Practice News

This article was originally posted on the Philadelphia Inquirer.

By Melissa Dribben, Inquirer Staff Writer

The equipment that could add years to Kevin Neary’s life came in a flat gray box the size of a frozen taco dinner.

His father, Joe, pulled the device out of a backpack and placed it on the desk in a nondescript medical office park in Egg Harbor Township, N.J.

“Let’s do this,” said Neary’s surgeon, Matthew Kaufman.

“I’m ready,” said Neary.

The 29-year-old graduate of the University of Pennsylvania had been on a ventilator since Nov. 15, when he was shot during an attempted robbery in Northern Liberties and left quadriplegic. Doctors thought that the damage from the bullet, which was still lodged in his neck, had impaired the phrenic nerve, which triggers the diaphragm and allows the lungs to draw in air.

Three weeks ago, Kaufman operated on Neary in a South Jersey hospital, expecting to perform a delicate and rare procedure with about a 50-50 chance of success. He was going to salvage one of Neary’s healthy nerves, the one that allows him to shrug his shoulders, and transplant it to replace the phrenic nerve. If that worked, it would have taken six to 10 months before Neary could try using a pacemaker to fire up his diaphragm and breathe without the ventilator for minutes, perhaps hours, maybe even 24/7, if they were very, very lucky.

But once the surgery was under way, Kaufman discovered that Neary didn’t need a transplant after all. His phrenic nerve was intact and functioning. It had been merely caught in a clutch of scar tissue and shoved out of place. Kaufman cleaned out the biological muck, both freeing the nerve and giving Neary more mobility in his neck, then sent him home to heal.

Kaufman also was able to extract the bullet from Neary’s neck and gave it to him to take home. (The bullet, about 3/4 of an inch long and weighing less than an ounce, will be handed over to the Philadelphia District Attorney’s Office this week.)

As soon as the scars healed to pink and brown dashes above his collarbone and along his rib cage, Neary was anxious to try out his new equipment.

He, his father, and one of his nurses had been up before dawn Wednesday, preparing for the 90-minute drive from Upper Chichester.

“Not many health-care professionals are comfortable with this pacemaker,” said Kaufman, an elegant man in a dove-gray suit. He is 39, tall and thin, with the poise and posture of a ballet dancer.

“The only thing we want to do is turn it on and see if he’s getting responses. We don’t expect miracles today. This is like Week One of a four-week training for a marathon.”

Neary laughed. “I do a lot of walking and running in my spare time!”

Neary’s father reached into the backpack for a 9-volt battery to plug into the gray box, which would emit signals to the internal transmitters. Then he tore off strips of athletic tape to attach the antennae – two rubbery-looking circles – to his son’s chest.

Then Kaufman’s assistant called Kenneth Aron, the vice president of sales and marketing for Avery Biomedical Devices, the company that manufacturers the phrenic nerve stimulator.

The device was first approved by the FDA in 1986, Aron said. In 2003, actor Christopher Reeve, who had been paralyzed in a horse-riding accident, was part of a trial testing a system similar to the one Neary received.

A few dozen patients have been breathing with these pacemakers for 20 years, Aron said. Fewer than 100 a year are implanted.

From his office in Long Island, Aron would be guiding Kaufman through the test run. He had planned to monitor, by telephone, how well the device was working, but the connection was not clear enough. Kaufman, instead, would report Neary’s oxygen levels and heart rate and adjust the power of the electrical impulse accordingly.

“You’re going to have to walk me through this,” said Kaufman. Normally, the test run is handled by a pulmonologist or respiratory therapist, but there had been scheduling difficulties and Neary was impatient, so Kaufman agreed to get him started. There was no risk, he said, because if the device didn’t work, he would immediately put Neary back on the ventilator.

“How do we want the settings?” Kaufman asked Aron.

“My starting point would be 1.8 to 2.4 . . . look for maximum diaphragm contraction.”

“OK,” Kaufman said, talking over static on the phone line. “Are we on Mars yet? On the transmitter, the lever is switched to B. . . . Is that correct?”

Neary listened carefully, trying to follow.

“Hello?” Kaufman asked. The telephone connection was lost.

While the assistant redialed, Neary complimented Kaufman. “I like your shirt and tie,” he said, offering to send him something from his own collection. Before the shooting, he had started his own business, recruiting health-care staff, and had been an impeccable dresser. Now his injuries made sweatpants and hoodies more practical.

With Aron back on the line, Kaufman flipped a few switches.

“OK. Take the vent off,” he told the nurse.

“Nice!” said Neary. “I hate the vent.”

The room fell silent. Everyone stared at Neary’s chest. The machine beeped. His rib cage jerked suddenly. Then again. “He’s getting some movement,” Kaufman said.

For the first time since he was shot, Neary was breathing independently.

His dad began to cry and left the room to regain composure.

“Apollo has landed!” said Kaufman. “He’s cranking.”

“It feels weird,” Neary said, mouthing the words. It will take months for him to learn how to speak with the reversed flow of air. And over time, as his breathing muscles regain strength, the contractions will grow smoother.

After 14 minutes, Neary’s oxygen levels were still at 98 percent, but Kaufman didn’t want to push him too fast, too far. “Why don’t we switch him back to the vent?”

Neary shook his head, “No!”

“All right. We’ll go to 15.”

Reattached to the ventilator a minute later, Neary thanked Kaufman. “Good job, doc.”

“You’re on your way, my friend.”

According to The National Stroke Association, public knowledge of stroke is low. That’s why The Institute for Advanced Reconstruction in Shrewsbury, New Jersey, is joining the effort during Stroke Awareness Month in May and throughout the year. The Institute is a leader in stroke treatment, performing life-altering procedures for select patients who have suffered from some devastating effects of stroke.

Definition

A stroke is the sudden death of brain cells in a localized area due to inadequate blood flow.

Description

A stroke occurs when blood flow is interrupted to part of the brain. Without blood to supply oxygen and nutrients and to remove waste products, brain cells quickly begin to die. Depending on the region of the brain affected, a stroke may cause paralysis, speech impairment, loss of memory and reasoning ability, coma, or death. A stroke also is sometimes called a brain attack or a cerebrovascular accident (CVA).

Some important stroke statistics include:

• More than one-half million people in the United States experience a new or recurrent stroke each year
• Stroke is the third leading cause of death in the United States and the leading cause of disability
• Stroke kills about 160,000 Americans each year, or almost one out of three stroke victims
• Three million Americans are currently permanently disabled from stroke
• In the United States, stroke costs about $30 billion per year in direct costs and loss of productivity
• Two-thirds of strokes occur in people over age 65 but they can occur at any age
• Strokes affect men more often than women, although women are more likely to die from a stroke
• Strokes affect blacks more often than whites, and are more likely to be fatal among blacks

Paralysis

Paralysis is one of the most common disabilities resulting from stroke. The paralysis is usually on the side of the body opposite the side of the brain damaged by stroke, and may affect the face, an arm, a leg, or the entire side of the body. This one-sided paralysis is called hemiplegia if it involves complete inability to move or hemiparesis if it is less than total weakness. Stroke patients with hemiparesis or hemiplegia may have difficulty with everyday activities such as walking or grasping objects. Some stroke patients have problems with swallowing, called dysphagia, due to damage to the part of the brain that controls the muscles for swallowing. Damage to a lower part of the brain, the cerebellum, can affect the body’s ability to coordinate movement, a disability called ataxia, leading to problems with body posture, walking, and balance.

The specialists of The Institute for Advanced Reconstruction deal with some of the results of stroke. According to Dr. Andrew Elkwood, “Whereas we cannot cure stroke, we can sometimes help treat some of the results. We can sometimes mitigate the paralysis and help patients with increased function. It is possible to lessen some of the spasticity caused by stroke. Ultimately, the goal is to cure and prevent strokes; nonetheless, surgeons at The Institute for Advanced Reconstruction can help limit its devastating effects.”

Relevant procedures deal the results of most major types of stroke. These include:

Right-Hemisphere Stroke

A stroke in the right hemisphere often causes paralysis in the left side of the body. This is known as left hemiplegia.

Left-Hemisphere Stroke

The left hemisphere of the brain controls the movement of the right side of the body. It also controls speech and language abilities for most people. A left-hemisphere stroke often causes paralysis of the right side of the body. This is known as right hemiplegia.

Brain Stem Stroke

Strokes that occur in the brain stem are especially devastating. The brain stem also controls abilities such as eye movements, hearing, speech and swallowing.

Innovative Stroke Treatments at the Institute for Advanced Reconstruction

At the Institute for Advanced Reconstruction, the world famous surgeons have pioneered treatments to help reverse arm paralysis in some stroke patients. In fact, the Institute was the first and only center in the nation and probably in the world to successfully perform nerve reconstructive surgery in a stroke patient.

For more on this procedure, and on The Institute for Advanced Reconstruction, log on to www.advancedreconstruction.com

This piece originally appears on the Plastic Surgery Center “Beauty Blog”

Caretakers are a critical part of plastic and reconstructive surgical care. However, even a thorough search of the Internet fails to account for the advice needed to optimally do this job. At the Plastic Surgery Center and The Institute for Advanced Reconstruction, we pride ourselves on fully informing both patients and their caretakers, thus providing knowledge and compassion on every aspect of patient care. It is yet another of the cutting-edge aspects of our practice.

Congratulations! You have the privilege of being the caretaker for a friend, family member or other person undergoing a cosmetic or reconstructive plastic surgery procedure. If you see this as an honor, you will enjoy being useful, and a positive force for your patient’s well-being, and ultimately, contribute to her* healing.

While it is important to undertake this task, depending on the procedure and your personal circumstances, evaluate whether you should be the sole caretaker.  In some cases, you may be better served by a professional caretaker (such as a nurse experienced in cosmetic surgery), or by having other back-up help. However, in most cases, simply following protocol, coupled with common sense, makes you perfectly qualified. Be assured that the appropriate steps are taken by your patient’s medical provider to make sure your patient is well cared for, and is safe before being released.

Your task is both a physical and psychological one. You want to take care of your patient’s basic needs, and support her emotionally with a competent, calm presence and positive attitude. Anyone can dispense a pill, but encouragement, an upbeat attitude and TLC can also be the best medicine for recovery.

That being said, and as you approach the procedure, if you are a friend or loved one, your concern for the patient is obvious. It is natural to be nervous for an impending procedure, and especially on the day of the surgery; remember that the doctor, nurses and staff at The Plastic Surgery Center and Institute for Advanced Reconstruction hear and see this all the time. It’s okay for your patient to express any anxiety (encourage it if necessary), and to let the staff use their expertise to reassure her. That can be amazingly calming. If you, too, are nervous, express that out of earshot of your patient, and allow the staff to comfort you as well. Additionally, post-surgery can also result in anxiety for your patient, for a variety of reasons. Understand that this is a natural part of the process, consult our staff if necessary, and just be a good listener. Remain upbeat.

As for practical matters: Prior to surgery, arrange all instructions and have on hand emergency telephone numbers and the number of a 24-hour pharmacy in case of need. At least one day before the procedure, review all paperwork for your patient, and pack it together with supplies. If you are new to the hospital or surgical facility, don’t simply print out directions or plug them into your GPS, but study them to ensure you have complete familiarity and avoid wasted time or anxiety by getting lost. Arrange to be freed up for any transportation, and for as long as necessary, for follow-up appointments and other needs, as some procedures require a longer break for a patient before she can resume driving.

The more competent and prepared you are, the more potential stress you take off the patient, and the more calm and confidence you inspire.

 

Here are a few other tips to ensure success in your role as caregiver:

Engage with the Staff - Get to know your patient’s doctor, nurses and support staff. Not only does it help to gather tips and inform yourself, a “kind word” is also appreciated by those working to serve you.

Make Yourself an Integral Part of the Process - If your patient is comfortable with it, go into all relevant pre- and post-procedure appointments so you will understand as much as possible. Ask any questions that will apply to the process. Post-surgery, carefully review with the medical staff how and when to change bandages or dressings, and deal with surgical drains if applicable.

Four Ears are Better Than Two - Listen to all instructions, and ask for any extra information not on the printed list. Write everything down—particularly since some of the most useful tips may come in conversation with the doctor, nurses and other expert staff. Take notes so you can remember everything and be well prepared. This takes a lot of the burden off your patient having to remember the details.

On Procedure Day, Be Prepared—for Your Patient and for Yourself - It is usually a long day(s), so have your supplies packed ahead of time. While you are of course focused on your patient, don’t forget yourself. Get a good night’s sleep prior to the procedure; bring water and snacks, and something easy to read (a novel or magazines) to pass the time. During your wait, take a walk or go for coffee or a meal, since it helps to break up the time and keep you fresh.

For post-procedure, pack extra clothing for warmth, have a large bottle(s) of water, with cups for easy drinking, as patients are instructed to hydrate well, and can get a head start on the way home (especially if it is a long drive).

Be Prepared for the Unforeseen - Next to doctor and staff, your patient relies on you—particularly in the crucial follow-up immediately following a procedure. Your understanding of the necessary post-operative care, and any signs that would alert you to telephone the doctor, allow you to confidently do your job.

Be Present, but Don’t Cling - You should not hesitate to be close and helpful, especially in the first 24 to 48 hours following surgery. Sleep nearby (in the same room if possible) and escort your patient to the bathroom or when she begins to walk around, since due to medications and being sedentary, some lightheadedness can be expected. Encourage your patient to get up and move as she is able, as walking helps facilitate recovery.

Help Your Patient Maintain a Healthy Recovery - Make sure she takes all medications–stay especially on top of pain medication as needed–and remind her to move her legs and or simply contract leg muscles frequently, to prevent the risk of clotting following anesthesia. Provide plenty of water, and make sure to include protein in every meal. Remember that your task can be tiring as well (such as being up in the middle of the night with your patient), and to continue to take care of yourself as well.

Provide a Patient Testimony - Encourage and assist your patient to write a testimonial, forms for which are provided by the practice; or, ask the staff how you can be most helpful. This is the best way of saying “Thank You” to your doctor, his/her staff and their practice for the service you have received.

While your patient may experience discomfort or moodiness, and at times you may feel stressed, hang in there. You are a vital part of your patient’s recovery. It is very satisfying to be a part of her care, and rest assured that she is grateful. Many of us can testify to the pleasure of hearing our patient express her thanks.

*The use of third person female, her, is used here to simplify the article. Men as well as women undergo these procedures at The Plastic Surgery Center and The Institute for Advanced Reconstruction

On Monday April 9, 2012, ABC-TV’s Good Morning America featured a story on migraine headache relief with specialized surgery. This treatment, including Botox and possible surgery for migraine sufferers, is offered by Dr. Matthew Kaufman of The Institute for Advanced Reconstruction, which is among the handful of practices offering specialized procedures in the New Jersey/New York regional area for qualified candidates.

Read all about it, and see our video, on the practice website, http://www.advancedreconstruction.com/migraine-headaches/.

“I refuse to let this diagnosis define who I am. What will define me is what I do in the future.”

That’s what 29-year-old Kevin Neary told the Philadelphia Inquirer in a March 26^th article. But it has been an incredibly hard journey to reach that remarkable conclusion. After being shot in a robbery last November nearby his residence in Philadelphia, Neary remains completely paralyzed. Since then, his journey has gone from desperation and darkness, to hope and determination.

On March 27^th, Neary underwent surgery with Dr. Matthew Kaufman of The Institute for Advanced Reconstruction and the Center for the Treatment of Paralysis at Jersey Shore Medical Center, in an effort to salvage Neary’s phrenic nerve and install a pacemaker to hopefully make his diaphragm work.

The phrenic nerve controls function of the diaphragm muscle – the primary muscle involved in breathing. Contraction of the diaphragm muscle permits expansion of the chest cavity and inhalation of air into the lungs.

The Inquirer legitimately characterized this difficult procedure as having only a “moderate” chance of success. Then again, Dr. Kaufman’s phrenic nerve patients, who come from around the country and the world, hear that kind of discouraging news from other doctors all the time. That’s why they seek him out.

Fate dealt Kevin Neary a devastating blow, but fate also landed him in the hands of Dr. Kaufman, who is the only known surgeon to perform nerve transplantation to reverse phrenic nerve damage.

“Kevin’s procedure went much better than anticipated.  We went into the surgery anticipating severe nerve damage and were elated when both phrenic nerves responded to external stimulation.  The prospect of him successfully weaning from the ventilator is excellent.  We will be initiating this process in two weeks and are hopeful that he will be breathing independently in the weeks and months to come.” – Dr. Kaufman

In the Inquirer article, Neary concluded, “If I can get off the ventilator for six hours, that’s a work day, or enough time to enjoy a Phillies game,” Neary said. “Work is a big part of who I am. It’s work and baseball for me.”

At the hands of Dr. Matthew Kaufman, Neary may, in fact, see the World Series hopeful Phillies repeat their 2008 title.

Neary underwent surgery with Dr. Matthew Kaufman of The Institute for Advanced Reconstruction and the Center for the Treatment of Paralysis at Jersey Shore Medical Center, in an effort to salvage Neary’s phrenic nerve