• A Conversation with Gabby Giffords' Neurosurgeon

    Author: Vivek Mehta, MD

    Martin E. Weinand, MD, is a neurosurgery residency program director and professor of surgery at the University of Arizona. On January 8, 2011, Dr. Weinand performed emergency surgery on US Representative Gabrielle Giffords after she was brought to University Medical Center in critical condition from a gunshot wound to the head. Eighteen other victims were killed or wounded in the shooting.

    Congress Quarterly: How did you initially hear about the shooting, and how did you become involved?
    Dr. Martin Weinand: I was the neurosurgery attending on that day. I had just arrived home after rounding in the hospital when I received a call from one of my senior residents. He told me a patient with a gunshot wound to the brain had been brought in and that it was our congresswoman, Gabby Giffords. At that time I told myself, “All right. We’re going to take care of this patient the same excellent way we take care of all patients with traumatic brain injury or any other neurosurgical problem.” I reviewed her CT scan from home. Based on that information I knew this was an eminently salvageable situation based on the criteria that most neurosurgeons use in a circumstance like this. I was surprised by the misrepresentation in the media of the situation. Our TV was on, and my wife was looking over my shoulders and said, “The media is reporting that she’s dead,” which I immediately knew was not true.

    CNSQ: Can you tell us about the initial steps in management?
    MW: As I was driving in, my residents had positioned her the way we had discussed. Michael Lemole, our division chief, had also come in. We applied the principles that neurosurgeons apply in these cases—to prevent infection and, when appropriate, decompression. What we did in the operating room was in no way remarkable or unique. We applied standard neurosurgical principles for patients with a survivable gunshot wound.

    CNSQ Can you tell us about the pre-hospital coordination of care?
    MW: The EMS system in Tucson, like many major or medium metropolitan systems in the United States, is well organized and efficient. The shooting occurred just north of the city limits of Tucson, so essentially in the greater metropolitan Tucson area. The transport time was fairly brief, measured in minutes, and the time to the operating room was 38 minutes after arrival at the hospital.

    From a neurosurgery standpoint, we do participate in trauma simulations prepara-tions, and protocols. Unfortunately, mini-mass casualties are routine experiences here. We rehearsed these kinds of scenarios on a monthly basis, because we’re a border hospi-tal, approximately 70 miles north of Mexico. It’s not infrequent to get vans that roll over with people migrating from the south. It’s not uncommon to have mini mass casualties peri-odically, particularly on the weekends. And so, yes, the institution simulates mass casualties, but we live mini mass casualties virtually every month.

    Fortunately, the care of gunshot wound victims in the 21st century is getting much better. If you look at the mortality rates of gun-shot wounds to the brain, they’re still coming down. And I think it’s really attributable to the systems approach, which we have in trauma, beginning with excellent triage at the scene by EMS, then directions from the emergency department in consultation with the trauma, in terms of what kind of triage has to happen in transport.

    CNSQ: Can you tell us about your obligations to government officials regarding giving updates, and what the initial response to the media inquiries was?
    MW: We weren’t given a lot of top-down direction. We had autonomy and decided it would be best to have one spokesperson from neurosurgery to ensure the message was clear, precise, and accurate. I’m a very private person and didn’t want to be too involved with the media myself. It’s just not in my comfort zone. The advice I would give for neurosurgical departments in treating high-profile patients is to preemptively identify an individual in your department who you think would be a good media spokesperson, and have that person step up to the microphone and speak with one voice to give a direct, accurate message that will require very little revision.

    CNSQ: How did you balance the need to maintain patient privacy with the need to give the public an update?
    MW: Well, Mark Kelly [Congresswoman Gifford’s husband] was essentially part of our team. He was ever-present, very dedicated to his wife at the bedside. We would ask him on a daily basis, “How are we doing? Are we within the boundaries that you’re comfortable with?” And the answer always was, “Yes.” He was very gracious and understanding of the need to keep the American people informed.

    CNSQ: Can you tell us about your interactions with the patient’s family and friends?
    MW: You have to remember that these are all human beings. You do what you always do. You finish your surgery and talk to the family. So, after surgery, we spoke with the family just the way you would with other patients’ families. Tell them what you did, what you found, what you think the diagnosis and the prognosis are, and keep them informed. Congresswoman Giffords’ staff were always present. They’re human beings too. They’re concerned about their friend and their coworker. We had daily contact with her chief of staff and members of her staff who just wanted to know as human beings, “How’s our friend doing?”

    CNSQ: You developed a special relationship with Mark Kelly—how did that evolve?
    MW: As an astronaut he has significantly disciplined training, and neurosurgeons appreciate this. He fit in very well with the neurosurgical team. He became a very good friend of our residents. You can imagine back to neurosurgery training, you’re making morning rounds, you’re getting up very early, you’re sitting at the front desk in the intensive care unit going over the patient list at about 6:00 in the morning, and Mark Kelly comes in, very bright. He meets with the residents and asks, “How’s my wife doing?” And he’ll go to the bedside with them and be almost part of the team. He’s very comfortable with the neurosurgical culture and the culture of discipline and professionalism. And so I think that was a very natural pairing with the neurosurgery residents.

    CNSQ: What was this experience like for the residents, and what lessons do you think they took from this?
    MW: I think the most important lesson is to maintain your professionalism. Maintain the excellent standard of care that you provide all patients. And don’t let any social or demographic factors cause you to cut corners or to change what you know works. We provided Congresswoman Giffords the same excellent care we provide to anyone, whether they come to us from south of the border or from the halls of Congress. You’ve got the Brain Trauma Foundation guidelines as your trauma bible, so to speak, combined with your neurosurgical experience and judgment. You apply that and maintain the same communication that you maintain with all families. And know that a member of Congress may have an extended family—husband, parents, staff, and governmental officials—that are going to show up from time to time. The residents were superb with communication, and I think they learned by example. Mike and I try to teach our residents how to carry themselves and how to act professionally, so they take our lead as a member of the faculty.

    CNSQ: What was the relationship between you and Congresswoman Giffords as she started to wake up, as she was being rehabilitated, and after she left the hospital?
    MW: It’s the same relationship a neurosurgeon has with a patient. We are both human beings, one with certain talents that another one needs. We initially noticed that when Mark would hold Gabby’s hand she would play with his wedding ring. That’s how we knew she was purposeful, she was communicating, and was in touch. I would speak with her daily, and based on my judgment and my assessment I would say to her, “Gabby, you’re going to be okay.” And she’d give me a nod.

    After she had recovered and been through rehab, I saw her at a trauma fundraiser, and she was a guest. Peter Rhee, the trauma director, reintroduced her to me. He said, “Here, Gabby. I want you to meet Dr. Weinand. He saved your life.” She gave me a hug, and we were able to converse more than we had in the hospital. She was very good with perceiving body language and nonverbal communication. She said to me and my wife, “You’re friends, aren’t you?” with-out immediately knowing who my wife was. We got to talking about how she had adopted her new dog, Nelson, and how she’s getting on with her life. It was very good to see that she was coming along. Subsequently I saw her recite the Pledge of Allegiance at a public gathering later in Tucson on the anniversary of the event and she did a good job with it, which was tremen-dously gratifying.

    CNSQ: President Obama and other senior congressional members visited Congresswoman Giffords in the hospital—can you tell us what that experience was like?
    MW: The Wednesday after the shooting, the President came to town. Of course, that’s going to change the dynamic on the intensive care unit. It was about 3:00 pm, and the President, First Lady, and their entourage come through an obscure back door that no one ever uses. He walks over to me, shakes my hand, and says, “I want to thank you for everything you’ve done.” I said, “Well, thank you, Mr. President. We’re honored to have you visit.” Then his wife very graciously says, “Oh, no, we’re honored to be here.” They then visited Gabby. As Commander-in-Chief, he understands war injuries, he understands trauma, and he was very comfortable being there. Nancy Pelosi, Kirsten Gillibrand, and Debbie Wasserman Schultz—all members of Congress, both branches—walk into the room to visit with their friend, Gabby. They’re all very good friends, so they start talking with her incessantly, as friends would. Up to this point, Gabby was able to open one eye, but with their encouragement, she opened both eyes for the first time.

    CNSQ: What advice would you give to a neurosurgeon who finds themselves in a mass casualty or high-profile case for the first time?
    MW: I think the best advice I would give is do what you know works. That is, fall back on your training and experience, your understanding of the TBI guidelines and the literature. Don’t do anything differently than what you would normally do. That is, treat everybody the same medically.

    From a neurosurgical standpoint, if you think your patient needs a debridement to prevent infection, do it. If they need a hemicraniectomy to prevent swelling, do it. It’s your judgment. If they meet the criteria for intracranial pressure monitoring, do it. Don’t be distracted by any of the peripheral events. And you’ll be surprised to find that you’ll be supported, because as a neurosurgeon, the public, law enforcement, Secret Service, government officials, mem-bers of Congress, even the President look to you for direction, and they are grateful for your expertise.

    Also, within your department, have some-one identified as spokesman. Hopefully it’s somebody young who’s got the stamina for the hours, and someone who’s eloquent in front of the camera and in public.

    From time to time, evaluate how your trauma system is working. How is your relationship with EMS and with the trauma program? Are things working the way you want them to? Participate in your quality improvement programs. If you notice that there’s anything that can be done better, advocate for it. For instance, I am our neurosur-gery liaison to the trauma program here. I’m on the American College of Surgeons Committee on Trauma, and so I know the trauma processes. I know that, for instance, an excellent Level I or Level II program will be responsible for reduc-ing the mortality by 20 percent, compared to a non-trauma program. We know that organized, systematically verified trauma programs do a great job. And so participate in that process, keeping your trauma program accredited to a level that’s appropriate for your environment, whether it’s Level I, II, III, IV.

    Education is also a very important part. After the event I had an opportunity to go to Congress and meet with many members. I met with Tom Price of Georgia, who is an orthope-dic surgeon and head of the Budget Committee in the House. He asked me what the members of Congress’ understanding was of trauma sys-tems, and I said, “Congressman, I have to tell you, education starts at the absolute beginning: I educated them on the difference between a trauma system and an emergency room.”

    Educating the public about the importance of a trauma system, a hospital trauma and neurosurgery program, helps the public understand better what crown jewels these medical systems are in our society.

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