Advances in the Treatment of Chest Wall Injury with Dr. Joe Forrester

On this episode of Scrubcast, we dive deep into the world of trauma surgery with Dr. Joe Forrester, an associate professor in the Division of General Surgery at Stanford University and the trauma medical director for Stanford Healthcare. In this conversation hosted by Rachel Baker, Dr. Forrester shares his personal journey as both a surgeon and a trauma patient. (He decided professional climbing wasn’t a long-term career strategy at the age of 20 after a serious rock-climbing accident. Read the story here.)

Dr. Forrester also serves as the founding director of Stanford’s Chest Wall Injury Center. He talks about bringing new surgical techniques to Stanford including surgical stabilization of sternal and rib fractures (SSRF) and how he shares he knowledge with residents and fellow surgeon (Learn more about RibFest.) all in the hopes of providing patients with the level of care he would want for his family and friends.

p.s. Dr. Forrester couldn’t divulge the details of a study that will premier at AAST this September but you can read the precursor paper here:  “Ultrasound-guided percutaneous cryoneurolysis of intercostal nerves.”

Rachel Baker: [00:00:00] Welcome to Scrubcast, where we take a closer look at the research happening at Stanford University's Department of Surgery. I'm your host, Rachel Baker. Today we're speaking with Dr. Joe Forrester. Welcome to the show.

Joe Forrester: Thank you so much, Rachel. I appreciate the opportunity to join Scrubcast.

Rachel Baker: It's great to have you here.

This episode will premiere on June 1st, so I can officially say that Dr. Forrester is an associate professor in our division of General Surgery's acute care surgery section. Congratulations on the promotion. Thank you. You also serve as trauma medical director for Stanford Healthcare. What drew you to specialize in trauma?

Joe Forrester: I have been an injured patient myself, so I have a very intimate understanding of what happens when you get injured and the kinda incredible lengths that people will go to help injured folks both in the United States and abroad. And I really enjoy working with trauma patients. I think there's the full spectrum [00:01:00] of society that you get to work with.

It's almost universal that no one chooses to come in as a trauma patient. And so people are kind of, uh, stuck in their most vulnerable. Physician trying to get better and it's a real privilege to be able to help them get better and achieve health.

Rachel Baker: That's a great answer. If anyone is interested in learning about Joe's, uh, past as a trauma patient, um, there's a great article on scope and I'll put that in the description.

You graduated from Stanford's general surgery residency program in 2018. You completed a surgical critical care fellowship in 2019, and in 2020 you became director of our brand new chest wall injury center. Um, that's really fast. What's your secret?

Joe Forrester: You know, I think the, for me, the secret sauce to being able to continue to achieve my goals has been being willing to learn from [00:02:00] failures, learn from adversity.

Uh, seek advice from mentors. And then be willing to grind really hard. Like success is not easy. I'm not necessarily the most intellectually gifted individual in the world. I don't have a, a, you know, a

Rachel Baker: A 140 IQ?

Joe Forrester: Yeah. Well, I, yeah, I mean, I don't know. I can't imagine after my head injury that I do it least.

But, you know, I don't know. I try and keep kinda my guiding principles first and foremost. You know, I try and think about the patients who are in front of me, the patients who I. Represented in Northern California through our trauma program. And I think what would be injured me one, if I was looking across the table, and particularly with respect to the chest wall program, I saw an unmet need and technology that had improved the point where I thought we could offer surgeries that had the chance to really improve someone's quality of life.

So kind of took it from there.

Rachel Baker: Nice. One of the things I like to do on this podcast is make sure we're all on the same page vocabulary [00:03:00] wise. When you say chest wall injury, we're talking mostly about rib and sternal fractures caused by blunt force trauma, AKA, a car accident or like an elderly person falling.

Joe Forrester: Mm-hmm. Yeah. So, uh, chest wall injury broadly encompasses rib fractures, sternal fractures. Soft tissue injury to the chest. So intercostal hernias, diaphragmatic injury or hernias, costal margin injury or hernias. So we see those patients both acutely coming in as trauma patients. And then the other aspect of the chest wall injury center is our outpatient footprint.

So I see patients with rib, non-union, sternal, non-union, uh, these chronic hernias and work to try and help them get better as well.

Rachel Baker: So you, maybe this is what you were talking about before. So I thought when you broke a rib, they told you to take an NSAID, slap an ice pack on it, and sent you on your way.

Surgical intervention was really only a thing when you [00:04:00] punctured a lung or something. So where do you come in?

Joe Forrester: Yeah, great question. So, you know, the vast majority of patients who are coming in as trauma patients across the country with rib fractures don't necessarily require a surgery. So we think about rib fractures existing along a spectrum.

So just like there can be a cracked egg that has like a little crack in it and a cracked egg that you're getting ready to fry up, like both of those eggs are cracked. But there's a big difference in how cracked the first egg is compared to the egg that you're getting ready to fry. And similarly, as improved, our treatment modalities for those fractures have changed.

So there are people who have non-displaced simple rib fractures. And oftentimes those can be treated with NSAIDs, multimodal pain therapy and non-surgical therapy. Then there's the people with very badly cracked ribs, the most severe among that being something we call clinical flail chest, where when you're breathing in part of your rib cage is not moving in the [00:05:00] same way that the rest of your rib cage is.

And for people with more severe chest wall injuries, or if people are having significant breathing issues associated with their rib fractures or a lot of pain associated with their rib fractures, we have a way to use what we call surfing or surgical stabilization of rib fractures. Uh, surfing. Yeah, surfing.

Um, you know, that allows us to provide mechanical stability to the fracture, which helps reduce some of the pain associated with the fracture. And really in the last 10 to 15 years, the technology has improved substantially With the implants that we use to stabilize the ribs, our surgical approaches have improved significantly so that there's very little morbidity associated with the, uh, incisions.

We're really just making skin incisions at this point. We oftentimes don't have to cut any muscle or nerves. That gives us the opportunity to provide this surgical stabilization, which improves the pain with little patient morbidity, which has essentially expanded [00:06:00] the indications for offering surgery to patients with rib fractures.

Rachel Baker: Okay, so let's dive into surfing or SSRF, surgical stabilization of sternal and rib fractures. I was able to photograph some of the tools you used to perform this surgery last year at RibFest, which is a one day annual intensive that you host to teach physicians and residents about this procedure. I mostly paid attention to the fact that it was all color coded, but I'm sure that there's something a little more technical there.

Particularly because there were like five different boxes. So, uh, can you explain why there are so many different options and how you first learned about this?

Joe Forrester: Yeah. So in Ribfest, uh, which is our day long CME course, uh, we have a vendor agnostic process, uh, whereby, uh, each of the vendors that offer implants for surgical stabilization of rib fractures have donated their sets.

So we as physicians in a very safe environment, can talk [00:07:00] about the strengths and benefits of each of the, uh, implant systems. And I think one of the things that's been special about surgical stabilization of rib fractures, particularly in the last 10 to 15 years, is the degree to which the industry partners have tried to support ongoing education efforts.

And are willing to do it in a vendor agnostic way. Not a lot of vendors and other specialties are willing to give money and give sets in a way that they're not directly potentially benefiting from. So, um, it's been a, a nice partnership over the last, I guess, five years now. And then how did I learn? You know, it was, it was interesting because I was at the University of Virginia for medical school and we were really weren't offering surgical stabilization of rib fractures.

I came to Stanford as a resident. We really weren't offering surgical stabilization of rib fractures. I left to go to CDC for my two years as, as an epidemic intelligence service officer. I came back, we still weren't offering really surgical stabilization of rib fractures. And you know, this whole time I kept thinking to [00:08:00] myself, you know, if I get injured or if one of my friend gets injured, like the technology is good enough and I feel like I am a savvy enough surgeon that, that we should be able to offer this.

And so. When I was finishing my fellowship, I took it upon myself to get some education and mentorship from Tom White out of Intermountain Health. I joined the Chest Wall Injury Society, which is, you know, the world's premier organization for management of chest wall injury. Through that, I developed a network of mentors kind of across the country.

I then did a number of different cadaver-based courses. Ran cases by my mentors and then started, uh, offering the operations here at Stanford. One of the things that I think contributed to our early success is I also invested heavily in getting the residents to courses where they could learn about the tools of the trade and the tricks to have a successful operation and the indications for surgery.

And then I also had a very intentional quality, uh, and performance [00:09:00] improvement process whereby every quarter we would review every single case that was done here at Stanford and ensure that the quality, uh, was at a level that I would want for my own family. And ensure that we were all on the same page with who we were offering the surgery to and why.

And so I think that contributed to a lot of the early success of the program.

Rachel Baker: That's fantastic. I had no idea that you had really put in all of this front-loading education of the residents. There's so much already packed into general surgery residency. How did you come out and just say like, I want to increase what you have to learn.

Joe Forrester: You know, it's interesting as a resident. A medical student, I think it was easy for me to think that the field of surgery is, is static. Hmm. But the reality is, the longer you practice surgery, the more you realize that things are changing all of the time, and that in order to push your own limits, in order to provide the best care that you can for your patients, [00:10:00] I as a surgeon also have to be continuously willing to adapt and willing to invest in my own education and.

Sometimes that means coming in late at night and reading. Sometimes that means, you know, going to observe other people's cases on the weekends. Sometimes that involves, you know, flying across the country for an education course to fly right back. But at the end of the day, when I think about the principles that guide my decisions, it's like, what can I do to provide the best possible care to the patient in front of me?

Sometimes those things are required, and sometimes that means less sleep. Like sometimes that means sacrifices, but at the end of the day, like when you get someone. Who might not have survived, you know, 10 years ago through an operation and through a hospital course and get them back to health. Like that feels pretty good.

Rachel Baker: Fantastic. Love that. Um, okay, so on that note, I read a publication, you were first author on it in injury. It came out last month. It was, uh, titled Ultrasound Guided Percutaneous [00:11:00] Cryoneurolysis of intercostal nerves. And so I was reading it and I was like, wait, this sounds so much like what Dr. Chao does in her pectus excavatum surgeries.

Am I completely off base or are they similar?

Joe Forrester: No, you're very on base. So, so broadly intercostal, cryoneurolysis involves freezing a nerve. It essentially kills the neuron, but the perineural tissue remains intact. So the way I like to think of it is we're essentially taking the nerve train off the train track, uh, for a period of time until the nerve has a chance to regenerate.

In pectus surgery, cryoneurolysis has been used now for many years to reduce opioid requirements, reduce length of stay, get patients back to feeling better faster. And when I was starting as faculty, intercostal cry, neurolysis, uh, was starting to be used for patients with rib fractures where we would do, at the same time as we're doing the surgical stabilization [00:12:00] of their rib fractures, we would do intrathoracic, cryoneurolysis.

So in the same way that they do cryoneurolysis for patients with pectus. Through that process, I thought, you know, what about the patients that we aren't doing surgery on? Like, is there a way we could use Cry Neurolysis to help for pain control for patients that we don't do surgery on? And I set forth, uh, with some partners from Interventional Radiology, our ICU and the trauma program to look at, uh, in a prospective randomized fashion, two groups of patients.

So we had two clinical trials. The first. If looking at patients 65 years of age or older where we randomize people to CT guided cryoneurolysis, uh, with standard of care versus standard of care alone. Then the second clinical trial, uh, out of which that paper was partially born, uh, was looking at people 18 to 64, where I would perform percutaneous, cryoneurolysis at bedside using ultrasound.

Ooh, yeah. That paper that you [00:13:00] referenced, uh, is uh, essentially our proof of concept early in the study. So it's our early group of intervention patients, but we will be publishing. And presenting at the double a ST in September, our full randomized control trial, uh, results. So I can't, can't disclose any of them, but, uh, it will be, it's, uh, it's gonna be hot on the podium in AAST 2025, so please come if you're interested,

Rachel Baker: Awesome! I'm looking forward to it. 'cause I know from experience that when your intercostal nerves hurt, it makes it really hard to breathe. And breathing is, you know, essential or at least, so I've been told.

Joe Forrester: Yeah, unless you're on ECMO, but you have a hard time, most people have a hard time living a normal standard life wall on a ECMO.

Rachel Baker: True. Uh, well that sound means that it is time for our lightning round. On each episode of Scrubcast, we ask each of our guests the same two questions. And the first one is, [00:14:00] who is a surgeon you admire and why?

Joe Forrester: That's, uh, there's, there's so many, uh, surgeons that I've interacted with over the years, uh, who've had very meaningful impacts on my life.

You know, I think when I look back, I think as a medical student, and I saw there was a surgeon at University of Virginia at the time, Rob Sawyer, the same Rob Sawyer who published the Stop at trial in the New England General of Medicine. Um. I have several cases that I remember with him of PA patients who came in very badly injured, some of whom lived, some of whom died.

But just his, uh, his ability to think through very complex questions in a very quick fashion. I. Um, was something that I found very admirable. And then, you know, as a resident there, we have such a spectacular panel of surgeons who we get to work with here at Stanford. You know, it, it's honestly very hard for me to say there's one person more than any other who, you know, drove my career forward [00:15:00] because so many people have in ways that many of them might not even know had positive impacts on my career.

So.

Rachel Baker: Awesome. Well, I'll have to look up your University of Virginia professor. He sounds cool.

Joe Forrester: Yeah, he's, uh, now chair of surgery at Western Michigan.

Rachel Baker: Oh, nice. Okay. Uh, the second question is, what is the best advice you have received in 10 words or less?

Joe Forrester: It's right up here for those.

Rachel Baker: Oh, I was reading that.

Joe Forrester: I, I may have even come up with it. I don't know. But grind harder, cut faster, and embrace the suffer.

Rachel Baker: I like that. I mean, cut faster. I think that must have been a surgeon, right?

Joe Forrester: Yeah. It, it may have been me, I don't know. Sometimes late at night, I forget what I say on call. So it's possible it was me.

Rachel Baker: Did someone give you that?

Joe Forrester: Yeah, Jeff. Jeff Choi did when he was finishing up his research done.

Rachel Baker: Very nice. Um, well, so actually we have a new question for this episode, and it was requested by a few of our department members at Holman Day. Mm-hmm. Their question [00:16:00] is, what is your OR music.

Joe Forrester: Yeah. It's, uh, that one's pretty easy for me.

I. I, I would, I would argue that maybe what you should do when surgeons come on is ask the scrub team in the RS what people's or music is. There might be a way to, to spice it up a little bit, but hands down, uh, uh, like AC/DC “Back in Black.” Yes. It’s a great way to start off with case.

Rachel Baker: I like that. Awesome. It does change?

Joe Forrester: Yeah, it definitely changes. I mean, I would say like I, I'm not, uh, sophisticated enough to have my own music box in the or plus in the section of acute care surgery, we operate in basically every or in the hospital.

Rachel Baker: Yeah.

Joe Forrester: We don't get the privilege of selecting, uh, music devices in a given room.

So I usually use Pandora in an AC/DC station.

Rachel Baker: Fabulous. Love that.

Rachel Baker: Well, it has been an absolute pleasure chatting to you. Um, but before we go, I wanna ask one final question, and that is, [00:17:00] what is next for Dr. Forrester?

Joe Forrester: Oh, I don't know. Grinding harder, cutting faster, and embracing the suffering and whatever comes my way

Rachel Baker: back to the OR?  

Joe Forrester: back to the OR or not I don't know. You know, it's, I'll say that one of the things that I was, I was reflecting on recently in my own career is that I have been presented with opportunities that I would never have expected.

And by being willing to take the risk in pursuing those opportunities, I've had experiences that I could never have anticipated. So I don't know, we'll have to see what the next, the next opportunity is, and I gotta be willing to take the risk and take the jump to make it happen.

Rachel Baker: absolutely, I'm looking forward to it.

Thank you again for coming on the show.

Joe Forrester: Thanks Rachel

Rachel Baker: …and thank you to our listeners for tuning in to this episode of Scrub Cast. Until next time, stay sharp. If you like Scrubcast, we hope you'll tell your friends and subscribe wherever you get your podcast. Scrubcast is a production of Stanford University's [00:18:00] Department of Surgery.

Today's episode was produced by Rachel Baker. The music is by Midnight Rounds, and our chair is Dr. Mary Hawn.