Transcription of Dr. Robert Ecker for the show East Meets West #28
Dr. Lisa: I’m especially pleased to have the chance to introduce this individual for Maine Magazine Minutes. This is Dr. Rob Ecker, and he is profiled in the upcoming April wellness issue of Maine magazine. This is the second full wellness issue of Maine magazine. The first one was the one that Genevieve Morgan and I did, well she interviewed, she actually did all the work, she just interviewed me last year. I continue to be impressed with the fact that Maine Magazine has such a focus on health and wellness. And impressed with the fact that we have, Genevieve has called him a Superdoc, people like Dr. Ecker, here in the state of Maine, who are practicing Superdocs. So I’m going to let Genevieve … I shouldn’t say let … Genevieve, please take over now.
Genevieve Morgan:Thank you, Lisa, and welcome, Dr. Ecker.
Dr. Rob Ecker: Thank you for having me.
Genevieve Morgan:It’s such a pleasure to have you here and have our listeners listen to what you have to say. We had a great interview for the Maine Magazine wellness issue. I want to give a brief bio of you just because you’ve moved to the state relatively recently and I wanted to let people know that you studied undergraduate at Harvard and received top marks from the Virginia Commonwealth University School of Medicine on a military scholarship. You did your residency at the Mayo Clinic and you were trained as an endovascular surgeon, is that correct? At the University of Buffalo?
Dr. Rob Ecker: Yes, Nick Hopkins who’s an endovascular neurosurgeon is kind of the grand daddy of bringing endovascular techniques to neurosurgery. And endovascular techniques are similar to the way that cardiologists will put catheters either in the arteries in the wrist or the groin and bring them up to the heart to treat heart disease. That can now be used to treat vascular disease in the head, so for acute stroke, ruptured aneurysms, unusual vascular malformations in the head and neck, we can actually in the same way go up through the arm or the leg to the neck into the brain itself and treat these disorders.
Genevieve Morgan:And you came to Maine Medical Center to be the only cerebrovascular surgeon with endovascular training in our state.
Dr. Rob Ecker: That’s correct. I’m the only dual-trained. So I do open surgery to clip an aneurysm or take a blood clot out of the head, or address a stroke in some way, and also to be able to actually go up through the vessels themselves to be able to treat them. So I’m the only dual- trained person in the state of Maine.
Genevieve Morgan:So what you do every day is go inside people’s brains?
Dr. Rob Ecker: Of sorts. That is broadly speaking what I do. I sort of view myself sort of as a body plumber. If it’s bleeding, I stop it from bleeding. And if it’s plugged, I open it up. And there are lots of terrific tools and techniques to do that, and I think we’re building a really nice team of people to help take care of these patients, who are often very very sick and need acute care basically from the emergency room to their post-operative care.
And as much as mine is sort of the technical part of it, these folks need really a good team put together and Maine Med provided really the opportunity to build a program that didn’t exist elsewhere. And that’s a rare thing even in the US. I looked all over the US, and there weren’t a lot of opportunities to build something that didn’t exist, and then also to be able to support taking care of these sick people.
Dr. Lisa: Well, you’re very modest about your skills, but but I know that it takes a lot of training and a lot of work to do what you do. In fact, you’ve described it to me as and art as well as technique. What is the artistic part of your job? How do you view that?
Dr. Rob Ecker: Neurosurgery as a whole has been described as essentially a three dimensional physical exercise. So when you are, from looking at a scan of a patient, to then deciding how you are going to treat them, from open surgery, opening up the head, to be able to even position the head, to orient the head to be able to find the sick blood vessel to be able to treat it, that sect of brain is kind of a three-dimensional exercise to safely get there.
And that requires some training or some art to figure out the most efficient way to do that. And then, endovascularly speaking, there’s not… you know, it’s almost like a game of chess. There’s sort of not one solution necessarily to get there, but trying to figure out the most efficient and safe solution often requires different tools, techniques, trying different things even if one doesn’t work to try to have a plan B or plan C to get there. I think that is often the art form to it.
Dr. Lisa: That three-dimensional exercise you’re describing, it requires the ability to visualize on a very high level, at a level that most people probably aren’t called on to do.
Dr. Rob Ecker: I think so. I think some people may gravitate, maybe it’s something I’ve just gravitated towards. And I know some who have a better three-dimensional sense than others. You can actually have them have done it for a while. I suspect like an artist watching someone paint, you kind of get a sense of watching someone work, and who seems to get there efficiently. I think that is a skill you develop. I think it’s also something you can work at to get better at over time by just doing a lot of cases and attempting to watch a lot of people who are very good at it do it. I’ve gone out of my way to try and find people I view as very very good and watch them work and see how they do what they do.
Dr. Lisa: And that’s appropriate to our theme of East-West, that journey took you to Okinawa, Japan, correct?
Dr. Rob Ecker: Yeah, right out of training, the Navy stationed me in Okinawa, Japan, which is for many neurosurgeons, considered a sleepy place. But I, in a bid not to lose my skill set, went out of my way to really partner with a Japanese neurosurgeon who was there. The Okinawa island itself is some part of the Ryukyu Archipelago, and there’s a university there, a university hospital there, and actually a very well cerebral vasular surgeon in his early 60s – Dr. Akio Hyodo was there. Had spent some time at the Mass General as a research fellow, so spoke pretty good English.
And I tried to work with him a couple of days a week, and he was a wonderful teacher. Almost a sort of second Japanese Fellowship. And he would go all the way around the islands to different hospitals to do different cerebral vascular cases, and he’d call me up and we’d go in his car, and we’d go do something else. And I think simply by having had enough, he knew that I had had a lot of experience taking care of these patients. And most of his fellows hadn’t. So I think he enjoyed having me around as a second set of eyes. And it was wonderful seeing him work. I learned an enormous amount.
Dr. Lisa: And then you went to Finland last year, so you went to the other.
Dr. Rob Ecker: Contingent on actually anywhere where I was interviewing after the military, there’s a man named Johann Ernest Neambi who’s at the University of Helsinki who I’ve always viewed as, of the generation in their early 60’s, the most cerebral vascular surgeon, so open, not endovascular surgeon. I always wanted to go watch him work, so I made it contingent on every job offer when I interviewed everywhere that I would go spend a month with him, and the guys at Maine Med and my partners let me go for the month of May last year. And it was spectacular.
Watching him work has actually improved my technique already. I never had a patient be able to have a clipped aneurysm, so an open surgery and be able to leave the next day, and not all my patients do, but I’ve had a handful now who I’ve operated on who have left the next day. And it’s simply by modifying that technique.
Dr. Lisa: I have so many questions for you. Let me to start with a very simple one for the people who are listening who aren’t doctors. Just tell me what an aneurysm is.
Dr. Rob Ecker: An aneurysm is a weakness in a blood vessel in the brain that can be something that is familial and genetic and it can be something that comes from a lifetime of smoking. They are, when they rupture, associated with a horrible morbidity and mortality. 20% of patients will die with a rupture. Of the remaining group who get to the hospital, nearly half of them will have major morbidity and mortality.
Genevieve Morgan:So it is a stroke of sorts.
Dr. Rob Ecker: It is. No, it is considered a stroke. So it is a hemorrhagic version of stroke. In fact in the young, it is the highest cause of morbidity and mortality of strokes. So if you group all strokes together, in the younger patients, subarachnoid hemorrhage, which is the kind of hemorrhage from an aneurysm, is the greatest cause of morbidity and mortality.
Dr. Lisa: Just talk for a minute about the prevalence of stroke amongst people in the United States and is that growing?
Dr. Rob Ecker: It is. Currently right now, it is the third most common cause of major morbidity and mortality in the US. And that also tracks in Maine similarly.
Genevieve Morgan:And you think that has something to do with the smoking piece?
Dr. Rob Ecker: It’s general health issues. Obesity, diabetes, smoking, all those pieces put together.
Genevieve: We talk a lot on the Dr. Lisa Radio Hour about preventative medicine and holistic health, but what you do, you treat people very often in emergency situations. And you have been trained allopathically, conventionally and that has such an important role in our health that I’d love to hear you speak about your view of Western medicine. Not versus Eastern medicine, but as part of an overall health care plan for somebody.
Dr. Rob Ecker: This is a funny dynamic. When you’d asked me to be on this show, sort of East versus West, but I think most of the conception of East versus West is one of alternative medicine strategies. So be it in opposed to surgery is someone who needs medicinal therapy, some sort of form of yoga, some other thing in order to help them get through whatever that process is that might otherwise be surgical.
My version of East versus West is experience with Japanese neurosurgeons, in fact I visited a number of others. I visited some guys in Kobe, in Osaka, in Tokyo. Up near Mount Fuji, another fellow who is very good at bypass, which is actually taking a face artery and plugging it into the brain artery for certain indications. These are all allopathically trained surgeons. The fellow I visited in Finland is an allopathically trained surgeon. So it’s not really East versus West. Its East and West.
We’ve talked a little bit about it before. I get involved when preventative medicine hasn’t worked. That’s really my main role. When all things have been tried and haven’t worked, and someone’s having a stroke or having a hemorrhage that needs to be addressed.
Genevieve Morgan:And everybody’s very happy that you’re there.
Dr. Rob Ecker: God willing.
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Dr. Lisa: Are you able to work with people who are further upstream? So, say you have a stroke patient who has come in and they now need rehabilitation. Do you go back and maybe work with somebody who does Chi gong or Tai Chi? Do you refer out to other practitioners who can help create a more holistic picture for that patient?
Dr. Rob Ecker: I do. So much of the work we’ve done with rehab has actually been through new England Rehab and they have strong ties to a lot of the different communities that run a lot of these programs for stroke. There’s even music programs for folks who’ve had brain injury – never mind East and West, but alternative therapies for them.
Dr. Lisa: So you are about integrative medicine?
Dr. Rob Ecker: Yes I think they are. But so much of that is, to some degree, a peripheral part of my practice. With those patients, it’s a matter of knowing where to refer them, but not actually, that’s not something I myself do. So as far as referring them in this community, it is something the stroke patients have an opportunity to be involved in.
Dr. Lisa: I wouldn’t discount that. You may not be directly involved, but there are some practitioners who are very high level surgeons, for example, who don’t want to refer out to a holistic practitioner. It doesn’t sound like you’re averse to that at all.
Dr. Rob Ecker: Not at all. My opinion is if it works, it doesn’t matter what you call it. It can be allopathic, it can be homeopathic, it can be, I mean, chiropractic care and spine care is another one. I think we send a lot of patients toward folks who do care like chiropractic care, and if they do, I think that’s terrific. I really have no inherent intellectual aversion to anything that works.
Dr. Lisa: But I would point out that this is a new view. You’re relatively young, and I think that older practitioners, and I don’t want to put all older practitioners in the same bucket, but I think people who are trained many years ago sometimes are not open to this idea.
Dr. Rob Ecker: I think that may be true. One of the sponsors I heard lecture once went “For the most part, a surgeon should judge his outcomes by how happy he is to see his clinic.” Especially in taking care of neurosurgical patients, I think it gives patients a good sense of ease, especially if they’ve come to surgery and they’ve tried everything else. So I’m a big fan of if a patient has some thought to try any other therapy as long as they don’t view it as something that will necessarily hurt them in the process, I’m absolutely delighted to have them do it.
Dr. Lisa: That’s great. A surgeon who doesn’t always prescribe surgery. I think that there’s a lot of fear out there that that’s what surgeons just want to do is cut into people. So the fact that you’re willing to go and recommend other practices before. But ultimately, sometimes you really do need surgery. And that’s when the advances in technology come into play. I know you’ve been around the world. You’ve looked at many different practices across the nation, and you are here in Maine, and relatively recently. You’re helping build a practice that is at the cutting edge technologically speaking in the country.
Dr. Rob Ecker: Right now there’s only one technology that we don’t have available in Maine that is available everywhere else in the world, which is a particular kind of stent for reconstructing very large aneurysms, but as of April 9th, that won’t be true anymore. It’s a stent that’s probably similar in how it delivers and in its indications to other stents, it’s just in the way it’s designed.
Dr. Lisa: And a stent is just a backup.
Dr. Rob Ecker: Right. A stent is just a small metal tube that is used usually to repair a hole in a blood vessel associated with an aneurysm or some other vascular lesion. There are a number on the market now that are approved for aneurysm work. There is only one of him that we don’t have here now. They deliver in terms of how they are used in very very similar manners, so it’s not that that first patient should rest assured they haven’t already done a couple hundred, that it’s not a uniquely new device. But it has some certain properties, especially it’s the amount of … They’re all woven a bit like chain mail and they’re not just solid metal pipes. Most of them, the amount of metal in them is very small, because you want them very flexible in the brain.
There are some though where you want to primarily put a stand and have more metal coverage to be able to occlude an aneurysm, and this is a stent that has more metal in it than the others, so that’s really it’s fundamental difference.
Dr. Lisa: So as of April 10th, we will have …
Dr. Rob Ecker: It’s called the pipeline stent. There will be nothing actually in cerebral vascular surgery and endovascular surgery that we will not have available here in the state of Maine.
Dr. Lisa: Which is pretty incredible, because for a long time, we’ve referred patients out to Boston for example, or New York, or other parts of the country because we haven’t had this. But now, in your particular field, we have the technology.
Dr. Rob Ecker: That’s correct.
Dr. Lisa: And we have, you said nine people in your practice here in Portland?
Dr. Rob Ecker: There are nine other surgeons in my practice. I have one radiology partner, Dr. Chris Baker who can’t be on call all of the time for acute strokes, so right now we are on call every other day. We’re probably going to need a third partner as we develop forward. I really don’t think there’s any other institution that has developed as much as we are the technicians. Like I said, there needs to be a whole background to getting these patients cared for. And I think we’re building that team now.
Dr. Lisa: And there are other conditions that your team treats aside from aneurysms, stroke. There’s the spinal issues.
Dr. Rob Ecker: Essentially, we cover all of neurosurgery; brain tumors, there’s a level I Trauma Ctr. That we staff, so all the trauma gets staffed through us. That includes spine trauma, degenerative spine is a huge part of our practice. There are also some specific other problems. There is some pain syndromes, like trigeminal neuralgia, which is a face pain syndrome we take care of. Pituitary disease, some people split out differently from other tumors, we take care of pituitary tumors. So the whole sort of complement of neurosurgery between nine of us, and there are likely going to be a few more of us in the years to come as we build the program. We’ll be taking care of it. We also have a pediatric neurosurgeon in our group, Dr. Jim Wilson, who’s been here for a number of years, so a good group of people.
Dr. Lisa: How did you become the doctor that you are? Why did you do decide, when you were in high school, “I want to go to college. I want to go to medical school.” What was your background? I’m interested in that.
Dr. Rob Ecker: If you told me in high school or college that I’d be doing what I’m doing, I’d tell you you were crazy. Actually this was not even on the radar. I originally had interest to get, I was interested in healthcare policy, I had actually worked a little bit on Capitol Hill along the way – I don’t know if Genevieve and I had discussed that before, but I had some issues of getting an MD and an MBA, but everything has a nexus. I’m a third generation surgeon – both grandfathers and my father were surgeons. But I apologized to my dad when I started medical school. I had no interest in being a surgeon. He laughs at me a bit now.
That being said, when I was a third-year medical student – the Medical College of Virginia has a very long history with trauma. It’s one of the leading level in trauma centers in the country. It developed some of the early thinking about how one treats raised pressure in the brain with head trauma, and it was a spectacular group. But I hadn’t really intersected. I did neurosurgery as a third-year medical student, and I interacted with a couple of patients who had ruptured aneurysms. And another patient who had a syndrome called the locked in syndrome. There is an artery that runs in front of the brain stem call the basilar artery, and when it gets occluded, patients literally can be wide awake, but move nothing but their eyes.
Dr. Lisa: There was a book about that – The Diving Bell and the Butterfly.
Dr. Rob Ecker: That’s exactly right. Beautifully written book, and a movie made about it too. And having seen a patient locked in, and I thought “Boy, there has to be better treatment for that.” I saw a patient after and they couldn’t be helped anymore. They’d already had their brainstem stroke, and seeing some patients with aneurysms, I was interested in both, and I was also interested in open technical neurosurgery. So I had this plan that I wanted to do open neurosurgery and endovascular, but wasn’t exactly sure how it would mete out. I really discovered that as a third-year medical student, so prior to that, I didn’t have particular interest in it.
Dr. Lisa: What were your interests in high school?
Dr. Rob Ecker: Oddly enough, my original interest in life related to a few different things. I always loved the ocean, so was interested in marine biology. As a kid, I had some interest in being an actor actually. I did a fair amount of acting in Boston Children’s Theatre in Boston.
Dr. Lisa: Do you think that this ocean thing – did that lead to the Navy piece for you? Or did they just put you where they wanted you?
Dr. Rob Ecker: No, I’m of a family type that will pay for whatever college you go to, so I went to Harvard. Cost my parents an arm and a leg with that, and after that, you’re on your own. So with that, both my grandfathers and my father had been my, one grandfather was in the Army, the other grandfather was in the Navy in World War II. My dad was a corps member in the Korean War. So joining the military to pay for medical schools like a natural fit.
Dr. Lisa: I just want to ask one last question about that. You did spend some time in Maryland with the Wounded Warrior project.
Dr. Rob Ecker: Right.
Dr. Lisa: Will you just described to listeners what you did there, because it’s really interesting.
Dr. Rob Ecker: For the first year and a half of my military service, I took care of the folks in Okinawa, which is about a half million people west of Hawaii, and after the last 2 1/2 years of my service, I spent taking care of the Wounded Warriors in Maryland. So taking care of all the guys from Iraq and Afghanistan who had neurologic injuries. There were 11 neurosurgeons there.
There were three guys who were similarly trained as myself with cerebral vascular taking care of the majority of the folks with head injuries. We had a great group of guys taking care of most of the spine injuries we’re in our group, but a bit separate. The best example is during the Icelandic volcano when the planes couldn’t land in Germany. Literally, you could get shot in the head in Iraq and you would be in Bethesda, Maryland 48 hours later. So a tremendous experience.
A lot of critical care experience – taking care of guys with injuries you just don’t see anywhere else in the world. You may see them anywhere else in the world, but the inability to care for them. So really, a group of dedicated military surgeons of all sorts of medicine doctors taking care of a great group of patients. I learned an enormous amount from that group. We had a fellow here I took care of, probably about six weeks ago, who had a tire explode in his face. A big truck tire – usually they’re done in cages – exploded. He had an injury that was awfully like a lot of the guys from war and that experience helped take care of this guy here. Great patient population. Really great group of guys.
Dr. Lisa: Rob, we’re so lucky to have you in the studio today. And lucky to have you in our state. Thank you very much for coming today.
Dr. Rob Ecker: I thank you for having us, and helping build and support this program and that we’re trying to build here.