President’s update: November 2017

Sir Simon Wessely tells the story 'The three walds – a story for which the world is not yet prepared'.

Once upon a time, dearly beloved, a sixth former wanted to get some work experience in medicine. He ended up observing a cardiologist at Barts. That showed some enterprise, although perhaps less so when I tell you that the cardiologist was his father. But give the lad a chance. He watched a particularly challenging case. A patient had been admitted after a serious cardiac event.

Action was required, but there was a problem. Even a psychiatrist could have spotted the scar on the chest showing that someone has been there before. “Quick!” says Father, “hand me the notes!”, but there were none to be found. They had vanished into the unknown. So the cardiologist had to go in blind, find out how many grafts had been inserted previously, and where. Definitely a three graft (or do I mean pipe?) problem. Fortunately, all ended well. The patient survived, grafts unblocked.

Father and Son are left alone in the coffee room. Perhaps Son is now a little more impressed with Father than before, perhaps not. As all parents know, it takes a lot to impress one’s own progeny. The best that you can expect is that if far from being gruntled, they are at least not disgruntled.

So Son’s eyes wander and fall upon the chest X-ray done before the intervention commenced. There is the sternum and the clear evidence that some unknown cardiac surgeon has already trod the territory that father is about to retread – a sternum decorated with four wires, restored to unity after it has been split down the middle.

And Son, tired of listening to Father lecturing about the significance of the sign of four and the blue cross in cardiology, starts to doodle. One of the wire ties looks rather like a face. Another can be doodled into a snake. He starts to daydream. A surgeon in a playful mood could even deliberately make his ties ornate, like a private game of origami. 'Guess what animal I am thinking about? Is it a giraffe? An aardvark?'.

He looks up, and when the Hollywood movie is filmed about these events, we see a strange quizzical look crossing his features. His brow furrows, and then his eyes suddenly sparkle; he turns to Father and says “Dad, I’ve had an idea”. Or, if the budget can only run to a cartoon, a light bulb appears above his head, as used to happen in the Tintin comics.

Son now talks in a rush “What if those sternal wires could tell a story, like a code, Dad? What if you could use those wires to tell the next person how many grafts you just did, and where you put them? It would be like The Arrow of Heaven!”. Dad starts to reprimand Junior for interrupting his story of the cardiological sequelae following a bite from the Giant Rat of Sumatra. “Of all the dash silly drivelling ideas I have ever heard… Hang on, wait a minute, what did you just say? You might be on to something!”, and so the game was afoot.

And indeed it was. Because, dear reader, this is not a previously unknown Conan Doyle short story in “Tales from Medical Life”, let alone a Hollywood Oscar contender, a father-son rite of passage/getting to know each other weepie with the late Robin Williams and Matt Damon. It really happened. The work experience student is Ben Wald, and his father is David Wald, Chair of Interventional Cardiology at Bart’s.

What they had just invented is now known as the ‘Wald Code’. It’s a clever system in which surgeons mark their trail – starting with the way they tie the first sternal knot to signal to another surgeon that the code is in use, with the next ties giving the number of grafts and location.

Simple, effective, important, and cost-free. Surgeons do this anyway, no extra training, no extra time, no extra cost. And now the next time a patient comes in requiring emergency cardiac intervention, with an obvious sternal scar but no notes, a glance at the chest X-ray will reveal all.

So how do I know this story is truth, and not fiction? Because Ben and David Wald took part in our last Medical Innovations Summit, with myself in the chair. This has become an RSM tradition, allowing people of an entrepreneurial bent to showcase new ideas and insights.

“Ah!” I can hear you say, “you mean ‘apps’ don’t you?” And I do. Apps figured highly. Lots of them. The medical apps market is booming, but as one of our speakers almost sang, “it’s a jungle out there”. I see it more as a primordial swamp, in which the ruthless process of natural selection which will decide which of the zillion molecules in the sludge will be the ones that will come together as a single cell, reproduce, create life and end up as homo sapiens, is only just kicking off.

The Innovations Summit wasn’t just apps. For example, who could have thought of bringing together a children’s nursery into an old people's home? The answer is Alibeth Somers and Stephen Burke. The result? An increase in the stimulation and quality of life of a lot of old people, as well as in the play opportunities for the children. The outcome also offered a greater understanding of the cycle of life and the positive role that the elderly can and should play, and indeed do in more enlightened societies than our own.

So, back to the Barts' Family Wald and their code. It is indeed a new and wonderful story, of serendipity, imagination and how chance favours the prepared mind. In the audience of the Summit, I spotted a face familiar to all of us who have dabbled in the dark arts of epidemiology. ‘Could that be Sir Nicholas Wald, the Chair of epidemiology at, er, Barts? Yes, it could! What a coincidence'. Or is it? Has having a father who is a leading light in cardiology, and grandfather renowned in public health and epidemiology, rubbed off in some way?

The world is full of obvious things which nobody observes. How else might it be that of the thousands of people who have looked at the patterns made by sternal ties, Ben Wald was the one who had the inspiration to see that these could be made into a code, and then, in my imagination at least, disturbed the peace of the coffee room with the shout of “Eureka”?

There is an alternative universe in which the Wald Code would be unnecessary. One in which records are never missing. Not in any circumstance. But, best beloved, having eliminated the impossible, what is left? Let us raise our glasses to the spirit of entrepreneurship and the Three Walds!

To contact the President you can email president@rsm.ac.uk or follow him on Twitter @WesselyS