May 29, 2014 Emory Surgery newsletter Department of Surgery of the Emory University School of Medicine


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By saving one life, Dr. Lattouf reunites two

Dr. Lattouf speaks about the case on Fox News.
Dr. Lattouf speaks about the case on Fox News.

In February 2012, Emory cardiothoracic surgeon Dr. Omar Lattouf experienced what he referred to as the most difficult case of his career: the emergency removal of a large blood clot in a young mother's heart immediately after her twins were delivered by c-section. When Dr. Lattouf and his team opened the patient's chest, they found one end of the clot dangling in her right atrium and the other in the left. "It was like someone shoots a bullet and you have to go in and grab that bullet before it hits the target," Dr. Lattouf said. The operation was a success, and the twins were sent home after several months in Emory University Hospital Midtown's (EUHM) special care neonatal and perinatal unit.

But for prominent surgeons like Dr. Lattouf, pinnacle events can become just one in a series of unprecedented situations. One afternoon in late April of this year, Dr. Lattouf was introduced to his next impossible, never-before-encountered case via several CT scans urgently sent to him over his cell phone. Relayed by an obstetrician from Northside Hospital, the scans were of the chest of eight-month pregnant Edita Tracey of Roswell, GA, who had presented at the ER with chest pains. The ER team was initially concerned that something might be wrong with the baby. What the scans revealed, however, was that Edita had a huge aneurysm in the wall of her aorta that was not only bulging, it was ripping apart. There was a foot-long tear in the inner wall of her aorta and blood was pooling around her heart.

"I have performed probably thousands of emergency heart operations and many dozens of aortic dissections, and I had never been so scared," says Dr. Lattouf. "That little soon to-be-born baby intimidated me like no one ever before. In her weakness she was the most powerful person I have ever encountered."

Edita Tracey with her husband Ken and baby Arabella.
Edita Tracey with her husband Ken and baby Arabella.

With time at a premium, Edita was airlifted from Northside to EUHM, where two surgical teams gathered: one led by Emory OB GYN Dr. John Horton to deliver the baby, and the other led by Dr. Lattouf to repair the aneurysm. "We had to do it right the first time," Dr. Lattouf says. "There was no room for error, there could be absolutely no missteps."

Being very aware that the general anesthesia going to Edita was also going to the baby, the c-section team performed their job very quickly. "As soon as mom went to sleep, it literally took about 30 seconds and that baby was out and screaming," says Dr. Lattouf. The child, named Arabella, was 6 pounds, 12 ounces, and perfectly healthy.

Dr. Lattouf's team immediately took over and began what would stretch into an almost nine-hour surgery. After opening her chest, they drained the blood pooling around Edita's heart and placed her on a heart-lung bypass machine. Dr. Lattouf replaced her aortic arch, reimplanted the great arteries supplying the arms and brain, replaced the ascending aorta and aortic valve, and re-implanted the coronary arteries. Once the last stitch was placed, the clamps removed, and the heart started beating on its own, Edita's various physiological processes began returning to near normal. Dr. Lattouf allowed himself to "take a deep breath."

"Those nine hours passed like nine minutes," he says. "There were no breaks, no story telling, no music in the room. Just full attention on one small area: Edita's heart. That was my entire world for that time period."

Despite one precarious moment after another, the procedure had gone well, and Edita awoke the next day in the ICU to her husband Ken and held Arabella for the first time. "What a great feeling to save a mom's life and see her holding her newborn child the next day," says Dr. Lattouf. "As I look back, I am so thankful that things turned out so well. I don't know if I could have continued my career if I had failed Arabella by not saving her mom."

Watch the Fox 5 Atlanta story.

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Emory CSAT liver app 1.0 available in iTunes, 2.0 in development

Screenshot of the Surgical Anantomy of the Liver app.
The portability of the liver app allows it to be used in a variety of environments, including the operating room.

Produced under the auspices of the Thalia and Michael Carlos and Alfred A. Davis Center for Surgical Anatomy and Technique (CSAT), the first version of the "Surgical Anatomy of the Liver" iPad app is now available to non-Emory users in the Apple iTunes App Store, and for free to Emory users via the new Emory Internal App Store (Apperian). The 2.0 version of the app has just received funding for development.

CSAT has existed since 1984 with the mission of providing education in human macro anatomy in order to create surgeons and surgeon scientists who understand and respect the anatomic basis of modern surgical care. Building upon a rich tradition of landmark publications in the field, CSAT is currently harnessing the communications innovations of the 21st century to package and transmit its educational resources, and the liver app has publicly initiated CSAT's new focus on electronic education.

Intended for trainees, medical students, instructors, and anyone that needs a quick way to learn or teach liver anatomy, this interactive 3D app allows users to mentally map the anatomy of the liver in ways that were never before possible with print illustrations or imaging studies. The user can rotate the liver, turn structures off and on to understand the relationships, and tap anatomy to reveal a label.

With the support of Dr. Keith Delman, program director of the Emory general surgery residency, Emory surgical oncologist Dr. Shishir Maithel guided Emory School of Medicine medical illustrator Michael Konomos through the intensive process of accurately sculpting the complex anatomy of the liver, with the end product achieving a synthesis of radiographic, cadaveric, and surgical references as well as the distillation of hundreds of hours of liver surgery. CSAT medical illustrator Andy Matlock contributed 3D animations that display the typical configuration of the liver as it pertains to surgical anatomy. The app also includes over 12 minutes of liver videos narrated by Dr. Maithel. Visit the app's website.

A screenshot of version 2 of the Surgical Anantomy of the Liver app
Concept art for the 2.0 version of the liver app.

In May 2014, CSAT was approved to receive an Emory Fund for Innovative Teaching Grant (FIT) to support the development of the 2.0 version of the liver app, entitled "Surgical Anatomy of the Liver: 3D Model and CT Scan Integration." FIT grants are awarded to projects that display progressive research in education, creative interdisciplinary pedagogy, and integration of teaching innovations into the future curriculum of Emory.

Building upon the first edition of the app, the team plans for 2.0 to include a CT scan function that perfectly matches the liver and would allow the user to understand the connection between 2D tomographic images and the 3D anatomy encountered in the OR. Users would be able to turn vessels on and off, rotate the liver and connected CT images up to 360°, and draw tomographic planes through the y and z planes of the liver that would create horizontal and coronal views of CT images.

This 2.0 version of the liver app is expected to be available on iTunes and for free to Emory users by February 2015.

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Tom Dodson
Tom Dodson

Dr. Dodson receives the Emory Williams Award for Distinguished Teaching

Established in 1972 by alumnus Emory Williams, the Emory Williams Award for Distinguished Teaching is Emory University’s most prestigious teaching award. Mr. Williams was a 1932 graduate of the Emory College of Arts and Sciences. He began serving as a trustee in 1964 and was elected to emeritus status in 1981. He died in February 2014 at the age of 102.

Dr. Thomas Dodson, chief of the Emory division of vascular surgery, was chosen to receive the 2104 edition of the award for fostering participation, inquiry, and creative expression in the academic environment; being an outstanding role-model for teaching and scholarship; and serving as a gracious, trustworthy, and admirable mentor to students.

Before enrolling in Emory’s vascular surgery fellowship in 1987, Dr. Dodson was an assistant professor of surgery and coordinator of the third-year surgical clerkship at Harvard Medical School and associate director of the SICU at New England Deaconess Hospital.

Upon completing his fellowship, Dr. Dodson joined the faculty of the Department of Surgery. He was appointed associate program director of the general surgery residency in 1991 and full director in 1997, a position he held until June 2011. He has received numerous teaching and best doctor awards, served as president of the Georgia Surgical Society, and was a member of the Education Task Force of the American College of Surgeons.

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Congratulations to our 2013-2014 graduating chiefs!

2013-2014 Emory Surgery chief residents with Dr. Keith Delman and Dr. John Sweeney.

The photo above—snapped by Stephen Konigsberg, PA-C, Emory Vascular Surgery—features Emory Surgery's 2013-2014 chief residents at the annual chiefs banquet, held on Saturday, May 17, at the Woodruff Arts Center. The photo includes Dr. Keith Delman (5th from left), program director of the general surgery residency, and Dr. John Sweeney (7th from left), interim chair of the Emory Department of Surgery. The residents are (left to right) Sameer Patel, who will go on to a surgical oncology fellowship at M.D. Anderson Cancer Center; Preeti Subhedar, breast fellowship, Memorial Sloan-Kettering Cancer Center; Jamil Stetler, endosurgery fellowship, Emory; Melissa DeVito, private practice; Jennifer Avise, vascular surgery fellowship, Wake Forest University; Peter Thompson, plastic surgery fellowship, Emory; Michael Lowe, surgical oncology fellowship, Memorial Sloan-Kettering Cancer Center; Sarah Hill, pediatrics fellowship, Children’s Healthcare of Atlanta; Swetha Ramakrishnan, colorectal surgery fellowship, Washington University in St. Louis; and Lee Ocuin, surgical oncology fellowship, University of Pittsburgh School of Medicine.

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Long-time CSAT editor Carol Froman retires

Phyllis Bazinet, Dr. Skandalakis, Cynthia Painter, and Carol Froman at the original CSAT offices, 1998.
Phyllis Bazinet, Dr. Skandalakis, Cynthia Painter, and Carol Froman at the original CSAT offices, 1998.

In the early 1990s, the volume of publications associated with the Thalia and Michael Carlos and Alfred Davis Center for Surgical Anatomy and Technique (CSAT) of Emory University had grown to the degree that Dr. John Skandalakis—CSAT's late founding director—began assembling an editorial staff. Carol Froman was hired shortly thereafter. Following two decades of faithful and effective service to the center's mission of educating professional physicians, medical students, and residents about the anatomic basis of modern surgical care, Carol will retire from Emory in late May.

"By happenstance, I was recommended to 'Dr. Skan' by a former neighbor who worked at Emory and was familiar with some of my freelance writing and editing," Carol says when reflecting on her first meeting with Dr. Skandalakis. "When he discovered that we shared an obsession with history, he was delighted."

Carol's versatile skillset was initially shaped by her study of linguistics, which earned her a BA from Wellesley College. "Understanding how languages work and the components of efficient versus ineffective communication can teach you what works best when writing for different audiences," says Carol. "Even though the audience for Dr. Skandalakis and his colleagues' work was familiar with the jargon of the field, the text had to be as uncluttered and direct as possible since it described complex and sometimes variable relationships between anatomic structures and certain surgical procedures. It was imperative for the readers to be able to take the concepts in the material and translate them to the OR with minimal struggle. Like anything instructive, the more concise the teaching, the better the recall."

However, editors are responsible for much more than polishing text, a fact that comes into play most intensively with books. To meet the demands of this extended format, editors must juggle multiple and overlapping tasks and associated timelines/deadlines, including the chapter assignment phase, numerous author and coauthor communications, manuscript reviews, requests for revisions, acquiring permissions for copyrighted materials, submitting material to the publisher, and other functions. Carol helmed this process for several of CSAT's most well-known and respected books, including the 2nd edition of Embryology for Surgeons and the 4th edition of Surgical Anatomy and Technique: A Pocket Manual.

Carol also shared author credit with Dr. Skandalakis on "One Snake or Two: The Symbols of Medicine," published in American Surgeon, 74(4):330-4, 2008. The article analyzed the history of the erroneous interchange between the caduceus (a staff entwined by two snakes topped with wings) and the asklepios (one snake wrapped around a staff) as the symbol of medicine. Both icons are derived from several ancient mythologies. Although the asklepios is generally considered the correct symbol because of its association with Asclepius, a deity that represented healing and medicine, the caduceus is still used as the symbol for such organizations as the U.S. Army Medical Corps. Carol and Dr. Skandalakis argued that this confusion did not arise from ignorance, but from the loss of the deeper significance of the symbols and the replacement of religious iconographic constraints by aesthetic and decorative considerations.

In August 2009, the center suffered a tragic loss when Dr. Skandalakis died of leukemia. "I truly admired Dr. Skan's curiosity and how much he loved what he did, and I was very, very sad that I wouldn't be able to share that with him anymore," says Carol. "He never stopped being a student of surgery and anatomy, which he called his mistress. He was also a faithful supporter of budding researchers and wouldn't hesitate to assist them with their writing and publishing pursuits."

Various projects were in process at the time, so Carol, CSAT editor Phyllis Bazinet (hired in 1996), and administrative manager Cynthia Painter (who joined CSAT shortly after Carol) focused on completing the publications while running the day-to-day activities of the center. Dr. Keith Delman was appointed director of CSAT in 2012, and began laying the groundwork for adapting Dr. Skandalakis' legacy to the communications technology of the 21st century. In 2013, the center relocated from its offices at 1462 Clifton Road, NE, to the Surgical Education Office in Emory University Hospital.

Carol Froman speaking at a Toastmasters event.
Carol is a founding member and former president of Toastmasters@Emory.

During this period, Carol and Phyllis—who retired in mid 2013—assisted Emory vascular surgery chief Dr. Thomas Dodson with the 5th edition of Medical Management of the Surgical Patient, a book featuring Emory authors that provides an evidence-based approach for perioperative care and surgical management. "It was a wonderful experience to work with surgeons across the entire breadth and depth of the Department of Surgery. There is such a passion for delivering optimal patient care across clinical fields," says Carol.

Throughout her CSAT years, Carol has been an avid participant in several of Emory's initiatives, including Mentor Emory, the Transforming Community Project, the Center for Women, and the Office of Sustainability. "My husband and I get particular pleasure from serving as a host family for international participants in the Humphrey Fellows Program of the Rollins School of Public Health," says Carol. She plans to continue such activities as a retiree, primarily because, "Emory has given so much to me, and I just want to give back."

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Upcoming events

The Prospective Surveillance Model at Grady Hospital & Implementing a Screening Tool for Identifying Patients at Risk for Hereditary Breast and Ovarian Cancer: A Statewide Initiative
Presented by Brannon Traxler, MD, and Veronica Jones, MD
– Breast Surgical Oncology Fellows, Department of Surgery, Emory University School of Medicine
7:00 a.m. – 8:00 a.m., June 5, 2014 EUH auditorium
Joseph M. Craver Visiting Teacher Lectureship
Pulmonary Endarterectomy (PTE)

Presented by Stuart W. Jamieson, MB
– Distinguished Professor of Surgery and Chief of Cardiothoracic Surgery, UC San Diego School of Medicine
– Dean, Cardiovascular Affairs, UC San Diego Health System
7:00 a.m. – 8:00 a.m., June 12, 2014 EUH auditorium
Department of Surgery Division Chiefs Meeting 5:30 p.m. – 7:00 p.m., June 17, 2014 Surgery Education Office, EUH H108 & 110
Technical Aspects of Pancreatic Surgery: Evidence and Controversies in Breaking the Third Rule of Surgery
Presented by Lee Ocuin, MD
– Chief Resident, Department of Surgery, Emory University School of Medicine
7:00 a.m. – 8:00 a.m., June 19, 2014 EUH auditorium
Using Guidelines to Approach the Diabetic Foot Ulcer Epidemic
Presented by Glenn M. LaMuraglia, MD
– Associate Professor of Surgery, Division of Vascular and Endovascular Surgery, Department of Surgery, Massachusetts General Hospital
7:00 a.m. – 8:00 a.m., June 26, 2014 EUH auditorium
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