course, which means that we should treat it with great respect. After all, I myself had a moderate, perhaps rather mild course, but with the symptoms of severe flu. My 80-year-old father has unfortunately died at the beginning of January. He was COVID-positive and the COVID definitely accelerated his underlying illness, so it affected our family as well.
On the other hand, I am also aware of the fact that we have to postpone operations on other patients with serious diseases such as cancer, since marginally we perform some oncosurgery as well. Therefore, it needs to be said that the coronavirus is not our only problem – there are also patients with other serious diseases.
Finally, I also perceive the economic dimension affecting certain professions. I feel sorry for all the people who can't work and whose industries are withering dramatically. I think of them a lot, because I personally don't know how I would deal with such a situation.
Do you think the measures are proportional to the severity of the infection?
I have no understanding of this in the sense of being able to assess what measure has what effect, but we see the reality in hospitals, and it leaves no doubt that it is necessary to fight the disease in all possible ways.
Lately, we’ve seen a huge wave of criticism, provoked by an advertising campaign promoting vaccination, for which the government paid TikTok influencers half a million crowns. Where do you stand on this?
Well, of course I've noticed that, but I don't really want to comment on it, as I think the context is very complicated. I don't even use any social networks. But I just don't understand why they would address teenagers and young people, which were undoubtedly the target group of the campaign, while we're having problems somewhere else entirely. In addition, our budget is limited now, so we should think more than twice about what we’re going to use that half a million for.
Finally, I’d like to mention your acting experience, as you portrayed the son of Marta Kučerová and Juraj Kukura in the movie "Shadows of a Hot Summer". How did you get to it?
I attended primary school in Ostrovní street. One day the door opened and some people from the film crew appeared, looking for a dark-haired boy that would look like Kukura. They asked me to tell a joke, to check whether I could speak, and then the director chose me based on a photograph.
What do you think about Professor Pirk’s guest appearance in the "Ordinace v růžové zahradě II" soap opera? Doesn’t this seem like a denigration of your profession to you?
(laughs) First of all, I had no clue, and secondly, Jan Pirk is a man I respect very much. I had the opportunity to operate with him, and we did several combined transplants together. That's about all I can say.
