Read accounts from doctors about advances in robotics and other areas, along with stories about memorable cases -- including that of a shark bite victim who still had the shark attached.
Liver Cancer: Going for
Dr. Mark Roh
Chairman of Surgery at MD Anderson Cancer Center Orlando
I’ve seen many patients survive liver cancer, but the one that’s a tug of the heart is a 26-year-old who had just gotten married and was diagnosed with a colon cancer that spread to her liver. It was years ago and back then chemo had a very low response rate. But when they’re that young, you go for broke.
We operated and took out part of the colon. She was stage IV (late-stage disease) and we took out the metastases to the liver. Five years, as you know, is considered a cure. But she’s gone on to have kids and I get a Christmas card from her every year. It’s been 17 years now and her daughter’s a senior in high school, ready to go to college. I think this shows that you never know until you try. And second opinions are healthy. Sometimes, it can be a double-edged sword as people are told the correct story and they’re still reaching out. But if you don’t like what you’re hearing, go to another doctor. Not me, necessarily, but someone else. She’d been told to get her affairs in order. I wish I could tell you what we did for her works for everybody, but that would be dishonest. It doesn’t. Still, it did work for her.
In general, we do better with metastatic liver cancers than primary liver cancers, which are usually cirrhotic and already compromised. Patients whose cancers spread to the liver from elsewhere tend to have normal livers, except for the cancer, and they can tolerate more aggressive treatments. You can push the envelope.
Just to give you an example, in 1987, if you had more than four tumors on your liver, we wouldn’t operate. Today, most patients have that many tumors and more and they’re operated on and they do just fine. Back then, only 20 percent of patients survived five years. Now, at least 40 to 50 percent of patients with metastatic disease survive this long and we’re starting to measure survival in 10-year periods. That reflects a lot of things, including more and safer surgery, and better drugs.
—As told to Susan Jenks
A Robotics Revolution
Dr. Vipul Patel
Medical Director, Global Robotics Institute, Celebration Health
I‘ve been doing robotic surgery for the prostate for almost a decade and we‘re approaching a significant milestone, our 5,000th procedure. I always thought if I ever got to 5,000 procedures, I‘d be 70 years old and ready to retire. I just turned 42.
Robotic-assisted surgery is the most commonly performed surgery for prostate cancer in the United States, with 85 to 90 percent of the U.S. market. I truly believe open surgery is going to disappear in the next five years. We’ve shown that prostate cancer patients treated robotically to have their prostates removed rarely need blood transfusions, have minimal blood loss and have a short operative time, about 1 to 1.5 hours. They go home the next day and they go home without taking narcotics, so their recovery is quicker, a few weeks versus many months.
The robot is empowering, but it’s the ability of the surgeon that gives you the best outcomes. The robot itself does not make a great doctor or great surgeon. It empowers you with its better vision and better instrumentation, but I’m still learning, and I’ve done the most of these in the world. We‘re not making drastic changes, though we‘re still changing parts of the procedure to get people potent faster, continent faster and with better cancer control. As doctors, we‘re always learning and I don‘t think that will ever change.
Dr. Robert Holloway
Medical Director of Gynecologic Oncology, Florida Hospital Cancer Institute
We use robotic-assisted surgery most often for hysterectomies and to stage lymph nodes (to assess for cancer spread) in endometrial or uterine cancers. We also use the robot for cervical cancers and occasionally to treat early-stage ovarian cancers, or, certainly, when we find an ovarian mass, which may or may not be cancerous, in a hysterectomy.
For disease that’s localized, the robot has clear advantages over laparoscopy and open surgery. And, by clear advantages, I mean the ability to do a better job, to do a better node count and I can do these procedures in a shorter operating time with less chance of having to switch to an open procedure. There’s also [evidence] that there’s less pain because we’re not traumatizing the abdominal wall with a lot of tugging and pulling the way you
do with traditional laparoscopy. With robotics, the movements are all done inside the abdomen.
Right now, we’re approaching 2,000 robotic-assisted surgeries. Half are for complex benign surgeries and half are for cancer surgeries. In 2010, 55 percent of hysterectomies for early uterine or cervical cancers in the United States were done with robotic-assisted surgery. I suspect that number will be higher in 2011, once all the data is in. And the vast majority of gynecologic oncologists who perform robotics would prefer not to go back to traditional laparoscopy when they clearly are doing a service to their patients in terms of less pain and fewer complications than in an open surgery.
—As told to Susan Jenks
The First Time I
Dr. Jeannie McWhorter
Director of OB/GYN Faculty Practice at Winnie Palmer Hospital for Women & Babies
It was very exciting because quadruplets are not something we see often. They are very rare. It was 2000-2001 and I was a second-year resident at Arnold Palmer Hospital. The woman had been admitted to the hospital in labor and she was there for quite some time. We took care of her for at least four weeks. She had undergone in-vitro fertilization and had three eggs implanted, one of which split, so she had one set of identical twins. We did a Cesarean section at 28 weeks. It’s not ideal, in terms of timing, but it worked out okay.
She had three girls and a boy. They each weighed around two pounds. In some ways, it was just another C-section because we get trained so well in our residency program. But, in another, it just amazes me how smoothly everything went.
The hospital set up two operating rooms. The mom was in her room with a neonatologist. In a separate room, they had the little warmers set up for the babies and a team there with another neonatologist. Typically when you do C-sections, there are two doctors in scrubs and a scrub tech. For this, there were three doctors, all in scrubs. While one baby was being delivered, another doctor would be cleaning the baby up, cutting and clamping the cord and handing off the baby to his team. At the same time, we were already going in for the second baby. Everybody worked together. It was like a mini-assembly line, getting each of the babies out, and getting them where they needed to be, so we could take care of them.
All of the babies ended up staying in the hospital in the NICU (neonatal intensive care unit) until they were full term. Neonatologists always tell moms “don’t expect them to go home until their due date.” All of these babies did fine as far as I know. The hospital follows them out, but they don’t come back to us.
—As told to Susan Jenks
How I Combat
Lloyd N. Werk
Division Chief, Consultative Pediatrics, Nemours Children’s Clinic
Many of the obese children I treat would have a lifetime of health problems in front of them if they continued their eating habits and inactive lifestyles. Getting children to embrace a new, healthier way of living is very hard, and doing so often means I have to encourage parents to change their ways as well. Motivation is the key. When I work with an obese child we set a goal to reach, like fitting into their favorite pants again or being able to climb stairs without stopping for a breath. But I don’t make weight loss the key to reaching the goal; changing their habits is the key. It’s important that parents support their child’s effort by stocking the refrigerator and pantry with nutritious foods. Chips, cookies and sodas belong at the occasional party and not as standard fare.
There are no quick remedies to obesity. You have to replace less productive habits, like grazing in front of a television, with good habits, like eating fruits and vegetables at each meal. At Nemours Healthy Choices Clinic in Orlando, we educate families on MyPlate, the U.S. Department of Agriculture’s new nutrition guide to avoid oversized meals, and provide the following simple tips that every parent can use to help raise healthy children:
• Use your child’s hand as a guide to the size of portions you serve him or her. For example, protein servings should match the size of their palm, the portion of grains and starchy vegetables would equal their fist, and the amount of fruits and vegetables would fill two cupped hands.
• Make at least half the grains you serve whole grains, like oatmeal and brown rice.
• Encourage them to drink water and up to three servings of fat-free or low-fat (1 percent) milk daily, rather than sugary drinks.
• Bag their lunches for school, designate fruit as an afternoon snack and set aside time each day for physical activity.
• Promote 5-2-1-Almost None as an easy message to remember.
The First Time I Treated
a Shark Bite Victim
Dr. David Varnagy
Vascular Surgeon at Florida Hospital
Shark attacks are quite rare, but in 2004 or 2005, there was a shark attack during my general surgery residency at Mount Sinai Medical Center in Miami. A shark bit this kid, who was 18 or 19 years of age, in Dania Beach, a very nice beach in South Florida. He had been snorkeling in the water, lobster fishing, when the attack occurred. Although he was rushed to Hollywood Memorial Regional Hospital, a trauma center about 5 miles away, there was a delay in getting him there because the shark bit him and got stuck. It was still attached to his belly. And, when the paramedics got to the water and saw this, they panicked. But I told them not to wait: “You have to bring him in with the shark.”
I was the chief resident then, so I was not only the first person to see him, I was the only one. It was my responsibility. The shark was alive initially, as sharks can live out of the water for about 45 minutes, and the patient kept saying he could feel its jaws biting him. I managed to remove the shark by breaking the seal between the mouth and eyes. Once I did, it was pretty easy to remove. Then, I sent the shark to the pathology department because, as a surgeon, anything we remove from the patient we send there for examination. They said it was a nurse shark, very young—about 1.5 years old—a meter [about 40 inches] long and female.
Fortunately, it didn’t do much damage. There were multiple abrasions of the abdominal wall, but the bite did not penetrate the bowel or any other organs. We stabilized him, kept him hydrated, watched for hypertension and cleaned the belly to make sure there was no infection. He was very lucky it was not a bigger shark and he was able to go home in a few days. I remember the only thing he asked me is, ‘Can I go back to the beach and back in the water?’ I’m sure he did—no question. Also, he wanted the shark as a specimen, although I don’t know what he did with it. He never came back to the office for follow-up. To be honest, I don‘t know what happened to him.
—As told to Susan Jenks
The Challenges of
Heart Disease in Women
Dr. Joseph Boyer
Director of Minimally Invasive and Robotic Cardiothoracic Surgery at Florida Hospital
Women do develop heart disease about a decade later than men. Some of that is real, meaning there are natural differences, certainly hormonal ones, although women, historically, have been undertreated for hypertension, or high blood pressure, and there may be access issues, as well. Women may choose not to go to a physician and physicians may not take their symptoms as seriously as they do men’s.
Some of the [gender] differences we see are related to anatomic differences rather than physiological ones. Women have smaller arteries, so a relatively similar amount of plaque buildup—or thickening of an artery—can have a substantially greater effect in women than in men. And, when women have heart attacks, they don’t recover as well as men. Again, part of that may be a function of how early they are entering the health-care system. Are they entering promptly at the first signs of a heart attack?
I joke with my surgical patients all the time that, generally speaking, men after surgery tend to act like wimps. They tend to be in more pain, more uncomfortable and they complain more than women. Most physicians who do heart surgery would agree. Women aren’t as pushy about their own health care, so they may come to the hospital, perhaps a little later than men, which contributes to a worse outcome. Then again, other reasons may include their smaller blood vessels, which are more difficult to open with medicine or balloons. And with surgery, there are lots of technical issues involved with smaller vessels, as well.
Since the beginning of this year, we‘ve been progressively moving toward robotics and robotic technology in all our cardiothoracic patients. I’m primarily using it for coronary artery bypass surgery. Does the robot compensate for the smallness of women’s arteries? Dramatically. You have 10 times the magnification, you have 3D vision, you can zoom in and you have much better control. We can see these vessels like we’ve never seen them before. It’s very helpful. We’ve done about 32 coronary cases, maybe more, where we use the robot to take down an artery from inside the chest wall, which is much better than veins from the leg, and we’ve been able to do the entire case without opening the chest at all.
—As told to Susan Jenks
Take a Day Off
Dr. Jay Falk
Chief Academic Medical Officer and Emergency Medicine Physician at Orlando Health
When I first started my fellowship in critical-care medicine in upstate New York in the late 1970s, it was a new program and I spent every fourth night on call in the hospital and the other three nights took calls from home. This was long before critical-care medicine became a board-certified specialty or there were duty-hour restrictions and limitations on how long you worked.
I decided to take a Saturday off and I told my boss a month in advance that I was going apple picking, one of my wife’s passions every fall. So, on this particular Saturday, after I made rounds, we piled our kid in the car and started driving down a country road to the apple orchards. Suddenly, the car in front of us swerves off the road and smashes into a tree. I say to my wife, “I didn’t see that. We’re going apple-picking.” She says, “What, are you crazy?” and, of course, I pulled over and we stopped to help.
There were three victims in the car. The passenger in the front seat clearly was severely injured and had an obvious fracture of her femur. I pulled her out of the car and stabilized her leg. Meanwhile, my wife calls 911 and the paramedics arrive and I got in the ambulance with them, heading to the hospital, about 5 miles away. The paramedics radioed in, “We have a couple of trauma victims and we have Dr. Falk with us.” The response came back “What do you mean? He was finally going to take a day off.”
Two of the three people in the car had to be transported on stretchers to the hospital in Schenectady, which is part of Albany Medical College. One had the leg fracture I mentioned, the other a pneumothorax (collapsed lung) and the third just had bruising. They were all elderly, in their early 60s, and the family wound up adopting me as a son, at least for a while, giving me cookies and the like. And, they were very appreciative. The people you help always are and that’s one of the most enjoyable parts of being an emergency physician. But did I ever get to go apple picking?
I think we went the following day.
—As told to Susan Jenks