From Operating Room to War Zone: A Cardio-Thoracic Surgeon's experience, interview with Dr Craig Jurisevic

Gavin Nimon: [00:00:00] I can still recall as a fourth year medical student watching cardiothoracic surgery, in particular cardiac artery vein bypass graft being performed. I felt like it was like watching man walk on the moon, with the heart being operated upon whilst in fibrillation and the heart and lungs being bypassed.

Gavin Nimon: It was amazing surgery, but I'm sure it's progressed over the last 35 years. I'm looking forward to hearing from Dr. Craig Jurisevic of what cardiothoracic surgery is like in 2023. G'day and welcome to Aussie Med Ed, the Australian medical education podcast. A program born during COVID times to emulate the general chit chat and banter around the hospital with the idea of educating the medical student and GP alike.

Gavin Nimon: I'm Gavin Nimon, an orthopaedic surgeon based in Adelaide, and it's my pleasure to bring Aussie Med Ed to you. And in today's episode, we're joined by Dr. Craig Jurisevic, a cardiothoracic surgeon at the Royal Aid Hospital. He has a focus on minimally invasive thoracic surgery, as well as trauma surgery. And he has had an extensive career in conflict zone surgery, both involving general vascular surgery and cardiothoracic surgery, both as an individual in [00:01:00] Israel, Palestine, Albania and Kosovo, and with the Australian Army in East Timor and Afghanistan.

Gavin Nimon: More recently, he's worked for at least five months as a volunteer as a trauma surgeon in the Russian Ukraine war between both August and October 2022, and between February and June 2023. It's my pleasure to welcome Craig Jurisevic to talk to us about thoracic surgery in general, as well as trauma surgery.

Gavin Nimon: I'd like to start by acknowledging the traditional owners of the land on which this podcast has been produced, the Kaurna people, and pay my respects to the elders both past, present and emerging. Well, it's my pleasure now to introduce Dr. Craig Jurisevic, a cardiothoracic surgeon and a trauma surgeon.

Gavin Nimon: He's a specialist thoracic surgeon at the Royal Adelaide Hospital. He's well known for humanitarian work in the conflict zones, caring for those in need. He's actually written a book on his experiences which can be found on Amazon and which is really an eye opener to what really happens during a war.

Gavin Nimon: It's titled, Blood on My Hands, A Surgeon's War Experience, and it's a fantastic read. Craig, can you tell me a little bit about yourself and how you got into cardiothoracic surgery? 

Craig Jurisevic: Thanks, Gavin. First of all, I'd like to [00:02:00] thank you for inviting me to this podcast and I'm really looking forward to it. Well, I initially started as a general surgical trainee.

Craig Jurisevic: I always loved general surgery and trauma. And eventually I thought one way to increase my broad depth of experience was to do some cardiothoracic surgery as well. So then I did a service year in cardiothoracic surgery and realized I loved it. Particularly the acute emergency work and the intensive care management afterwards.

Craig Jurisevic: So that sold me and I continued on with cardiothoracic surgery. But that was after... Spending quite a bit of time doing general trauma and vascular. 

Gavin Nimon: Brilliant. And you specialise more in thoracic surgery now, or do you still do cardiac as well? 

Craig Jurisevic: No, purely thoracic now. I've always had a big interest in thoracic.

Craig Jurisevic: There was a big need for dedicated thoracic surgeons, especially 20 years ago or more when I started as a specialist. And I took on a big workload and found that I probably didn't have enough time to dedicate to cardiac. Surgery enough time to dedicate to cardiac [00:03:00] surgery as I should, so I moved into thoracic surgery.

Craig Jurisevic: I did go back and do cardiac surgery on a few occasions in 2008 and 2012, but my passion was thoracic and trauma. 

Gavin Nimon: So would you divide a cardiothoracic job into sort of cardiac, thoracic and maybe even adult versus paediatric? Is that a good way of thinking about it? It 

Craig Jurisevic: is now, so if you're coming out as a cardiothoracic surgeon now, you would probably have a mixture of cardiac and thoracic surgery.

Craig Jurisevic: As opposed to when we came out, a lot of people went into pure cardiac and a few did cardiothoracic and a smaller number did pure thoracic. But now you really need a mix of both for two reasons. The first reason is that the number of thoracic surgical patients has increased significantly because we're picking up cancers much earlier than we did 20 years ago.

Craig Jurisevic: And number two, the number of cardiac surgical procedures is dropping because the cardiac The cardiologists are doing a lot of non invasive things that would usually have been done through a [00:04:00] stenotomy. 

Gavin Nimon: Well that's brilliant. So it's good to hear that the cardiology work with the stents and things like that are actually paying dividends.

Gavin Nimon: Perhaps should we start off going to thoracic surgery and tell us what sort of thoracic procedures are commonly done by yourself? 

Craig Jurisevic: Oh, well the majority of the thoracic procedures are done for cancer. Lobectomies, where you take a whole lobe of the lung. Pneumonectomies, where you take a whole lung or segmentectomies, where you take a segment of a lobe.

Craig Jurisevic: The other common procedures are those for people who have pleural space infections or empyemas, where we have to either with keyhole surgery or thoracotomy, a larger cut, drain all the pus out and peel the thick layer off the lung so the lung can expand. And then we have the variety of mediastinal tumours.

Craig Jurisevic: Another common procedure is done for spontaneous pneumothorax, which happens in a lot of younger people, including medical students where you have small cysts on the top of the lung, which can burst resulting in pneumothorax. So we have to do a video scopic surgery to staple off the little cysts or blebs [00:05:00] and put talcum powder in to stick the lung up to the chest wall.

Craig Jurisevic: And 

Gavin Nimon: are those spontaneous pneumothoraces, are they more common in collagen deficient patients? 

Craig Jurisevic: They are, they're more common in people with Marfan syndrome and Ehlers Danlos syndrome, but they're relatively common in people in their teens to late twenties, particularly tall, thin people. 

Gavin Nimon: And where's the division between in cardiac and thoracics when you're looking at the aorta as well?

Gavin Nimon: Is that more of a cardiac division or is that a bit of, you do a bit of that as well? 

Craig Jurisevic: Oh, now looking at aortic surgery. The cut off for cardiac surgeons is the end of the arch of aorta. So, cardiac surgeons operate on the acine, the aortic root, the acine aorta, down to just beyond the left subclavian.

Craig Jurisevic: From the left subclavian down is the domain of the vascular surgeons. And we tend to work closely with them, especially with all the stenting options the vascular surgeons have now. Excellent. 

Gavin Nimon: Perhaps you could go into what makes thoracic surgery a [00:06:00] little bit unique compared to general surgery that we would do in orthopaedics, where we just have an anaesthetic and maybe some muscle relaxant for a period of time.

Gavin Nimon: I believe there's a particular things that need to be taken into account when considering thoracic surgery, like the types of intubation tubes you might use, 

Craig Jurisevic: et cetera. Well the big difference in thoracic surgery, we have to operate, obviously usually operate on one lung at a time. So. Traditionally, in the old days, you'd have a large incision, a big thoracotomy right from basically from behind your shoulder blade, under your shoulder blade, all the way down below your nipple.

Craig Jurisevic: And we'd wind the chest right open and you do the operation with a single lumen tube with both lungs ventilating and the assistant would push the lung away. But for many years now, we've been using what lumen endotracheal tubes. And I should have brought one to show you today, but it's a technique where the anaesthetist puts a tube with two ports down through the vocal cords and they put the tip of the tube into the lung you want to operate on.

Craig Jurisevic: They blow up [00:07:00] the balloon in that tube, excuse me, and they ventilate the other lung through another hole in the port. So it's a double lumen tube. So now we operate. with the lung decompressed and not ventilating, which makes it a lot easier and you definitely need that for videoscopic surgery. So that's one important point.

Craig Jurisevic: The patients are always, almost always operated on in a left lateral position. And another major advance over the years has been the use of regional anesthesia. So blocks. So the anaesthetists use various blocks to block the intercostal nerves or another block called an erector spinae block which gives you fantastic pain relief around the chest wall so that when they wake up they're comfortable enough to deep breathe and cough.

Gavin Nimon: Excellent. Is it still left lateral for when you're doing a right lung as well then, or is it? Yep, 

Craig Jurisevic: that's right. You've remembered that well, Gav. So, yeah, left lateral for a right lung and right lateral for a left lung. Some procedures we do for example, in emergency thorocotomies for various reasons.

Craig Jurisevic: If you, for example, if you, somebody comes [00:08:00] in and they in the ED and they're bleeding to death from below the diaphragm, one thing you anterolateral thorocotomy with a patient on their back. being resuscitated, open the chest and clamp the aorta to allow the heart and the brain to remain alive whilst you resuscitate the patient.

Craig Jurisevic: Now that's done in a supine position, but pretty well every other operation is done in the lateral position. Except for one other procedure called a sympathectomy which you can do in the supine position. And 

Gavin Nimon: that has done, a sympathectomy is done for excessive sweating and things like that, is that correct?

Gavin Nimon: For 

Craig Jurisevic: hyperhidrosis, excessive. sweating in the hands and axillae. I tend to do it in the lateral position and then rotate the patient to the other side. 

Gavin Nimon: One condition you haven't talked about, which I often get patients refer to me as the thoracic outlet syndrome. Do you deal with that as well? 

Craig Jurisevic: We do.

Craig Jurisevic: I do quite a few thoracic outlet procedures. The approach, so the thoracic outlet syndrome is where you get compression of either the [00:09:00] brachial plexus, The, or the subclavian vessels as they pass between the clavicle and the first rib. And it's relatively common. And if it gets to the point that they need surgery, there are several approaches.

Craig Jurisevic: The traditional approach which the vascular surgeons did was through the front of the neck. But that's quite a complex approach and you have to pull aside all the structures and you're left with a very small window to take out the first rib or the extra axillary rib. The approach I use is a, an auxiliary thoracotomy where you have the patient in the lateral position with their arm up and you make a cut under the hairline and you dissect up to, you can see the first rib and we take the first rib off.

Craig Jurisevic: As, as much as possible to free up the brachial plexus subclavian vein and arteries. That is a very common syndrome. 

Gavin Nimon: Right. And the patient can get by without a rib there for breathing, there's no issues associated with that at all?

Craig Jurisevic: No. You can get by without your first rib quite 

Gavin Nimon: easily. No worries.

Gavin Nimon: Well, apart from using the double lumen, is there any other special techniques that are used in... Thoracic [00:10:00] surgery. I know in the past they might have used bypass machines to help aerate the blood. Is that still required or is that nothing? No, I 

Craig Jurisevic: think what you can sometimes, so usually a double lumen tube is all you need.

Craig Jurisevic: Occasionally if you have patients who have or what's the one word? You can, for example, if you have major injuries in trachea where you can't ventilate the patient and they need surgery, you can use a a technique called Veno venous ECMO or extracorporeal membrane oxygenation. So if you have a proximal tracheal lesion and you can't ventilate the lungs beyond, you can put them on through the femoral artery and vein on a machine that oxygenates the blood so you don't need to ventilate.

Craig Jurisevic: But usually you get by with a double lumen tube for everything. 

Gavin Nimon: Excellent. And therefore the requirement for these extra machines aren't particularly required anymore. And you can actually do everything through a double lumen. It's, yeah. 

Craig Jurisevic: We, you've virtually never used bypass in thoracic surgery.

Gavin Nimon: What about the use of endoscopy as well? Is that [00:11:00] you've, I think you've touched on that, that's more commonly used nowadays. 

Craig Jurisevic: Yeah. We use it preoperatively, especially for cancers. Everyone has a bronchoscopy, a fiber optic bronchoscopy. We a flexible. Bronchoscopes pass through the nose or through the mouth so you can have a thorough look at the airways.

Craig Jurisevic: You can biopsy the tumours from within the airways and you can also use an endoscopic sorry, excuse me a bronchoscopic ultrasound. So you can actually see the lymph nodes around the airways and biopsy the lymph nodes and staged the tumour. So you can preoperatively, the lung physicians can work at exactly what stage you've got before we operate, which is something new 20 years ago, we didn't have that.

Craig Jurisevic: So you would often operate. And take out lymph nodes in the chest and find the patient had much more advanced cancer than you realise preoperatively. Right now, in 98 percent of the patients, the staging pre op is perfectly accurate. Now we 

Gavin Nimon: have touched upon with Hubertus Jersman about lung cancer.

Gavin Nimon: But most of the lung cancers you'll be treating and doing lobectomies and [00:12:00] removing segment, segmentectomies are for primary lung cancer or they, do you ever treat secondary cancers as well? And how common is secondary cancer in the lung as well? We 

Craig Jurisevic: do treat quite a few cases of secondary cancer.

Craig Jurisevic: It is relatively common now. It's probably more common now than 10 to 15 years ago because of the survival of people with metastatic disease. And a good example is a patient with metastatic melanoma, which often goes to the lungs. 10 or 15 years ago, we didn't have all the targeted therapies. So patients with metastatic melanoma would often die within 12 to 18 months.

Craig Jurisevic: So now we find patients who have what we call oligometastatic disease or patients with not many metastases and they're often in the lung. So we do wedge resections or segmentectomies for secondary deposits in the lung. And it's also relatively common for bowel cancer, stage four bowel cancer, which now can have up to a 50 percent cure rate.

Craig Jurisevic: and renal cancer and other cancers that spread to the lungs. So secondary cancers are [00:13:00] relatively common and we're treating many more patients now than we did before, which is great. Brilliant. 

Gavin Nimon: Are there any contraindications to doing surgery in these patients? So the things that you'd watch out for? 

Craig Jurisevic: Just in lung patients in general.

Craig Jurisevic: So one thing we need to know is that. If we're going to take out a significant amount of lung tissue, we need to know they have enough reserve. So we do pulmonary function tests beforehand. And so the patients whenever possible do pulmonary function testing before, and we look at several measurements, the FEV1, which is the forced expiratory volume in one second, that has to be greater than we measure that then you have the force vital capacity, and then you have the most important one, which is called the DLCO, which is the oxygen diffusion.

Craig Jurisevic: So basically how effectively the lung absorbs oxygen from the air. And that's the most important one. If patients have a DLCO of less than 50%, their risks are very high. So we love to have lung function tests pre op. And if the lung function tests [00:14:00] a borderline we can do other calculations to work out what their lung function would be if we took out a lobe, for example.

Craig Jurisevic: And if the lung function would be too low, then we don't offer surgery. You have other options such as stereotactic radiotherapy or SABRE radiotherapy to blast the tumours. 

Gavin Nimon: Excellent. Thinking about the different areas you're working in and also knowing that the podcast was done in the past.

Gavin Nimon: One of the big issues that's come through or one of the big advances has been artificial intelligence and that's helping us work out flow diagrams and treatment algorithms. Has that had a process in your area as well? 

Craig Jurisevic: It is coming into it slowly, but surely as far as, it's making itself known in the robot world of robotic surgery but it also does help with in screening patients.

Craig Jurisevic: But at this stage it's still at early stages of being involved in thoracic surgery. 

Gavin Nimon: And is there robotic surgery used 

Craig Jurisevic: in thoracic surgery as well? There is, yeah. Robotic surgery is becoming more and more common worldwide. We've just started doing thoracic [00:15:00] robotic surgery in Adelaide here. One of the other surgeons at the Royal Adelaide Hospital started doing robotic wedge excisions and metastomal tumours and will be Helping him to go all the way to lobectomies and we'll probably end up doing 30 percent of our work robotically within the next five years.

Gavin Nimon: That'd probably be similar to the renal cancer type work where it's actually used to help increase dexterity and also vision. 

Craig Jurisevic: Absolutely. Yeah, the dexterity with robotic surgery is amazing. 

Gavin Nimon: That's fantastic. But perhaps we could go on to the cardiac types area. I know it's not your main area, but you're obviously trained in it.

Gavin Nimon: Perhaps you can help the medical students outline what sort of main cardiac procedures are undertaken 

Craig Jurisevic: nowadays. So the majority of the procedures done in any big hospital are now, the most common would be coronary artery bypass grafting for patients with coronary artery disease. The next most common would be valve replacements or repairs for people with aortic, mitral and tricuspid disease.

Craig Jurisevic: The next... Most common procedures are aortic procedures for patients with [00:16:00] dilated as acid or arch of aorta and patients with aortic dissections where the inner layer of the aorta tears and results in ischemia to the rest of the body, basically. And then yeah, so they're the main cardiac procedures, and you have other odd procedures such as cardiac tumours, the most common being mixed sos on the aortic or on the mitral valve.

Gavin Nimon: Right, and are they still done in the same way as I learned when I saw them 35 years ago, putting the heart into fibrillation and cooling the body and using bypass machines, or they also got new techniques than 

Craig Jurisevic: 35 years ago? Well, they have changed a bit in 35 years, and you and I worked in the same unit 35 years ago, and one of the techniques, one of the old techniques for operating on the heart involved fibrillate, making the heart go into ventricular fibrillation.

Craig Jurisevic: So taking it back a step, the way the bypass machine works, and I wish I brought a diagram, but if you can imagine, the heart, the left ventricle pumps blood into the aorta, and the blood returns to the heart through the vena cagae into the right atrium. [00:17:00] So what the cardiopulmonary bypass machine does, is basically we drain the heart from the right atrium with a large cannula, it goes into the bypass machine, which oxygenates it, and then pumps it back into the aorta, where we put a small cannula to perfuse the rest of the body.

Craig Jurisevic: The old technique to still the heart whilst you operated on the grafts on the coronary arteries was to fibrillate. So he made the heart fibrillate. So it was not completely still, it was just quivering. Now, the new technique now, which has been around for many years, is to basically we put the heart on the bypass machine.

Craig Jurisevic: And then we clamp the aorta just below where the blood's going back. And then we put in a solution with high potassium concentration which arrests the heart. So the heart's arrested, it's not using oxygen and you get on and operate. It's truly 

Gavin Nimon: amazing. And does it involve cooling the heart, the body as well at the same time?

Gavin Nimon: Do you need to do that as much now? We used to cool 

Craig Jurisevic: a lot more than we do now. What, the [00:18:00] most common technique now is used to use almost normothermic cardiac arrest. So we keep the heart as close to body temperature as possible. Usually it drifts down to about 35 degrees Celsius. We don't cool the heart completely, except for procedures that are going to take a long time.

Craig Jurisevic: For example, replacing the aorta where you cool the heart down and you don't just cool it down, you cool it all the way down to less than 20 degrees Celsius. And then you have complete circulatory arrest. You switch the bypass machine off. So everything's stopped. Right. 

Gavin Nimon: And that would still, with this new surgery, you still use an ECMO machine to help oxygenate the blood as well?

Craig Jurisevic: The cardiopulmonary bypass machine includes an oxygenator. Definitely. Yeah, so you oxygenate the blood. 

Gavin Nimon: And where do they take the grafts from? Is it still from the saphenous veins and things like that? Is that still the most common 

Craig Jurisevic: one used? Yeah, the most common grafts used are the long saphenous vein from the leg.

Craig Jurisevic: Then, and they tend to be used for the arteries on the right side of the heart, the right coronary artery. or on the left [00:19:00] side, the left circumflex artery. The most important for fusing artery of the heart is the left anterior descending. And for that artery, which sits on the front of the heart, we tend to use the left internal mammary artery, which is behind the sternum, the left side of the sternum.

Craig Jurisevic: We harvest that artery, leave it attached to the subclavian vein at the top, and plug it into the left anterior descending artery. So it's a pedicle graft, which is alive. And feeds the left anterior descending. And that's the most important graft of any coronary artery bypass graft. The other conduits you can use are the radial artery, and that's used relatively common too.

Craig Jurisevic: So number one, saphenous vein, mammary, internal mammary, and radial. 

Gavin Nimon: Brilliant. It's certainly come a long way since I saw it many years ago. What are the, one of the big things we hear about now is the ablations for arrhythmias. Is that, is there a cardiac surgical side of that as well? Or is it still just ablations the main treatment for that?

Gavin Nimon: Well actually it 

Craig Jurisevic: started off as a cardiac surgical procedure. Because atrial fibrillation originates In the Atri le, the left atrium [00:20:00] particularly, and one of the procedures that it's called the Cox Maze procedure, basically involved slicing left atrium open in various ways and resiting it together, the break to break the electrical conduct channels now.

Craig Jurisevic: But over the past 20 years, this has now been done by Cardi Cardiologists Percutaneously, where they. go in through the femoral artery and and then go through into the left atrium. And they basically make little burns throughout the wall of the left atrium and around the pulmonary veins to stop the AF circuits.

Craig Jurisevic: So most of them now are done by cardiologists. But in surgery, if we have a patient who needs cardiac surgery, particularly a valve, and they have atrial fibrillation, we still do the surgical procedure in various forms. But most of that is now done by cardiologists, and not many cardiac surgeons do a lot of AF surgery.

Gavin Nimon: Brilliant. Looking at the we talk about the cardiology involvement. In the past I know there used to be quite a team involving cardiologists work [00:21:00] up and in post operative care with the surgeon involved. I presume that team's probably expanded nowadays to a lot of other allied health treatment.

Gavin Nimon: So what makes up the cardiothoracic surgical team that you commonly deal with? 

Craig Jurisevic: So now we're basically, the cardiac surgical team involves the cardiologists, the cardiac surgeons. Then you have the cardiac physiotherapist, the electrophysiologist, the pacemaker people. So it's quite a big team and we.

Craig Jurisevic: All the patients tend to be presented in a multidisciplinary team meeting and then the best treatment for that patient and that patient's disease is decided on in the meeting and then they go and have the appropriate surgery. The same for thoracics. You have a thoracic MDT with a thoracic physicians, oncologists and radiotherapists and surgeons and we have we make a decision as to what is the best treatment for the patient.

Craig Jurisevic: All decisions now made with multidisciplinary teams? 

Gavin Nimon: Yeah, it's it's amazing. It's a always liken it to actually working in a sports club. We actually have the whole [00:22:00] process and the whole team helps the victory and that's what we're looking at for a patient, about a combined care.

Gavin Nimon: So it's brilliant to be involved that you're involved in all the, all these teams are going along. Perhaps we go on to talking about what other innovations have really developed. I think you've probably expanded upon most of that, the robotic surgery and the minimally invasive surgery. Where do you think cardiothoracic surgery is going to go, and particularly thoracic surgery in the future?

Gavin Nimon: What do you think the new innovations will be? 

Craig Jurisevic: Cardiac, firstly, I think cardiac surgery will continue along the way it is now. But I think the cardiologists are taking over even more of cardiac surgical the cardiac surgical realm than we would ever have dreamt of 20 years ago. For example, now a large number of aortic valve replacements are done percutaneously and they're called TAVI, T A V I, and they're done through the groin artery where basically a catheter is put through the femoral artery, they go through the aortic valve, they break open the aortic valve and implant a valve [00:23:00] percutaneously.

Craig Jurisevic: And that's moving ahead in leaps and bounds. It's only for specific patients, but the group of patients that are are being put up for tabbies is expanding and they're also doing mitral valves as well. So I think the amount of cardiac surgical procedures will reduce. I think thoracic surgery will increase significantly.

Craig Jurisevic: And it is because we have started screening programs. We're going to pick up. many more early lung cancers, so there'd be much more mentally invasive lung surgery, removing smaller parts of the lung, such as segments, and a lot of that would be done robotically. So I think there may be a gradual decline to a certain steady state in cadex surgery, but thoracic surgery is increasing.

Gavin Nimon: Wow, that's truly amazing. And I presume for the aortic stenosis type surgery you're talking about, that's for the, that leads to delayed cardiomyopathy, is that correct? Or is that what 

Craig Jurisevic: it leads to? Oh no, with tight aortic stenosis, you can get heart failure due to the extreme work the ventricle has to perform.

Craig Jurisevic: Cardiomyopathy just means [00:24:00] the left ventricle is not functioning as it should, and it can be caused either through lack of blood flow, such as with coronary artery disease. It can be caused through viral infections or other diseases which can cause cardio and cardiomyopathy. And there is a large percentage of patients who have idiopathic cardiomyopathy.

Craig Jurisevic: What about, 

Gavin Nimon: The other thing that comes to mind is with recent COVID infections, there's been a lot of pericarditis. Is that impacted on your work at all? Is that 

Craig Jurisevic: something you've seen? It has impacted on cardiac surgical work to a degree. The surgeons report that patients who've had bad COVID can have quite a few adhesions in the pericardium.

Craig Jurisevic: And you don't just get a pericarditis with COVID, you get a myocarditis as well. So people can have moderately impaired heart function after they've had a COVID infection, which can be permanent. And 

Gavin Nimon: is, and this is a different type of picture that you get with other conditions like RSV, et cetera. Yeah, 

Craig Jurisevic: absolutely.

Craig Jurisevic: Very different. It's very unique. 

Gavin Nimon: It's truly amazing. Well, I want to move on to your other area of your work, which is your humanitarian work, your [00:25:00] trauma work. And perhaps you can, first of all, tell me about what drove you down that pathway, and obviously you've had some interest from the start, but perhaps outline your story with that, please.

Craig Jurisevic: Well, initially, I've always had an interest, when I was A kid, I always wanted to be a doctor and work in the third world country to help those who are in need. It's just something I've always wanted to do. And as I went through med school, I realized probably the best way to do that for me would be through surgery.

Craig Jurisevic: So even as an intern, I decided working as an intern at the Royal Adelaide Hospital was extremely exciting, but not exciting enough and it didn't expose me to trauma. So through the help of one of my previous mentors, who I can mention now, Mr. Peter Devitt, a general surgeon. I went to work, spent part of my internship in Sabah in in Borneo, Malaysia and saw quite a bit of trauma there.

Craig Jurisevic: And then I came back, started basic surgical training and realized that involved a lot of paperwork and not a lot of trauma. So I went to do a year of trauma surgery in Israel and and [00:26:00] Palestine. And I saw a lot of trauma there. And then I came back and did general and cardiothoracic surgery. And towards the end of my training, I volunteer to help with trauma surgery and running trauma surgery in refugee camps and frontline areas during the Kosovo War of 1999.

Craig Jurisevic: And after that, I joined the Australian Defence Force and did some more trauma work in East Timor, Afghanistan, and then more recently on my own in Ukraine. So I've always had an interest in combat trauma surgery, and as I did more of it, I became more adept at it, and then more willing to go to rather more extreme places to assist.

Gavin Nimon: That's truly amazing. It must be quite frustrating though, when we spend all this effort with one patient, but we're looking after a lung cancer. And then you see a war conflict where hundreds or thousands of people were killed. And it must be quite hard to take. How do you mentally deal with that yourself in that scenario?

Craig Jurisevic: It was hard initially when, for example, [00:27:00] Kosovo was the biggest, I was in Israel for a year, we saw a lot of trauma during the intifadas there and the conflicts in that region. But the, Kosovo in 99 was a full blown war. And I saw a lot of frontline traumas, even involved in treating at the frontline.

Craig Jurisevic: And then coming back to Adelaide where things were much quieter and then it was difficult to adjust initially that I did eventually. But as I got older and more experienced, I realised that the mentality in war zones is very different to the mentality in a peaceful country. So I realised that.

Craig Jurisevic: But something that would seem stressful here in Adelaide would seem like a minor issue in a country at war, for example, Kosovo or Ukraine recently. But I realise that everything is relative. So we're here in Adelaide and what some people see as extremely stressful here is stressful for them relative to their normal daily existence, whereas [00:28:00] people living in a country at war have a much higher threshold for stress.

Craig Jurisevic: That's 

truly 

Gavin Nimon: amazing. A great way of thinking about things. What are the main type of injuries you'd have seen in a war zone then? What are the main ones you would be treating? And perhaps outline some of the the more common ones and how you deal with them. 

Craig Jurisevic: I think if you go to the latest conflict, the conflict in Ukraine, that's a conflict on a scale we haven't seen since World War II.

Craig Jurisevic: There's a 2, 000 kilometre front line and most of the injuries at the front line are blast injuries secondary to artillery and missiles. So, for example, when I was operating at the frontline damage control units attached to the Ukrainian military, we would get, for example, in a, we had three units within 35 kilometres of the frontline.

Craig Jurisevic: Each of those had two, two operating rooms. And in each of those units, we could get up to 200 patients a day. You could get, you could be doing 20 to 30. Damage control operations [00:29:00] every day and a damage control operation, for example, in your standard patient would be a male who had blast injury, lost one or two limbs.

Craig Jurisevic: They have penetrating blast injuries to the abdomen and chest and in 20 percent they'd have all that plus a brain injury. So you'd have to operate on them which would involve stopping the bleeding limbs, doing a laparotomy to stop the abdominal bleeding and a thoracotomy. And then you would package them up and move them onto the next level of care, which is three hours away, and send them on their way.

Craig Jurisevic: So you could do 20 to 25 of these operations every day. And the casualty numbers, to give you an example, at its peak when I was there, they were losing, they could lose up to 250 soldiers a day with more than 1, 000 injured. And putting that in perspective, whilst we in Australia were in Afghanistan for 11 years, we lost 42 soldiers over 11 years.

Craig Jurisevic: They lost could lose up to 240 a day. So the casualty numbers in [00:30:00] Ukraine were massive and something that we probably wouldn't cope with in the West, US, UK or Europe, but the Ukrainians tend to be coping with it. Oh, it's 

Gavin Nimon: truly amazing. The, what's the sort of level of so those people who you'd under, undergone damage control surgery, the, there'd obviously be a high attrition from those.

Gavin Nimon: What sort of percentage would actually survive that sort of area? 

Craig Jurisevic: The usual journey from point of injury, for example, the front line to reha rehabilitation, reconstruction is like this, you have, so if you're at the front line in the trenches, you get injured, you get first aid you're taken to a roll one, where they do, they stabilise you, which is, a roll one is a little unit within a kilometre of the front line, they put in drips, put a chest tube in, save you, then they move you to the roll two, which is within an hour from the front line, And that is where you do the damage control surgery.

Craig Jurisevic: Between roll 1 and roll 2, people will die. Once you get to the roll 2 and you have your surgery if you had 100 people having damage control surgery, [00:31:00] maybe 60 65 or 70 would survive, 30 would die. Those 65 or 70 percent who survive damage control surgery, then go to the roll 3. Which is three hours away, which is where we would do second look operations.

Craig Jurisevic: Once they've been patched up and stabilised in the roll two, we would operate on them. And there another 10 to 20 percent die. So really about 40 to 50 percent will survive their frontline injury. So it's a big attrition, but better than it used to be. Wow, 

Gavin Nimon: truly amazing. It's just giving me goosebumps even thinking about all this.

Gavin Nimon: Quite amazing. Completely different. As you said in your book when in the opening chapters, you talk about thinking about the life back in Adelaide, walking on the beach at Brighton compared to being in the on the, in the front line of a trauma scenario. It's very different. Yeah. What would you say to doctors who want to, or medical students who want to go and help out and in these areas?

Gavin Nimon: Where's the pathways? I mean, obviously you hear about different NGOs that actually offer services and [00:32:00] things. What's the way to head down the way, the same sort of way you did start off with the surgical background and or i c u, an anaesthetic type background and head down that way, or, 

Craig Jurisevic: well, you can do, if you're interested in doing.

Craig Jurisevic: humanitarian work, you first have to decide what speciality you want to get. And basically, you can do anything from general practice, which is extremely useful everywhere and or you can go down the surgical pathway or anaesthetics or ICU. So I think either general practice, surgery or anaesthetics ICU.

Craig Jurisevic: Now, I wouldn't go down the pathway I went because unfortunately, it's very dangerous and unorthodox. So I would. Recommend, if you're interested in voluntary work, you should join Get Experience First here in Australia. And most NGOs, non government organisations who provide humanitarian experience, want people who've had several years experience in their area of specialty.

Craig Jurisevic: So if you've been a GP for three or four years, you can apply to work for someone like Doctors Without Borders, that's Medicines on [00:33:00] Frontiers, or there are various other big groups that are well established. And the same with surgery and anaesthesia. There's not much point going before you've almost finished or finished your training and you have a few years experience because you need experience to cope with what you'll see, particularly in war zones.

Craig Jurisevic: And also, a lot of this work is dangerous so you have to be willing to take the risk. I wouldn't recommend going to places that I've been recently unless you're, have a military background or, and a military surgery or medical background as well. And even then, it is quite dangerous. But yes, do your basic do your training, and once you've been trained for a few years, then go and do some volunteer work, and you also have to take into account that by the time you've done your training, and you've had a few years experience, you may have, if you're going to have children, you'll have small children, that has to be taken into account as well, because you don't want to be away from them too long.

Gavin Nimon: Trust me. Excellent. Well, I think there's some great great lessons there to be learned and great [00:34:00] advice. Perhaps what would you where do you think medical medicine is going for cardiothoracics and this military area and everything? Where do you think we're heading in the future?

Gavin Nimon: Do you think there's always going to be a requirement for cardiothoracic surgeons and there's always going for people helping out in war zones? Or do you think we're going to get this utopia of everything settling down? 

Craig Jurisevic: In an ideal world, the preventative medicine will work so well that you won't need cardiac surgery for coronary artery disease or valve disease and we won't need to do any surgery for lung cancer, but unfortunately I think we will.

Craig Jurisevic: So I think there'll always be, I think in future cardiac surgery will be, the future cardiac surgeons will do minimally invasive cardiac surgery and may even get involved in doing the percutaneous stenting and valves. Thoracic surgery, I think will, for at least the foreseeable future, will always require some sort of operation to remove tumours, especially early stage tumours.

Craig Jurisevic: But there are new techniques such as radiotherapy [00:35:00] and ablation techniques which can treat cancers without surgery. But I think there will be a need for us all. Now if there were no more wars, you wouldn't need people like myself, but unfortunately humans being humans, there will always be conflict. And I think Unfortunately they'll need, always need trauma surgeons.

Craig Jurisevic: It's a good, trauma surgery is very exciting. It's not a fantastic lifestyle. So if you're going to surgery or medicine for lifestyle, you won't be doing trauma surgery or volunteer work. But there'll always be a call for people who are interested in that. It's always good to help things 

Gavin Nimon: out. I think one of the advice, and I'm sure you'll back me up on this, Craig, but one of the advice I say to my medical students is that we're very lucky in medicine in that we get rewards in multiple ways, but one of the biggest rewards is the reward of actually helping people and the excitement you get from actually making people better or at least making their life different.

Gavin Nimon: And I'm sure that's a big driver for yourself. Is that correct? 

Craig Jurisevic: Absolutely. Being able to improve patients [00:36:00] lives. You don't look for gratitude, but when you see a patient very happy and relieved that they've had their treat illness treated, it is very rewarding, yeah. With medicine, probably 90 percent of it's hard work and not very glamorous, unlike Grey's Anatomy.

Craig Jurisevic: And 10%, 10 percent of it is extremely rewarding. And that's what we do it for, that 

Gavin Nimon: 10%. One of the things I didn't say at the start, but I'll mention now, is that Craig and I were actually interns together in 1990 at the Royal Adelaide Hospital. Our friendship goes back for many years before that as well.

Gavin Nimon: So it's great to see him again and to see him doing so well. So look, I'd really like to thank Craig for coming on Aussie Med Ed. It's been brilliant to have you here today. And thank you very much for your time. No, it's been 

Craig Jurisevic: a great pleasure. Thanks, Gav. Thank 

Gavin Nimon: you very much. I'd like to thank you very much for listening to our podcast.

Gavin Nimon: I'd like to remind you that the information provided today is just for general medical advice and does not pertain to one particular medical condition or one way of treating a particular condition. If you have any concerns about the information raised today... Please [00:37:00] do not hesitate to contact your general practitioner for further information.

Gavin Nimon: We hope you've enjoyed the podcast and please don't hesitate to give us a review or tell your friends about it. We look forward to presenting another podcast to you in the near future on a different topic. Until then, stay safe and thank you very much.