Thursday, June 26, 2014

The art of veterinary surgery: interview with specialist surgeon Sarah Goldsmid

Dr Sarah Goldsmid, surgeon at the Animal Referral Hospital in Sydney.

Veterinary surgery can be extremely rewarding, but it can also be extremely challenging. Surgical specialists take on the really tough cases. Dr Sarah Goldsmid, based at the Animal Referral Hospital, is one woman who has carved out a career at the cutting edge. Not only can she perform surgery that many others won't - she often gets out of bed in the middle of the night to do it. She's the kind of person we want to be when we grow up. But she was still happy to chat to SAT about her career.

It is often said that some people are born surgeons. So were you naturally good at tissue handling from the get go, or did you have to work on this?

I think it is true to say that good surgeons naturally have a reasonable amount of dexterity and creativity. I loved craftwork when I was young – especially needle work. I was good at making things with my hands and I think that is a good skill to start with. As far as dealing with body tissues – you need to be confident in your anatomical knowledge and you need to practice, practice, practice. Watching gifted surgeons at work is also an inspiration in how to handle tissues, hold instruments, retract and follow Halsted’s surgical principles.

There must have been a certain level of natural surgical skills, because I remember my first live dog spey when I was in 4th year vet science (at Sydney Uni Camperdown). I did the procedure in ½ hour and it went really well. The surgical registrar was impressed and told me I was going to be a surgeon …. she obviously knew more than me at that stage. I hadn’t even considered specializing and had no idea what was involved.

Sarah performs surgery on a dog with a GDV (gastric dilatation volvulus).
How did you improve and hone your surgical skills? 

I have already partly answered this, but certainly practicing procedures is important. I learnt quickly and once I had done a procedure even just a couple of times, I became a lot more confident. As a surgical resident, the specialist surgeries were learnt by firstly watching specialists do the surgery at the university as an assistant. Then I would perform the surgery with a specialist assisting me. Finally I was let loose on patients without my hand being held. I paid close attention to any tips or pointers that other surgeons would give (some I found useful, but not all). I also tried to attend as many conferences on surgery as I could and even better if there was a practical component in the course.

Performing an L7-S1 laminectomy in a dog.
Specialist surgeons appear to tackle anything with ease. How much planning goes into your surgical approach? What procedures take more planning than others?

Any surgery requires planning. You need to consider your surgical approach, options when you are in surgery (always have a plan B and maybe a plan C and D as well), have an understanding of possible complications that might occur during surgery and postoperatively (and have a plan of how you would manage those complications if they arose).

A linear foreign body. Note the plicated intestine. Definitely a surgery you need a plan B, C and D for...
While some procedures that we do regularly do not require so much thought – some of the more unusual procedures require a lot more planning.

For instance – some of the mandibulectomies or maxillectomies to remove oral cancers are planned by creating 3D reconstructions of the lesion and skull from our CT images. Difficult fracture repairs can be likewise planned on reconstructions or using templates. For corrective osteotomies we might have the implants pre planned and pre made (such as Type II or III or Ring External Fixateurs). Reconstructive surgeries require a detailed understanding of skin flaps and grafting techniques. It is an artform (much as a sculptor plans in 3D) to create an appropriate flap from adjacent skin or move a free flap from another part of the body (carefully trying to match colour, hair type and hair direction) to end up with a cosmetic and functional result. Spinal and brain surgeries require careful planning to ensure an approach that is minimally traumatic and gives the best access to the site of the problem – usually with the aid of an MRI.

Pre-operative MRI aids planning.
Did you have any surgical mentors and heros/role models when you were training?

My two main mentors were Dr Chris Bellenger (particularly in soft tissue procedures) and Dr Ken Johnson (mainly orthopaedics). During my time as a resident at Sydney University, I was also lucky enough to be exposed to at least another 6 Boarded North American surgeons who visited and worked at the uni during the time I was there. It was like visiting all the major veterinary university surgical services in the USA – but they came to me. That doesn’t happen now and I think it was a wonderful learning experience for me.

Am I easily impressed...or is this the most impressive prostatic cyst you have ever seen?
What is your favourite surgery to perform and why?

That’s a hard one to answer, because I get a thrill from any surgery that goes well and the owner’s and patients are really happy. I love seeing a spinal patient (that was carried in to the consult) walk out the door to go home – that is a great feeling. I love hearing from the owner that their dog has become like a puppy again since I removed the chronicly infected ear canal with a total ear canal ablation and lateral bulla osteotomy. I find it really rewarding to see a dog walk and run after their fracture was repaired, or their cruciate ligament deficient stifle was stabalised. It is so rewarding when a dog with cancer can be successfully surgically treated and be cancer free, or a cat with 3rd degree burns to all 4 feet can be managed to have fur regrow on all feet and walk, run and jump again.

I think what I really enjoy about being a specialist surgeon is the huge variety of cases and the unexpected and unusual cases.

Total hip replacement in a dog.
What surgeries do even specialist surgeons find challenging? > or what is your LEAST favourite surgery?

It is always a little challenging to be the second surgeon to perform the procedure. So, for instance, when someone has attempted resection of a cancer and has placed a drain several centimeters from the original mass – so you are forced to remove not only the original mass with a margin, but all the drainage tract with a margin as well. Or, having to reconstruct a fracture that is infected and has unstable implants already placed – that can be a little challenging.

I think the most frustrating cases are those that if you had only seen them a little earlier – the prognosis would have been vastly better. So particularly things like acute spinal cases, due to herniated intervertebral discs, that lost deep pain more than 24 hours ago ….. if you had just seen them a couple of days earlier the prognosis may have been 85-90 per cent chance of walking again (while they still had deep pain) vs  less than 10 per cent when they have lost it for more than 24 hours.

Sarah works with a dedicated team.
Complications occur in medicine and surgery. What is the most challenging complication you've ever dealt with?

When doing a PDA (patent ductus arteriosus) surgery – the biggest concern is the vessel you are trying to ligate may tear and the puppy will bleed out in a very few seconds, particularly when they are often only a kg or two in weight. Naturally you are thinking about this while carefully dissecting around the vessel and placing the suture. 

I remember one such surgery, right at the critical point when I was just passing the suture around the vessel – the surgical intern who was assisting me passed out and fell backwards. The vessel tore, the puppy started to bleed out and I quickly managed to get the suture around the bleeding vessel and tie it to stem the blood flow. Meanwhile yelling for someone to come and assist my intern while the nurse managed the anaesthetic. Both intern and puppy did well after the ordeal. My heart beat a little faster for a while.

A good surgeon is calm under pressure.
What character traits are desirable for a career in surgery?

I know I am female – but I often say you have to have “balls” to be a good surgeon. That is to say – you need to be confident, bold and definitive. It’s no good being really gentle, slow and hesitant. So when the bone is bleeding dramatically while you are sawing away part of the maxilla – you have to keep going because you cannot control the bleeding until you have the jaw removed and you can access the origin. When you are doing cancer surgery, you have to remove the cancer with a margin of normal tissue, in other words you have to be bold and make a damn big hole. Then you have to have a plan (or maybe two or three) of how to deal with the big hole.

To even get to be a surgeon you have to have perseverance, discipline and be prepared to work hard (day and night).

It is probably not the best career to choose when you are a mother – having said that I have successfully had two children and raised them to adulthood. Neither of them have become axe murderers, yet. I couldn’t have done what I do without a very supportive husband. It is tough to be working long days, trying to run away at the end of the surgery to pick up a daughter from childcare when they are charging you $8per minute you are late. Or getting called out in the middle of night, then rushing home to get them up to get to school, remembering the school project, gym clothes, softball bat and violin …. you get the picture. It can be done, but you have to be organized, resilient and have a sense of humour.

A surgeon's view...
What is the difference between a good surgeon and a great surgeon?

Communication skills. You can be the best surgeon in the world, but if you can’t communicate with your clients to explain the procedure, prognosis and complications in understandable terms and appear confident – then no owner will want you to operate on their pet.

Of course you have to be able to deliver on the surgery as well.

Thank you Sarah for sharing you're incredible story and case load with us - and thanks for these amazing photos. If you want to read more about inspirational surgeons, check out this post on pioneering neurosurgeon (and bloke of my guinea pigs is named after), Harvey Cushing.