Antarctic surgery via satellite

The weather outside was frightful, at 60 below zero, and one of the surgical assistants was a cook.

But a family physician at the South Pole has successfully repaired a meteorologist's ruptured kneecap, guided by specialists watching via two-way satellite hookup from Boston, 10,400 miles away.


The July 5 operation was the first "telemedicine" surgery ever attempted at the United States' Amundsen Scott South Pole Station.

"It went very well, exactly as we planned," says Dr. Bertram Zarins, chief of sports medicine at Massachusetts General Hospital, who supervised the surgery from Boston. The patient - 29-year-old Dar Gibson - is said to be making a full recovery.


Telemedicine hookups are most often used to provide expert consultations and diagnoses to local physicians, according to Jonathan D. Linkous, executive director of the American Telemedicine Association.

In 1999, South Pole physician Jerri Nielsen was diagnosed with breast cancer after microscopic images of her biopsy were transmitted to specialists in the United States. Last year, sonogram data sent from the Pole to Denver aided in diagnosing Dr. Ronald Shemenski's heart ailment. Both doctors were evacuated in dangerous winter airlifts.

But assisted telemedicine surgery is rare, in part because insurance companies won't cover it, Linkous says. "Primarily, it's been done on a demonstration basis to test how well it comes out. To have it done on an emergency basis, in real time, is unusual," he says.

This year, 51 scientists and support personnel are buttoned up at the South Pole Station, isolated by the deep cold and darkness of the southern winter. No aircraft can reach them until October.

Without timely surgery, Gibson faced permanent damage to his knee and a lifetime of limited mobility.

Zarins headed a team of physicians enlisted by the National Science Foundation and by Raytheon Polar Services, which operates the polar station for the foundation. Their job was to evaluate Gibson's injury and consult with the station's sole doctor, Dr. Timothy Pollard, 46, of Seattle.

The team also included Dr. Vicki E. Modest, an anesthesiologist at Massachusetts General. Consulting before the surgery were Drs. Frank J. Frassica and John H. Wilckens at Johns Hopkins Hospital in Baltimore; and Brian A. Smith, a surgeon at the University of Texas Medical Branch at Galveston.

"My initial reaction was that it would be too risky to do the surgery at the South Pole, and that it would be better to accept the consequences of the injury," Zarins says. The surgical risks included postoperative infection, or worse - a deadly error in giving the anesthesia.


But there were risks for Gibson in doing nothing too, Zarins says: "He probably would be unable to run or climb, and he would lose strength in the knee and lose" flexibility.

Gibson, from Manchester Center, Vt., slipped on ice June 28 after making surface observations outside the station's domed shelter. His left knee was stiffened by minus-90-degree temperatures, and apparently bent too far, separating the tendon that connects the kneecap, or patella, to the lower leg.

It can be repaired successfully by suturing the tendon back onto the kneecap, Zarins says, but only "if you operate right away, before the anatomy has changed and the thing is scarred into an abnormal position."

Through conference calls and e-mail exchanges, the consulting team gradually concluded that Pollard had the skills, the drugs and the equipment to perform the surgery safely.

Pollard says he has performed Caesarean deliveries in Alaska, and more than 800 major surgeries as a missionary in Africa. The knee surgery would not risk vital organs, and there was little chance of damage to major nerves or blood vessels.

"It's the anesthesia that has the scariest impact on the patient," Modest says. "The patient can die if the problems that can arise from the anesthetic are not managed in an appropriate and timely fashion."


Modest quizzed Pollard about the drugs and equipment he had. She sent him memos outlining things that could go wrong. She discarded the favored anesthetic approach - an injection into the femoral nerve in the leg. "The femoral nerve is directly next to the femoral artery," she says. A mistake could send the drug into the artery, producing life-threatening seizures and cardiovascular collapse.

She and Pollard opted instead for a spinal anesthetic that would numb everything below Gibson's waist. Pollard had performed the procedure several times before.

Zarins, meanwhile, gave Pollard a short course in knee repair. "We spent several hours on the telephone, and I explained the procedure in detail and asked him to tell it back to me," he says. "He demonstrated knowledge of the steps involved. He knew what to do."

After a dress rehearsal, a portion of the station's clinic was cleaned and sterilized.

Physician's assistant Tom Barale and the station's cook - a former veterinary technician (who was not identified) - scrubbed up to help Pollard.

As the surgery began at 9:40 a.m. EDT on July 5, the midsummer sun was driving temperatures in Boston toward the 90s. But at the Pole, which operates on New Zealand time, it was 4:40 a.m. the next day, in the sub-zero darkness of mid-winter.


And the clock was running. The surgery had to start and finish during the six-hour "window" when the communications satellite was overhead.

From Boston, Modest asked Pollard to show her the vials of anesthesia drugs he was preparing to use. "He rotated it in front of the camera so I could read it," she says.

One of the medicines contained an unwanted preservative, and another was "grossly" out of date. But substitutes were found, the anesthesia was administered without incident, and the surgery began.

Zarins and Modest had a clear, detailed view of the operation. The sound quality from the operating room was spotty, but they managed to converse with Pollard and his patient, who remained conscious.

The satellite link was lost several times during the surgery. Each time, contact was quickly re-established using a satellite telephone. Pollard never missed a beat, Modest says. "Even when we were out of communication ... he just continued on."

In three hours his work was done. Pollard says his patient is progressing well and has begun physical therapy.


The case "highlights what can be accomplished in rural and remote settings with planning, training ... and technological links to larger centers," he says. "I hope that our experiences will be used to improve the quality of care available to rural Americans."