The Irish Surgeon and America's Wounded Warriors

The toll of US soldiers wounded in Iraq and Afghanistan now exceeds 41,000, and the trademark of these battles is the vet who lost a limb. Many of these wounded warriors are battling long-term to recover from instantaneous carnage. Eimear Vize speaks to an Irish surgeon in Manhattan, who is helping to save the limbs of America’s wounded war heroes.

US Army Captain Brian Jantzen was only days away from surgery to remove his lower right leg. Military doctors had told the young captain - whose legs, feet and anklebones were shattered when his vehicle was hit by an IED (improvised explosive device) while on patrol in Ramadi, Iraq - that amputation was necessary. Then a chance conversation led him to Dubliner Dr John Kennedy, a top Manhattan orthopaedic surgeon, for a second opinion. That was three years ago and Jantzen was the Irish doctor’s first referral from the Wounded Warriors Project, which aids severely injured service members. With the help of a groundbreaking bone regeneration technique, the young soldier kept his leg. And John has gone on to perform a growing number of limb-saving surgeries, free of charge, for gravely wounded veterans of the Iraq and Afghanistan wars.

An RCSI graduate, John Kennedy is an Associate Professor of Orthopaedics and the director of research in the Foot and Ankle Department at the Hospital for Special Surgery (HSS) in New York - ranked as the number one orthopaedic hospital in the United States. During an awards dinner in 2007, at which he was named one of the "Top 100 Irish Americans", John found himself sitting with Flip Mullen, another of the honourees. John was receiving the coveted award for his work in Santo Domingo where he performs 15 to 20 orthopaedic surgeries every year for those patients in the greatest need. Flip, a retired New York fire fighter, was being honoured for tireless work with the Wounded Warriors Project. The two men started talking and within minutes a relationship was formed that has since offered fresh hope to severely wounded soldiers, helping them to take back their lives.

“The work that Flip and his team were doing to help wounded veterans was simply inspiring and humbling. Flip has dedicated his life’s mission to helping the men and women who become severely injured in the fight to keep us all safe,” John tells Scope from his office in New York.

“All the branches of the armed service have an outstanding medical operation and they were doing exceptional work at the front line, in Germany, and ultimately in Walter Reed here in the US and other institutions. However, there are a certain number of soldiers who I thought might benefit from some of the procedures that we were doing at Hospital for Special Surgery, so when I was speaking with Flip that evening I suggested that we might be able to help.”

Soon after, Flip met 29-year-old Jantzen, who was on a Wounded Warrior trip to New York, in part to observe how the amputees cope to prepare him for his own imminent surgery. The two fell into conversation and Mullen questioned Jantzen about his wounds and the prognosis. “He said: ‘I know a doctor…’” Jantzen recalled in an interview later.

“Since that time, my work, in collaboration with my colleague Dr Austin Fragomen, has been small by comparison to the hundreds of volunteers from the NYPD, NYFD and ordinary folk who have given of their time, expertise and compassion to the Wounded Warriors,” John is quick to acknowledge.

“In return we all get something that is not quantifiable but is worth more than anything else that we work for in our daily lives. To make even the smallest bit of difference to these men and women returning from war, whether by a surgical procedure, or to have dinner and listen, or to simply acknowledge their sacrifice and the sacrifice of those that will not be returning, is something that instils a deep sense of gratitude on both sides.

“These are the best America has - the fittest, smartest, toughest people who went out to put themselves in harms way for the rest of us. When you see the destruction that war visits upon them, it underscores the sacrifices they have made.”

When invited to talk about some of these cases, John hesitates. “This is hard because most of these guys don’t want any publicity and don’t want to be written about. In general, their stories are all similar. It’s just a different time and a different place. All of them have been in the wrong place at the wrong time and so much of this is just bad luck.”

He recalls one of his patients, Capt Ryan Miller, a US Army Ranger who was on patrol when his Humvee hit an IED. The bomb killed his best friend. Surgeons in the Landstuhl Hospital at Ramstein Air Force Base in Germany removed a copper shell casing from his abdomen, which Ryan now wears around his wrist with the name and serial number of his buddy who died. 

“Capt Miller was a 4.0 grade point average student who was headed for Harvard when 9/11 happened. He joined West Point instead and went to serve his country. When that IED went off his country did everything it could to help him, and the men and women of the medical corps performed miracles so that Ryan would survive. At the end of his treatment, Ryan was left with a leg deformity from blast injury and shrapnel that left him with a drop foot, missing a part of his foot and a leg that was mal aligned and rotated.

“Ryan has been through four operations with us and is recovering from his fourth, and hopefully last, to address all these concerns. Ryan is typical of the men and women we treat. He is proud to have served but now wants to resume living his life. He has applied to Harvard business school and when he recovers fully plans to run a marathon.

“As a surgeon there is no better patient to have than one who is motivated to overcome their injuries no matter how severe and see the positives in life rather than the negatives.”

But John understands that in some of these extreme cases it is often not clear whether he truly can save a limb and, if so, at what cost? “There are times when amputation is the best way forward. There is no training in medical school to know when enough is enough. There are the hard cases where you have given 110 per cent to put it all back and as functional as possible, and then the patient says take it off doc, I cant deal with the pain.”

Ryan’s story is emblematic of many of today's wounded warriors. The ebbing death rate from battle wounds often translates to a rising tide of maimed survivors. The US armed forces have lost almost 4,400 soldiers in action in Iraq since 2003, and a further 1,000 fatalities have been recorded in Afghanistan since 2001, according to the latest data from the Iraq Coalition Casualty Count (www.icasualties.org). However, in Iraq alone, the ever-ascending tally of wounded soldiers has reached a staggering 31,616.

“I saw Jeff Guerin today. He was a 22-year-old army volunteer that was blown up by an IED outside of Baghdad three years ago. We have done several operations on Jeff and he came in today for a follow up with his Dad,” says John.

“Jeff’s face is scarred for life. He can see out of one eye only, the other is fixed permanently looking up and out, sightless. His skin is pock marked with purple and black shrapnel that is making its way slowly to the surface. Jeff is a Man United fan and wears their latest gear proudly and chats about how he loves how they beat Liverpool. His dad has devoted his life to helping Jeff get over his injuries, and sits proudly with a cap declaring "Go Army": A Proud dad.

“Jeff isn’t one bit sorry for himself. He has just got married and is getting on with his life as best as his injuries allow. Jeff has one major remaining orthopaedic issue - his talus bone lost its blood supply after the blast and his bone was dying in his ankle. Our treatment is typically to put these soldiers in a frame that distracts the joint and prevents the bone from collapsing while the bone revascularises. We perform tiny drill holes in the bone to allow marrow cells to populate the bone and start producing blood vessels and new bone. It’s a time intensive procedure but can be very worthwhile ultimately.”

John explains that distraction arthroplasty, or the use of a frame to spare the joint while the joint and surrounding bones heal, has been used previously only in very select cases. Having had the experience of using this technique in several of the wounded veterans, John and his colleague Dr Fragomen can now refine its application to the civilian population.

“These cases are all done at HSS,” he adds. “When I spoke to Tom Sculco, the Surgeon in Chief, about the wounded warriors, he was very supportive. The hospital donates the OR and staff for any surgery and post op care.”

Another of Kennedy’s Wounded Warrior patients is Sergeant John Borders. Both of his legs were crushed, his left arm sustained two open fractures, his ring finger was severed, he fractured a vertebra in his neck, had contusions to his lungs, a lacerated liver, shrapnel to his eyes, face and torso, and multiple burns in an explosion that happened while he was on patrol in Taji, Iraq in 2006.

Sgt Borders had undergone 50 operations, including the amputation of his left leg, and met with Kennedy and his team as a last ditch effort to save his remaining leg. They operated with great success in December 2007. “Dr Kennedy is a life saver,” Borders’ wife Mollie told Irish America recently.

It is to be expected that John’s interaction with these brave soldiers - all of them so young but dealing stoically with their enormous trauma and loss - has left an indelible impression on the Irish surgeon.

“War is a tragic waste of the best a nation has to offer,” he ponders quietly. “The men and women I have met through the wounded warrior program have left a profound effect on me, and my family. I am humbled and honoured to know them. During the summer of 2009 the Wounded Warriors had an award ceremony. I was very lucky to be invited and even luckier to get an award along with many other recipients. When I went up to receive the award, a young 19-year-old marine was looking at me. He had returned from Afghanistan two months earlier. He had no legs and no arms. He had a new prosthetic arm and was learning to try and use it. He looked at me and tried to clap. I will never forget that man or that moment.”

The Sports Doc

Dr John Kennedy credits his interest in orthopaedics to his involvement in sports. As an athlete, he said he “broke plenty of bones” competing at national and international levels in track, rugby, fencing, and water skiing, and became fascinated by how they healed. He graduated from RCSI in 1989 and, in the mid-nineties, immigrated to Boston to begin a fellowship in orthopaedic sports and orthopaedic joint reconstruction at Saint Elizabeth’s Medical Center.

During this time, John was also involved in the Children’s Hospital and the Andres Laboratory of the Harvard Medical School where he spent time investigating new composites in bone regeneration, which he later presented as a thesis for his master’s in surgery.

As part of his Fellowship year, the young Irishman was engaged as an assistant team physician to Boston College Football. Ever since, John has been actively involved in the treatment of both recreational athletes as well as elite athletes from the New York Giants, New York Metro Stars, Manhattan Rugby, the National Basketball Players Association, and the National Basketball Referees Association.

2001 found Dr Kennedy in New York City where he worked in the Memorial Sloan-Kettering Cancer Center before moving on to the Hospital for Special Surgery (HSS). He is currently the clinical director of the running clinic in the gait laboratory at HSS. Dr Kennedy's involvement in all aspects of lower limb sports injuries has led him to publish articles on running injuries, cycling injuries, ballet injuries, and ankle instability following sports injuries. He has published more than 100 peer-reviewed articles. Read more about Dr Kennedy on his personal websites, www.sportsmedicinenewyork.com; www.osteochondraldefects.com.

Extremity war injuries

“During World War II, the likelihood of surviving battlefield wounds was 69.7 per cent; by the end of the Vietnam War it had improved to 76.4 per cent; and survival of those wounded in the current Iraq War has increased to an astounding 90.4 per cent.”

US Department of Defence’s Directorate for Information Operations and Reports

The majority of trauma that currently occurs among both military and civilians in Iraq and Afghanistan involves the upper and lower extremities, and happens as a result of the detonation of explosive devices. That’s according to a paper summarising the findings from the Extremity War Injuries Symposium held in Washington, DC, published in the January 2010 issue of the Journal of the American Academy of Orthopaedic Surgeons (JAAOS).

"Our military medical personnel in Iraq and Afghanistan are facing serious challenges on every level," noted key author, Dr Andrew Pollak, Professor and Head, Division of Orthopaedic Trauma, University of Maryland School of Medicine, Baltimore, MD. "But the most critical need right now is funding for more research, so medical personnel can offer the highest level of care," he added.

"Our goal is to provide our wounded warriors with the best care possible to improve their quality of life. Since orthopaedic injuries result in the largest source of disability cost for the government, investing to improve care should result in less expense for the taxpayers in the long run."

The symposium also revealed important information related to host nation care capabilities. A major portion of the care currently delivered by U.S. military medical personnel is offered to the local population. In Afghanistan, this includes many enemy combatants and insurgents as well as members of the regular Afghan military forces.

"The common theme we learned is that the inherent capacity of the Iraqis and Afghans to deliver this care themselves is extremely lacking—and even absent in some areas," said Dr Pollak. "The patient follow-up care also is not available in these countries."

RISE OF THE MACHINE

Hearing the words ‘master’, ‘slave’ and ‘robot’ in the same sentence conjure images of alien invasion but Professor Tony Costello is describing an invaluable addition to his surgical team. A mammoth robot with multiple surgical arms operates on his patients while he sits at a control consol several feet away; manipulating it’s every move. 

“When the surgeon moves his hand in a particular way, the robot mimics that: it’s what they call a master-slave robot - a scenario that reverses when I go home,” laughs the Australian surgeon, who spoke to Scope during a recent trip to Ireland where he was awarded an Honorary Fellowship of the RCSI.

A Professor of Urology in the Royal Melbourne Hospital and University of Melbourne, Tony is one of the leading prostate specialists in Australia. He pioneered the use of laser surgery in the 1980s as a viable alternative to traditional transurethral resection and in 2003 he became the first surgeon in the Southern Hemisphere to perform a Robotic Assisted laparoscopic Prostatectomy (RALP).

“I’m very proud to be awarded an honorary fellowship of the RCSI, partly because of my Irish heritage and partly because the RCSI is such a prestigious insitiution. It’s  very validating thing for me to be given such an honour, it’s a very big deal, I’m very excited about it,” he affirms.

Surgeons from around the world, including Ireland, travel to Melbourne to train with Tony and his team at the Richmond campus, Epworth Hospital, where more than 700 cases of robotic laparoscopic prostatectomy have been performed.

Designed by NASA and the US Department of Defence to facilitate remote-controlled surgery in space and on the battlefield, this groundbreaking surgical robot provides unprecedented laparoscopic vision and precise robotic instrument manipulation. Its makers call it the "da Vinci" and it has been cited as number one in Forbes Magazine's "Five Robots That Will Change Your Life".

“It takes surgery beyond the limits of the human hand. We now have a robotic programme responsible for outstanding results with regard to return of urinary continence and preservation of sexual potency. And a couple of our best surgeons have some to us from Ireland,” says Tony, who is very proud of his “100 per cent Irish” heritage. His dad hails from Mayo and his mum from Clare.

He explains that, with a high-tech device like the da Vinci Surgical System, patients can experience smaller incisions and quicker recovery times. Surgeons can sit rather than stand for lengthy surgeries and have their skills enhanced through the precision of the robot.

Robotic surgery also reflects a broader push to reduce the risk of infections and other complications, to shorten hospital stays and to get patients on their feet in days rather than weeks.

“It’s the logical next step; surgery is very technology driven. It has been a sea change in abdominal surgery and it is starting to break through into other disciplines - cardiovascular surgery and gynaecology cancer, head and neck cancer. We’ve now set up a programme for cancer robotics for gynaecology cancer and colon cancer with the da Vinci robot,” he adds.

Surgical robotics was little more than a medical curiosity until 1999, the year California-based Intuitive Surgical introduced the da Vinci Surgical System. Today, this revolutionary technology is being used in a wide variety of surgical procedures, including mitral valve repair, cardiac revascularisation, gastric bypass surgery, radical prostatectomy (da Vinci Prostatectomy), hysterectomy, myomectomy and sacrocolpopexy, cardiac tissue ablation, and epicardial pacemaker lead placement for biventricular resynchronisation.

More than 1,000 da Vinci robots have been installed in hospitals worldwide, including two in Ireland - Cork University Maternity Hospital and the Galway Clinic – with a third recently purchased by the Mater Private Hospital in Dublin.

“Surgeons who use the da Vinci just love it; once you start, it’s a very beguiling technology. You can see ten times better, you have a three dimensional view of the surgical field, and you can be far more dextrous.” Tony remarks, expounding that it achieves this by scaling down and filtering out any tremors of the surgeon’s hand and translating his or her actions into the seamless movements of the instruments.

The patented surgical instruments also have a wider range of motion than a human hand and wrist, making it easier for a surgeon to manoeuvre in tight areas. Furthermore, the surgical robot employs a variety of overrides and fail-safes that prevent harmful mishaps. For example, if the surgeon were to suddenly swing her arms outward while keeping her hands in the gripper stirrups, this movement would be disastrous for the patient. But the da Vinci doesn’t translate such erratic motions to the robot arms at the patient cart. It knows to keep the instruments within the fixed positions of the incisions.

“We first introduced the da Vinci robot to our hospital in Australia in 2003. The technology sort of came on in 2001 in the US in one centre, and in 2002 in two centres, we were about the sixth centre in the world.”

His RALP unit’s complication rate has been reduced from 12 per cent in its first 100 cases to around about 2 per cent in the last 300 cases. “And we have had no deaths related to our surgery,” Tony stresses. By comparison, open radical prostatectomy carries a complication rate of 10 per cent and there is one death in every 200 surgeries.

“It’s amazing to see how far we’ve come and how much we’ve achieved in those few years. We have performed about 710 robotic assisted prostatectomies at the hospital. Between myself and one of my colleagues, we do about 300 cases a year, and we have trained lots of surgeons from America, seven from Ireland, and from all over Europe.

“We give a very didactic and modular learning on robotics and then they go back and usually their hospitals, because they have someone who is fully trained, will then install a robotic programme, so it’s working pretty well. I’m really pround of our surgeons.

“Basically, the surgeons who are accepted onto our programme come for a year to train and they receive what we call a robotic fellowship. At first the fellows get to use the machine without a patient underneath it. They will perfom basic drills with it so they can get use to the technology, and then we get them to be what we call a bedside assistant, who changes the robotic instruments and introduces sutures when required. 

“They then transition to the consol and we divide the operation into a number of steps, the easier steps they do.  I sit beside them and assist if they need it, and then take over, so it’s very structured learning, it’s like teaching a pilot,” he offers. “In fact, using the da Vinci feels like flying a plane. It’s very similar to using your hands and feet to flying a plane, that’s what I would say.”

Tony’s fellows can usually take their first patient after six to eight months of training. The training programme he has developed at Epworth is light years ahead of his own training experience in 2003 at the University of California Irvine: “When I was being taught, the surgeon had only done 60 cases himself, so it was a very new technology and there were no textbooks to guide you through, it was really more of a ‘seat of the pants’ thing. We would watch the procedure being done and then we did cadavers. The first time I operated on a live patient with the da Vinci I felt privilaged but also pretty scared because I wasn’t sure this would work. Now it’s very teachable, it’s very structured and it’s much easier for the doctors to learn the surgery.

“I’ve trained seven Irish surgeons so far,” he continues. “There are a lot of intellectualy bright people here in Ireland. I always welcome them to come and work with us in Australia and make it better for us. I have another surgeon coming to work with me from Dublin called Stephen Conway, he’s starting in July and I’m sure he’ll get involved in the robotics when he comes back here after his training. Two of the Fellows have stayed with me and the others have returned to Ireland with a new skill that can offer so much more to many patients than traditional surgery.”

Two of his prodigies, consultant urologists Drs Paddy O’ Malley and David Bouchier Hayes, who were the first to return to Ireland following their fellowship training, performed the first robotic assisted prostatectomy in Ireland in November 2007 and soon after established the country’s first robotic surgery unit for the treatment of prostate cancer, based in the Galway Clinic. The unit’s €2.2 million Da Vinci system is the largest capital investment in the treatment of prostate cancer in the history of the state.

Now in its third year, the unit has yielded encouraging results comparable to international standards. “Between David and myself, we have done about 100 cases to date and I’d say our complication rate is about 5 per cent,” Paddy tells Scope.

“The machine was funded locally. We had a unique sitation where the entire cost was underwritten by a group of 20 local business men, on the basis of the business case we gave them that the robot would pay for it’s self over a number of years. They guaranteed that if there was a shortfall they would pay, and they have been released from that already because we have reached ort target for the first three year. It is currently being paid off at the projected target,” he says.

The major thrusts in surgery today are to develop more precise and minimally invasive procedures. Tony is convinced that it is through increasingly sophisticated technology that surgeons will find the best treatment for their patients.

“No doubt about it, I think our improvements in surgery are technology based, so I can’t see us going backwards. I think it’s going to be very rare that a patient will get an incision in their tummy or their chest, it’s going to be a thing of the past.

“With the proviso that this technology is expensive and it will take some time before the cost comes down, once that happens you’ll see the technology spread through all surgical departments, in the western world anyway,” he predicts.

Tony adds that patients are far from daunted by the conceivably intimidating apperance of this huge octopus-like robot. “They don’t mind at all in fact,” he points out. “I think most patients are attracted to high-tech, provided of course there is the caviat that it’s actually better for them. It is very enticing for patients to think that they have got the latest in technology that will make a better outcome. They love the da Vinci; patients really love it. It makes a big difference for them too. With only a tiny incision to deal with, the patient can get out of bed the afternoon after the surgery or in the morning after surgery, so you don’t get the DVTs or the pheumonias or the cardiovascular complications. And they don’t need any blood. Typically, when I did open surgery, probably about 80 per cent of patients would have to have a blood transfusion but now we never or very rarely have to give a blood transfusion.”

He also points out that a RALP procedure takes the same length of time as traditional surgery, perhaps even a little quicker under the right circumstances. “Once you have all the nurses and everybody is familiar with it, we can move very quickly. It takes us about an hour and forty minutes. It has actually developed a good team relationship; the nurses really took to it; they love the technology and they get to do a bit more as scrub nurses than normally. So it has been a great thing for the team and quite a moral booster for the hospital I think as well.”

As a pivotal member of his surgical team, does his mechanised surgical assistant have a name? “We wanted to give it one, we even had a competition but there were so many different versions we never came up with one. Robodoc was the closest we got,” laughs Tony.

Prostate cancer surgeons 'feel' with their eyes

Robotic surgical technology with its three-dimensional, high-definition view gives surgeons the sensation of touch, even as they operate from a remote console. A new study describes the phenomenon, called intersensory integration, and reports that surgical outcomes for prostate cancer surgery using minimally invasive robotic technology compare favouurably with traditional invasive surgery.

Led by physician-scientists at New York-Presbyterian Hospital/Weill Cornell Medical Center and appearing in the March 2010 issue of British Journal of Urology International, the study is the first to show that a lack of tactile feedback during robotic surgery does not adversely impact outcomes in patients with prostate cancer. It also identified various visual cues that surgeons can use to improve clinical outcomes.

"Anatomical details and visual cues available through robotic surgery not only allow experienced surgeons to compensate for a lack of tactile feedback, but actually give the illusion of that sensation," says Dr Ashutosh Tewari, the study's lead author; professor of urology, urologic oncology, and public health at Weill Cornell Medical College; and director of the Lefrak Center of Robotic Surgery and the Institute of Prostate Cancer at NewYork-Presbyterian Hospital/Weill Cornell Medical Center.

"For patients, this means the safety of knowing the benefits of a robotic approach, including a quicker recovery, don't compromise the surgery's primary mission of removing the cancer."

In recent years, robotic-assisted laparoscopic prostatectomy (RALP) has become a popular surgical method for treating prostate cancer because it is less invasive than traditional surgery. No studies have shown that RALP leads to worse outcomes, but doctors have wondered whether this was the case because surgeons often use their fingers to feel the prostate during traditional surgery to refine how much they cut to achieve the best outcome.

Cancer cells produce changes in tissue firmness that surgeons can sense. Because this tactile evaluation is not possible for surgeons using RALP, clinicians have wondered whether the robotic approach could lead surgeons to miss some cancer, and thus subject patients to a greater risk of cancer recurrence.

To find out, the investigators videotaped 1,340 RALPs. After every couple hundred procedures, they examined the pathology results of the prostate that was removed to determine the incidence of positive surgical margins, an indication that a surgeon might not have removed all of the cancer. In this study, the investigators focused on the posterolateral surgical margin (PLSM+), the area where the prostate is attached to the nerves.

"When you look at the entire specimen after surgery is done, you want to see cancer inside of the prostate but you don't want to see cancer touching the surface," Dr Tewari says. "After surgery we look at the specimen, and if there are no cancer cells touching the surface, we call that a negative margin. If cancer is touching the edge, then we say it has positive margins. This means there may be some cancer left in the patient."

The investigators then studied the videotapes to determine what refinements in the procedure resulted in negative margins. Using this new knowledge to refine the surgery, they conducted the next couple hundred RALPs, reviewed the videotapes, refined their techniques, conducted the next round of RALPs, reviewed, refined and so on.

The investigators found that robotic surgery did not compromise outcomes. The incidence of PLSM+ was 2.1 percent, which gradually declined to 1 percent in the last 100 patients. Positive PLSMs are found in 2.8 percent to 9 percent of patients undergoing traditional prostatectomy.

The researchers say that the enhanced vision allowed by the robotic approach brings about a "reverse Braille phenomenon" or the ability to "feel" when vision is enhanced. They have also identified a number of visual cues that clinicians can use to improve outcomes, including the colour of tissue, the location of veins as a landmark for the location of nerves, signs of inflammation, and appreciation of so-called compartments outside the prostate.

"As someone with 30 years of experience as a pathologist, I, too, have developed the ability described in this paper. I can look at a tissue sample and know if it is firm or soft and what to expect in its pathology - something that helps me to home in on the area with the abnormality," says Dr Maria M. Shevchuk, the study's senior author, associate professor of pathology at Weill Cornell Medical College, and a pathologist at NewYork-Presbyterian Hospital/Weill Cornell Medical Center. "It is only natural that this ability would also be present in experienced robotic surgeons."