3rd July 2008

Professor Fiona Wood

Professor Fiona Wood presented the 2008 John Chalmers Oration on 19 June 2008. In his welcome speech, Professor Paul Worley, Dean of the School of Medicine said “Fiona’s work is something of which all Australian’s are proud

Here we include the transcript of a short interview with Professor Fiona Wood:

Introduction: Professor Fiona Wood is currently Director of the Western Australian Burns Service and consultant Plastic Surgeon to Royal Perth Hospital and Princess Margaret Hospital for Children. She is the Chairman of the McComb Research Foundation, which she established in 1999 along with scientist Marie Stoner. She is the cofounder and a director of Clinical Cell Culture (C3) a skin tissue engineering company and Chairman of the Scientific Advisory Board.
Fiona’s research through the McComb Research Foundation involves several collaborative research projects focused on the multidisciplinary clinical & scientific team approach to the treatment of burn injury. The ultimate aim is scarless healing to ensure the quality of the outcome is worth the pain of survival.

Fiona was awarded the Australian Medical Association “Contribution to Medicine” Award, in 2003 and also received the Order of Australia Medal for work with Bali bombing victims. She was named West Australian of the Year for 2004, and was nominated as a National Living Treasure and Australian Citizen of the Year

The Chalmers Oration was established in honour of the clinical, teaching and research contribution made to the School of Medicine and Flinders Medical Centre by Emeritus Professor John Chalmers, foundation Professor of the Department of Medicine. This is an annual event and is free for anyone to attend.

Transcript of interview

The title of your presentation is ‘Basic science to the bedside – past, present and future’. What will you talk about today?

I plan to give an overview of the work I have been doing to reduce the affect of burn scarring. The whole thrust is to reduce scarring, but it is so multifactorial. I will explore from a size point of view from big to small, tissue based and the neurology. Then I will talk about some of the issues I was faced with in 2005 when I was asked what message I had to share with Australians in that year.
Bringing science to the bedside is fascinating, interesting and exhilarating, it’s a real privilege. But it’s not sustainable in our society unless the whole society is behind you, with individuals understanding they have to take responsibility for themselves.

What do you mean ‘society must be with you’?

We have a health system that is second to none in the world. But it is not sustainable. I think people are beginning to understand that. One of the huge problems is that people don’t take responsibility for their health, and their education. Perhaps because no one has actually mentioned it. When in fact, they can look after themselves and they don’t need to have a first line medical contact for many smaller things.

As an example, consider first aid for burns and consider what we could do to make a difference to the health budget.  If you take the initiative to go and do a first aid course for burns, you will influence your ability to cope in a situation that may involve yourself, and those around you, and you will have an affect on the health budget. For example, consider a scald wound on a child. If you cool that wound for 20 minutes with cool water at 15-18 degrees, you will reduce that burn would by 80%. Translate that, not only will you reduce pain and suffering, but also the course of that event will be dressings for a couple of weeks, sun block and minimal scarring. As opposed to surgical intervention, dressings, pressure bandages for 2 years,  and reconstructive surgery to reduce scarring when you’re a teenager. Your talking about a 1 to 20 cost differential from accurate appropriate first aid.

What are the benefits of being able to combine both a clinical and research approach at the bedside?

I approach things by thinking there has to be a better way, we have to be able to improve. Maybe that’s because I work in an area where, although we do have a lot of knowledge, we have only begun to scratch the surface.

We don’t know why scars in some individuals are so profound. I do the same operation in 10 different people and I will get 10 different results. We don’t know the processes behind this.

I work in an area where there is enormous scope for improvement. There’s no opportunity for stasis in that environment. I am always thinking who can help me make this better? Who can help me look at this whole multi-factorial problem. We need to be looking at the regenerative capacity of the individual, the wound, the cells, right down to the level of the genetics. You need a functioning zoom lens to work out the big picture, but the small pieces that make up the big picture. No head can hold all of that, but there are a lot of people with knowledge that can help you reduce the suffering of your patients. And that path is called collaborative research.

 I spend a lot of my time working with others. I’ve never done anything in isolation. I am almost the conduit. I was one of those kids that always ask why. I am turning into one of the old people that always ask why.

I see that I have a clinical problem. The solution will be found in science and technology, and translating that into a solution is an art of itself.

What led you to burns?

I was clear from the start I wanted to be a surgeon. But what kind of surgery? I was keen on any surgery. I saw plastic surgery was quite creative and innovative – this was in the late 70s, and plastic surgery was about rebuilds rather than makeovers.

My first plastic surgery position was at the Children’s’ Hospital Greater Ormond St. I didn’t get a lot of exposure to burns there, but the little bit I got was really interesting and challenging. It involved intensive care, nutrition, pain management, infection control, as well as the surgery. It was more than just the surgery.

I sought out a job at East Grinstead, where Second World War air force personnel were treated. They called themselves the ‘guinea pig club’. And some of the leading plastic surgeons of the day were there. Young men, hands and faces often burned. They realised that if you fell in the North Sea, in cool, salty water, you did better. So when I was there, they had big salt baths. So the surgeons were re-building the patients, and some of the patients were still there in ’85, coming back for treatment. Burns is a lifelong recovery.

I observed the patients we were treating. There had been a big advance in many ways, but I thought Whoa! There is a big need because the scars weren’t a whole heap different. Better nutrition, better pain management, but the quality of the scars was what struck me, and I figured we had to be able to do that better.  I was very naive. It’s a lot harder than I thought it was going to be.

Let’s talk about your spray on skin. What led you to develop it? When did you know it was going to work?

The skin story began for me in 1985 in East Grinstead. We didn’t have a lot of research time, we were service driven and there to learn the craft of plastic surgery, but I did see  a little bit of what they were doing. They were just beginning to grow the skin cells into sheets, based on technology developed in Boston and first used in 1982.

In 1990, I was the Registrar and there was a patient in our hospital in Perth who was doing very poorly – repeated infections. With burns, it’s a race between closing the surface of the wound and more infections getting in …

I was driving along. I heard on the radio in my car that a team at Monash - burns surgeon Prof Masterton and scientist Joanne Paddle - had been to Boston and learned how to grow skin cell sheets. To cut a long story short, I coerced people into letting me send the last piece of skin from the donor site to Monash. They grew it in Melbourne and came back with skin cell sheets and put it on our patient.

It was 5 months post injury and our patient healed. Some weeks later she died suddenly with a fungal infection in her heart.  She’d been exposed for so long…. I thought if we can do that quicker, the outcome would be different.

Not much later, I was burns surgeon. We had some big burns come in. I haggled for money – we needed a lab. It was too expensive to fly skin from Melbourne, and the time was a problem. It took about 3 weeks to grow skin sheets. Many people around the world still grow sheets, but I figured there must be ways to grow the sheets quicker.

In 1993,  Marie Stoner and I got a grant and our own lab in the Children’s Hospital. I had spied Marie working late at night. I would receive the skin sheets for Melbourne and would be preparing the last stages at night, so it was all fresh and ready for the morning list. I’d see Marie getting bone marrow stuff ready. When I got the money, I poached her from Haematology. I said to her unless we can do this in less than10 days it’s really not useful. In her first attempt, she grew a sheet in 10 days. We were in business!

The sheets were friable, fragile. People wanted big chunky sheets, skin grafts. I said that doesn’t make sense  - skin grafts take by blood supply, this is epidermis only, there is no blood supply in the epiderms. We don’t need this big chunky thing, 10 cells thick.

So we were questioning what was going on. And we were working with fragile sheets that were hard to peel off the culture flasks. We were toying with the idea of putting the cells on as a liquid, rather than as sheets. At one point I thought we should just spray this on ….

We were working on one patient with a big burn, the wounds on the hand weren’t as bad. I couldn’t justify using the skin on them, but they weren’t healed. And I thought – put this liquid in a glove, put the hands in the glove and move the fingers around in the liquid. I was thinking I would come back in a few days when we had more skin ready and do the definitive surgery. And blimey, they were healing. I didn’t need to!

We had done some basic work like this and we had done some work on cell adhesion. We had seen that when our sheets were fragile and holey, they actually didn’t blister in the way that more traditional sheets did. And that made sense to me because the surface integrens weren’t the same expression. So we looked at the expression of surface integrens and the character of the adhesion and what was different. And we asked ourselves if we were going to spray it on, how were we going to spray it on? We became nozzle experts! We went through a whole raft of experiments, and tested lots of different sprays – nose spray, hair spray, and so on. The nozzle of an Italian mouth freshener clicked onto a 5 ml syringe and gave us a 90 % plus viability of cells coming through. We were spraying by 1995.

We don’t use spray on skin in isolation – we use it in association with other traditional skin graft techniques as well. We get the best of both worlds. We want to be able to cover as much of the wound in one operation – speed is very important for scarring.

Then we started exploring the notion of using the body as the incubator for the tissue culture environment. And that’s when we developed the kit. So now I work at the cell level, to take skin at the time of the operation  and use a kit that we’ve developed that takes 30 minutes. We take cells from as close to the injured site as possible for the best match, we put these in an enzyme mix which is the first stage of the tissue culture process and we get a cell suspension that we can spray on within 30 minutes. So we do all of this at the time of the operation. We take part of the tissue engineering laboratory, put it into a kit, take the kit into the operating theatre, using the body as the tissue culture environment means your surgery has got to be meticulous – but it should be anyway.

Where to next?

Neuroanatomy was an early area of special interest when I began my career. And its come around, back to that. I am fascinated by the neurological responses to injury, and the potential to use those to drive regenerative repair.

What fascinates me is that we retain our morphology throughout life and we don’t know how. I think it’s a connection between direct feedback for example from the surface of tissues and indirect feedback such as vision and auditory, and a cognitive overlay. We see different responses at all those levels to injury. We see people with different pathologies healing differently. I guess I’ve got more than 20 years of clinical observations in my mind, of how people have healed a particular type of burns injury with a whole spectrum of pathology behind it.

And so I am very keen to join the dots  with respect to the plasticity of the nervous system that is implicated in not just healing, but in the quality of healing. I have felt for a long time that scarring is not just a cutaneous phenomenon, there is a lot of interplay of the underlying tissues with relation to the positions that scar contractures take up. So exploring the neurological responses to injury is what I would like to explore further.

Working again in  very collaborative way   so that we can put as many pieces as possible in that jigsaw before I hand over. And building the team so they can do without me and I am redundant. It’s important to keep things moving forward.

What would be your advice to our current medical graduates? 

I think the only thing any of us has got is choice. You have to understand how to make good choices for yourself.

I believe if you get up in the morning and you enjoy what you do, you do it well. The bottom line is to enjoy what you do. And if you don’t, you should be brutal and change, and not become locked into a situation that will limit your ability to explore your real potential. And it’s different for everyone.

I go into the Oncology ward in the kids ward and wonder how can these staff work here? It’s so sad. They come up to the burns unit and gasp and ask the same question.

Everybody has a niche and I don’t know that everyone takes the time to find out what it is. Near enough is not good enough.

I think I have been very lucky and had a clear idea that anatomy was it! I never really wavered from that. Anatomy led to surgery, led to burns. And as I have gone forward it has been exciting, stimulating. The people you treat are inspirational. So too are the people you work with, who can help you – the other scientists and clinicians.

I think its important to find a space & place that make you want to get out of bed.

Do you still feel that?

Oh, yes, if I didn’t I would stop. The advice I give my kids is make sure you enjoy what you do. Your education and training give you the choice, so that when you get out of bed in the morning you enjoy what you do.

Thank you

 

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