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Enter the Surgineer

January 10, 2020

The wound was deep. At least 4 inches. And the surgical opening was at least that wide.

Three Johns Hopkins engineering students, clad in green scrubs, huddled around the patient. They quietly conferred on how much surgical sponge was needed to fill the wound, then set about cutting the black sponge into pieces to fill the large incision. Six hands working quickly, they carefully adhered the skinlike adhesive over the opening and attached the seal for the wound vacuum. As the vacuum suctioned air and fluid from the sponge pieces, the wound began to seal, and the graduate students began to relax. When it was clear that there were no leaks, they high-fived and began peppering the nearby Johns Hopkins surgical resident, Eric Etchill, with questions.

After Etchill examined each group’s work from the class of 22, a few students picked up scalpels. Then they cut thick slices from the watermelons (which were being used as substitutes for the vascular patients) in the Carnegie Center for Surgical Innovation—and spent the next few minutes enjoying their juicy snack.

It was just another Thursday morning in Surgery for Engineers, a graduate-level course created by Jeff Siewerdsen, the John C. Malone Professor and vice chair for clinical and industry translation in the Department of Biomedical Engineering.

Siewerdsen’s full-year course series, called Surgineering, aims to bring new perspectives to the operating room: first, to expose engineering students to real-life principles, workflow, and challenges of clinical medicine; and second, to bring engineers with a depth of understanding in both medicine and engineering to the challenges of 21st-century medicine.

“The challenge is not only to innovate,” says Siewerdsen, who is co-director of the Carnegie Center, a collaboration between the Department of Biomedical Engineering and the Department of Neurosurgery. “It is to ‘bury the complexity’ of systems that affect a patient’s care and to transform the hospital into an enterprise that continuously learns and improves.”

Enter the “surgineer,” a new kind of engineer, who, Siewerdsen predicts, will become an increasingly essential member of the clinical workforce. With a foundation in biomedical engineering, expertise in systems and data science, and—most importantly—a genuine understanding of interventional procedures, “the surgineer will be equipped to apply perspectives of systems engineering and data science to improving workflow and patient safety in the OR,” says Siewerdsen.

Now in its second year, the Surgery for Engineers course takes 20 or so graduate students from the Whiting School of Engineering and the Johns Hopkins University School of Medicine through 13 areas of interventional medicine, including general and specialized surgeries, interventional radiology, and radiation oncology. Over the course of the fall semester, the surgineers scrub in to learn surgical skills, such as the basics of suturing, cautery, and wound closure, and they practice taking biopsies and placing endoscopes—often under the watchful eye of surgical resident Sandra DiBrito, who has been integral to course planning.

“This class gets at fundamentals,” Siewerdsen says. “A stronger foundation helps to fuel better innovation and more meaningful solutions. For a biomedical engineer, there is no better way to spark ideas on important problems than to connect with clinicians.”

Noah Yang

Noah Yang, a master’s degree student in bioengineering innovation and design, couldn’t agree more. “The best way to understand something is to try and do it yourself,” says Yang. “As a biomedical engineer, much more design insight can be gained from doing a procedure versus watching a video or having it explained to you. The course is a once-in-a-lifetime opportunity to use the same tools and techniques that I am going to try and improve,” he says.

In the spring, eight students from the first-semester course are selected to take part in the semester-long Surgineering: Systems Engineering and Data Science in Interventional Medicine.

The surgineers work alongside surgeons, nurses, and staff members at the Johns Hopkins Hospital to learn real-life challenges and understand the full spectrum of patient care. These mentorships are both observational and hands-on, giving each surgineer a firsthand perspective on workflow, the interaction among multiple departments in the care pathway, and the continuous capture and curation of data. Their overarching task? To understand the complex interplay of clinical systems and find ways to overcome complexity, improve quality, and enable new advances in clinical care.

By midterm, projects crystallize in a lively idea-mapping session with footlong Post-It notes and much discussion. The group narrows its efforts to four projects that it tackles through the rest of the semester. Students make final presentations to an audience of engineers and clinical collaborators in May.    

“Surgineering reflects an outlook that is deeply Hopkins,” says Siewerdsen. “The work we are doing is inspired and conducted right in the heart of the most vibrant clinical environment imaginable. Hopkins has been at the cross-section of science and medicine since it first opened its doors, and the spirit of discovery and innovation driven by clinical need has never been stronger.”

The concept is one that excites Michael I. Miller, the Bessie Darling Massey Chair in Biomedical Engineering. “By bringing together their respective engineering and clinical expertise,” he says, “Hopkins surgineers and their physician collaborators have immense potential to revolutionize the standard of patient care and engineer the future of medicine.”

‘THE OR IS A TEAM SPORT’

Siewerdsen’s inspiration for the program was sparked 10 years ago, when he joined the faculty at Johns Hopkins and learned of a short summer course taught at the Homewood campus by engineers and computer scientists in collaboration with Johns Hopkins surgeon Michael Marohn. The course covered the ins and outs of the operating room, basic principles, and advanced specialties, including robotic and minimally invasive surgery.

“I always thought the class was brilliant,” says Siewerdsen. “But two weeks gives only a taste, and I wanted to expand it to a full semester—or a full year—and teach it right in the hospital.”

To Siewerdsen’s delight, Marohn still serves on the faculty of the surgineering program. For the fundamentals course, he covers minimally invasive surgery early in the fall semester, injecting a little humor in his experience and perspective on how medicine moved from large incisions to minimally invasive laparoscopy. “Most of you don’t have lights inside of you, even though your mother says you do,” Marohn jokes as he demonstrates a laparoscope’s light guide and view inside the patient.

Joining Siewerdsen and Marohn on the faculty are a dozen other surgeons in specialties ranging from neurosurgery to gynecology, including Gina Adrales, who co-directs the course and leads several classes at the Minimally Invasive Surgical Training and Innovation Center. There, the surgineers gain exposure to basic and advanced techniques in laparoscopic surgery, including robotically assisted surgery on the Intuitive Surgical’s da Vinci system.

The surgineers start with the basics: who’s who in the OR, how to scrub in, how to safely attach a scalpel blade on a handle. Marohn has endless patience as the students try to master the seemingly simple yet awkward task of placing a blade on a knife handle and handing it (safely) to Marohn. “The OR is a team sport,” Marohn reminds them as they stand over a table filled with needles, blades, retractors, and surgical scissors. “At the end of this course, we want you to say, ‘There’s got to be a better way.’”

Yang has found that getting his hands on actual surgical instruments and watching surgeons use those surgical tools has been invaluable. He’s been able to see firsthand what works—and what doesn’t, he says. “Dr. Marohn showed us an instrument used for laparoscopic surgery that was so difficult to maneuver that it was not commercially successful. The tool worked in theory but was difficult to place properly intraoperatively.” Lesson learned for Yang? “Personally,” he says, “I’m going to approach engineering with a greater focus on user testing and iteration.”

Sarah Capostagno

Sarah Capostagno, a PhD student in biomedical engineering, took the surgineering program last year, completing both courses. After her clinical rounds mentorship in the second semester, Capostagno is now working on a project to design a better workflow for the intraoperative MRI at the Johns Hopkins Hospital—a special operating suite containing a mobile MRI machine that gets deployed during surgery to bring the magnet to the patient via ceiling-mounted rails.

“Intraoperative MRI allows surgeons to obtain an MRI scan of their patient during an operation to better see and avoid critical structures in the brain; perform minimally invasive, image-guided procedures; and confirm in the operating room (before closing the incision) whether the surgery has been successful or if more needs to be done and/or corrections need to be made,” she explains.

While observing cases, Capostagno saw the potential to improve workflow within the room. “There are a lot of safety issues and workflow inefficiencies, including the transitions to prepare for the magnet to be brought into and out of the operating area,” she says. “When I observed cases, for example, I saw that there was time wasted trying to find appropriate cables to stretch to the machine and to the patients. I knew it could be fixed with an engineering solution.”

She simulated the workflow and the roles of everyone in the room: surgeons, anesthetists, nurses, techs, and patients. In her models, she rearranged roles, schedules, equipment placement in the room, and how to get people in and out. “My role was to make the dance of people more synchronous,” she says.

One important solution she came up with was to lessen the rotation of the floor-mounted patient table. This decreased the risk of tubes, lines, or cables getting tangled or disconnected. She also changed the placement of the anesthesia cart, to be at the patient’s head during intubation. “This relocates the anesthesiologist and anesthesia cart into an area of the room where they don’t have to move during the transition to deploy the magnet, improving time and safety,” she says.

Ultimately, her plan shaved 12 minutes off the setup stage for the room.

“When I was doing it, it seemed basic to me,” she recalls. “But when I showed the clinicians, they were impressed and agreed that it could work.” Capostagno has presented her plan to the Johns Hopkins Hospital governance safety committee and to a team of engineers in Johns Hopkins’ Armstrong Institute for Patient Safety and Quality. “They’re talking about implementing my recommendations,” she says. “This proves that little things that make sense to me have an impact.”

The surgineering program also had a personal impact for her: After she completes her PhD, Capostagno intends to apply to medical school, with plans to be a neurosurgeon.

Prasad Vagdargi, a PhD student in computer science, focused his surgineering project on analyzing anesthesia data. As he watched anesthetists monitor patients before, during, and after procedures, often rotating between different ORs, Vagdargi wondered if there was a way to better predict a patient’s anesthesia needs.

“Accurate predictions could create a more efficient workflow for anesthetists, along with reducing their workload and fatigue,” he says.

His surgineering project helped to inspire an area of his PhD research, which he is pursuing in collaboration with Siewerdsen: developing novel navigation and imaging systems for orthopedic trauma surgeries. “This course gave me a new way of looking at problems and the perspective to care not just about patient health and outcomes, but also about improving a surgeon’s capabilities and skills,” says Vagdar​gi.

One of the most rewarding aspects for Vagdar​gi was the time spent with the surgeons in and out of the OR. He observed surgeons scheduling patients, reviewing cases, and interacting with the families of patients. “[I had] lots of collaboration with clinicians, which made this one of the rarest opportunities I have had,” he says.

Those connections, says Siewerdsen, are among the most valuable takeaways from the surgineering program.

“My hope is that surgineering will give students insight on both routine practice and major unsolved—often unarticulated—problems,” he says. “These are the brightest biomedical engineering students in the country, and they are the ones who will help transform medical practice in the decades ahead.”

SURGINEERING’S CHAMPION

Jeff Siewerdsen

As a PhD student at the University of Michigan, Jeff Siewerdsen conducted his research at the University of Michigan Medical Center. “Our lab was based directly in the hospital clinic, which gave daily inspiration of how clinical practice really works and what the needs of patients and physicians really are. That really shaped my outlook as an engineer,” he says.

It certainly shaped Siewerdsen’s research in medical imaging. His own work includes the development of cone beam CT for image-guided radiation therapy, which is now the standard of care, as well as cone beam CT on mobile C-arms for image-guided surgery. He founded the I-STAR Lab (Imaging for Surgery, Therapy, and Radiology) for development of advanced imaging technologies and co-directs the Carnegie Center for Surgical Innovation in collaboration with the Department of Neurosurgery.