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Advice from the heart

He picks up the pieces after life has taken its toll on our vital organs. Today surgeon Alex Manché tells MARIKA AZZOPARDI why he worries about the impact of today’s hectic lifestyle on the Maltese population and also gives his views on the recent doctors’ dispute

There is nothing like being a heart surgeon to give one an insight into just how unhealthy the Maltese lifestyle is, as Alex Manché knows only too well.

During the many hours spent operating on failing hearts and lungs, he has accumulated an enormous insight into the nation’s eating habits, stress levels and in particular its smoking addiction.

"My task is that of performing cardio-thoracic surgery, mainly involving heart and lung interventions," he explains. "Around 80% of the operations centre on heart by-passes, the rest deal with heart valves, transplants and congenital problems."

He jokes, wryly I must add, about the fact that it is not the hospital which employs him, but the major cigarette companies which have so many people keeping them in business.

"My work would be severely depleted if people stopped smoking," he says, sardonically.

By the time a patient reaches Mr Manché’s team, he would generally be in a very bad state indeed. "Smoking affects both the lungs and the heart and when a patient reaches the stage of requiring major intervention, the condition would generally be quite alarming," he explains.

He admits that there are cases when a patient requires the removal of a lung to survive, but eventually dies of heart failure anyhow, because the smoking would have already wreaked havoc on that organ.

"In Malta, around 30 or 40 years ago, only men smoked," he admits. "So we are reaping the effects of that phenomenon; men who have smoked cumulatively and regularly for so many years.”

He points out that the male sex is well-known for dealing with stress in a very bad manner.

"Men were meant to go out, hunt, fight and be the main providers of a family requiring fierce protection. This has all changed and men have had to adapt to living in a world of controlled stress," he says. One way people have chosen to deal with stress is by smoking.

As Mr Manché rightly observes, smoking trends have changed and since women have followed suit and taken up smoking cigarettes themselves, the likelihood is that within 30 or 40 years we will be treating females for what today are still considered typically male health problems.

He confirms that at present the average age of his patients is about 65, although he has operated on people as young as 30 and as old as 85. Statistics show that a hefty 75% of all his patients are male whilst just 25% are females.

It has been scientifically and medically confirmed that the younger one starts smoking and the more one smokes, the greater the health risks. But what about the younger generation? Aren’t they more aware of the risks?

Mr Manché doesn’t seem to think so.

"The majority spend their evenings out clubbing, smoking, drinking and eating junk food," he says. "Very few exercise regularly. Malta used to be an extremely healthy country. Now we are bombarding our naturally healthy Mediterranean genes with many negative traits, which cause increased stress levels.

"The healthiest people I’ve met are the farmers who have a traditionally healthy job – farming. If I have to operate on a person who is a farmer, there are usually never any complications at all."

I ask Mr Manché which strata of society and what kind of workers are more at risk from heart or lung problems. "The majority of my patients are middle-aged men, but they derive from all classes of society and from all sorts of employment," he answers. "There is no predisposing factor which I can put my finger on, although some men who have very heavy manual work or who are involved in certain mechanical work, are not able to keep their employment after a major operation of the sort my team performs."

Which leads us to the subject of Mr Manché’s most well-known patient, Prime Minister Eddie Fenech Adami. Many people had wondered whether Dr Fenech Adami had returned to work too soon after such major surgery and wondered whether this had been medically correct.

"Dr Fenech Adami is an exceptional man, otherwise he would not be Prime Minister of course," is the surgeon’s answer. "But when an operation which lasts only about two and a half hours is over, then the patient can leave hospital after barely three days.

"He can start walking immediately, although it is not usually recommended that one starts working straight away. In the Prime Minister’s case, he had people popping into his room right after the operation, asking for signatures and wishing him well. And I imagine he had a lot of obligations which he felt he had to respect even at that time. However, the quicker one gets back to normal routine, the better. There is less thinking about what happened and more positive thinking all round."

Mr Manché stresses, however, that to get back in shape so quickly requires one to be in the best shape possible before the operation.

He places great importance on positive mental attitude.

"Again I cannot overemphasise the fact that people here give far too much importance to material things, whilst forgetting to simply be," he says. "We are a very competitive nation, but unfortunately not where our health is concerned."

Having spent one year on the West Coast in USA and 16 years in the UK before moving on to Malta, he claims that he suffered a huge culture shock. Not moving back to Malta, but actually shifting from the States to the UK. "I was in the middle of my studies to become a doctor, when the doctors’ strike here caused me to halt and move to the UK to complete my exams. I only spent one year in America but it was an immense difference going back to England. When I returned to Malta, I had several people who all helped me to adjust to the shift and I must say I’m very happy here."

His attitude to life spills into his favourite pastime - music.

"My paternal grandfather taught me how to play the piano at age three," he says. "He was a musician and he was my tutor until I was around 12. He was also a painter, and he is the person through whom I obtained my artistic skills too." Now he plays the piano with friends at least twice a week and occasionally within bands, in aid of charity. He and his colleagues also enjoy playing music at work. "We always have music on during the operations. It all depends on who chooses the music, so we always have a variety of styles to listen to."

Mr Manché, together with a junior surgeon, leads a team of nine. Most of the team have been working together for seven years. "It is fantastic working with people you know well and can rely on. It helps when we are preparing for an operation, to know that we can rely on each other a hundred per cent," he says.

Reliability is definitely required when one considers that in 2001 the team carried out 400 heart operations and approximately 100 lung operations. All in all, he estimates that the team has completed around 3000 operations.

What about the failures? "We have a very low mortality rate, which I believe is due to the fact that we are a small team sharing the same philosophy – obsessive characters, really attentive to detail in all we do."

There have, in fact, been just 29 failures, out of the 3000 operations where generally the patient died after around two weeks of intensive care.

"Yes, it can be immensely demoralising if we lose a patient," he admits. "And uncannily enough, one generally tends to remember the failures with more intensity."

Such an enormous number of operations prompts me to ask just how much a typical operation would cost the hospital. "Lm1,200 for a bypass from beginning to end, including all details and as long as it is a routine case. This includes the aftercare which is technically the most delicate part of the whole process."

I ask Mr Manché what he thinks of doctors' conditions in Malta "I feel doctors are underpaid in Malta," he says. "With regards to long hours I have mixed feelings. I have spent many, many years of long hours in hospitals in the UK and the US and I honestly say it was tiring, but useful. One of my bosses always said to me that we are very privileged to be allowed to operate on human beings. We are never prepared enough. The longer the hours (of quality time with supervised teaching) of training, the better we will be prepared. There is a danger that hours will become curtailed because of regulations, and that a newly appointed consultant may not be proficient enough to deal with seriously ill patients. We should choose to do medicine because we are public spirited."

Mr Manché is well-known for the way in which he dedicates himself to his work, and for his gentle bedside manner plus the meticulous follow-through of each individual case. In fact he was recently award the ‘Midalja Ghall-Qadi Tar-Repubblika’, by the President of Malta. "When I received the phone call informing me about this award, I thought it was a joke! But it was not!" he laughs. " I was actually going to India when they phoned me, but although I told them about this trip, they told me I would receive the award at a later date."

Alex Manché admits he likes receiving cards from people he has operated on.

"Many times the message is written from the heart, even though the person who sends it doesn’t even know how to write, and actually asks somebody else to write in the words," he says. "The cards are very touching and I keep them all."