Dr. Michael Lemole: Shooting Thrusts Neurosurgeon Into the Spotlight

January 18, 2011

January 17, 2011 (Tucson, Arizona) — In the aftermath of a mass shooting of 20 people that left 6 dead and Rep. Gabrielle Giffords (D-AZ) clinging to life, the throng of media that gathers at University Medical Center (UMC) has fallen silent each morning when surgeons G. Michael Lemole, MD, and Peter Rhee, MD, MPH, step up to the microphone for daily updates on Giffords and the other shooting victims.

Drs. Lemole and Rhee, who head the UMC's Departments of Neurosurgery and Trauma, respectively, have become the voices of calm authority — and the faces of hope — amid the chaos after the shooting, delivering details on the victims' injuries and recoveries with a careful mix of compassion and caution.

The sole patient who has remained in critical condition, Rep. Giffords, who investigators say was the target of the shooting, has been a central focus of the attention, and the surgeons have been pressured to walk a thin line between divulging essential details and protecting patient privacy.

A Different Perspective

Three days after the shooting, a reporter flatly asked Dr. Rhee the question on the nation's mind — did he think the congresswoman would survive? "I don't just think there's a 100% chance she'll survive — I think there's a 101% chance she'll survive," he declared. "She will not die. She does not have that permission from me."

Dr. G. Michael Lemole talks about the condition of US Representative Gabrielle Giffords, D-AZ, at University Medical Center during a news conference in Tucson, Arizona, Monday, January 10, 2011. Matt York/AP Photo

As the neurosurgeon charged with delivering some of the more uncomfortable details of a popular congresswoman's brain injury, however, Dr. Lemole has been the more reserved of the two.

"Dr. Rhee and I approach this from a very different perspective," he told Medscape Medical News. "He is a trauma surgeon and for him, it's all about saving lives. I'm a neurosurgeon, so I've got that longer view of neurologic recovery."

He also keeps a sharp awareness of the context of recovery from the public perspective.

"I try to keep in mind that a layperson's measure of success is very different from a medical person's, and as a result, I trying to be as precise in my verbiage as possible without being confusing," he said.

"I don't want people to have expectations that are not real, nor do I want them to give up hope."

Dr. Rhee hired Dr. Lemole, a leading expert on skull base surgery, to head the Division of Neurosurgery in 2009 as part of a sweeping expansion of the UMC Trauma Center, which is southern Arizona's only level 1 trauma center.

I'm a neurosurgeon, so I've got that longer view of neurologic recovery.

Before his arrival in Tucson, Dr. Lemole led the Skull Base Multidisciplinary Program at the University of Illinois at Chicago, where he also served as co-director of the Chicago CyberKnife Radiosurgery Center at Advocate Christ Medical Center.

Having earned his undergraduate degree from Harvard University, Dr. Lemole went on to receive his medical degree from the University of Pennsylvania. He completed his residency in 2002 in neurological surgery at Barrow Neurological Institute in Phoenix, where he had fellowships in complex spinal surgery and cerebrovascular/skull base surgery.

Although Dr. Lemole gained recognition by the national media in the wake of the shootings, he has another interesting association to fame — he is a brother-in-law to TV host Dr. Mehmet Oz, widely known simply as Dr. Oz, who is married to his sister, Lisa.

Well Prepared

As a specialist in traumatic brain injuries, Dr. Lemole was well prepared for a critical headshot wound case such as Giffords', and the added element of working under the national spotlight has gone smoothly.

"Clinically, we do this on a regular basis," he said. "We're possibly among the top 10 busiest level 1 trauma centers in the nation, and it's not the first time we've dealt with this kind of problem.

"The challenge has been balancing media interviews, getting the word out correctly, and walking the fine line between releasing enough information while using caution to avoid violating the family's wishes for privacy."

By all accounts, Giffords was indescribably lucky in that the gunman's 9-mm bullet passed only through the left side of her brain and did not cross hemispheres or reach the lower portions of the brain responsible for critical function.

With this kind of injury — a penetrating injury to the skull — the chance of survival, let alone recovery, is abysmal. She has no right to look as good as she does.

"With this kind of injury — a penetrating injury to the skull — the chance of survival, let alone recovery, is abysmal," Dr. Lemole told reporters in the first days after the shooting. "She has no right to look as good as she does. We're hopeful and we just all have to be extremely patient."

Only a small percentage of victims of gunshot wounds to the head even survive, and several major news organizations, including National Public Radio and CNN, in fact erroneously reported Giffords' death at the outset.

But when the congresswoman arrived at the UMC Trauma Center, she was showing signs of life and responding to commands, reportedly as soon as 20 minutes after the shooting.

Decompressive Craniectomy

Dr. Lemole said Giffords' bleeding wasn't as severe as it could have been, but with a computed tomography scan showing brain swelling, he made the quick decision to perform a decompressive craniectomy.

"There are some people who are against craniectomies, but the simple argument for it is not only if you expect swelling in the future but if you have swelling at the time of surgery, and the important thing was that she did.

"There was enough swelling right there at the time of surgery, in fact, that we simply did not want to put that bone back in," he explained.

From then on, "things were pretty much out of our hands in terms of which way she would turn," he said.

"We knew that, if necessary, we would have used our ventriculostomy tube to drain the pressure and measure the pressure in the brain and use drying agents if needed," he explained.

"We also knew we had the option of going all the way to barbiturate coma to slow the brain's metabolism, which is similar to what (ABC News reporter) Bob Woodruff had. But we didn't have to do that and that's fortunate."

Dr. Lemole noted that since that first day, Giffords' brain swelling has been much less than he expected.

One concern about craniectomies is the potential for disfiguring scars that can be left behind, but Dr. Lemole said surgical incisions are carefully placed in the hairline as much as possible.

Difficult Decision

Another concern is the potential to stretch the fibers of the brain beyond their normal extent, Dr. Lemole explained.

"When swelling is so bad that the brain goes way out beyond the edges of the skull, that brain is going to die. But the problem is, if you've got that kind of swelling and you haven't taken the flap off, the whole brain is going to die anyway, due to the swelling within the skull."

That's not to say the decision to perform a decompressive craniectomy comes lightly.

"It can be a very difficult decision," Dr. Lemole said. "Obviously you have to be very careful. You don't want parts of the brain to swell out, and it's a judgment about how much bone you take off and which areas you put at risk for that outward swelling."

But the bottom line is, we're finding more and more from military experience that this does save lives.

"You need to balance that with how much pressure you need to [alleviate] to prevent the inward swelling," he added. "But the bottom line is, we're finding more and more from military experience that this does save lives."

While removed skull sections are sometimes stored inside the patient's abdomen to preserve bone marrow, Dr. Lemole said he opted to store the section in a deep freezer in Giffords' case.

"One problem with storing the section of the skull in the abdomen is we need to make another incision on the belly, and if you leave it in longer than 3 months, usually beyond 6 months, the bone can begin to become reabsorbed, so the pieces don't fit back as well," he said.

In situations such as a military setting, in which the bone needs to be stored safely or the patient needs to be rapidly transported, the abdomen option might makes sense, but in Giffords' case, the bone was placed in a deep freezer, Dr. Lemole said.

"We also still have the opportunity to use a prosthetic bone made by a computer, and we still will consider those options."

Four days after the shooting, Dr. Lemole, along with Dr. Rhee and other UMC staff, took a break to attend a memorial service for the victims at the University of Arizona's McKale Center, where the surgeons were cheered like superstars as they entered the stadium and hailed as being among the tragedy's "heroes" in a speech by President Barack Obama.

At the next day's press briefing, Dr. Lemole was asked about the rousing reception.

He shook his head and paused. "It's humbling."

"We do this day in and day out and it's nice to know there's this kind of outpouring, but it doesn’t change what we do or how we do it. If you were injured, it's only the same thing we'd do for you. It's why we got into medicine."

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