What if tapping into the veins of a dialysis patient were as easy as blowing up a football? Or if catheters could be effortlessly removed each day, minimizing the infections and clotting often associated with their long-term use?
Twenty-five years after helping to create the catheter that bears his name, Dr. Robert Hickman still ponders ideas for how to revolutionize vascular access, a field vital to the survival of patients whose medical conditions require regular access to their blood supply.
For now, though, he's satisfied to ensure that patients at the Seattle Cancer Care Alliance are cared for with the vascular-access revolution that he and the Hutch transplant team developed in the mid-1970s - a simple but lifesaving device called the Hickman catheter.
Last week, Hickman, a transplant team member until 1991, joined the radiology department of the Alliance outpatient clinic, where he once again will surgically place the eponymous catheter in every patient requiring long-term intravenous nutritional support, chemotherapy and blood draws.
Despite the success and widespread use of Hickman catheters, clotting and infection can still be problems. Whether or not Hickman himself will be the one to invent the next refinements to the device, he can't help brainstorming new approaches such as the football analogy.
"Given enough time, we could revolutionize vascular access," he said. "It's very difficult for the human body to contend with having a foreign body implanted for extended periods of time."
Dr. Marc Stewart, Alliance medical director, said that earlier this year he found himself wondering whether Hickman might be available and interested in joining the Alliance staff as a clinician.
'Absolutely the best'
"I was thrilled to have him say yes," he said. "He is known to be absolutely the best at what he does, and we are lucky to have him with us full-time."
Hickman, formerly a member of the Clinical Research Division and a semi-retired kidney specialist at both the University of Washington and Children's Hospital and Regional Medical Center, has spent several of the last 10 years on sabbatical. He has traveled to Haiti and more recently to Israel, where he helped to establish a university medical clinic.
But his lifelong curiosity has been to seek ways to improve the quality of life and medical care for critically ill patients whose veins simply cannot withstand additional needle sticks.
The story of Hickman's renowned invention had its roots in his early career and took shape with an apparatus that originally was named for a co-worker.
Shortly after completing medical school, Hickman joined the nephrology division at UW, where he was a fellow under the direction of Dr. Belding Scribner. In 1960, Scribner's group had pioneered the development of shunts and catheters that could be surgically implanted for dialysis and other procedures.
"At that time, materials that were bio-compatible had been discovered that allowed these devices to remain inside the body," Hickman said. "At the same time, doctors began to realize the critical need for developing shunts that could be used to provide nutritional support for very ill patients who were unable to eat. There was also a great deal of research progress in developing nutritional solutions that could be administered to patients."
In 1968, a medical fellow in Scribner's group named Dr. John Broviac developed a catheter that represented a successful merger of these disciplines. Constructed of a bio-compatible material known as Silastic, the catheter passed through a vein in the chest into the right atrium of the heart and allowed for successful delivery of intravenous nutrition. The device worked so well, Hickman said, "it stunned people," but it hadn't been tried in bone-marrow transplant patients.
Hickman was conducting kidney consults for those treated in the Hutch transplant program.
"These were very sick patients," he said. "They had come to the Hutch as a last resort, and after all the other treatments they'd been through, the vast majority of their veins had been used. You'd stand in awe of the nurses who could find usable veins."
Hickman recalled one patient in 1973, a UW physician's wife with advanced-stage leukemia.
"The nurses threw up their hands. They couldn't find a vein," he said. "I offered to place one of these Broviac catheters. She was the first one."
At that time, central venous access was controversial, as there were concerns that the devices would cause infection and clotting.
"It took a leap of faith on the part of Don Thomas and his colleagues to try this," he said, referring to center's Clinical Research Division director who later won a Nobel Prize for pioneering the technique of bone-marrow transplantation.
Although the UW physician's wife ultimately succumbed to her disease, her positive response to the intravenous nutrition was dramatic enough to open the transplant team's eyes to the potential.
Gradually, Hickman placed more Broviac catheters in transplant patients, and he credits Hutch nurses who played a critical role in the evolution of the device.
"The nurses said, 'Well, this is nice, but we need a bigger line,'" he said. "So we had the engineers design new catheters. The Broviac line was sacred, for nutrition and nothing else. But the nurses said, 'We need to draw blood.' We developed a new catheter with additional lumens, the portals through which fluids can pass."
Thus was born the Hickman catheter, which could be used for nutrition, blood draws and delivery of chemotherapy.
"Once Don Thomas published his successful results with this catheter, the whole world fell into step," Hickman said. "They made it well known."
Thomas said the catheter made transplantation a viable option for many more patients.
"It enabled us to do more transplants and to improve the quality of life and care we could give," he said. "It became standard to place a catheter in every patient who would need days or weeks of hyperalimentation (nutritional support)."
Thomas said the catheter was of particular benefit to pediatric patients.
"Children were very threatened by needle sticks," he said. "Once they had that catheter implanted, they would protect it like it was their lifeline."
Hickman's skill at placing the catheters, and his dedication, are legendary.
"We were spoiled by having him," Thomas said. "Hickman was absolutely the best man at putting them in. If he was called at 2 a.m. with a problem, he'd be there in 15 minutes. And he had such a way with the children. I'm delighted to hear he's back."
Hickman is gratified to be back in the thick of a field he describes as both his career and his hobby - and to be back with familiar faces from the past.
"The Hutch was always a place where there was a tremendous amount of camaraderie, and the crossing of intellectual and medical barriers," he said. "It was always on the threshold."
Transformation of patient care
Judy Campbell, research nurse who joined the Hutch transplant team in 1969, knows well the transformation of patient care brought about by use of the Hickman catheter.
"It had a dramatic impact on our ability to care for patients," she said. "Patients were spared from multiple needle sticks per day, which made a huge difference in their quality of life."
What she most remembers, though, is Dr. Robert Hickman's dedication and bedside manner.
"I was always impressed by how involved he was willing to be, no matter what time of day or night," she said. "And the conditions he had to work to place the catheters in the early days - sometimes it was just a little side room, or even at the bedside. He was just wonderful with the patients."