Interviewed by Katarina Zorcic and Shreya Sharma

Could you please introduce yourself to our audience and tell us about what you do?

Dr. McAlister: Vivian McAllister is my name. I’m a surgeon at [London’s] University Hospital. My special interest is in transplantation. I do liver, kidney, and pancreas transplantations. I’m also a professor at the University of Western Ontario’s Medical School.

While having a successful and relatively comfortable career, what inspired you to become a combat surgeon?

Dr. McAlister: Along my career, I’ve been teaching residents [for] many years. In Halifax, there were a lot [of residents] who were members of the Canadian Armed Forces, and one of them asked if he could do a fellowship with me. I was a transplant surgeon, so I thought ‘we do a lot of very good surgery, but it’s not combat oriented’. We developed a program for him and he had a career in the Canadian Armed Forces. Much later, [I] met up [with another old student from Halifax] and he gave a talk at one of our doctor’s meetings [where] he described what was happening in Afghanistan. I don’t know what overcame me, but I suggested that the wrong people were being sent overseas. We shouldn’t be sending young people to face these awful situations; it should be guys like me who were pretty well worn out. As a result of that conversation, I ended up volunteering as a civilian. And then as a result of my experience of deploying in an argumentative role, I decided the best thing I could do was actually join the Canadian armed forces.

Did you have hesitations before deciding to go overseas?

Dr. McAlister: Oh, absolutely. The biggest fear I had, and I think I probably share it with all surgeons, is ‘will I do my job’? When I’m faced with a terribly difficult operation, I’m worried [if] I would do my job and give the patient the best chance. There are natural fears too – that you’re going into the unknown. Will I be able to adapt to the situation over there? What I’ve done to figure out how I can cross a bridge that [is] unknown to me is to see how other people crossed ahead of me. It gives you great confidence. 

Can you give us some information about the new trauma protocols you developed overseas? What were the main implications of these protocols?

Dr. McAlister: That’s a thing all surgeons do – we adapt our training to the situation on hand, and we’ve been sharing the knowledge we gain from these new situations all throughout our career. One of the worst injuries that we had to deal with over there was [with] the anti-personnel improvised explosive device. It’s a desperate weapon that is designed to cause maximum injury in the person who is targeted; this huge explosive force blows their limbs off and causes terrible pelvic [and other] injuries. We documented how [we thought] the weapon was being refined to actually cause maximum injury in the target, which is actually a war crime. We found ways of trying to help with PPE that might be able to deflect some of the force. [Additionally], I [had] experience with patients undergoing dialysis because I’m a kidney transplant surgeon, [but] there’s no dialysis available in many of these areas. Short-term dialysis is often needed for patients who are severely injured, so we learned how to improvise peritoneal dialysis and apply it to that patient population. We saved several lives that way. We had to improvise; we made recipes for the solution out of commonly available materials and we published all of that.

It’s hard [for] all the medical care workers, especially now in the pandemic. There’s a lot of stress; you face patients in terribly difficult situations. All we can do is do our best because you can’t guarantee a good outcome for everybody. What is appalling about the experience in Afghanistan and Iraq is that these injuries were man-made – they were unnecessary. Maybe they were done for legitimate reasons, but it’s an illegitimate way of carrying out your actions. It actually negates whatever purpose you had in that combat. If you use a weapon like that on somebody else, all of the good that people have been trying to achieve is made worthless. This applies to a lot of violence that I’ve seen in my lifetime. Unfortunately, a lot of the people who carry out these acts are young and they will regret them when they mature. If they could teach the next generation not to do it, maybe something will be saved from this awful situation.

An enemy is an enemy [but] I never looked at an enemy as an evil person. There are conflicts and conflicts are maintained because each side feels legitimacy in what they’re doing. They just can’t find a common pathway. Ironically, there are always common pathways and ways that you can share whatever vision you both have. As physicians, as caregivers, as nurses, we never distinguished between the enemy and ourselves. We always looked after everybody with the best intentions and the best of our ability. And we had a funny effect: some of those who were opposed to us changed their opinions. Certainly they changed their behavior because they saw Canadians acting in a very honorable way when they were injured and they needed help.

What are some of the key differences you have experienced between transplant surgery in Canada compared to overseas?

Dr. McAlister: I didn’t do any transplantations overseas, but we tried to replicate [the standards of surgeries in Canada] as much as possible overseas. However, we were working in restricted environments. We call them austere situations. The material that we used for dressing [our] instruments, the sutures, and everything that we used on patients over there was Canadian standard. The supply route was just fantastic. The operating room was small and it was improvised, but it was still very good [and] clean. So in Afghanistan, we were able to carry out surgeries almost really to Canadian standards, and for trauma, some of the things that we were able to do, like evacuating the patient from a point of injury to the hospital was just remarkable. In Haiti or Iraq, it was dusty and difficult, but still we did everything that we could to replicate [Canadian] standards. Now, at times we [would] run out of resources and then we would have to ration them [to] try to get through to the next supply. But we never really were critically impacted by that. 

Based on your experience and opinion, how has COVID-19 impacted the current experience, and future, of transplant surgery?

Dr. McAlister: COVID has [had] a big impact on everybody and it’s probably had a magnified impact on transplantation. [However] when there was a life or a life altering opportunity for a transplant patient, the hospitals did everything in their power to prevent the pandemic from interfering with that opportunity. They have protected transplantation to the best of their ability. [Additionally] immunosuppressed patients are at great risk for severe COVID and dying from COVID, unlike the general population. We’ve [also] discovered that we know a lot about immunity and transplantation, and COVID deals with immunity. The virus itself can blunt or alter the immune response in the host. If the virus changes the immune response into a different type of immune response, it can either persist to cause severe disease or chronic disease. If you have what’s called a type one immune response, you can reject the virus straight away and you develop memory to have an even brisker immune response for the next time you encounter the virus. That’s what vaccination was trying to do. So transplant understands all of these features and the [importance of] vaccination. We also knew that the transplant recipients who are immunosuppressed may not respond to vaccination in the same way, so we advocated for them to be in the early vaccination cohort. One of the things I am a little nervous about is that we don’t measure an antibody response to either the virus or to the vaccine. That’s very important to know because [it] tells you when these special populations have responded with an immune memory that will protect them in the future. Lastly, we’ve learned the value of the medical care that we give, not only transplantation, but specialized medical care, like getting your hip done [or] getting your cataract fixed. These are all very valuable things. We took them for granted when they were easily available and the pandemic took that away. They now regained their true value. And for a while, at least as we try and catch up, people will understand how valuable these types of care are. 

Are there any misconceptions that you might have held or heard that you realized weren’t true when you went overseas?

That’s a good question and I haven’t considered it before. I think mainly by large [the] reporting is true, but you have to see that there is an incentive for a reporter to have an interesting story. If you report mundane things, the editor is not going to print this stuff. The principal lesson that I did learn was that the people that I encountered in Afghanistan and Haiti are exactly the same people that live in Canada. The circumstances are different, and I am not certain that we would be able to live in the circumstances that they live in. The resilience that they have developed both through selection and through their experience has resulted in them being able to survive some of these very, very difficult situations. You know, I read something about the ice man. About 20 years ago, they found a frozen corpse of the Alps that was thousands of years old. There was this fiction that you could have brought them back to life. The interesting thing [was] that if we brought the ice man back to life, he [would] be able to adapt to modern society in about a few days. He’d be almost as good as we are at everything living in this world. However, if we had to go back to the ice age, we wouldn’t be able to adapt at all. We would probably all die. [This] is very similar [to] the situation overseas. When you look at it, we look at those people as being inferior to us. And that is a terrible mistake. In fact, they may well be superior because they are the same, but they have survived and are currently surviving in situations that we probably would not be able to survive.

How would you say that your experience overseas shaped your work now that you’re back in Canada as a transplant surgeon, as a professor, just going about your everyday life?

Dr. McAlister: I think when you come back, you prioritize slightly differently. There were things that were terribly important to you, and they now have no importance; they’re often unnecessary personal comfort items that were never important. You [also] put things in a better perspective with respect to dealing with people. I really hope that I’ve always looked at everybody, those who are sick, those who I have to operate on, those who may have caused their illness, as never being inferior. I hope my experience overseas has reinforced the notion that I would get rid of any moral judgments of any of my fellow men because I know that given the circumstances, I might well be in the exact same situation. These are generally principles that we live by in Canada. Put the effort into looking after your neighbor and their neighbor will look after yourself.

What advice would you give to someone who maybe feels a similar sense of duty towards their country and is unsure of the impact that they can make?

Dr. McAlister: I’ve been terribly unsure of myself all through my life. I never thought that I would do anything like what I have done. I’ve [always] looked at people ahead of me and said, well, they made it through medical school, they made it through this exam, they made it through that. My advice is to have more confidence in yourself because we are all very gifted, very lucky people. If you are motivated to contribute more, [it is] important to have confidence in yourself and do your job the best possible way you can do it. You don’t have to go overseas, you don’t have to join the Canadian forces. [But if] you do volunteer, it will be very rewarding. You will get more back from it than anything that you have to give. 

And for students, when I have them working with me, I say, don’t work too hard. Don’t waste all of your time consumed with your studies; get out there and enjoy it because there’s lots of opportunities to have fun that you won’t have when you get older. Another thing I have noticed in my work and probably in recreation is that if you are enjoying yourself, by the way you can enjoy yourself doing hard work, it reflects on others. Occasionally I’ve had the time where I feel I’m really doing well and everything’s going really well; it’s like riding a bicycle very quickly. You’re going very fast, but you have an opportunity to look around. I look around and I see that those who are working with me are enjoying it too. Whereas if I come in in a bad mood and I scowl a bit or whatever, I can turn the mood in the room right down. So you do have a terrific, positive, effect. If you have that [positive] attitude, you’ll have the same effect on the people all around you. 

There are two things I learned in the basic training that we could really apply in university, especially in the sciences and in medicine. The first was ‘mission, team, self’ – that’s the order of priority. You actually come third in the order of priority; you’ve got to complete the task. It could involve giving up certain things, but the task has to be completed. You also have to look after your team, but your team is looking after you too. The second thing I learned in basic training was that a lot of the tasks that we were given were team-based and although you’re marked individually for your contribution to the team, you didn’t pass unless you completed the task. I liked that type of training where it’s not you going off and learning by yourself in the books and then doing an exam. You learn as a team. If you have a weak member of the team, you’re going to have to make that member stronger to get the task done. You learn the core knowledge far better and you learn how to function in teams because that’s the way you’re going to work when you graduate.

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