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The pioneering Kiwi surgeon who heads a world-leading team

Team leader Simon Talbot in 2011, ahead of a bilateral mid-forearm transplant, a first of its kind for the US hospital where he works. Photo/J. Kiely Jr/Supplied

Harvard-based New Zealander Simon Talbot leads a team of surgeons performing astonishing hand transplants and plays a part in operations that give patients a new face.

In 2009, Charla Nash was horrifically injured when her employer's chimpanzee attacked her in Stamford, Connecticut. Her face and hands were torn off and she lost her sight. The savaging became global news after the release of a recording of the emergency call seeking help for Nash in which the chimp can be heard screeching in the background.

Enter Simon Talbot, a New Zealand-born, US-based surgeon. In 2011, Talbot and his team operated on Nash, giving her a new face and new hands. She now lives a mostly independent life, despite medical setbacks. Talbot has helped give new faces to seven patients, and hands to five others.

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He grew up in Hamilton in a medical family – his father, Richard, a doctor, his mother, Mary, a nurse. He and his twin sister, Sarah, are both doctors. Their older brother, David, did law and Talbot credits him with inspiring his own study habits.

Talbot is married to US doctor Elizabeth Morgan; both work at Brigham and Women’s Hospital in Boston and Talbot is also an associate professor of surgery at Harvard Medical School. He recently returned home to visit family and friends and to receive a Distinguished Alumni Award from the University of Auckland.

You’re doing pioneering surgery. Do you think being a Kiwi, with the No 8-wire mentality, has helped you in this risky and specialised work?

It’s all about the No 8 wire. It’s ingrained in us, as New Zealanders, to think outside the box and to be innovative and inventive. That is a huge part of taking on this kind of work. Another aspect, which I hadn’t much appreciated until I got into this, was how good New Zealanders are at teamwork. My job is keeping everybody working well together as a team and doing their part.

Simon Talbot with his twin sister, Sarah, on graduation day in 2001. Photo/Talbot family/Supplied

Family life also played a big part in your decision to go into medicine.

When you grow up in a medical family, and you’re immersed in medicine, you don’t realise some of the majesty of it, some of the magic behind what goes on, and the excitement, because you see it every day. So, it wasn’t actually until I was in medical school that I solidified my idea that this was what I wanted to do. But Sarah and I were very science-oriented and medicine seemed like a logical path. We went to Auckland Medical School together, we were in the same class and we lived together. We’re very close. She’s wonderful and a very good friend.

What do you mean when you talk about the majesty and magic of medicine?

There are a lot of intangible things in medicine that give you satisfaction or joy or an opportunity to make a difference. And it’s really hard to describe to people the excitement and satisfaction that come out of some of the things we do. There is something incredibly special and even magical about being able to help somebody in a way that will forever change their life.

Talbot in 2019. Photo/Clare de Lore/Listener

Is giving a new face or hands to a patient at the outer edge of what is surgically possible?

I think so, and I’m lucky in that I get to be the figurehead of a team of people. This is one of those things that no one person could possibly achieve. These operations require a team of 10, 20, sometimes 30 people. Putting together teams like this means we can achieve things that no surgeon could do alone.

Aside from the surgical and fine motor skills and everything else you need, endurance must play a role. How do you stay on your feet for surgery that can go on for 24 hours?

Part of it is just being used to working long hours and being able to pace yourself. These things are like a marathon, and you’ve got to plan how you’re going to do it. We have a checklist, a plan and a timetable. We’ve practised this on cadavers and in the lab, so we know about how long things take. We also rotate people on and off. If I see somebody getting tired, or if I’m getting tired, I’ll switch with somebody fresh and good who is going to do the best job they possibly can.

Quadruple amputee Richard Mangino ahead of his bilateral mid-forearm transplant in 2011. Photo/J. Kiely Jr/Supplied

New Zealanders who choose to become a potential organ and/or tissue donor have this information recorded on their driver licence. But what about face and hands? That’s a big call. Where do you get them from?

Our donors are people who have become brain-dead for any number of reasons.

We have a separate consent process from the way that people give consent for what we call solid organs, such as kidneys, livers and lungs. Our organ bank works with potential donor families, and they ask them completely separately from us. This is for the simple reason that we feel ticking the box on your driver licence isn’t quite the same as agreeing to give up your hands or your face, and we want people to be completely on board with what we’re doing.

[In 1998, New Zealander Clint Hallam became the first person in the world to receive a hand transplant, in a 13-hour operation in France. The hand was later amputated after complications arose, reportedly as a result of Hallam’s failure to take anti-rejection meds and do follow-up exercises to build strength and motor capabilities. He also complained the new hand did not match his skin tone.] Demand for new hands or a face must far exceed supply, so how do you assess a candidate’s suitability for a transplant?

There have been about 100 hand transplants worldwide, and about 20% have ultimately failed. Sometimes it’s very soon after surgery and sometimes it’s years later, after they’ve developed untreatable rejection or problems like that. One of the projects I’m involved with is looking at all the different psychosocial factors that may influence the ability for a hand transplant to survive. Whether that’s somebody’s ability to reliably take medication, take part in physical therapy, attend appointments and, importantly, have family who are supportive, encouraging and enthusiastic.

Blood flowing into one of Mangino's hands. Photo/J. Kiely Jr/Supplied

Do people have realistic expectations of how a new hand might change their life?

Setting appropriate expectations is a big part of this. We help patients to be realistic about what to expect afterwards, so that they’re not disappointed or trying to do things that are unreasonable. Our goal is to give patients back the ability to do basic activities around the house: feed themselves, perform basic hygiene tasks, clean themselves and have the ability to get out of the house if there is a fire or something. Simple things like that. Those are critical things to independence and quality of life.

When I first started doing this work, I thought, “Would I really think it’s worth going through all the surgery and having all these rejection medications just so I could brush my teeth or feel the pages of a book?” But when you talk to patients who have not had that for 10 or 15 years, it’s absolutely profound just how liberating it is to have the ability to do some basic things, such as feed yourself or take care of your own hygiene.

Some of the 40-person team, led by Simon Talbot, who worked on Mangino's double transplant, which took them more than 12 hours. Photo/J. Kiely Jr/Supplied

What about the cost?

It’s not as high as you might think. It’s on a par with a heart or a lung transplant. To date, all our hand transplants have been done on research protocols. My hospital takes the view that this is important and we’re going to spend some of our internal money on it. The research aspects of it have been paid for, almost exclusively, by the US Department of Defense, because a lot of veterans who lost limbs in the Middle East stand to gain from this.

What happens if someone’s face transplant is rejected and you’ve taken off what was left of their own face? Where do you go after that?

With a hand transplant, we’re a little more comfortable with risk because, if things go bad, we can take it off and they’re usually no worse off. With a face, if you take it off, you have a fairly big problem. We’ve done face transplants that are just the lips, and you can replace those with tissue from elsewhere in the body, an alternative that at least keeps the person alive. We ask these patients to accept significant risks with limited knowledge of the future – in that way we consider them like astronauts, pioneers who are willing to take a tremendous risk for a potentially huge gain.

Face-transplant recipient Charla Nash in 2014, three years after her surgery. Photo/Getty Images

Is this an emotionally draining part of your work?

It is. There is the constant thought in the back of your mind, “How are my patients doing?” If somebody is having rejection problems, thinking about how we are going to manage that. So, yes, it is draining, but it’s also incredibly rewarding. There is joy in seeing a patient’s reaction to having touch or function again. Like watching a child learn to ride a bike or realise their sense of touch, it’s truly magic.

The final frontier of transplant is, I assume, whole-head transplants, but could that ever happen, even if only for people who are already paralysed?

The big crux of this is that the spinal cord can’t regenerate. So, if you transplanted a head onto somebody, you would, by definition, make them quadriplegic. My take on this has always been that, with our current technology, if we suddenly figure out how to repair a spinal cord, such that we could do a head transplant for a patient, we should probably start by fixing all the people with spinal-cord injuries, paraplegia and quadriplegia. Wouldn’t that be a marvellous thing? We have enough challenges with hand and face transplants, so we shouldn’t try biting off too much more than we can chew.

Simon Talbot with his wife, Dr Elizabeth Morgan, last year. Photo/Talbot family/Supplied

Speaking of which, what happened to your patient who wanted to be a chef after his hand transplant?

He’s doing well, and although he is not a chef, he’s cooking at home for himself and his wife, and that is huge progress.

What about Charla Nash, who had the face and hand transplant after the chimp attack?

She got very sick after surgery and ended up losing her hands, but keeping her face. For a long time afterwards, we discussed whether we should try transplanting hands again or if that would put her at too much risk. We decided we should quit while we were ahead.

What about reading? What do you enjoy?

A lot of what I read is work related. I have a fascination with physician and patient well-being, so I have been reading a lot of “business” literature such as Thinking, Fast and Slow by Daniel Kahneman, which looks at ways to improve the way we do our jobs. I recently started a forestry project in northern Maine, so I am reading about local ecosystems and trees. I am also reading An Island to Oneself: The Story of Six Years on a Desert Island, by New Zealander Tom Neale. When life gets as busy as mine, it is an incredible fantasy to be on a desert island by yourself.

This article was first published in the March 23, 2019 issue of the New Zealand Listener.