The Conference: A A New Learning Experience

617-638-8124
Department of Otolaryngolog y
Head and Neck Surger y
Department Affiliates: The Boston V.A. Healthcare System, Lahey Clinic Medical Center, Boston Children’s Hospital
Administrative Office: 617-638-7933 • www.bumc.bu.edu/orl
Volume 01 • Issue 14
The
Spring 2013
Conference:
A New Learning Experience
A
ll physicians have the responsibility for managing difficult cases and confronting situations that make them apprehensive. It is fair to say that we,
as otolaryngologists, have all been scared at some point in our professional
careers. Whether that fear occurs when encountering an unexpected major
complication or when faced with a difficult airway emergency, it is always
comforting to share the experience with a colleague who then benefits from
learning about the situation. During my fellowship, Dr. Ralph Metson would
say, “You learn more from 1 complication than you do from 100 cases that go
well.” Focusing on cases that were frightening to manage, the Department of
Otolaryngology- Head and Neck Surgery at Boston University has developed
a new educational course that provides exceptional learning opportunities.
The Scary Cases Conference was conceived by Dr.
Kenneth Grundfast several years ago as a fast-paced,
case-based approach to learning with the hope that
we would all learn from each other to improve patient
care and safety. His vision was realized on Halloween
2011, with the first Scary Cases Conference held at the
Massachusetts Medical Society (MMS) in Waltham,
Massachusetts.
In 2012, the Scary Cases Conference was again a
success with increased turnout despite a last minute
change of venue to the Massachusetts Eye and Ear
Infirmary due to a hurricane-related power outage
at the MMS. Well-respected and experienced academic and community-based otolaryngologists each
presented one of their scariest cases to an audience of
over 100 clinicians. As expected for these unique and
difficult cases, each presentation was followed by lively
discussion and commentary.
In addition to the cases presented by our physician
colleagues, we were fortunate to have special guest speakers who included Clyde Bergstressor, JD (2011); David
Gould, JD (2011); and Fran Miller, JD (2012), all experts
in medical malpractice law; Luke Sato, MD (2011),
Chief Medical Officer of CRICO malpractice carrier;
and George Annas, JD, MPH (2012), a world-renowned
authority on medical ethics and health care policy.
We brought our Scary Cases Conference on the road
to the AAO-HNS 2012 Annual Meeting in Washing-
Michael P. Platt, MD
ton D.C. with a very
Course-Co-Director,
well received audienceScary Cases Conference.
response
interactive
Assistant Professor
mini-seminar.
Ralph
Metson, MD; Dennis
Poe, MD; Daniel Lee, MD; Wendy Stern, MD; Reza
Rahbar, MD; and Robert Dolan, MD, gave outstanding
presentations that both scared the audience and taught
them how to deal with unexpected and difficult problems.
Following are some responses from meeting attendees:
- “Always good to hear experts admit that they get
worried too!”
- “It was great! My heart was racing for them in their
recall of the scary situations.”
- “Fantastic learning experience. I hope this will be
repeated.”
- “It is nice to know that all of us are ‘mortal’.”
- “Riveting! Best course/miniseminar all week.”
- “Thanks for sharing your experiences to teach us!”
Meeting attendees agreed overwhelmingly that the
Scary Cases had provided an exceptionally valuable
learning experience. With the new Massachusetts
requirement for CMEs specific to risk management, the
Scary Cases Conference fulfills these credits with a fun
learning experience. All of us at Boston University are
grateful to Dr. Grundfast for sharing his vision to make
this annual conference a success. We hope to see you on
November 1 for The Scary Cases Conference 2013. Executive Editor: Kenneth M. Grundfast • Editor & Writer: Nina E. Leech • Design: Educational Media
Arthur Cohn, M.D.
General otolaryngology
Anand K. Devaiah, M.D.
Ear and hearing disorders; Balance
disorders; Anterior skull base/sinus
disorders; Head and neck cancer
Waleed H. Ezzat, M.D.
Facial plastic and reconstructive
surgery; microvascular surgery; head
and neck reconstructive surgery
Richard Grentzenberg, M.D.
General otolaryngology
Gregory A. Grillone, M.D.
Laryngology and voice; Head and
neck cancer; Sinus surgery
Kenneth M. Grundfast, M.D.
Pediatric otolaryngology; Ear and
hearing disorders; Balance disorders
Scharukh Jalisi, M.D.
Head and neck surgery;
Microvascular-reconstructive
surgery; Skull base surgery; Larynx
and voice disorders
Susan E. Langmore, Ph.D.
Speech language pathology
Jessica R. Levi, MD
Ear, nose, and throat disorders of
childhood; pediatric airway and
voice disorders, pediatric sinusitis,
pediatric neck masses
Elizabeth Mahoney Davis, M.D.
Allergic disease; Paranasal sinus
disorders/nasal obstruction;
Pediatric otolaryngology; General
otolaryngology
J. Pieter Noordzij, M.D.
Laryngology; Care of the professional voice; Endocrine surgery
Michael P. Platt, M.D.
Sinus surgery; Allergy; Rhinology
Jeffrey H. Spiegel, M.D.
Facial plastic surgery; Reconstructive surgery; Head and neck
surgery; Microvascular surgery;
Anterior skull base surgery
John R. Stram, M.D.
General otolaryngology;
Otolaryngic allergy
Clarke Cox, Ph.D.
Audiology
Zhi Wang, M.D.
Basic science & technology research
Some highlights of
Presentations
It Was Not Your Fault!
Charles Vaughan, MD
In unstable systems such as medical care, even
when excellent, “scary” events are normal
and to be expected as are both good and bad
outcomes. Although they are to be expected,
they cannot be predicted; indeed, many are
unknown prior to their appearance.
A case in point is one of episodic vertigo
(Meniere’s disease) treated by an attempt at
hydrops decompression via opening the endolymphatic sack into the cerebro-spinal fluid.
However, the intra-dural location of the sack is
often not obvious. I had discovered previously
that prior to its entry into the dura, the duct
could be palpated easily and that following
it would lead to the sack. This was demonstrated to the resident who was then asked to
“try it.” On doing so, the resident mumbled,
“Oops!” Because how to repair a transected
duct was unknown and because its transection also might provide hydrops relief, the
procedure was terminated. Over six months
of follow-up, the patient reported no further
attacks of vertigo. Wonderful! Great result!
But what about guilt over allowing the transection? Should this have been anticipated?
Avoided? Of course -- Guilty! But what
about the happy, serendipitous discovery of a
new therapy? Yes!!! A dumb accident does
not deserve praise, but the discovery of penicillin resulted in a Nobel Prize. So why not
seek some applause? The Swedish report on
sham endolymphatic decompression solved
this dilemma and further demonstrated that
in unstable systems, such as medical care,
Dr. Spiegel presents his theories on patient concerns that can make plastic surgery seem scary.
even when excellent, “scary” events are normal
and to be expected as are both good and bad
outcomes. Although they are to be expected,
they cannot be predicted; indeed, many are
unknown prior to their appearance.
As an afterthought, one other case warrants
mentioning: debilitating Meniere’s disease in
a farmer from Maine -- this time treated with
a CNS vasodilator. On six-week follow- up,
the farmer reported, “I bought the pills on my
way home. When I got home and got out of
my car, I tripped and spilled my pills all over
the yard. The chickens ate ‘em... and died.”
(My God! I’ve killed his chickens!) The
patient stated, “Powerful medicine doc!
Haven’t had a spell since.”
Dr. Charles Vaughan demonstrates on Dr. Bruce Gordon how to do an emergency cricothyrotomy using
a pocket knife.
2
A Night of Trauma
David Rudolph, MD
I will never forget my scariest night as a physician. I was on-call for the sleepy South Shore
Hospital many years ago, when I had just fallen
asleep and both the pager and phone went off
simultaneously -- it was an ominous sign. A
panicked internist covering the ED requested
me to come in immediately to treat multiple
gunshot wounds. Upon my arrival, there was
not a single parking space as the ED was in
chaos. There were numerous police officers,
anxious visitors, nurses from around the hospital, and a variety of physicians who do not
specialize in trauma who were called in to help.
As the ambulances pulled in, I found myself
alone in a bay with a 15-year-old girl who suffered multiple gunshot wounds to the mandible
and neck that were actively bleeding. Without
consent or family notice, I rushed her to the
operating room where blood transfusion, nasal
intubation, and control of the bleeding in her
neck were performed. I called in my senior
partner, Dr. John O’Brien, to help. Without
any break, I moved back to the ED where the
patient’s younger brother had just arrived with
two gunshot wounds to the neck. There was
massive swelling and oozing from the wounds
that necessitated an emergent trip to the OR
for control of bleeding. Once the wounds
were stabilized, I immediately went back to
the ED to see the third victim, a 13-year-old
boy who was only concerned about his two
other siblings. He had 3 gunshot wounds to
the neck, one to the chest, but no heavy bleeding. His wounds were explored in the OR and
no major injury was present.
All of the victims whom we had seen survived
this endless night. It was the most terrifying
experience of my career, having to deal with
emergent problems in numerous patients in
one night without the usual support of a busy
trauma center. The rush of emotions ranged
from overwhelming adrenaline, to fear of who
could have done this, to ultimate exhaustion in
the morning. What I learned from this experience was that physicians are sometimes called
upon to perform at a higher level without
warning and in these times, our training and
experience guides us to accomplish whatever is
needed to help our patients.
An Unusual Specimen
John Stram, MD
I was performing a mastoidectomy at the
VA hospital on a 55-year-old man with a
chronic draining ear that did not respond to
medical therapies. The case was proceeding
as expected with slow clearing of granulation
and sclerotic bone from a poorly pneumatized
mastoid bone. The PGY-4 resident was drilling with a rope-driven, Jordan Day drill which
spun at 80 rpm using a re-usable cutting burr.
As the antrum was being enlarged, the drill
penetrated the tegmen and was buried in the
temporal lobe. When the resident removed the
drill, there was 2 cm of brain tissue on the burr.
This was the first time that I had encountered
this problem and I wasn’t sure how to address
a brain injury, CSF leak, or tegmen repair. I
called the neurosurgeon who arrived in the
OR and promptly asked, “Why did you drill
that hole?” We repaired the defect with gelfoam, a temporalis muscle flap, and packing in
the mastoid. The patient was awakened with
no neurological deficits and had an uneventful
recovery after being observed in the hospital.
This case was difficult because I was faced
with a new, unexpected, and potentially dev-
Dr. Gavin Setzen from Albany, New York, explains
how to prevent airway fires during surgery.
Scary Cases Course Co-Directors: Dr. Michael Platt and Dr. Kenneth Grundfast (with two meeting attendees!)
astating complication during surgery that was
caused by a resident. During the discussion
at the conference, a prominent and respected
neuro-otologist commented that this had
happened to him on more than one occasion
and it was always important to not scold or
demoralize the resident because it can have a
significant adverse effect on their career. What
I learned from this case is that sharp instruments are safer than dull ones, call for help
when you need it, and scary cases can have a
good outcome.
The Uninsured Patient
Wendy Stern, MD
A 62-year-old man presented with 6 months
of nasal obstruction. He described a “balloon
that comes out” of his nose that needed to be
pushed back in. His history was significant
for prior sinus surgery and on physical exam,
obstructing polyps were found on both sides.
While he needed sinus surgery, the patient
was concerned about cost as he did not have
health insurance. He negotiated a reasonable rate with the hospital and I performed
the surgery without charging him. He had
excellent post-operative results and in lieu of
payment, he insisted that he do yard work at
my house. He also didn’t want routine followup because he lacked insurance. The last time
I saw him was when we were raking up leaves
in my backyard. He was doing quite well.
The patient returned 18 months later complaining of a plugged right ear and was found
to have a unilateral serous middle ear effusion
with no polyp or mass obstructing the eustachian tube orifice in the nasopharynx. The ear
was aspirated and one week later, the patient
noted new numbness and tingling around his
ear. An MRI scan was ordered. He didn’t get
the MRI scan or follow-up because of his lack of
health insurance. He returned several months
3
later with more severe symptoms and finally
agreed to get the MRI scan, which revealed a
skull base tumor. Endoscopic biopsy diagnosed
this mass to be lymphoma. The patient had a
complete response to medical therapy.
This case was scary. There was pressure on
both the patient and me to reduce cost due
to lack of insurance. I was uncertain as to
whether microscopic pathology had been performed at the time of my first sinus surgery in
an effort to reduce costs. Had I or the pathologist missed the tumor? It turned out that we
had done pathology and had not missed it. It
was also suggested that bartering for medical
care is illegal. As I later learned, bartering for
medical services is acceptable as long as it is
appropriately documented and accounted for
in the records and with the IRS. I learned that
you can still be Ms. Nice Lady, but you need
to know the law, follow the standard of care,
and utilize hospital resources, when necessary,
to provide care in circumstances like this case.
Continued on Page 4
Dr. Bill Mason explains the intricacies of
medical malpractice litigation.
Brief Scary Cases Presentations
Continued from page 3
Facial Nerve Injury
Dennis Poe, MD
I can recall a case that was particularly scary
to me. An 11-year-old girl with chronic otitis media was found to have an aural polyp.
Removal of the polyp under anesthesia
revealed an attic cholesteatoma for which the
patient underwent canal-wall-up mastoidectomy. Cholesteatoma and granulation tissue
filled the middle ear and mastoid with only a
remnant of an incus and malleus but no discernible stapes. As I entered the facial recess,
bleeding adherent granulations were debulked from the promontory, round window
niche, and epitympanum. There appeared
to be free edges of inflamed fibrous strands
overlying a dehiscent facial nerve, which was
edematous and indistinguishable from the
fibrous strands!
The facial nerve monitor had been silent
during the case. Stimulation was attempted
with a probe and there was no response.
Despite increasing the amplitude, changing
the probe, checking impedances, and testing
for muscle relaxants, there was no stimulation of the facial nerve. At this point, I was
concerned that the nerve was injured. Intravenous corticosteroids were administered
followed by canal-wall down approach and
decompression of the facial nerve. A handheld probe was then used and the facial nerve
stimulated successfully!
The patient was awakened after completion
of surgery and she had normal facial function
in the recovery room. It turned out that there
were a defective lot of facial nerve stimulation probes. I learned from this case that
Dr. Mark Volk dons a surgeon’s cap to add reality to
his re-enactment of a scary case
World-renowned medical ethicist George Annas gives a lively presentation on the
intersection of art, medicine, and law.
granulations can be more destructive than
cholesteatoma but don’t need to be removed
in entirety as it will likely resolve following
removal of the underlying cholesteatoma. I
also learned that you cannot always rely
on any technology because there will be
instances when it isn’t available or doesn’t
work as expected.
Facial Nerve Injury
Robert Dolan, MD
A 56-year-old woman presented to her PCP
with asymmetric sensorineural hearing loss.
An MRI scan was ordered which revealed
an incidental parotid mass. She was referred
to an interventional radiologist for a core
needle biopsy of a deep lobe parotid mass.
The patient had immediate facial paralysis
with the biopsy, for which the pathology
was non-diagnostic. She was referred to a
second surgeon for treatment and a parotidectomy was attempted. The facial nerve
would not stimulate intra-operatively and the
pathology of an incisional biopsy revealed
adenocarcinoma. The patient was sent to me
for definitive treatment.
At this point, the patient was found to
have an incidental finding with no symptoms. She had seen three specialists who
performed procedures that resulted in complete facial paralysis and pain and she still
4
had a malignant tumor in her parotid. She
was losing faith in the medical system and
was not very happy about driving 230 miles
to see me.
A re-review of the pathology from the
incisional biopsy demonstrated a pleomorphic adenoma. I performed a transcervical
approach to excise the tumor and the facial
nerve was found to be attenuated and splayed
over the tumor. Post-operatively, she had a
complete facial paralysis. A gold weight was
placed in the upper eyelid, but as she regained
facial function, it was able to be removed 6
months later. Her recovery was complicated
by first-bite syndrome and significant pain
that resolved over the next year. She regained
near-complete facial function with no evidence for tumor on follow-up MRI scans.
Ultimately, she was extremely pleased with her
care and medical condition.
This case demonstrates the service recovery
paradox where a failure ultimately results in
increased patient satisfaction. There were
many lessons that I learned from this challenging case that outline how to achieve
the service recovery paradox: encourage
good communication, be available for your
patients, provide compassionate care which
trumps all, fully disclose risks of medical
procedures, and do not practice outside your
field of expertise. What is a Scary Case?
— Did you believe that you did everything
correctly and the outcome was
unsatisfactory?
— Did a patient have an unexpected
serious condition that was difficult to
diagnose?
— Were there major complications?
— Were you falsely accused of committing
malpractice?
— Did you encounter something
unexpected or challenging during
surgery?
— Did you have a difficult ethical dilemma?
— Was there a pitfall in the management of
a patient?
— Was there a perplexing case with elusive
diagnosis?
— Did a case result in litigation or claim of
malpractice?
— Were you required to treat a condition
beyond your expertise?
— Did you make a wrong diagnosis before
arriving at the correct diagnosis?
Do you have a Scary Case to present?
Call or contact Dr. Michael Platt at
617-638-7933 or miplatt@bu.edu
Educational Grants
— Acclarant (2012)
— Medtronic Surgical
— Techologies (2012)
— Stryker (2011, 2012)
— Synthes (2012)
Exhibitors 2011
Professor Susan Langmore
Receives Highest ASHA Honor
S
usan Langmore, PhD, CCC-SLP, nication disorders. Each year, the Annie
Professor of Otolaryngology at the Bos- is given in her name to an individual who
ton University School of Medicine (BUSM) demonstrates Mrs. Glenn’s spirit.
and Director of Speech Language Pathol- In 1988, Dr. Langmore revolutionized
ogy Services at Boston Medical Center the field of dysphagia management when
(BMC), has been honored by the Ameri- she developed and validated the Fiberopcan Speech-Language-Hearing Association tic Endoscopic Evaluation of Swallowing
(ASHA) with its highest honor, Honors (FEES) examination and protocol. Today,
of the Association. At the 2012 ASHA FEES is used in both inpatient and outpatient
Annual Convention in Atlanta, ASHA settings by speech language pathologists,
President, Shelly Chabon, PhD, CCC-SLP, neurologists, and otolaryngologists worldpresented the award to Dr. Langmore for wide. In 1998, after leading a NIH-funded
her “distinguished and clearly outstanding program grant, Dr. Langmore published a
contributions to the field of speech, lan- landmark paper establishing the risk factors
guage and hearing.” ASHA is the nation’s for aspiration pneumonia. Recently, she has
leading professional, credentialing, and worked to determine the efficacy of dysphascientific organization for speech-language gia rehabilitation treatments in the head
pathologists, audiologists, and speech/lan- and neck cancer population. With over
guage/hearing scientists. Also attending 25 years of clinical experience, teaching,
the meeting were former U.S. Congress- and research experience, she is a worldwoman Gabrielle “Gabby” Giffords and renowned clinician/scientist who frequently
her husband, Commander Mark Kelly; lectures nationally and internationally.
former Senator John Glenn and his wife, Dr. Langmore is currently on the editorial
Mrs. Annie Glenn. Congresswoman Gif- boards or serves as an ad-hoc reviewer for
fords and Commander Kelly received the eleven peer-reviewed journals and has just
ASHA Annie Glenn Award in recognition completed a four-year rotation on an NIH
of “their hard work and steadfast dedication study section. Professionals from all parts of
to Congresswoman Giffords’s recovery and the world travel to BMC to attend her FEES
to each other.” (Congresswoman Giffords course which is given five times per year.
developed aphasia as a result of injury to Professor Langmore joined the Department
her head in a 2011 assassination attempt.) of Otolaryngology at BMC/BUSM and the
The Annie Glenn Award, was presented faculty of the Boston University Sargent
by Mrs. Glenn who is known nationwide College of Health and Rehabilitation Scifor her advocacy for those with commu- ences in June 2007. Background is a candid cellphone photograph taken at the 2012 ASHA Annual Meeting of former
Congresswoman Gabby Giffords, and Dr. Susan Langmore, also shown below.
— ArthroCare
— Entellus Medical
— Gyrus ACMI
— Hart Associates Inc
— Hill Dermaceuticals Medtronic
— Surgical Technologies
— OmniGuide
— Takeda Pharmaceuticals?
Exhibitors 2012
— Grace Medical
— OmniGuide
— OTOSim, Inc.
— Karl Storz
— Tracey Medical Products
— Medtronic Surgical Technologies
Giffords image courtesy of- http://www.flickr.com/photos/billmorrow/5452203816/sizes/l/in/photostream/
5
T
Otolaryngology Unsung Heroes
he outstanding physicians of the Department of Otolaryngology are well known,
but the Department members who manage
day-to-day clinical and administrative operations smoothly and with grace are often unseen.
In each issue of The Scope, we recognize two
unsung heroes who make important contributions to the success of the Department of
Otolaryngology – Head and Neck Surgery.
Dolores Rodriguez, Patient Access Representative
I came to Boston from El Salvador in 2000
and I spoke no English at all. I got a job at
Jera’s Juice in Coolidge Corner and everyday, I would write down different English
words that I heard; and on the way home
on the train, I would look the words up
in an English language book and write
them and say them until I knew them. In
six months, I could speak English! I then
moved to the Bank of America branch in
Revere where I worked for three years as a
cashier. I enjoyed this work very much as I
liked helping the customers, especially the
Spanish-speakers, but I wanted to do more. Using the same method I
had used to learn English, I began to teach myself Portuguese so that
I could communicate more helpfully with the Portuguese-speaking
customers. They actually were so kind to help me learn. One of my
customers worked at Boston Medical Center and suggested that my
language skills might be of great value in working with the diverse
population at BMC. I applied for a job and was hired in the Department of Otolaryngology. I have worked in the Department for four
years and I am so happy to be working in a field that gives me the
opportunity to grow personally and to help others.
On November 27, 2012, I completed a 10-month course at Cambridge
College for certification as a medical interpreter. I learned medical terminology and principles and protocols of being in the exam room with
a patient and doctor. Considerations of privacy and confidentiality are,
of course, basic but also understanding that an interpreter is a “bridge”
and not a participant in the interaction is key. Patients’ cultural biases
are not to be judged or corrected by an interpreter who is privileged to
understand them. An interpreter must accurately convey what is communicated by the patient and physician in a completely neutral way.
I love learning and want to do more. This Summer, I hope to enroll
in a course to help me to improve my written English. I think I have
a talent for languages and my goal is to use it to help as many people
as I can. I am very happy being in a setting that enables me to assist
people who may be experiencing stress and to be able, in some small
way, to ease their anxiety. I believe we are in this world to help each
other whenever possible.
Dolores lives in Revere with her 7-year old daughter, Jissell, and her
husband, Fermin. She and Jissel both sing in the choir at the Church of
the Most Holy Redeemer in East Boston.
Fran Serino, Team Coordinator
I have been at Boston Medical Center for
five years. I formerly worked part time for
Children’s Hospital Boston at the Peabody
Satellite while my husband, Rich, and I
were raising our four daughters. His sudden
death instilled a new drive in me to support
my family. With that in mind, I began to
nurture his small dental lab business and
take on a new position as Practice Assistant
at the Department of Otolaryngology.
Within a short time, I became Team Coordinator and have enjoyed the fast pace and
unpredictable routine that keeps me happily immersed in the daily activity of the clinic. I feel fortunate to be
surrounded by a team of bright and hard-working physicians and staff. I
am grateful for the personal growth I have achieved by working within a
department with unparalleled levels of knowledge and humanity.
Frani is busy settling into her new condo in Peabody and enjoys theater, entertainment, and spending time with her three grandchildren,
family, and friends. Previous
Presenters
2011
Don Annino
Barry Benjamin
James Burns
Dan Deschler
Anand Devaiah
Robert Dolan
Robert Frankenthaler
Terry Garfinkle
Stacey Gray
Gregory Grillone
Kenneth Grundfast
Scharukh Jalisi
Paul Konowitz
William Mason
Michael McKenna
Ralph Metson
Pieter Noordzij
Dennis Poe
Edward Reardon
Elie Rebeiz
2012
David Roberson
Douglas Ross
Robert Sofferman
Phil Song
Jo Shapiro
Wendy Stern
John Stram
Richard Wein
6
Tim Anderson
Peter Catalano
Cathy Chong
Michael Cunningham
Jaimie DeRosa
Ramon Franco
Bruce Gordon
Gregory Grillone
Chris Hartnick
Daniel Lee
Miriam O’Leary
Rafael Ortega
David Rudolph
Jerry Schreibstein
Andrew Scott
Gavin Setzen
Jeffrey Spiegel
Charles Vaughan
Mark Volk
Bill Wood
2013 Otolaryngology Graduates
Wayne Chung, MD
When I first opened the letter on Match Day, I
had mixed emotions. On the one hand, I was
excited to have matched at such a well regarded
program, but I was also nervous about leaving
New York City and the simplicities of being a
medical student for the hard life of a resident in
Boston. I also had heard a lot about Red Sox
nation, so I decided to tell everyone I was a Mets
fan to deflect the animosity toward the Yankees.
Despite all the angioedema, epistaxis, and
facial trauma consults, the sleepless “home
call” nights, and the complicated transfers
from outside hospitals, I have thoroughly
enjoyed these past few years and will be sad to
leave them behind. Residency has been a time
of professional as well as personal discovery.
Residency has taught me humility, consistency, responsibility, and respect.
Five years later, I am still not a Red Sox or
a Patriots fan, but I have no doubt about my
good fortune to have been matched at this program. The diversity of patient population and
the educational experiences offered by the faculty make this a great program. I feel prepared
and am excited to continue my endeavors in
New York City.
I first want to thank my family for their
support and understanding. They were led
to believe that since Boston is only 3 ½ hours
away from New York City, that I would be able
to go home more often than I actually did.
They have forgiven me for missing important
family events and holidays. I cannot repay
them or make up for any time lost, and I know
that I was not the only one suffering during
those call nights.
Thank you to all of the faculty at Boston
Medical Center, Lahey Clinic, the Boston
Veterans Administration Hospital, and Children’s Hospital Boston. It has truly been a
privilege and an honor to work with all of you.
I have learned so much at each institution and
with each attending. I am thankful that you
entrusted me to take care of your patients. I will
take all your words of wisdom and advice with
me, but don’t be surprised if you receive a phone
call from New York asking you for a reminder.
Alphi Elackattu, MD
My history with the BMC Department of Otolaryngology started in the Summer of 2007,
when I started as a research fellow after graduating from Northeastern Ohio Medical School.
After a year of working with just about every
physician in the Department, I was privileged
to join the team for residency. I have been fortunate to be trained by some of the best physicians
in our field who have a true zeal for teaching.
Our exposure to the entire spectrum of training and practicing environments from BMC
to Lahey Clinic to the VA hospital systems has
given me well-rounded experience which will, I
believe, in the end help me to be the best otolaryngologist that I can be and at the same time,
provide exceptional care for my future patients.
During my third year of residency, my wife,
Anita who was at that time a pediatrician in
Brockton, and I were blessed with a son, Benjamin, on March 11, 2011. Benji has definitely
been a blessing and a challenge at times. Without the help of my and Anita’s mothers to help
take care of him, it would have been much more
difficult for the both of us to manage – given
our careers. Anita’s support and enduring love
have been the cornerstone of our relationship
and our successes.
After graduation, I will be joining the Presence Hospital System on the Northside of
Chicago – minutes from where I grew up. I plan
to use my well-rounded training to develop a
true “general” otolaryngology practice. I will
always have fond memories of my times in
Boston and, most importantly, of all those who
made the experience the incredible journey that
it has been.
Bharat Yarlagadda, MD;
Wayne Chung, MD;
Alphi Elackattu, MD
7
Bharat Yarlagadda, MD
Thinking about graduating from residency
makes me realize how quickly the past five
years have gone by. My experience at Boston Medical Center has been filled with both
challenges and success and has certainly been
a meaningful experience. I have loved living
in Boston which, as we all know, is one of the
liveliest and most fun cities around.
My post-residency plans include a one-year
fellowship in Head and Neck Oncology and
Microvascular Reconstruction at the Massachusetts Eye and Ear Infirmary. I am excited
about this chance to enhance my training
and focus on my clinical interests. Afterwards, I hope to join a faculty practice. My
destination will be, of course, influenced by
my wife’s career path as well. I am definitely
looking forward to knowing where we will
be headed!
I wish to express my sincere gratitude
to everyone I have worked with at Boston
Medical Center, Lahey Clinic, the Veterans
Administration Hospital, and Boston Children’s Hospital. This includes the entire
faculty, staff, administrators, nurses, and
especially my co-residents. Also, I want
to thank my mother, father, and sister who
have always supported me despite the hundreds of miles between us. Finally, I want to
thank my beautiful and caring wife Sail - I
cannot describe how lucky I am to have her
by my side. Charles W. Vaughan, MD –
A Department of Otolaryngology Treasure
A
ll of the presentations given at the 2012
Scary Cases Conference were fascinating and loaded with useful information.
The presenters are to be commended for
their willingness to share their frightening
medical experiences and for their efforts
to extract from their own experiences the
lessons learned that were so valuable to colleagues, residents, and others who attended
the Halloween day meeting. One of the most
distinctive talks given was the one entitled, It
was Not Your Fault!, presented by Dr. Charles
W. Vaughan, who was the very first resident
in the Boston University Otolaryngology
Residency Program.
In his unique presentation, Dr. Vaughan
introduced esoteric concepts involving theories of random occurrences and challenges
in attributing causality to events that occur.
He showed a close-up photograph of three
piles of sugar crystals and then, in successive
photographs, showed what happened when
additional sugar crystals were added to each
pile. (Photo 1) Eventually, each of the three
piles of crystals collapsed with the addition
of more crystals, but each pile re-configured
in a different way. (Photo 2) Dr. Vaughan
then told the meeting attendees, who were
enraptured by what he was saying, that each
Dr. Vaughan teaching at the Boston University School of Medicine
Introduction to Clinical Medicine (ICM) Class in January 2013
surgical case is different and even though
most cases go well, at times, just one thing
done differently can result in an adverse outcome even though what was done may not
have been inherently wrong.
Photo 1
Photo 2
8
Dr. Vaughan gave an example of a surgical case that he had done during the years
when he was still doing otologic surgery. He
described the incident of an otolaryngology resident’s being shown how to palpate
the endolymphatic sac while operating on a
patient with Meniere’s Disease and accidentally puncturing the sac resulting in leak of
endolymphatic fluid. The leak was an accident but what had occurred was tantamount
to an endoloyphatic sac decompression.
Unintended, but the result was relief of the
patient’s symptoms of vertigo. Dr. Vaughan
quoted Osler, “Variability is the law of life, as
no two faces are the same, no two bodies are
alike, and no two individuals react alike, and
behave alike…” Furthering Osler’s thought,
Dr. Vaughan described life as inherently
unstable (chaotic) as demonstrated by the
sugar crystals. Which crystal, when, and the
nature of the deformity are completely random, unpredictable; the only certainty is that
it will happen and although the result may be
“scary,” it should be considered normal, a nofault event from which one can learn and even
earn a Nobel Prize.
Dr. Vaughan likely may be the faculty
member at the Boston University School
of Medicine with the longest continuous
record of having been an active teacher. He
joined Dr. Stuart Strong on the faculty in the
Department of Otolaryngology immediately
following completion of his residency in 1960,
and he is still teaching medical students in
the Introduction to Clinical Medicine (ICM)
course. He still teaches residents in the temporal bone dissection/drilling course and he
occasionally attends conferences and didactic
teaching sessions. Dr. Vaughan was an adept
innovative laryngologist before laryngology
was ever recognized as a sub-specialty in
otolaryngology. Many modern-day laryngologists consider Dr. Vaughan to have been such
a pioneer who is viewed as one of the revered
forefathers of laryngology in the United States.
In fact, Dr. Steven Zeitels, perhaps the most
well-known and most respected laryngologist
in the world, says of Dr. Vaughan, “I have
greatly benefited from Dr. Vaughan’s unique
approach to surgery as an art and craft. By
adopting his intense respect for history, while
espousing a philosophy of questioning the
validity of conventional wisdom, I became
better equipped to see beyond surgical dogma
and thereby aspire to more creative surgical
problem-solving.”
In the years after retiring from active
medical practice, Dr. Vaughan has had time
to pursue some of his artistic interests. He
is a creative and talented artist whose works
include the group portrait (2008) of the
faculty in the Department of Otolaryngology that has been hanging in the entrance
Dr. Vaughan and Dr. Strong, 2004, (Acrylic on canvas)
to the Department for the past five years
and the portrait of himself and Dr. Strong
that hangs in the Strong/Vaughan Otolaryngology Conference Room in FGH 4. Dr.
Vaughan is also an expert videographer who
has amassed a collection of video interviews
with many of the greatest otolaryngologists of
our time. Recently, when someone asked Dr.
Vaughan why he continues to give lectures
to students and attend resident teaching sessions, he replied with a broad grin, “Because
it’s so much fun!” The Boston University
Department of Otolaryngology’s first resident
certainly has been a loyal graduate, an innovator, a superb teacher, a wonderful mentor,
and the greatest role model – showing all of
us how to have a successful career while at the
same time enjoying life. The Department of Otolaryngology faculty, 2008, (Acrylic on canvas)
9
NIH Funds
BMC Department of Otolaryngology –
Head and Neck Cancer and
Boston University Department of Biomedical Engineering
Collaboration for Better Surgery and
Prognosis of Oral Cancer ($523,940)
Development of Elastic Scattering Spectroscopy (ESS) to assess surgical margins for
resection and diagnosis of oral cancer.
Gregory Grillone, MD, Principle Investigator; Zhi Wang, MD, Investigator; Irvine Bigio, PhD., Investigator.
T
his is a 2-year clinical study of oral cancer which is one of the most common
cancers seen in the head and neck. Surgical
resection remains a primary modality for
treatment but local and regional recurrence
remains the most common problem after
surgical resection, resulting in a 60-80%
recurrence rate in the first three years.
Inadequate tumor excision is a common
cause for such local recurrence. This could
be explained by the current inadequacy of
methods for assessing surgical margins and
by the presence of “satellite” malignant
cells (“skip lesions”) in sites away from the
primary cancerous lesion which occur as a
result of the “field cancerization” phenomenon. Currently, surgeons often depend on
their own judgment or visualization under
white light to determine surgical margins.
Confirmation of negative margins is often
based on randomly selected samples for
frozen section biopsies, leaving much of the
surgical margin unexamined. Moreover, frozen section analysis can be time consuming,
expensive, and have a high rate of false negatives. A new approach is highly desirable.
Drs. Grillone and Wang bring otolaryngologic clinical experience and technological
expertise, respectively, to the project.
Optical technologies can be used to
distinguish in situ benign from malignant
mucosal lesions. ESS is a point spectroscopic measuring technique that can detect
with great sensitivity sub-cellular morphological differences between benign and
malignant tissue, such as changes in nuclear
grade, nuclear to cytoplasm ratio, mitochondrial size and density. ESS provides
the advantage of real-time, objective and
quick assessment of tissue morphology. This
study will examine the diagnostic potential
of ESS patterns to differentiate benign from
Zhi Wang, MD and Gregory Grillone, MD
malignant tissue in grossly normal appearing mucosal margins in oral cancer. Dr.
Bigio and his group in the Department of
Biomedical Engineering at Boston University will design and fabricate the required
instrumentation to obtain and record these
patterns intra-operatively, develop analytical
models and analyze clinical data provided
by the clinicians. This collaboration will
explore the feasibility of extending this optical technology for a new clinical application
for oral cancer surgery and optimize the
design of the systems and tools for clinical
friendliness.
The hope of the collaborators is that this
new optical technique will greatly improve
surgeons’ accuracy in determining and
assessing surgical margins in excision of oral
cancers compared to traditional approaches
alone, thereby significantly reducing local
recurrence rates. Irvine Bigio, PhD
10
Dr. Scharukh Jalisi, President of the Massachusetts Society
of Otolaryngology – Head and Neck Surgery (MSO)
S
charukh Jalisi, MD, Director, Division
of Head and Neck Surgical Oncology and
Skullbase Surgery, Department of Otolaryngology – Head and Neck Surgery, Boston
Medical Center; Assistant Professor of Otolaryngology and Neurosurgery at the Boston
University School of Medicine, currently is
President of the Massachusetts Society of
Otolaryngology – Head & Neck Surgery
(MSO). The MSO is active on behalf of its
237 members in working with the legislature
on issues that pertain to otolaryngologists as
well as with the Massachusetts Medical Society (MMS) to help MSO members implement
reporting and billing requirements of the
State’s largest health insurers.
This year’s significant legislative accomplishments include:
Introduction of a bill in the Massachusetts
State House: An Act to Provide Increased Access
to Hearing Aids. This bill was introduced in
the State Legislature with a goal to improve
patient care by allowing patients to see
fewer doctors and specialists, save time and
treatment costs and copayments by allowing
otolaryngologists to sell and/or dispense
hearing aids to their patients.
Support for a bill with MSO to provide
Insurance Coverage for Hearing Aids for
Children and Cleft Palate. This bill requires
health insurers to provide coverage for hearing
aids for children 21 years or younger and for
children under the age of 18 for treatment of
cleft lip and cleft palate.
Working with the MMS this year, the MSO
was able to relieve otolaryngologists of arduous
Blue Cross Blue Shield audit requirements
imposed by the BCBS designated vendor in
favor of in-house audits. The MSO also engaged
with Harvard Pilgrim Healthcare to review the
Practice Variation Data on nasal endoscopy.
Delineating to HPHC the limitations of their
research methodology, the MSO offered to work
with them via the Academy of Otolaryngology
– Head and Neck Surgery to define national
standards of nasal endoscopy. The MSO is also
endeavoring to work with HPHC on reduction
of E/M payment by 50% on the same day as a
procedure is performed.
Dr. Jalisi, MSO President, Introduces the Speakers
at the February 27th Meeting
Dr. Hillel, (1974 Residency Program Graduate)
Speaks at the February 27th MSO Meeting
Vartan Mardirossian, MD
2013 Otolaryngology Fellow in Facial Plastic and Reconstructive Surgery
V
artan Mardirossian, MD, will be graduating in June 2013 as the fourth Fellow
in Facial Plastic and Reconstructive Surgery
at Boston Medical Center. Dr. Mardirossian
joined the Department of Otolaryngology –
Head and Neck Surgery in 2006 as a Research
Fellow working with Drs. Grillone and Wang
on the spectroscopy study with MIT. He
then was accepted into the BMC residency
training program in otolaryngology and
graduated in June 2012. For the past year,
Dr. Mardirossian has been working under
the mentorship of Jeffrey H. Spiegel, MD,
The healthcare reform landscape is rapidly
changing with the advent of global payments
and accountable-care organizations. For this
purpose, the MSO organized a CME course
on February 27 2013 entitled, ACOs: Survival
Guide for the Otolaryngologist. The featured
speakers were Dr. Barbara Spivak and Dr.
Richard Hillel. The program also educated
the audience of otolaryngologists about the
new legislation, Chapter 224, recently passed
in Massachusetts which includes policies
around physician apology.
The MSO continues to educate its
membership on issues related to legislation,
reimbursements, and changes in the
healthcare landscape. Chief of Facial Plastic and Reconstructive
Surgery in the Department of Otolaryngology – Head and Neck Surgery. Vartan sums
up the past year, “I thank my wife, Galina,
for her continued support during this year. I
have worked to refine my clinical and surgical
skills and acquired important knowledge in
the field of facial plastic surgery from a worldclass mentor.” After graduation, Vartan will
be moving to the Palm Beach area of Florida,
where he intends to establish his own facial
plastic practice. He says, “I am looking forward to it!” 11
BOOOOOOOOOOOOO!!!
Scary
Otolaryngology
Cases
The Conference Center at
Waltham Woods
Waltham, Massachusetts
one day after. . . . Halloween
November 1, 2013
Boston University School of Medicine
Continuing Medical Education
Kenneth M. Grundfast, M.D., F.A.C.S
Michael P. Platt, M.D., F.A.A.O.A
Chief, Department of
Otolaryngology-Head and Neck Surgery
Boston Medical Center
Professor and Chairman of
Otolaryngology-Head and Neck Surgery
Boston University School of Medicine
Assistant Professor of
Otolaryngology-Head and Neck Surgery
Boston University School of Medicine
Boston University School of Medicine is
accredited by the Accreditation Council for
Continuing Medical Education to provide
continuing medical education for physicians.
This activity has been approved for
AMA PRA Category 1 Credit(s)™
Do you have a
to present?
Call or contact Dr. Michael Platt at 617-638-7933 or miplatt@bu.edu
Boston University School of Medicine
820 Harrison Avenue, Boston, MA 02118
Here
Stamp
Place
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