Medical Elective Report: Francesca Saldanha

A Plastic and Reconstructive Surgery Clinical and Research Elective .....

INNOVATIVE INSTITUTIONS AND EXOTIC ENVIRONMENTS

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ELECTIVE 2013 Francesca Saldanha, University of Cambridge (1550 words)

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AN ELECTIVE IN PLASTIC AND RECONSTRUCTIVE SURGERY

ELECTIVE 2013

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BOS T H JU ON NEJUL 21ST COIMB Y A 23R D JU TORE A U G LY - 1 8 T H UST

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Francesca Saldanha

Email: fyls2@cam.ac.uk

Boston Children’s Hospital, USA AN ELECTIVE IN CRANIOFACIAL SURGERY COMBINED WITH VASCULAR ANOMALIES BASIC SCIENCE RESEARCH AT HARVARD

For 6 weeks (10th June to 31st July 2013) I chose to do research in the Vascular Anomalies Center Laboratory in Boston Children’s Hospital, an Affiliate of Harvard University in Boston, Massachusetts. Although research was the main focus of my time at Harvard, I combined this with a clinical observership in Plastic and Reconstructive Surgery.

Research exposure as an undergraduate is rare, especially basic science research. After some deliberation, I chose a to apply to Harvard for laboratory-based research; I was confident that I would gain valuable research experience and learn alot in the process. I felt my time would be highly productive; the laboratory that I applied to has an outstanding reputation for research (with Dr Greene’s laboratory having an excellent track record of publications in vascular anomalies research).

I chose the project at the Vascular Anomalies Center (VAC) which was looking at vascular malformation angiogenesis.I felt that this project was a great opportunity to pursue my interest in Plastic Surgery outside the clinical remit.

The diversity and heterogeneity of vascular anomalies

Vascular Anomalies are a heterogeneous group of disorders, which cause functional impairment, organ dysfunction, aesthetic disfigurement and can sometimes be lifethreatening

Weekly Vascular Anomalies Conference- an multi-disciplinary meeting discussing complex and new cases from around the USA and often international cases too

My lab bench in the Plastic and Oral Surgery Research lab

The VAC is committed to “championing the cause of people living with disfigurement and visible loss of function.” due to vascular anomalies

www.fyls2@cam.ac.uk

My supervisor Dr Arin Greene, Director of Plastic Surgery Research

Boston Children’s Hospital, from the outside

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Ganga Hospital specialises in microsurgical reconstruction of complex and major mutilated injuries

BOSTON CHILDREN’S HOSPITAL (CONTD.)

The Vascular Anomalies Laboratory offered an exciting opportunity to participate in plastic surgery research at the interface of translational medicine; a great insight for a future clinician.Vascular anomalies research is a unique and emerging field; our current understanding of the aetiopathogenesis of vascular anomalies expansion is limited, consequently treatments are often inadequate at preventing progression, restoring function and achieving good cosmesis. Patients still suffer significant morbidity and a devastating psychological impact of these lesions. The insights into the aberrant biology of vascular malformations derived from this project, could be be translated into more targeted pharmacotherapy (preventing the expansion and ultimately the recurrence of these lesions).

Ganga Hospital, Coimbatore,India AN ELECTIVE IN RECONSTRUCTION OF COMPLEX INJURIES AND MICROSURGERY I decided to visit the Ganga Hospital after reading, a report published in the RCS bulletin (2011). It spoke very highly of the unit as a vastly rewarding lear ning experience.As a leading tertiary referral centre in the developing world, I felt the breadth and volume of clinical presentation here is an educational opportunity that is just not available to me in the UK. Major fields of interest at the unit include reconstruction of major mutilated injuries to limbs and face.

Over their working lifetime, Ganga Hospital has become a model to the world of how these injuries can be treated to retain functioning limbs without amputation ( which is still the endpoint of these injuries in may parts of the world). Ganga Hospital seemed like the ideal place for me to develop my knowledge and appreciation of reconstructive techniques that can be employed when challenged with complex injuries, and better understand the role of microsurgery in reconstructing these injuries.

Ganga Hospital, from the outside

www.fyls2@cam.ac.uk

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My supervisor Dr Raja Sabapathy, Chief of Plastic Surgery

Ganga Hospital is in Coimbatore ( aka the ‘Medicity’),a popular destination for patients requiring expert medical care in many fields from all parts of India.

Ganga Hospital attracts patients from far and wide from both developed and developing countries

THE COLLECTOR!

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The morning ward round with the entire surgical firm: Chief,surgeons, residents, juniors and nurses

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Hand surgery in Boston

Elective Activities WHAT I WAS ABLE TO ACHIEVE GENERAL AIMS I hoped to develop my practical skills especially suturing, skin grafting, local flaps and careful handling of delicate and vulnerable tissues in plastic surgery. I also aimed to gain a strong g ro u n d i n g i n s c i e n t i fi c r e s e a r c h m e t h o d o l o g y, statistical and critical analysis.Both my elective institutions pride themselves o n c l i n i c a l e f fi c i e n c y, excellent outcomes and maximal patient satisfaction.

I was confident that I would return more well-rounded and better equipped to approach the challenges of a future in surgical training.

expression that may underlie the pathogenesis of lymphatic and venous malformations). I had also been granted permission to be a clinical observer in the Plastic and Reconstructive Unit, an opportunity that I was very excited about.

Boston Children’s is one of the top hospital's in the country and has just become home to the world’s first paediatric hand transplant program. I was unsure what the balance between research and clinical would be but I was hoping that I would do be able to do both at the same time.

BOSTON CHILDREN’S HOSPITAL INTENDED PLANS I was assigned a research project, looking at angiogenic basis of vascular anomalies (specifically the aberrant gene

I underestimated the commitment that a basic science research lab project would involve; not only was I new to the environment and learning the techniques from scratch, but I was also trying

to fit “ a year’s worth of work from someone’s PhD” into 6 weeks. This was no easy task. So most of my days were actually spent in the lab as I wanted to really do the project justice.

As part of the research team my other academic activities were - Tuesday mornings lab meetings; a collaboration between orthopaedics and plastic surgery where all researchers would exchange ideas on how to progress the research.

My lab bench; this was the first day that I was testing the primers I had designed. they would eventually be used to determine the expression of various genes in pathological tissue samples

ACTUAL ACTIVITIES

The Enders Research building where our laboratory was

www.fyls2@cam.ac.uk

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Elective Activities ( cont’d) WHAT I WAS ABLE TO ACHIEVE The Oupatients waiting area starts filling up from7am- 2 hours before clinic starts

We also had Monday meetings with our supervisor from the Vascular Anomalies lab where we had to justify our work.

Wednesday afternoon’s were always occupied by a big clinical MDT meeting involving round-the-table discussions of complicated vascular anomalies patients, some of which were international referrals. Such meetings provided a unique and important clinical context for the work I was doing up in the laboratory.

GANGA HOSPITAL -INTENDED PLANS I was expected to participate in theatre lists and outpatient clinics (seeing up to 200 patients per day). I was be working the same hours as the trainees (7am to 10pm, six and sometimes seven days a week). This was the ideal way for me to test my stamina and commitment for a potential future surgery. I was also been allowed to undertake their RCSapproved 5-day microsurgery course.

ACTUAL ACTIVITIES

The day started with a 7am daily ward round focusing on wound care, pain control and antibiotic therapy in order to maximise healing. After that we had the outpatients clinic. Up to 200 patients would be seen in a clinic over a 4 to 5-hour period, presenting with anything from basal cell carcinomas to post-operative limb amputations, limb reconstructions and brachial plexus injuries.This kept my mind sharp like an OSCE-style examination, ideal for student experience.All patients were reviewed by a consultant before and definitive management plan was set then and there.

Waiting lists were non-existent; patients seen in outpatients that morning would often be operated on that afternoon.

Theatre list often exceeded 20–30 cases per day, the list would only stop at 8 or

9pm. All the while, major and complex mutilating injuries arrived at any time of day and would be dealt with alongside the elective cases. It was every wannabe surgeons dream come true- all the opportunities you would ever want to scrub in.

On the microsurgery course, every day started with a video demonstrating the techniques we would be using, followed by practice on anaesthetised laboratory rats.We then practiced by suturing a rubber glove with 10-0 nylon and attempted to anastomose a chicken leg artery. In the next few days, we tried to c l a m p, s e ve r, a n d a n a s t o m o s e numerous rat femoral arteries and veins. It was satisfying to release the clamps and have a flowing vessel.

My first successful femoral Opportunity complex reconstructive work and microsurgery in the hand, that restores normal hand function arterial anastomosis (1 mm) diameter vessel)

www.fyls2@cam.ac.uk

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Assisting on a reconstructive hand surgery for Keinbocks disease ( avascular necrosis of the lunate)

Experiences gained LEARNING POINTS FROM ELECTIVE GANGA HOSPITAL

I was fortunate enough to have worked with some surgeons who were incredible teachers in theatre; they have helped my confidence in my practical surgical skills to grow immensely. They initially started with teaching me the basics of instrument holding, suturing delicate structures, scar placement and skin grafting. Under their guidance, I slowly started to assist on more complex cases Particular highlights: assisting on a case of an old brachial plexus avulsion injury which had left a young man unable to use his right arm- the insertion of the trapezius muscle was detached and used to restore the shoulder abduction and external rotation (meaning that he could used his arm again); assisting on cases following all manner of industrial and motorbike accidents allowed me to see how creative plastic surgeons are at recreating eyelids, replanting severed fingers, and repairing highly mutilated injuries

I really enjoyed the microsurgery course; it really made me appreciate how fragile and vulnerable the tissues can be and how good tissue handling in surgery is essential for good outcomes.Starting with little knowledge in this field, I finished confident in various microsurgical principles, having acquired useful skills which I can definitely practice at home Finally, the high volume of patients in the outpatients clinic created great opportunities to get involved with presenting the patient to the Chief surgeon, Dr Sabapathy, and to participate in clinical discussions and decision making processes.The patient population varied not only in presentation but also in origin ( some travel more than 4000 miles to seek treatment at Ganga).The lear ning experience in clinic was vast: a myriad of cultures and conditions- from craniofacial syndromes to rare hand pathology- I never anticipated that I would learn so much.

BOSTON CHILDREN’S HOSPITAL

I spent the majority of my time doing basic science research, I gained a vast amount I was exposed to a broad range of new concepts and techniques including immunohistochemistry, real-time PCR and cDNA and mRNA extraction from tissue samples resected by the surgeons in theatre.

Most importantly all these ( contd.........) www.fyls2@cam.ac.uk

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Using the surgical microscope to operate on a rat

(contd) techniques were underpinned by how to correctly use a pipette to measure out the miniscule reaction volumes that we would be dealing with in our project. This seemingly simple skill was the gateway to mastering other difficult techniques and also crucial to not wasting reagents some of which cost $500 for 5ml!!). I recall spending a “fun” 6 hours practicing pipetting water into various containers- arguably the most useful 6 hours I spent to get this project underway.

Vascular anomalies, is a new and emerging field of research; there was not much previous literature published on this area to guide me. It encouraged me to think independently and creatively to solve research and experimental design problems without the aid of a large evidence base from which to draw likely solutions..

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The chief of Plastic Surgery in the Physiotherapy department examining a patient

In between the 70 PCR reactions and countless immunohisotchemistry experiments I was able to attend theatres where I got to see some amazing surgery including a cranioplasty, a surgery to expand the skull vault of a child in which the sutures had prematurely fused due to Saethre-Chotzen syndrome.

I ended up spending less time doing clinical work than I expected- part of me was disappointed about this. However, what I did leave with was an incredible valuable and original research experience and the knowledge of how to design a robust study that will form the origin of a good research paper.

Summary A REWARDING ELECTIVE THAT FAR AND AWAY EXCEEDED EXPECTATIONS As a result of my elective I was fortunate to walk away with many things: not least of them was the feeling that I had had the experience of a lifetime. Looking back over the nine weeks, I have been able to see and participate in many unusualand interesting surgeries and meet incredible patients from all walks of life. Along the way I learnt much more than I could have predicted I would on this elective: from how to extract DNA from

tissue samples collected in theatre, to anastomosing a delicate 1.5mm wide vein to a 1mm wide artery in a rat, or transferring toes to make fingers in the working man who is terrified that he will lose his job.

It was very humbling to see so many operative cases where seemingly desperate situations were converted into functional recovery that enabled people to lead a normal life.

I feel privileged to have met some of the most inspirational people: the doctors at Ganga Hospital, who works 6.5 days a week, 365 days a year, and the surgical team at the Vascular Anomalies Center in Boston. They all showed a passion and commitment that has hugely extended the boundaries of patient. Working at both these hospitals showed me that what is important, is that today, in an increasingly more sophisticated set-up, doctors retain this same enthusiasm and commitment to doing the best for their patients.

I found it extremely valuable undertaking two separate placements for my elective and would recommend it to any medical student.

It enabled me to experience health care in two different settings with very diverse cultures with plenty of fun opportunities to explore outside the hospital. This trip concreted my wish to pursue plastic surgery as a career path and I look forward to revisiting my colleagues at Boston Children’s Hospital www.fyls2@cam.ac.uk

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Bilateral cleft hand: a rare congenital anomaly

Both Boston Children’s and Ganga Hospital epitomise the quote by Hippocrates: “Wherever the art of Medicine is loved, there is also a love of Humanity”.

I would highly recommend them to anyone who is looking a good clinical experience as well as seeing good clinicians in action

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Most Memorable Event....

A TRIP TO ISHA YOGA CENTRE, COIMBATORE Inside one of the Isha meditation rooms

My first ever venous anastomosis

The learning curve for the delicate world of microsurgery was steep. The second day of the microsurgery course we were learning to do femoral venous anastomoses; the vessels were 1mm wide and very flimsy; the day seemed like a neverending struggle.

At the end of the day, we decided to drive into the mountains to the Isha Yoga Centre,a space for meditation; in India, the belief in the strong healing power of meditation is widely held and even today spiritual practices often take precedence over mainstream medicine.

The centre is surrounded towering pine trees and has a small pool located 30 feet below the ground level in which sits a 660 kg mercury lingam (representing the Hindu deity Shiva).The pool is around 6 feet deep and the lingam is immersed in the pool water, giving it medicinal properties. This so-called healing water is said to have an uplifting effect on the body; touching the lingam is meant to promote health and longevity. I guess only time will tell if this is true but the experience of going into tis underground pool was unique.

The peace and serenity that engulfs Isha is something that can be

experienced but never be described in words. However, meditating in the mountains on a starry night, surrounded by fresh air, candlelit wood carvings and flowers made for a particularly memorable experience.It was definitely the prefect antidote to a stressful day of staring down the microscope.

Bathing in the waters around the lingam

The entrance to the Isha meditation room

www.fyls2@cam.ac.uk

Lingam in the underground pool

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Challenges of the Elective...

THE THINGS THAT I FOUND MOST DIFFICULT The Boston skyline at night

Local street food in India

Looking back on my elective, there are no parts of it that I actively did not enjoy; rather there were challenges to be met and at times steep learning curves.

In Boston for example, from the outset I was given almost complete responsibility for my research.Other than being given the research question and a brief induction of the basic techniques that I would need, I was the left design the appropriate experiments to address the research question. Having so much responsibility for my research also came with great accountability; I had to be able to justify my work at the weekly laboratory meetings .To get on with the project,virtually unsupervised, was a challenge, but it made the work more rewarding. I was able to troubleshoot my own experiments, be creative and running

a successful experiment was all the more satisfying.

On the other hand, it did mean that a “bad day at the office”, when none of my experiments went according to plan was even more frustrating. On these occasions it was helpful to take the setbacks in my stride and go spend a few hours in the vascular anomalies clinic; seeing the promise that translational medicine could have for patients suffering with these lesions, reignited my enthusiasm after the day’s setbacks.

The work in India felt like more familiar territory (aside from the the rare surgeries I was lucky enough to see!)- ward rounds, clinics, and theatre lists. However, the microsurgery course involved operating on live rat models, At first I was uncomfortable working on the live animals as it seemed like the procedures would be

painful and distressing for the rats, especially given the way that they were secured to the board. However, I soon learned, the optimal control of anaesthesia meant that the rats were comfortable and pain-free, if a little too inquisitive about the surgery that you were doing on them!!

As far as the challenges of traveling from Boston to India: very different customs, cultures and cuisine.I decided that stepping out of my proverbial “comfort zone” was the best way forward. By convincing myself to try being more adaptable, I really feel that I was able to get the best out of both my electives. I experienced the rich cultural and historical heritage of both places- and some amazing local food.My biggest struggle was having no Wifi or mobile data., especially in India. At first this seemed like a terrible thing but it ended up being to be “off the radar” for a while.

Internet connection was not always guaranteed

The busy streets of Coimbatore, India at night-time

First time working with live animal models

www.fyls2@cam.ac.uk

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A photo from the wall of the operating theatre complex that serves as a timely reminder of the hospital motto

Inside Harvard’s bookshop

BOSTON - for 6 weeks

Plane Tickets, Airport Tax and Travel Insurance

£640

Accommodation for 6 weeks in a university halls

£672

Food

£200

Activities/general living costs

£120

Travel from Accommodation to research labs/hospitals, etc

£67

View of Boston from our laboratory window

COIMBATORE - for 3weeks Plane Tickets, Airport Tax and Travel Insurance

£530

Accommodation in hospital visitors flat

£249

Food for 3 weeks

£100

Activities/general living costs

£50

Travel from Accommodation to research labs/hospitals, etc

£20

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View of Coimbatore from the operating theatre window

TOTAL COST: £2648

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I am very grateful to the following organisations for the funds they provided, these helped a great deal and allowed me to meet my budgetary requirements:

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• BRITISH ASSOCIATION OF PLASTIC SURGEONS STUDENT BURSARY • THE HEALING FOUNDATION • BRITISH MEDICAL AND DENTAL STUDENTS TRUST AWARD • THE RHODRI WILSON MEMORIAL FUND • MEDICAL WOMENS’ FEDERATION • PRIESKEL PRIZE FOR SURGERY FROM THE ROYAL COLLEGE OF SURGEONS and especially

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SELWYN COLLEGE MEDICAL ELECTIVE FUND (whose generous contribution financed my place on the microsurgery course in India)