Teams Save Lives: Team Mentality

David Kulber, MD '88, relies on the expertise of his surgical team, at home and abroad.

Challenging surgeries are the life's work of David Kulber, MD '88, FACS, one of the nation's leading plastic surgeons and founding director of Los Angeles, CA-based Cedars-Sinai Medical Center's Plastic and Reconstructive Surgery Center of Excellence. But one of the most nerve-racking operations he has performed still plays in his head two years later.

"A 6-month-old baby burned from the top of his head to the back of his neck — his entire skull was exposed and badly infected," Dr. Kulber recalled. "If I didn't operate, he would die. If I did operate, he might still die."

The tiny patient had been carried a long distance by his mother to a hospital in the southeastern African nation of Mozambique, where Dr. Kulber volunteers as the lead plastic surgeon for multidisciplinary, team-based surgical missions organized by the non-profit Mending Kids. Working under extreme pressure, in extreme heat, with very limited resources, the team takes on an outsized role in patient outcomes.

It takes a whole team of people to collaborate, to educate and to work together.

"All the things we take for granted inside and outside the operating room — they have none of that," Dr. Kulber said. "You have to improvise and that makes the whole concept of surgery, let alone caring for very challenging patients, a lot more complex. The only way to do that is for everyone to chip in, share ideas. It's a lot of coordination and problem-solving."

As Dr. Kulber and the team, including surgeons from Mozambique, operated on the infant, he was forced to remove the entire skull.

"I performed what essentially is a brain surgery," he said. "That's not a surgery I do. We scrambled to figure out what instruments to use. The anesthesiologist was worried. I was worried. I was definitely out of my comfort zone."

Dr. Kulber cleared the infection and used cadaver dermis that he'd carried for the trip to temporarily cover the back of the skull. The baby eventually underwent skin grafting.

"A year later, he was doing well," said Dr. Kulber, who last year performed a neck contracture release on the young patient, using a muscle flap from his back.

"Babies are born with cells that continue to form bones on the dura (the tough membrane that protects the brain and spinal cord) and allow all regrowth of the cranial bone."

Dr. Kulber has worked with Mending Kids for eight years, helping to attract what is now a 30-member team of volunteers — doctors, nurses, physical therapists, wound care specialists — to Mozambique. He is helping the organization create self-sustainable mentorship programs with local surgeons and medical communities. 

"We're operating on children with congenital deformities and devastating injuries, but we're also educating the people in Mozambique and we're teaching doctors," Dr. Kulber said. "You can't just go and perform surgeries and then leave. It takes a whole team of people to collaborate, to educate and to work together."

Using virtually-guided surgery and an internet connection boosted by mobile hotspots, Dr. Kulber is mentoring Drs. Selma Issufo and Pedro Santos, the first and only plastic surgeons in the country of more than 28 million people. About once a week he watches and guides, from his home, as the surgeons in Mozambique operate while wearing Google Glass.

You want people you trust working with you, involved in your surgery, which makes for a much safer atmosphere and better outcomes.

"I can see what they're doing in real time and offer direct input, as needed," he said. "I can take a picture of what I'm seeing, draw on it and send it back."

Dr. Kulber is director of hand and upper extremity surgery, Department of Orthopedics Surgery at Cedars-Sinai Medical Center. He is also director of the Plastic Surgery Division of the Cedars-Sinai Medical Group, specializing in breast, abdominal and hand reconstruction and peripheral nerve surgery and regeneration. He serves as professor of surgery for Cedars' Clinical Professorial Series, and clinical professor of plastic surgery at USC Keck School of Medicine.

A good surgeon is acutely aware, during every surgical procedure, that the patient's health and life hinges on the knowledge and communication and teamwork of each member of the surgical team, Dr. Kulber said.

"You want people you trust working with you, involved in your surgery, which makes for a much safer atmosphere and better outcomes," he said. "It's very easy, as a surgeon, to have tunnel vision. You have a problem and you're trying to fix it. But you can't lose your peripheral vision. You have to remember to keep everyone involved in that problem-solving, because you're much stronger when you have everyone actively helping you — including residents — rather than you giving commands. When they're asking questions, that makes you better. You realize you're part of a larger system and that people are there to help you, if you let them help you."

Dr. Kulber's many research projects include the application of stem cells in tissue regeneration in the hand and wrist, and he has also developed several new surgical techniques, including a novel method for the reconstruction of severe abdominal wall herniations and the use of fibrin glue for nerve regeneration. A prolific presenter and author, he has co-authored 56 research publications, six book chapters and 106 abstracts.

"The thing about medicine is that every day we learn something new," Dr. Kulber said. "We have to be open to that and we have to have a team mentality. We have to work together to solve increasingly complex medical challenges — infections, transplantations, reconstructions. We can't work any other way and get successful outcomes."