ICU Surgeon Takes Cutting-edge Approach to Help Crush Victims
Dr. Andrew Doben has two real passions — beyond his family, of course.
Sailing and surgery. Not necessarily in that order, but probably.
They have been both pursuits and professions for Doben, and they are both well-represented on the walls and shelves in his small office at Baystate Medical Center.
Indeed, hanging next to his medical-school diploma is a poster from that famous (or infamous, depending on your point of view) 1983 America’s Cup, the one where Australia II, with its revolutionary winged keel, which Doben would describe in great detail, ended the New York Yacht Club’s 132-year hold on the cup. Not far from a shelf crammed with thick medical textbooks is a photograph of Doben and his children on his boat, a 41-foot Oceanis. And just across from a model of the titanium rib fixture he uses to save (and change) the lives of his patients, is another poster, this one complete with bits of sail flown by America3 in its successful America’s Cup defense in 1992.
“I know they’re genuine,” Doben said of these strips of sail, “because it looks like there’s some salt leaching onto the matting.”
Sailing and surgery; surgery and sailing. Doben can do more than talk about them with confidence and reverence in his voice. He can draw some stirring parallels and analogies between the two professions, as we’ll see. Together, they provide a window into how he views his work as director of the Surgical Intensive Care Unit at Baystate.
Which brings us back to that model mentioned earlier and a surgical treatment known as ‘surgical stabilization of rib fractures’ (SSRF), or rib fixation, which, as that name suggests, uses surgically implanted hardware to stabilize rib fractures. The procedure yields quicker recovery times, decreased mortality, reduced incidences of pneumonia, reduced use of ventilation after trauma to the chest, and less chest-wall deformity.
Doben explained. “With pretty much every bone in the human body, when you break it, you are, in some way, shape, or form, holding that bone stable while it heals, whether you put it in a cast, or you put some degree of fixation on it or through it — you stabilize that bone.
“And almost every bone in the body has had that to some degree, with the exception of the ribs,” he went on, adding that this is largely because they are always moving. “Fractures in motion will not heal.”
Years ago, surgeons would try casting or binding the ribs, Doben noted, but because they are so important to the respiratory process, this strategy is almost universally fatal. “People couldn’t take a deep breath, they got pneumonia, and they died.”
People trust a lot in you when you operate on them, and it’s very similar to the feeling you get when someone asks you to be their captain; they give you their boat, and they ask you to carry them through to safe passage; it’s very similar.”
Matters are further complicated by the fact that, if someone has endured an injury forceful enough to break several ribs, they have likely also damaged one or more of the organs that the ribs protect, he said, adding that for decades the hallmark of treatment of such patients was pain control, which led to slightly improved outcomes, with the emphasis on slightly.
Roughly 75 years of technical and medical developments, accelerated by several wars, have produced a fixation system, one that uses a combination of metal exoskeletal plates and pins to keep the ribs entirely immobile while damaged bone and tissue heal, resulting in reduced pain and a much shorter recovery time, as we’ll see later.
Doben’s emergence as one of the leading practitioners of rib fixation — he has performed the procedure more than 200 times, in his estimation — goes a long way to explaining why he is one of two winners in the Healthcare Heroes category called Innovation in Healthcare.
But that’s only part of the story. His tireless work to help make this surgical procedure more mainstream, thus saving more lives, is another big part. Indeed, while fib fixation is widely available in other countries, that is not the case in the U.S.; Doben is working to change that equation.
He noted that, while the number of rib-fixation procedures being performed in this country has risen, those numbers are skewed by the fact that most procedures are being undertaken at a handful of high-volume centers.
“Only a few dozen people in this country have performed as many as 100 of these operations,” he explained, adding that one of his goals moving forward is to create centers of excellence that will become referral centers for the treatment of people with such injuries and training centers for those who perform the procedure, with Baystate likely being one of the first of these centers.
Taking the High Road
As he talked about the start of his professional career — which saw him on the water, or ‘blue water,’ as it’s known to those who navigate it, and not in the OR — Doben made it clear that, while he misses some if not most aspects of that work, he has no regrets about wearing blue scrubs to work every day.
Nor does he have any regrets about not getting into finance, which would have been the most logical path to take with his degree in economics. Instead, he took, well, a different course, actually hundreds of them, as a professional sailor after being part of a nationally ranked sailing team at Connecticut College, a small liberal-arts school located across the street from the Coast Guard Academy in New London.
“I lived on boats and traveled all over the world,” he explained. “I was a captain and delivered sailboats; I did about 35,000 miles of open-ocean sailing prior to going to medical school.”
Elaborating, he said he was first employed by different companies that would lease out boats for sometimes lengthy excursions. It was his job to sail a boat back after a lessee was through with it.
“So someone might start in Tortola in the British Virgin Islands, and they’d finish in Antigua,” he explained. “Well … somehow that boat has to make it back to the British Virgin Islands. Someone has to have that horrible job of sailing that boat back.”
Later, Doben did well in the business of delivering sailboats to their owners. “Let’s say you live in New England and have a boat you keep in Newport, and you want it in the Caribbean for the winter, but you’re busy; you have a lifestyle where you can’t do it yourself. So you call someone up, and you pay them to bring that boat to you.”
They actually pay more than what he’s making now as a surgeon, Doben said with a smile on his face, noting that, while that life on the ocean sounds like something that would be difficult to leave, he did — and for several reasons.
For starters, life as a sailboat captain didn’t jibe with his ambitions for starting a family — “it’s a tough thing to step aside and say, ‘see you in 35 days,’” he noted. And despite the pleasing picture this lifestyle probably presents in one’s mind, reality is a little different.
“When you’re 600 miles from shore in 140 mile-per-hour winds wondering if your boat is going to sink, it’s not exactly the type of lifestyle most of us want to have in our mid-40s,” he told BusinessWest.
But, and this is a big but, he desired a lifestyle and a profession that would in many ways mirror what he found on the water.
“I wanted to find a career that was very dynamic, that was constantly changing,” he explained. “One of the things I love about being on the water and navigation is that you can study your whole life and still have things to learn about it.
“No matter what you think you know, things change so rapidly,” he went on, still referring to life on the ocean. “You can start out in the day in beautiful, sunny skies and finish in a tremendous storm, and you have to adjust to it. That dynamic part was something that was very important to me.”
And he’s found it in healthcare, and, more specifically, the operating room.
After going back to college and taking the requisite science courses, he enrolled in medical school at the University of Pittsburgh and quickly narrowed his focus to surgery. And in what couldn’t be considered an upset, he found some parallels between that specialty and being a sailing boat captain.
“I felt that there was a real connection to patients, and much more of what I would call a contractual agreement,” he explained. “People trust a lot in you when you operate on them, and it’s very similar to the feeling you get when someone asks you to be their captain; they give you their boat, and they ask you to carry them through to safe passage; it’s very similar.”
Fast-forwarding a little, Doben came to Baystate and its 16-unit surgical intensive-care unit in 2010, a destination he chose because of the specific challenges and rewards it presented. And, once again, he can find similarities to life on the blue water.
“When I made the decision that I was going to this [surgery], I decided that I wanted to take care of the sickest of the sick,” he told BusinessWest. “I have the type of personality where … I was out with a friend sailing a few weekends ago, sailing in 40-miles-per-hour winds. I was having a blast.
“I’m not the sort who gets freaked out by bad things happening around me; I’m just sort of even-keeled,” he said, using terminology directly from his previous profession. “If something’s going wrong, I’m just going to focus and try to solve the problem.”
That phrase ‘sickest of the sick’ is often appropriate when taking about candidates for rib fixation. These are usually the victims of crush, fall, and explosive-force injuries and are often elderly, said Doben, adding that he considers himself at the forefront of efforts not only to perform this procedure, but to educate the medical community about its ability to save lives and improve quality of life, while dramatically reducing the overall costs of treating such patients.
“Most bones heal in six weeks, but with ribs, because they’re constantly moving, you’re talking about three to six months,” he said while explaining the many benefits to be derived from this procedure. “If you’re a contractor and you’re self-employed, and you have a raise a hammer over your head, six months to not be able to do that is a long time.
“Roughly 60% of the people who have a severe chest-wall injury remain unemployed for up to a year,” he went on. “We can get people back to work, full-time employment, in three to six weeks.”
He reports that some progress has been made in mainstreaming SSRF, but there is still considerable work to be done.
“In 2009, we wrote a paper on this during my fellowship, and we basically had tomatoes thrown at us when we were at the national meetings,” he recalled. “And now, we’re asked to come to the national meetings and talk about it; it’s been such a frame shift.”
Progress is reflected in the number of rib-fixation procedures being undertaken in this country, he went on, noting that there were maybe 100 cases performed in 2001; by 2014, that number had risen to more than 3,300.
But behind those statistics are some troubling trends, he went on, adding that there are only 20 surgical centers across the country that are performing this surgery more than 30 times a year.
“Most centers are doing one or two a year,” he explained. “And when you look at the patient pool and the injury-severity scores, meaning ‘how badly injured is this patient?’ the number is almost double at the high-volume centers. So the sicker patients are being treated at the high-volume centers, and the mortality is half what it is at the lower-volume centers. So the lower centers are seeing patients who aren’t as sick, with less frequency, and they’re having worse outcomes.
“And that makes sense,” he went on. “If you don’t do the operation a lot and you don’t have a lot of experience, your outcomes are not going to be the same. This is concerning to me, and we’ve been working on that.”
This work is largely focused on creating those centers of excellence he mentioned, adding that he and others with the Chest Wall Injury Society are working to establish the criteria for such centers.
And there is much more to this than having specialists who can perform the rib-fixation surgery, he explained.
“The operation is only one-tenth of the puzzle,” he explained. “The puzzle is the team that takes care of these people. The respiratory specialists, the ICU, anesthesia, the pain management, the post-op management, the physical therapists … it’s a whole host of people. The operation just helps accelerate that process.”
And while establishing these centers of excellence that the ill and injured can be referred to, Doben and others will work to greatly increase the number of surgeons who perform this procedure, with an eye toward improving care in currently underserved areas.
Elaborating, he said there are maybe two dozen facilities that may soon become centers for excellence, and most are clustered in the western part of the country, where there are higher incidences of motorcycling and skiing injuries. Other parts of the country are underserved, he went on, listing Boston, where there is only one surgeon who performs this procedure, as an example.
“There are many people who don’t even know this procedure is available,” he said, adding that his goal now is to not only change that equation, but make the procedure available to more people.
Stemming the Tide
Returning to his thoughts about why he chose surgery as a profession and the ICU as the place to call his professional home, Doben recalled something that a friend of his father and a cardiologist by trade once said to him — something that has obviously stayed with him.
“He said, ‘being a doctor is a great privilege, where you get to see people in their most vulnerable states,’ and there’s nothing more true about that than the ICU, both for patients and families. And I enjoy that relationship of being able to work with people to get them through all that, to get them to safe passage.”
“Sometimes they don’t get there; they don’t survive,” he went on, adding that helping people live out their final days and moments in dignity is often as rewarding as saving a life.
That reference to safe passage was yet another analogy to sailing, a profession Doben has left behind him. Yet the sailing mindset remains — to focus on the horizon and chart a course that will get where you need to go.
And with SSRF and the challenge of bringing that breakthrough technology to more of the people who can benefit from it, he has done just that.
George O’Brien can be reached at firstname.lastname@example.org