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Body Language

By Lyndon Stambler • Photography by Ann Johannson

One veteran surgeon’s love of anatomy is helping new generations of surgical residents to sharpen their skills for the benefit of patient care.

Dr. Warwick J. Peacock dreamed of the Surgical Science Laboratory as a place where surgical residents could not only master anatomy, but also experiment, with the ultimate goal of improving patient care.

On a February morning, under the glare of operating-room lights, six UCLA neurosurgery residents embark on a rare adventure into the human body. As they start cutting into three bodies, Professor of Surgery Warwick J. Peacock, MD, encourages them. “That should be the linea alba,” he says, in his gentle South African accent. “There are some adhesions. Always stick your finger in to make sure you’re not cutting into the bowel. It spoils the day.”

Incisions made, the residents approach the spine from the front, sawing through the sternum, moving beyond the lungs and following the rib head to the pedicle, then removing a thoracic disc on each body — in two hours.

Of course, completing a discectomy in two hours on a living patient would be extraordinary. But this was no OR. No one is worried about scheduling, anesthesia or bleeding. The bodies are cadavers, and the bitter and antiseptic scent of embalming fluid, not blood, fills the air. In UCLA’s Surgical Science Laboratory, one of the few of its kind dedicated to the training of surgical residents, the fledgling surgeons can practice and make mistakes. They bubble with excitement, viewing anatomy rarely seen in this era of minimally invasive surgery and computer modeling: lungs, the front of the spine, the aorta.

The operating-room-like lab has five stations and can accommodate many residents at once
The operating-room-like lab has five stations and can accommodate many residents at once, providing a bustling forum for practice and experimentation.
For Dr. Peacock, an emeritus pediatric neurosurgeon who developed new techniques for treating children with cerebral palsy by first trying the techniques out on cadavers, teaching residents and exploring the human body on a daily basis has been “one of the most fascinating parts of my life. It is a novel experience every time.”

After completing the discectomy, three of the residents — Sergei Terterov, MD, Jasvinder Nangiana, MD, and Rich Everson, MD — remove their caps and masks, revealing young faces. They speak with Dr. Peacock, the lab’s director, about challenges in the OR. “If there’s anything you guys need, let me know,” he tells them.

Engaging and passionate, Dr. Peacock is a born teacher. In 2013, he received the first Distinguished Service in Education Award from the David Geffen School of Medicine at UCLA. Colleagues called him a “master educator” and a “visionary,” who is “revolutionizing surgical-anatomy instruction.”

“The most-important aspect of teaching is not the transmission of fact,” says the tall, thin man with blue eyes. “It’s the transmission of enthusiasm.”

That enthusiasm is infectious. “Dr. Peacock is an amazing teacher,” says Dr. Everson. “He includes just the right amount of detail; it’s clinically oriented. He was a practicing neurosurgeon. There’s nobody better to teach us than someone like that.”

Dr. Peacock envisioned the Surgical Science Laboratory as a place where surgical residents could not only master anatomy, but also experiment. The goal is straightforward: to improve patient care. “If you know your anatomy, you’re going to be able to treat your patient a lot better than if you don’t know your anatomy, no question,” he says. “When they finish their course with me, they know their anatomy.”

Medical students learn the basic structures of the human body, but a surgical resident must know how to reach his or her target without damaging anything along the way. Surgeons, Dr. Peacock says, “are athletes of the small muscles,” and it takes hour upon hour of practice and repetition to train those muscles to perform the way they must.

“I don’t think anyone has anything quite like what UCLA does and what Dr. Peacock does,” says pediatric and fetal surgeon Diana L. Farmer, MD, chair of the Department of Surgery at UC Davis Medical Center. “It’s brilliant and it’s clever, and it wouldn’t surprise me if it becomes the standard throughout the country.”

FOR YEARS, DR. PEACOCK TAUGHT ANATOMY TO UCLA SURGICAL RESIDENTS wherever he could find space. Needless to say, it was unwieldy. “We had to roll these bodies around all over the place. It was a blooming nightmare,” he says. In 2009, he approached Alan G. Robinson, MD, then-executive associate dean of the medical school, about creating a dedicated lab. “Would you like a surgeon who doesn’t know his anatomy to operate on you?” he asked.

“Oh, my God, no, this is a no-brainer,” Dr. Robinson responded.

Even with Dr. Robinson’s support, it took three years to establish the lab. “I was a real nuisance,” Dr. Peacock says, a twinkle in his eyes. “It does take a crazy person who has a bit of time to pester and push to get it done.”

Dr. Peacock pushed back when one administrator told him, “We’re not going to do it,” referring to installing expensive new air ducts in the basement of the UCLA Center for the Health Sciences, where the lab is located.

“Oh, yes we are,” Dr. Peacock shot back.

Since the lab opened in April 2012, its use has expanded from only general surgery to group sessions with more than a dozen disciplines, from orthopaedics to OB/GYN. Dr. Peacock works one-on-one with general-surgery residents in 20 two-hour sessions, dissecting the entire body, and others, like neurosurgery resident Dr. Everson, can ask for his personal guidance if they wish. “To my knowledge, UCLA is the only place in the country that does that,” says Dr. Farmer.

As Dr. Peacock and a resident prepare to begin their lesson, they first solemnly thank the body donor. Dr. Peacock then extends his hand, telling the resident: “Here’s the scalpel, let’s start.” Whereas some surgeons desensitize themselves, Dr. Peacock remains fully engaged: “The beauty of the human body, as I find it when I dissect, makes me aware of a great joy that I am seeing such wonders, such perfection, I just don’t believe something like this can happen just by chance.”

The lab is producing results. Before it opened, Dr. Peacock tested 40 general-surgery residents. Only two could correctly identify more than 80 percent of the body parts on a cadaver. Dr. Peacock repeated the test a year after the lab opened; not one resident failed, and two had perfect scores. Moreover, a survey taken several months after the lab opened found that residents had a positive reaction to the lab for learning procedures and boosting their confidence.

 The lab also provides a forum for ex

hysicians from a variety of specialties develop their skills in the Surgical Science Laboratory
Top: Physicians from a variety of specialties develop their skills in the Surgical Science Laboratory, including emergency-medicine attending Dr. Nicholas Miniel (left) and emergency-medicine resident Dr. Stephanie Brenman.

Bottom: General-surgery resident Dr. Irmina Gawlas practices a procedure on a cadaver in the lab before performing it in the operating room.

perimentation. Avital Harari, MD, an endocrine surgeon, spent time in the lab to master a technique for removing the adrenals through the back instead of through the abdomen. In addition, UCLA’s face-transplant team rehearses there. “The only shortcut needed in surgery is preparation, and Dr. Peacock’s lab allows us to do just that,” says Kodi Azari, MD (FEL ’04), chief of reconstructive transplantation. “The hand- and face-transplant programs would not exist without the ability to go through the procedures until the surgical team performs as a perfect symphony.”

Sam Lan, MD, PhD, a retired general surgeon and medical-school classmate of Dr. Peacock’s who now teaches anatomy at the Albert Einstein College of Medicine in New York City, called the lab “unique.” “It is set up as an operating-room theater. They can experiment. They might even be able to innovate. That applies not only to residents, but also to surgeons who are trying to innovate new surgical techniques. That is definitely different,” he says.

DR. PEACOCK KNEW WHEN HE HAD AN APPENDECTOMY, at age 11, that he would become a doctor. “I was so excited by the doctors and the hospital that I never considered anything else,” he says.

As an intern at Cape Town’s Groote Schuur Hospital, he worked alongside pioneering heart surgeon Christian Barnard, MD, who performed the world’s first heart transplant in 1967, and initially aspired to become a cardiac surgeon. But during his general-surgery training at Durban’s King Edward Hospital, Dr. Peacock switched to neurosurgery. King Edward was, in apartheid South Africa, an overcrowded black hospital where patients slept on mattresses on the floor. In contrast to his predecessors, Dr. Peacock aggressively treated patients who had been paralyzed from stab wounds to the spine. Instead of dying, many recovered. After training in Toronto, Canada, as a pediatric neurosurgeon, he returned to South Africa, treating patients with brain tumors, epilepsy, spina bifida and cerebral palsy from around the whole country. To refine the rhizotomy procedure he applied to improve the walking patterns in patients with cerebral palsy, Dr. Peacock first visited the pathology lab, practicing on cadavers and, later, baboons.

But South Africa’s apartheid struggles hit close to home. His son organized protests against apartheid and his daughters were tear-gassed at rallies. Meanwhile, Dr. Peacock staged his own protest at Groote Schuur Hospital, where he worked in the mid-1980s. He was reprimanded when he began moving black children from their overflowing ward to the half-empty white-children’s ward. But he persisted. “On the third attempt, they let it go,” says Dr. Peacock. In 1985, Donald Becker, MD, then UCLA’s chief of neurosurgery, invited him to UCLA to become the school’s first pediatric neurosurgeon. The invitation came in the same mail delivery as his son’s Army induction papers, and Dr. Peacock and his wife Ann, now a successful screenwriter (her credits include The Chronicles of Narnia: The Lion, the Witch and the Wardrobe, Nights in Rodanthe and The Killing Room), pulled up stakes and moved to Los Angeles. The move, he says, was “like going from Earth to Mars” for his family.

 Dr. Peacock spent 11 years at UCLA before becoming chief of pediatric neurosurgery at UC San Francisco. He retired in 2001, but that was short-lived. In 2005, he returned to Los Angeles, and UCLA asked him to teach anatomy to medical students and then exclusively to general-surgery residents. Dr. Peacock felt “privileged” to do his part, and for years he taught anatomy just for the joy it gave him. As he puts it, “The single-most-important experience that turns a layperson into a medical person is dissecting a human body, a dead body. You have to come to terms with death. When you have taken a human body apart and come to understand how it is constructed and how it functions, you become a very different person.”

Though Dr. Peacock regrets the general movement among medical schools away from human dissection — today’s students often learn their anatomy in the first year of medical school from prosected human cadavers rather than dissecting the bodies themselves — he has grudgingly come to accept the trend. In years past, aspiring surgical residents had to pass an exam in surgical anatomy before they could begin learning their skills in an operating room. Today, new surgical residents starting in the OR have to draw upon their vague memories of anatomy learned from observing already-dissected bodies years before in medical school.

Not so at UCLA. “The first reason for starting the Surgical Science Laboratory was to correct that deficit in anatomical knowledge,” Dr. Peacock says. “The second was to provide an opportunity for the residents to learn surgical skills and procedures on dead bodies rather than live ones. Apart from rare occasions, this was not happening.”

Residents working in the Surgical Science Laboratory are able to select from among thousands of tools and instruments that are donated to the lab.
Residents working in the Surgical Science Laboratory are able to select from among thousands of tools and instruments that are donated to the lab.
Dr. Peacock is passionate that “those who are going into surgery (16 percent of UCLA medical graduates in 2013) need to really learn their anatomy very thoroughly,” and today residents in nine of the 10 surgical specialties trained at UCLA spend time in the Surgical Science Laboratory to achieve this goal.

When they enter the lab, the students find five stations within its windowless room. Up to 20 bodies, with another 15 in an adjacent room, can be stored at one time. The facility also is used by surgeons like limb-transplant chief Dr. Azari and his teams to work out and rehearse their techniques. On one morning, a team of gynecological surgeons worked on a torso at one table, while two hand surgeons dissected an arm at another.

Everything that happens in the lab is done under the watchful eyes of representatives from UCLA’s Donated Body Program. “From the time that the body arrives at UCLA to its final disposition, we control where that body is at all times,” says Dean Fisher, director of the Donated Body Program. Throughout the procedures, there is utmost respect for the men and women who have willed their bodies to advance medical science. Each May, medical students and residents hold a memorial service that includes poetry and songs to honor the donors.

IN LATE JANUARY, A GROUP OF EIGHT GENERAL-SURGERY RESIDENTS visited the lab at 9 am to practice kidney transplants. They removed the left kidneys from four cadavers, preserved the vessels and transferred them to the right side. Residents Patience Odele, MD, and Nicholas Lahar, MD, were cutting through fat
and connective tissue when they discovered the kidney they were working on had a double ureter, a rare occurrence. “It’s amazing how different everybody is,” Dr. Odele says. “We always talk about these variations, and sometimes you see those variations in patients.”

Dr. Peacock, an enthusiastic pianist who keeps his fingers limber on the keyboard during down time (he has a small electric piano in the locker room across the hall from the lab), sees these “variations on a theme” daily. “If you look in a textbook, it’s beautiful,” Dr. Peacock says. “The nerves are color-coded yellow and the arteries are red and the veins are blue. That’s not what it looks like inside the body. Not only that, but they’re covered with fat and tissue planes. So when you open the belly, there is no textbook that looks like what you see.”

Vatche Agopian, MD (RES ’10, FEL ’12), a transplant surgeon, helps the residents acquire the hands-on experience. “Bodies aren’t built like Hondas or Fords,” he says. “There’s no manual. Here, the residents can do extensive dissections and solidify their knowledge of three-dimensional anatomy.”

Dr. Agopian lauds another team at work in the lab, Elise Lawson, MD, and Rena Farhadi, MD, as they quickly remove the left kidney. “This is perfect, guys,” Dr. Agopian says, holding up the kidney for everyone to see. “This is the ureter that drains the urine. This is the artery that brings the blood from the aorta into the kidney. This is the gonadal vein, and this is the ureter that goes into the bladder.”

Drs. Farhadi and Lawson then work together to suture the kidney into the right side. “I don’t think you could do it if you didn’t enjoy it,” Dr. Farhadi says. “You have to love it.”

“Not just like it, but love it,” Dr. Lawson agrees.

Drs. Agopian and Peacock give pointers on dissection techniques, keeping the atmosphere light. “I want it to be fun,” Dr. Peacock says. “They can make a mistake. It doesn’t matter. I just say to them, ‘Okay, you cut that nerve. Suture it together.’ And they won’t forget it. I don’t expect them to know; I expect them to learn.”

After finishing the kidney transplants, the general surgeons return to ORs around Los Angeles — Harbor-UCLA Medical Center; Olive View-UCLA Medical Center; UCLA Medical Center, Santa Monica; Veterans Administration hospitals; and Ronald Reagan UCLA Medical Center — with more knowledge and experience. “The biggest difference is the difference between zero and one,” Dr. Peacock says. “To do one of these procedures here before you do it on a patient is huge.”

That is exactly what the six neurosurgery residents have experienced, practicing skills in the lab that translate to the OR. An attending surgeon showed them a procedure on the brachial plexus, a complicated area of nerves in the shoulder, which residents later applied in the OR. During another visit, Neil Martin, MD, chair of UCLA’s Department of Neurosurgery, worked with residents on a carotid endarterectomy. The residents have done dozens of neck surgeries since.

Another time, they practice the anterior approach, often used if there is a tumor on the front of the spinal cord. Spine surgeon Langston T. Holly, MD ’95 (RES ’01, FEL ’02), is teaching the residents, and Dr. Peacock moves a plastic skeleton next to the cadaver on which they were working to help reinforce Dr. Holly’s points. As a resident, Dr. Holly had worked with Dr. Peacock. “He’s very patient,” Dr. Holly says. “He does a good job of explaining the anatomy. Probably more important than anything, he loves teaching.”

Despite his wry humor, Dr. Peacock maintains a serious demeanor, although it is not funereal. The lab gets noisy as residents call out for various instruments — an extensive and scrupulously maintained assemblage of retractors, Mayo scissors, clamps and Adson’s forceps. When a visitor expresses concern about possibly bothering the residents, Dr. Peacock responds, dryly, “You can’t bother a neurosurgeon.”

As soon as the residents arrive in the lab, Dr. Peacock gets them working on the cadavers. In short order, they expose the abdomen and the thoracic area, procedures usually reserved for general and thoracic surgeons. For these neurosurgery residents working in a minimally invasive world, this is a rare experience. “The trend now is that less is more,” Dr. Nangiana, one of the residents, says. “It’s excellent for the patient, but when you’re looking at a small corridor to get down to the tumor through the vessel, you don’t see the whole structure and the anatomy around it. To come here and get a full dissection, not only of the corridor you’ll be using, but also of the anatomy around, it gives you more confidence when you’re in the OR.”

While Dr. Nangiana is speaking, Dr. Martin enters the lab and puts on gloves and a gown. He walks over to a body being dissected by two residents. “These guys got down there in a flash,” Dr. Peacock tells Dr. Martin.

Neurosurgery residents Drs. Andrew Yew (left) and Ausaf Bari
Neurosurgery residents Drs. Andrew Yew (left) and Ausaf Bari (right) observe as Dr. Warwick J. Peacock (center) demonstrates the skills he learned over his four-decade-long career as a pediatric neurosurgeon.
Dr. Martin peers into the abdominal cavity and points, asking, “What’s the most impressive thing you see there?” He is pointing to the aorta and the vena cava. “You’ve got to be super, super careful,” Dr. Martin says. “A little tiny nick in the aorta would shoot blood up and splatter it all over the ceiling. You can’t go in there blind.”

The residents are already well-aware of how risky spinal surgery can be, but the pointers from Dr. Martin are appreciated. “You’ve got to be extra careful. A small mistake can be disproportionately large,” says neurosurgery resident Ausaf Bari, MD, PhD.

The work being done in the lab with cadavers is “absolutely essential” for training surgeons, Dr. Martin says: “The tactile feedback is crucial. It doesn’t supplant the apprenticeships that people get in the operating room, but this is a non-pressure environment, so the trainees aren’t distracted by other issues. We want everyone to know their way around the human brain and spinal cord and the entire body, as well as they do around their bedroom at night when the lights are off.”

Indeed, no one wants to operate in the dark, especially not these residents. “No surgery is too difficult if you know where you are,” says Dr. Terterov. “It’s only difficult if you’re lost or unsure about what to do. If you take some care and you’re meticulous in your preparation, it’s easier than it seems.”

Lyndon Stambler is a freelance writer and teaches journalism at Santa Monica College.

 





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