World-Renowned Pediatric Surgeon Charles Fraser Comes Home to UT

By Robyn Ross in Features, Nov | Dec 2018 on November 1, 2018 at 8:00 am | 1 Comment

Baby John Doe lies on the operating table, his brown plastic skin shining under the surgical lights. Nurses at Dell Children’s Medical Center of Central Texas have run an IV drip to one arm and placed an endotracheal line in his airway so he can be connected to the ventilator during surgery. The operating room is packed with hospital staff in stone-blue scrubs: cardiologists, anesthesiologists, nurses, and a perfusionist who runs the heart-lung bypass machine.

All eyes are on Charles Fraser Jr., BA ’80, Life Member, Distinguished Alumnus, the hospital’s new chief of pediatric and congenital cardiothoracic surgery. Baby-faced, with friendly hazel eyes, he stands 6 feet 3 inches tall but with a slight hunch in his shoulders. Today’s mock surgery is a dress rehearsal, with a medical manikin standing in for a real patient as a nurse jots down Fraser’s notes. It’s a chance for Fraser to walk the hospital’s cardiac surgical team through his process, to get the operating room to his exact specifications, and to begin training Dell Children’s in the uncompromising attention to detail that makes him one of the best congenital heart surgeons in the world.

“We need to pretend we’re starting from scratch,” Fraser says. His registered nurse first assistant shows him how the baby has been positioned and points out which screen displays the information from which monitor.

“I like to hear the monitors,” Fraser says. “What do they sound like? Let’s try them to see if I’m alive.” He pulls a sensor from the baby’s foot and clips it on his finger. Silence. He looks around, the hint of a smile on his lips. “Am I alive?” Someone turns up the volume, and a rhythmic beeping fills the room.

It’s July 19, and Fraser has been on the job for 10 weeks. The mock surgery is a practice run: on July 31, he will operate on his first patient in Austin. Before that happens, his team needs to understand his expectations. How loud should the monitors be? Where does he like to have the cauterizing machine and defibrillator? Which words, exactly, does he want the nurses to say to indicate they understand his instructions?

On the day of an actual surgery, it takes at least 90 minutes to anesthetize and position the patient; get the monitoring systems in place; and prepare the surgical instruments. The operation itself can take all morning. Today’s exercise, which lasts about an hour, is not meant to simulate any particular procedure. In athletic parlance, it’s a chance for the new coach, a national champion, to make sure his team knows all the plays.

Post-surgery, little John Doe is carefully moved to an infant warmer and transported to the pediatric ICU. Operation complete, Fraser scans the room, making eye contact with each person.

“Are we good?” he asks. “OK, after we’ve gotten stable, I’ll go with the cardiac nurse and talk with the family.”

Each year,about 40,000 infants in the U.S. are born with congenital heart disease, the most common of all birth defects. A quarter of them will need surgery or other medical interventions to survive. Heart disease in adults most commonly connotes blocked coronary arteries—an acquired condition often connected to lifestyle—but pediatric heart disease is a malformation of the basic structure of the heart. The wall between the two lower chambers of the heart may have a hole in it. The main pulmonary artery and the aorta—which carry blood to the lungs and to the body, respectively—may be transposed. The entire left side of the heart may be underdeveloped.

Because of improvements in fetal imaging technology, many complex congenital heart defects that will need surgery are detected during pregnancy. While it’s daunting news to receive after a 20-week ultrasound, the information allows parents to begin meeting with a cardiologist and the surgeon who will perform a corrective procedure six months, a few days, or even hours after the baby is born.

Fraser has spent his career mending these tiny hearts: closing holes in their wet-tissue-paper walls and sewing together their spaghetti-thin blood vessels, sometimes reconstructing whole chambers of a heart that failed to develop properly. His work requires an encyclopedic knowledge of anatomy, a steady hand, and the ability to change course intelligently and decisively when a surgery isn’t going according to plan. Not required, but certainly appreciated, is a good bedside manner: the grace to deliver difficult news gently and explain a complicated surgery in layperson’s terms.

Fraser grew up in Midland and majored in mathematics at UT, where he played varsity tennis. He attended medical school at the University of Texas Medical Branch in Galveston; completed two separate residencies, in surgery and heart surgery, in Baltimore at Johns Hopkins University School of Medicine; and was a pediatric heart surgery fellow under Roger Mee, one of the best pediatric heart surgeons in the world, at Royal Children’s Hospital in Melbourne. In 1995 he left the Cleveland Clinic for Texas Children’s Hospital in Houston, where he directed the congenital heart surgery program and built it into one that U.S. News and World Report named top in the country last year. The surgeon has an international reputation for excellence and has participated in more than 18,000 cardiothoracic surgeries over the course of his career.

“For the 23 years that Chuck Fraser was in Houston, he grew that program to be No. 1 in cardiovascular surgery by any number of different metrics,” says Dell Children’s Medical Center president Chris Born, who previously held leadership positions at Texas Children’s, where he worked with Fraser.  “We’re hoping for him to do that here.”

After more than two decades at Texas Children’s, Fraser returned to Austin and his alma mater in May, becoming both the chief of the pediatric and congential cardiothoracic surgery program at Dell Children’s and a professor in the departments of pediatrics and of surgery and perioperative care at Dell Medical School. When the move was announced, Byron Holt, Dell Children’s chief of cardiology, called it “tremendous.” Clay Johnston, the dean of Dell Med, called him a “perfect fit.” For his part, Fraser said it was emotional and a wonderful chance for him to give back to UT.

His expertise will form the foundation of the new Texas Center for Pediatric and Congenital Heart Disease that’s a joint program of Dell Children’s and UT Health Austin, the clinical practice of Dell Medical School. Dell Children’s previously had a congenital heart surgery program, but its sole surgeon wasn’t able to serve patients with more complex conditions, who often went to Dallas or Houston for care. Nor was the program able to carry out the volume of surgery needed for the 46-county area the hospital serves. The center now has three surgeons: Fraser, plus Carlos Mery and Ziv Beckerman, who completed fellowships with Fraser at Texas Children’s (where Mery also practiced for five years). Studies have shown that hospitals conducting a higher volume of surgeries tend to have better outcomes, because surgeons become more practiced at procedures and can fill in for one another in emergencies. The hospital is also outfitting a second cardiac operating room with state-of-the-art heart-lung bypass machines, anesthesia machines, infant warmers, monitors, and other equipment.

Born says the goal is “to keep Austin kids in Austin with the highest-quality care, with the best possible outcomes,” and that Fraser is the man for that job. “He is just incredibly driven in excellence in everything he does. He’s very focused, very diligent, very exacting, but he creates a team where everybody wants to achieve higher levels of care and quality in outcomes.”

At their most basic, “outcomes” are mortality rates. The Society of Thoracic Surgeons awards a one-, two-, or three-star rating to congenital heart surgery programs based on their voluntarily reported mortality data. Dell Children’s currently has one star; Texas Children’s has three. Fraser is adamant about improving the Austin hospital’s numbers. But most families care about more than mere survival. They want to know about quality of life, which includes everything from the potential of more surgery down the road, to their child’s ability to attend school and play Little League baseball. Quality of life—being normal—is hard to quantify, but Fraser is implementing programs to help him answer those questions.

The task is complicated by advances in surgical techniques and technology that save children who, a few decades ago, didn’t have a chance at survival. Now those children are living into young adulthood, but no one knows their life expectancy or long-term prognosis because the “long term” has never existed before.

Fraser explained the dilemma in August to the parents of a boy who’d been diagnosed, in utero, with a complex heart defect. “Unfortunately, it’s a brutal truth that there’s nobody on earth who’s my age who has what your baby has,” he told them. “When I was a baby, no one survived with these problems. It’s only been about the last 25 years that we’ve gotten much better at taking care of these types of very complicated heart problems. So predictions about what would be necessary 20, 30, 50, 80 years from now—they’re just predictions. We wouldn’t be able to say for sure.”

***

What Fraser does know for certain is how to organize a top-flight pediatric heart program. When he came to Dell Children’s, he began holding a Thursday-morning teaching conference, bringing surgeons, nurses, cardiologists, and other medical professionals into one room. Fraser may walk the group through the surgical correction for a particular heart defect, or the group may discuss care for children in the ICU, pharmacology, or healthcare economics and policy (occasionally the conversation veers toward sports or fly fishing, one of Fraser’s hobbies).The weekly session helps staff across disciplines develop a better understanding of the procedures and their role in the patient’s care.

In the operating room, Fraser insists on an atmosphere of complete focus. He doesn’t allow chit-chat, music, or distractions like the sound of doors opening and closing. In the quiet, he and his team can be alert to the smallest of sounds: a slight change in the baby’s heart rate, or a leak in the endotracheal tube.

Like high-level college football assistants often follow head coaches when they land new jobs, so have a few longtime Fraser acolytes.

“He does not compromise at all,” says Anna Groneck, his registered nurse first assistant. Groneck worked with Fraser for 12 years at Texas Children’s and followed him to Austin this summer. She often serves as Fraser’s translator, communicating his preferences to others in the operating room. “If it’s wrong, it’s wrong. He expects perfection. He’ll say, ‘I know you can’t be perfect—nobody’s perfect—but if you strive for perfection, you achieve excellence.’”

When Groneck positions a child for surgery in Fraser’s operating room, she uses a laser pen to make sure the catheter coming from the patient’s wrist is aligned correctly with the transducer that relays the blood pressure information to the monitor. Without that extra step, the monitor might display—and the surgical team might move to treat—an inaccurate reading. “You can’t say, ‘I think this looks OK, it looks about right,’” Groneck says. “That’s not good enough. It’s got to be perfect.” The same standard of perfection applies to the postsurgical dressing, since it’s typically the family’s first impression of how the surgery went.

Pediatric perfusionist Blake Denison also moved to Austin this summer after working with Fraser for six years at Texas Children’s. Over those years he learned that when Fraser gives instructions in the operating room, he expects them to be repeated back to him exactly, to avoid misunderstandings. “If he says, ‘I want you to do this,’ you say, ‘I’m doing this,’” Denison says. “It’s never ‘Yeah’ or ‘Uh-huh.’ Because who knows what your perception was of what you heard?

“So he’ll say, ‘Pump on,’ and if I say, ‘OK, going on,’ he’ll stop everything and say, ‘When I say pump on, you say pump on.’ It has to be that regimented.”

Denison operates the heart-lung bypass machine, which circulates blood and oxygen through the body while the heart is stopped for surgery. He also lowers the patient’s body temperature to protect the heart during procedures. When the heart is restarted so the patient can come off bypass, he gradually re-warms the body back to 36 degrees Celsius. But certain types of repairs inside the heart cause micro-inflammation near the conduction system, which controls the heart’s rhythm. In those cases Fraser instructs Denison to stop the warming at 35.9 degrees Celsius. Temperatures just over 36 degrees can potentially trigger dangerous irregular heartbeats called arrhythmias, so by stopping below 36, Fraser’s team can reduce that risk.

“Someone who’s untrained may wonder, ‘Why is he harping on that?,’ but just 0.1 degrees matters,” Denison says.

***

By 7:20 a.m. on a Thursday in August, all the seats in a Dell Children’s classroom are filled for “Fraser Rounds,” the surgeon’s weekly teaching conference. Doctors and nurses crowd against the back wall as Fraser enters the room, holding a steaming Styrofoam cup of coffee.

“I thought we’d spend today talking about the atrioventricular septal defect,” Fraser begins, and the morning chatter ceases. “Yesterday I met with a family whose baby has it. It’s common, complicated, not well understood, and we have to do well with it.” An echocardiogram of a baby’s pumping heart—in reality the size of a strawberry—fills the room’s projection screen, the heart’s muscular tissue white, its chambers shadowed.

He sketches a couple of hearts on the whiteboard, one normal and one with a defect. “In an AVSD, there are holes between the chambers of the heart, and the valves are always abnormal,” he explains. “The role of surgery is to close the holes, fix the valves. Pretty simple.”

He draws three new diagrams representing the surgical techniques for fixing an AVSD.  Some surgeons close the holes with Gore-Tex, Dacron, or animal tissue, he explains, but he prefers to use patches from the patient’s own pericardium, the membrane that surrounds the heart. It heals faster, morphs into the lining of the heart, and has the right tensile strength compared to what it’s sewn to.

He looks around the room, a sea of blue scrubs and attentive faces. A few people are taking notes. “Now, what are our expectations for this procedure?” Fraser says. “And what do we communicate to the family?” The Society of Thoracic Surgeons (STS) database offers some answers: of the roughly 3,000 infants whose complete AVSD repair was conducted between 2014–2017 and reported to STS, the mortality rate was 2.5 percent. But, Fraser says, those numbers are from across the country. They’re not institution specific, so they’re of no help to parents choosing between two hospitals for their child’s surgery.

“We need to talk about what we do here. The value proposition is that we measure what’s important and communicate that: survival rates, risk of complications, how long the patients stay in the hospital, whether they’ll be on a ventilator,” Fraser says. “I need to tell the family things like there’s a one in 10 chance of needing a follow-up operation.”

A hand pops up in the corner of the classroom near the screen where the heart still beats silently, squeezing and opening like a stuttering ghost. “What are the long-term outcomes for these patients?” someone asks.

Fraser nods. “Great question. That’s why we’re here in Austin, and that’s where the rubber meets the road. I told the family last night, I have one patient who’s now a student at Auburn University. He works at H-E-B in the summers. He’s doing fine. But I don’t know what he’ll be like when he’s 70. If we—Dell Children’s, Dell Med, social work, child life—don’t work together to follow patients and collect data, how do families know what to expect for quality of life, or what operations they’d have again?”

Part of what made Texas Children’s the nation’s top program was Fraser’s relentless measurement of outcomes. Reporting those outcomes fosters honesty and transparency, and it focuses a hospital’s efforts or improvement.

“I’m a surgeon because surgery is definitive,” Fraser says. “An operation is right and accurate, and the patient does well, or not. There’s not any kind of confabulation about it. I like that; I’m a mathematician. My brain is linear.”

Mortality rates are definitive. Well-prepared families ask about other medical outcomes: Will the patient need more surgery? What about a pacemaker? Under Fraser’s direction, Dell Children’s is standardizing the way it collects data to better answer those questions.

But there’s another set of questions that matter, ones that are raised in virtually every one of Fraser’s consultations with parents of a baby whose cardiac abnormality is diagnosed in utero. In those appointments, he talks with the parents about how the baby will be born; the nature of the baby’s heart defect; what operation will correct it; and what the risks are.

At some point, he says, the parents’ eyes glaze over. One or both may be crying. Then one of them will say, “OK. That’s great. Thank you. All I care about is, is my child going to be normal?”

“And I say, ‘What does that mean to you?’” Fraser says. “‘Can they play soccer? Will they be able to be smart? Will they be able to be a doctor or a writer? What’s possible for them?’ Because that’s what all parents want to know. And that’s where it gets really emotional for everybody. I tell them the little bit that we know, but I can’t tell them the whole story.”

Leslie Fertitta, BA ’01, can relate. Her fourth child, John, was diagnosed with transposition of the great arteries when Fertitta was 20 weeks pregnant, and Fraser performed surgery to correct the defect when John was five days old. “It’s so stressful, and there’s a lot of fear,” Fertitta says. “You’re not sure what the result is going to be. At that point I hadn’t
even seen the range of issues this child could have—thank heavens, because it would have scared me even more.”

John is now 7 years old and in good health. He can read. He plays sports. “All these things that make you say, ‘I never thought he’d be this normal,’” Fertitta reflects.

That’s the kind of information that, if collected from all patients over time, would help answer parents’ anguished questions. Fraser and his colleagues will start by following patients longer than the 30 days that’s standard for congenital cardiothoracic surgery. That window covers immediate post-surgical complications and recovery, but babies with congenital heart defects aren’t “cured” by their initial surgeries. Some will need additional procedures, and some may have lifelong restrictions based on their condition.

The Texas Center plans to track patients long term, partly by employing the expertise of Dell Medical School’s Value Institute for Health and Care, which focuses on the transformation of health care services and the measurement of their outcomes and costs.

One way the institute does that is through “experience groups,” a research method of observing interactions among a group of people who share medical circumstances. The facilitated conversations capture the families’ lived experience with that condition outside the hospital—and well beyond that 30-day marker.

“These conversations are not focused on the patient experience in the hospital or clinic,” the institute’s director, Elizabeth Teisberg, says. “They’re focused on how life goes at home, the rest of the year.”

***

Fraser and his colleagues are working with the Value Institute and other units at UT on more projects: helping parents tell friends and family about their baby’s diagnosis in a way that doesn’t create additional stress for the parents. Understanding the impact of these medical conditions on family relationships. Studying how cultural and economic factors, called the social determinants of health, affect a child’s long-term recovery.

Meanwhile, Fraser’s calendar continues to fill with consultations and procedures. Since his first surgery in August, he has completed more than 40 operations. Each one keeps him on his feet for as long as 12 hours as he literally holds a child’s life in his hands, repairing tiny valves and rerouting wayward arteries. He’s a mathematician and a rigorous data collector, but he also describes his workplace in spiritual terms. His is not a rock ‘n’ roll operating room that tolerates the kind of banter depicted on medical TV shows. It’s a place for complete focus on the miraculous, exhausting work of mending hearts.

“The operating room is sacred space,” he says. “The hospital is sacred space. We don’t exist for any other reason than to take care of suffering. We are there to do serious work. It is sacred space, and I don’t own it. It’s there for the patients.”

Photographs (from top): Matt Wright-Steel, Drew Anthony Smith (2)