Dr. Nicole Kopari on Burn Surgery in the “Swamp” and Her Preferred Blade Techniques

In this episode, Dr. Roselle Crombie, general and burn surgeon from CT Burn Center, Yale New Haven Health System, speaks with Dr. Nicole Kopari, the Pediatric Burn Medical Director at Children's Hospital New Orleans, on why she became a burn surgeon, her preferred blade techniques, and how operating in the “Swamp” has its own challenges.

The opinions expressed, and techniques described, herein are general in nature and based on the clinical experience of the presenting physician. Physicians should use their own professional judgment and consider patient-specific factors in treating their own patients. 

Drs. Crombie and Kopari are paid consultants of Integra LifeSciences, but they have not been compensated for their participation on this podcast.

Visit the Tissue Technologies blog to learn more.

Transcript

Dr. Crombie:

Dr. Kopari. Thank you for being here. I know who you are, but could you just tell us a little bit about yourself? Where you trained, where you are?

Dr. Kopari:

Sure. So, I’m a Minnesota kid. I grew up in Minnesota. I went to medical school in Minnesota, and I ended up doing general surgery residency in Michigan. And it was kind of a unique experience because I did not have a burn unit associated with my program. So I was lucky enough to snag a burn fellowship, because it was something that I had always wanted to do. And so I did burn fellowship in Harborview in Seattle. And then I went on to do a trauma and critical care fellowship in Houston.

We had kind of worked it out with Dr. Aaron Holtz, who was a previous ABA president. He was going to stay on, and when he retired, I was going to take his position, so that's what I did. And I worked in Minnesota for two years, and then I moved to California, and now I'm currently the pediatric medical director in New Orleans.

Dr. Crombie:

Think back to when you were training, the first time you were looking at burns. What were you looking for in the wound bed? And how has your practice and debridement evolved from back then to where you are today?

Dr. Kopari:

I trained in a period where it was interesting to hear the attendings kinda say, "If you have a hair-bearing area, to excise all the hair, to make sure that you didn't have those hair grow underneath your skin graft," if you were going to do a sheet graft or something. 

Then, when I took my first job, everybody was like, "Leave more, and come back and debride multiple times." I think I probably am more aggressive now than what I was when I first started training. Getting the wound bed is the most important part of the whole procedure. And so I’m more aggressive; I probably take more than maybe you need to, but I certainly think it results in making sure that you have a good wound bed to going forward to whatever the next step is.

Dr. Crombie:

You've got residents. You've got fellows. What are you telling them about the wound bed that tells you I've got to take a little bit more? I've got to take a little less. What are you actually physically looking for?

Dr. Kopari:

When I'm looking at the wound bed, after I've taken my first swipe, whatever instrument that I'm using, I was trained always to kind of swipe back with the blade and you're really looking for this uniformed bleeding. The punctate bleeding from the venous bleed or the arterial bleed—that's not what you're looking for --You really want to see this uniform wound bed. I believe in a lot of tumescence for my wound beds, especially in the pediatric population, and sometimes when we were putting epi in our tumescence, it would really change the appearance of the wound bed. And sometimes I think it still does because it doesn't bleed as much. So those are the kind of the areas where I'm wondering if I take a little bit deeper. But you’re really looking for that uniform bleeding. 

Then if you get down to fat, you're looking for that perfect hue of yellow on fat. You don't want anything orange or anything kind of reddish. It’s this – I don’t know how to explain it – it’s this yellow hue that you’re looking for wound bed for those two scenarios. 

Dr. Crombie:

You do a lot of pediatrics. Now, what is different about the kids' skin? How do you describe to your residents what you would do differently with an eight-month-old baby versus your 61-year-old burn patient?

Dr. Kopari:

The thing probably the most is the kids, they bleed. They don't bleed as much, but they bleed out much quicker. So we don't use a lot of tourniquets in the pediatric population, just because it's so small.

So you're really being careful about your bleeding wound bed. And I think the thing that I've noticed the most is that the pediatric skin is so thin. You can take a Weck at 4/1,000, and you can be full thickness.

That’s where I really come into using more of the tumescence to make my wound bed nice and firm when I take my swipes with my Weck or the Goulian or the-

Dr. Crombie:

Right. So you can have a precise depth.

Dr. Kopari:

Yeah.

Dr. Crombie:

Perfect. So none of us were born being burn surgeons, and we've made a lot of mistakes, and we've learned from them. What are the mistakes that you think you made earlier in your career that's kind of really changed what you do in terms of your management of debridement now?

Dr. Kopari:

The night before my procedures, I always kind of visualize my plan. I write a wishlist for the operating room, and that wishlist says everything that I'm going to need for that procedure. And it's interesting, because I don't ask for anything unless it's on that wishlist, because it's what I'm going to do. Sometimes there's some variables, but I really think about what are the steps that I'm going to go through. And I've held myself to that standard, because there have been times when I've changed the plan inter-operatively because I think, “oh well, maybe we can get by doing something else”, and then the outcomes aren't as good.

I really try to make sure that if I, this is a big burn, and I'm going to excise and put a dermal substitute or a secondary --stick with that plan versus trying to go straight to a skin graft because the majority of the time, those skin grafts die because of something else was going on.

I really use that day before to visualize, and I know that's weird, but I'm a college athlete, and we did a lot of visualization. And I just think that sticking with what you were going to do, unless there's a huge curve ball in the operating room. To follow your plan.

Dr. Crombie:

You're the second college athlete surgeon that has told me that, by the way.

Dr. Kopari:

Good.

Dr. Crombie:

And it works.

Dr. Crombie:

When you're thinking about whether or not a wound bed is ready for either your ADM or your graft, what are the things specifically that you're looking at?

Dr. Kopari:

Lots of things kind of come into play with that, and I think the patient status is huge. So, nutritional status, the size of burn, how they're doing in the operating room from a resuscitation standpoint, are they on pressors? Are they cold? Those are all the things that I kind of think about in that moment. Can I push this and go straight to a graft? Or should I do an ADM?

My philosophy with using the dermal substitutes versus an allograft is, in my mind, it makes sense for me to put something on that's potentially going to get me closer to my end product, or instead of putting something on that I'm going to then just remove.

I would rather put something on that's going to benefit me in some way. And I understand that there's this concept that they're incredibly expensive, and I'm not trying to waste them, but if I get 30, 40, 50% take of even a dermal substitute, it's better than where I was had I put an allograft on that I'm going to then remove, potentially have to re-excise the wound.

Dr. Crombie:

How do you decide between where do you put an ADM versus just flat out, this needs to be allografted? What are you looking at?

Dr. Kopari:

In my training, I learned that using the ADMs were really important for cosmetically important areas, right? Because they're expensive, we kind of trained to use them over joints, and again, cosmetically important areas. When I went out into practice, I started at a burn facility where they were using ADMs on everything. So they would do ADMs on backs and posterior thighs and all these things. And I think we saw a lot more loss in those areas, and now I've gotten away from that. I try to limit it, because the pediatric population, I want to make sure that I can get them healed, because I do think that the healing time is so much more important than some of the other things that we do.

I'll be honest, I haven't used allografts in... Maybe twice in my entire career. I just don't use it.

Dr. Crombie:

Just in terms of your kiddos; although your kiddos are kind of special because you have that special population down there. One of the things is if you were  managing a kid by expectant management and biofilm.  Eventually they get kind of infected … I know that you've got a special population, particularly where you are geographically.

Dr. Kopari:

Every single one of us burn surgeons think our patients are special. We all take care of the same patients. But the swamp adds another whole level of biofilm to our wound bed.

And I think that's another thing, to get the wounds healed. I had somebody call me recently, and they're like, "Well, do you get infections? What are you doing for yeast and mucor?" And I'm like, "It's because you need to get your wound bed closed." You don't get mold and things growing on your wounds if you can get them to heal quick.

And so the goal, especially on the pediatric populations, is quick healing time.

Dr. Crombie:

Right, and with adequate [inaudible] as you said, doing more now. So just in terms of debridement techniques, if you were teaching your residents or your fellows, what's a basic set of techniques that you would recommend for them about debridement—the basic tenets that they should look over, just as they approach a wound?

Dr. Kopari:

Just looking where you are operating on, you know location of the wound, really matters. And that kind of determines the technique that you know, and I always think back to Dr. Gibran. She would always tell us, "Really loose on the hand." You're not pressing and pushing hard with the Weck or the Goulian or whatever. It's really, really loose, and my wrists are loose, and you're kind of gliding over the tissue and letting the instrument actually do what it's supposed to do.

Again, and then swiping back, looking for a good bleeding and looking just for that appearance, which I do think comes with time of what the healthy wound bed looks like. In the biofilm and potentially clearing an infection or whatever. In my training we used to do biopsies, and we would send them off for quantitative, and I don’t have that access anymore, and so I don’t do it anymore. But it is something that as you're training and you're starting to put these ADMs on, sometimes it's not a bad idea to send off some cultures and make sure that you have a clean, healthy wound bed before, or put them on antibiotics until you have a final result on that.

Dr. Crombie:

So, that's fabulous that you actually had that ability at Harborview. I'm sure you probably were taking mental notes of what was growing and that, what did that look like? I'm sure you probably learned to look at it even without, because I know for me, I know exactly what is in that biofilm when I see it.

Dr. Kopari:

Absolutely.

Dr. Crombie:

There are certain features of it.

Dr. Kopari:

Oh, there's an appearance. It's the shiny, slimy, grungy… It's funny, one of my other previous trauma partners would find mold on every single patient.

Every little thing. I was like, "Stop looking for it." I'm like, "I will never find mold because I'm not looking for it." Every black little fleck, she would be like, "That's mold," and it was always mold. So I think it's kind of what you're looking for, but sending the biopsies more when I'm using the dermal substitutes before I put the skin graft on it.

Because there is an appearance to that granulation tissue where it's clean and healthy and ready for a graft versus grungy, and you probably need to do a gentle excision on the top of that.

Dr. Crombie:

So, big kiddo burn, 80%, 90%, your fellows asking you, what are the things that you're going to do in terms of thought process to take them to the OR? How long are you going to be there? What are you going to try to accomplish within the first week or two?

Dr. Kopari:

My training was not to be in the operating room for longer than four hours if you can help it. Sometimes that gets pushed, especially when you're proning a patient, because honestly turning a patient takes an hour to two. At best.

Even if you're great at it, it takes forever. The kids, maybe not so big, you pick them up and flip them over.

I try for early excision. I will do within 24, 48 hours, for sure. I want to make sure that the patient's not failing a resuscitation first, but I certainly will get them to the operating room, but I do limit myself based on the time. But also on the percent burn. I try to not go for all of it at once. Even when I had multiple partners together in the operating room, we still kind of would say somewhere between 40% is probably as much you want to push that patient.

The goal is to get all of the burn off within that first week. That's always been my goal, but like I said, I'm probably more aggressive in return trips every 24, 48 hours, as the patient can tolerate it. And then get something on that wound that's going to start changing the patient's response to this injury.

Dr. Crombie:

In terms of blood loss, temperature… Do you want to make a comment about that?

Dr. Kopari:

I'm crazy about that. So, it's interesting. This pediatric hospital that I am now, the OR temperatures don't warm up more than 74 degrees, which is-

Dr. Crombie:

Crazy. That's crazy.

Dr. Kopari:

That's crazy, right? It's a pediatric hospital. All these babies are cold. I trained with putting the blue gowns on patients extremities. In the last two jobs that I have had, I am notorious for walking to the cafeteria and stealing the Saran Wrap.

So I steal the big rolls of Saran Wrap, and I will wrap the entire child in Saran Wrap, including their head, around their ET tube and any area that I'm not operating on. They're like a little sweaty burrito in there, and it really keeps them warm. The kids get cold so quick.

I try not to operate when they're less than 35°C, but sometimes you have to. When you've got skin, you've already taken skin and they're getting cold, you have to put that skin on. I try not to use a lot of the heat lamps, because I'm concerned that they've lost their barrier.

Dr. Crombie:

Desiccate it, yeah.

Dr. Kopari:

And you desiccate it. But for a while we were doing that. I think they mostly make me sweat more than the patient. And then blood loss, I trained at a really busy trauma center. And so I'm a huge proponent of whole blood or 1:1:1 transfusions.

And so if I give blood, I give FFP. If I give six of blood, I give platelets and cryo. And I really use a lot of communication with the anesthesiologists throughout the entire case, like how the kids are doing. And I'm sure that a lot of the anesthesiologists, they're like, "Oh, Kopari micromanages it," but I'm not. I just want to know what's going on.

So we use a lot of colloid and blood and stay on top of it.

Dr. Crombie:

To your point about the anesthesiologists, I think they don't necessarily realize how one small thing can change the outcome for you and I, that they're not going to manage.

Dr. Kopari:

Yeah.

Dr. Crombie:

And then certainly for that patient. So I think that is a very valid point.

Dr. Kopari:

When I was a fellow, I had a patient who was a 16-year-old kiddo that we were, two, attending and a fellow were excising on the head at the same time. And we bled him out. And anesthesia was in the middle of shift-change, and the circulating nurse was on the phone calling for blood, and nobody was at the bedside with this kid, besides us operating. All of a sudden we're coding this child with a scalp burn. And from that moment on, blood loss is incredibly important. And you're a little bit more diligent, because I've had that experience, where I never want that. That kid is fine. He's a great kid.

But you want to make sure that those things don't happen again, and so I'll tell the anesthesiologist, "Every 0.2 in temperature, I want to know."

Up or down. Because if I can drop the room in temperature to make everybody more comfortable, they're more likely to want to work with us.

Dr. Crombie:

That's true. That's so true.

Dr. Kopari:

Right?

Dr. Crombie:

Yeah.

Dr. Kopari:

Because they don't like to work with us-... Because we're too demanding, and it's too hot. And so if you can eliminate those things. 

Dr. Crombie: 

Exactly. That’s so important. 

Dr. Crombie:

As you were going through your training. I'm sure you did a lot of necrotizing fasciitis and a lot of other wounds like that. What are the differences in sort of the wound bed that you're looking for, for that particular problem versus burns? 

Dr. Kopari:

Yeah. With the necrotizing, again, I'm aggressive. I go big or go home. Get the wound out of there. I like to probably not have to take a patient back more than two or three times. I love taking care of the nec fasc patients, because although I love my trauma colleagues, I think the multiple excisions over and over and then letting the wound granulate for the next two months before they refer them to us for a skin graft, it's really hard on the entire system.

I'm looking for a healthy wound bed, no expanding erythema. I'll squeeze the skin. And see if there's any purulence that kind of comes out, and take more. I tell people I'm skin-deep. I can put skin on anything. So if I take a couple more centimeters or inches, it's okay.

Looking for that wound bed of just clean, healthy, not desiccated fat, usually, is the best.

And then even when it comes to the ADMs there, I make sure that I'm picking something that's not going to kind of hide and fester an infection, because you never know what's left behind.

Dr. Crombie:

What do you think, just in general, we are facing in terms of the challenges as burn surgeons today?

Dr. Kopari:

We just finished the physician SIG, and it was the conversation for the entire hour about this looming deficiency in burn surgeons and burn-trained general surgeons, even. I think we're going to try to lobby to make sure that we can get the burn rotation back as a requirement for residents. And it's not about that. It's not about them learning how to do a skin graft. I'm a little bit protective about who we teach how to do a skin graft, because I don't want everybody to be out there just doing these skin grafts, because it's not about that.

It's about everything that goes into the burn care after the skin graft. It's the aftercare. It's the therapy. It's the psychotherapy, garments, compressions, laser, all these things that we do kind of as a whole. And I think that's really important that we get that education out, that it's not just about how to take a skin graft, how to prep the wound and put a skin graft on it. I had a button during residency, that said “A monkey could do my job, but why would he want to?” Because you can really train anybody to do these things.

It's about the whole thought process. And I think that if we don't do a better job of getting people interested, and good residents interested in burns, not the ones that can't do other things, so they get pushed into burns-

... I think we're going to be in trouble as a whole, because there's a huge gap between the surgeons who are retiring and then the fellows. There's not a lot of people kind of in the middle. And I think we need to change that.

Dr. Crombie:

What inspired you to go into burns? When did you first fall in love and how?

Dr. Kopari:

So I wanted to be a surgeon since I was four. I don’t know why. My uncle was a plastics and an ENT, and my mom said, "Instead of growing up to marry a doctor or a lawyer, just become one." I just was going to always be a surgeon, and nobody ever questioned it. But I also didn't have any mentors. Like, all the way through, everybody said, "Don't do it. As a woman, you're going to give up too much. You're not going to be able to have a family. You're not going to have time. If you want to make money, go into business. If you want to change the world, go into public health."

I really struggled finding a mentor. And when I went to medical school, there was a three-week rotation during the summer on burns. And Dr. Aaron Holtz is a world-renowned butterfly expert. And he used to shut the operating room lights off and show his butterflies. And so I was like, "I want to do that rotation for the butterflies."

And literally on the first day, the other partner there said, "What is this future orthopedic surgeon doing on my service?" Because I was a college athlete, and a tall, female, I was going to be orthopedic, right?

And I was like, "No, I'm going to come back and take your job." And I had to stick with it, because I don't lose challenges.

But I do, I love burns. I love the patient population. I love the continuity of care. I like taking care of trauma, but you take their spleen out, and you'll never see them again. With a burn, you're going to get a Christmas card from them for the next 50 years. And maybe at 52 years, you're going to fix their scar. And so, they just become part of the family. And I think there's not a lot of other specialties that have that longevity that we do with our patients.

Dr. Crombie:

And certainly not within surgery. I agree. So, that's perfect. Well, thank you.