Mark Fleming, DO, FAAOS, FAOAO, a new orthopaedic trauma surgeon in Massachusetts General Hospital's Department of Orthopaedic Surgery, recently retired at the rank of Captain from active duty in the United States Navy, and has expertise in orthopedic trauma surgery, combat casualty care and amputation management. Fleming previously served as the Deputy Director for Surgery and the Director of Orthopedic Trauma at the Walter Reed National Military Medical Center (WRNMMC). Most recently, he served as an attending orthopedic trauma surgeon at Los Angeles County + University of Southern California Medical Center and as the deputy director of the Navy Trauma Training Center.
We sat down with Dr. Fleming to discuss his distinguished career and what he hopes to accomplish at Mass General.
Q: You were living in southern California while working at USC. What brought you to Boston and to Mass General?
I just retired from the Navy after more than 30 years of service. I wanted to continue to practice orthopedic surgery in an academic setting, and when I learned of the opportunity to work at Mass General, I jumped at it. Recognizing that Mass General is one of the most renowned hospitals in the world and is affiliated with Harvard Medical School, I knew I wanted to be part of the innovative research and care this medical community delivers.
Q: What are your research interests?
My initial research focused on the epidemiology, patterns and outcomes of combat related orthopedic injuries. After taking care of casualties for several years, I started to recognize a change in the injury patterns that service members were experiencing. Specifically, I was seeing more patients that sustained dismounted complex blast injuries (DCBI). DCBIs occur when personnel step on an improvised explosive device (IED). The injury patterns typically involved devastating injuries to multiple extremities. Those extremities not amputated were often severely mangled. As the conflicts in Iraq and Afghanistan progressed, I started to see more patients with multiple extremity traumatic amputations to two, three or even four limbs. This pattern was significantly different from previous wars, as historically, patients that sustained this burden of trauma would typically succumb to their injuries on the battlefield. As a result of the changes in combat casualty care, and specifically modernization of the aeromedical evacuation system, the increased use of field tourniquets, wearing of enhanced body armor, institution of more aggressive, massive transfusion protocols and rapid transport to surgical resuscitation and stabilization, many more of these casualties were surviving, despite their devastating injuries. I didn't see this injury pattern described in the literature, so I started to document my observations: the injury patterns, the epidemiological aspects, how frequently the injuries were occurring, the required resources to manage the injuries and the complications.
Alongside this research, I wanted to learn how to best optimize the outcomes in managing these casualties. A significant number of the casualties sustained composite tissue injuries to their extremities (injuries to all structures that make up the extremity such as skin, bone, muscle, nerve and arteries). Additionally, they often lacked adequate donor sites to acutely reconstruct their limbs. Around this time, I was named a traveling exchange fellow of the Armed Forces Institute of Regenerative Medicine. This fellowship afforded me the opportunity to learn about the burgeoning field of regenerative medicine and how it might apply to my other research.
As part of an Orthoplastic team (a collaborative approach to managing patients using principles of orthopedic surgery and plastic surgery), I started exploring the use of regenerative medicine modalities to reconstruct extremities. One such project was the introduction of combine technologies to regenerate traumatic skin loss: My team introduced the use of a template to regenerate the dermal layer of skin, and a "spray skin" modality to regenerate the outer layer, the epidermis. With "spray skin," we would harvest a very small patch of skin, about the size of a postage stamp. Next, we would denature the harvested skin with an enzyme to create a suspension of cells. We would then spray the suspension onto the wound to achieve soft tissue coverage, all at the point of care.
Q: Where are you from, and what led you to practice medicine?
[chuckles] I'm laughing, because as I reflect on my career, I recognize that it has been heavily influenced by my father. I'm one of eight kids, the “middle child” and the only one that pursued a career in medicine. I greatly admire and have a great deal of respect for my father. His career served as a template, so to speak. While some may say I’ve attempted to follow in his footsteps, realistically, I wanted to carve my own path. In a sense I’ve attempted to emulated him; if emulation is defined as "matching or surpassing (a person or achievement), typically by imitation," I sought to surpass my father’s achievements. As an example, my father attended the University of Michigan, so to emulate him, I attended Michigan State University. My father was a career army officer, retiring as a “full bird” Colonel from the U.S. Army; to emulate him, I received my commission in the Navy retiring as a “full bird” Captain. He was a cardiothoracic surgeon, and I am an orthopedic surgeon. When my father retired from his military career in the US army, he was appointed to the academic faculty at UCLA. My final Navy assignment was at USC. The list goes on and on. Having my father as a role model led to my interest in the military as well as medicine. After he finished medical school, my father completed his internship, residency, fellowship and then became an attending surgeon at WRNMMC. Walter Reed is where I was born, and where I eventually spent the first decade of my career as an orthopedic trauma surgeon.
Q: Can you tell us more about your experience as a combat surgeon in Iraq?
My third deployment while serving on active duty in the US Navy was with the US Marine Corps to an area within the Sunni triangle in Iraq, called Ramadi. It was a unique, yet very challenging, experience. I learned a tremendous amount about resiliency. Despite having already been a trauma fellow, I learned a lot more about trauma. The weather in Iraq was incredibly overbearing. It was 120 degrees every day, even in the operating room. A concept I learned to appreciate early in deployment is the “Triad of Death.” This is a physiologic response after severe trauma, where patients can enter a deadly cycle from a combination of coagulopathy, acidosis and hypothermia. Hemorrhage or blood loss and hypothermia from exposure can lead to coagulopathy and acidosis. So here it is, 120 degrees, but my patients with severe trauma can become hypothermic. The general surgeon I was deployed with was on his 7th deployment. His mantra was that we would not keep any patient on the operating room table longer than one hour, because of his grave concern with the triad of death.
During my deployment, I also got to work in Baghdad at Ibn Sina Hospital, which was a commandeered Iraqi hospital that supported an army combat support hospital (CSH). I got to appreciate the resiliency of our patients. They sustained the most egregious wounds and trauma you can ever imagine, and we were able to get them stabilized enough to get them back home. Once back home, they would undergo definitive management, rehabilitation and reintegration back into society. So, it was interesting being a trauma surgeon deployed in Iraq, taking care of casualties in an austere environment but then also seeing the whole evolution of care from initial injury to damage control surgery, eventual definitive surgery and rehabilitation back in the States.
Q: You mentioned you came to Mass General because of its academic reputation and the opportunity to work with residents and fellows. How do you approach resident training?
Progressive responsibility. There are several stages within a residency, and the residents, of course, get more responsibility as they progress. I enjoy working with residents and helping them master all phases of medicine and surgery, so that when they graduate, they are proficient in their craft. It is my opinion that during the first couple of years of residency, the trainees should focus on the perioperative management of patients, that is, preoperative optimization, recognizing the indications for surgery and appreciating the associated potential complications of surgery. During the next phase of training, the residents should start to integrate the technical aspects of orthopedic surgery into their repertoire. Next, while continuing to have mastered the perioperative management of patients, the trainees should have the opportunity to further hone or master the technical aspects. Simultaneously, they’ll start to manage a team. By the time one becomes chief resident, they should have mastered all aspects. I became an academic surgeon to give back, while also making sure the next generation can take the mantle and run with it when it’s their time.
Q: I imagine you've seen a lot over the years. What do you think are the most important attributes for a trauma surgeon to have to be successful?
That is a tough question. I think, first, one must define "successful," as that term means different things to different people. Albert Schweitzer noted that, "Success is not the key to happiness. Happiness is the key to success. If you love what you are doing, you will be successful." With that, it is my observation that most orthopedic trauma surgeons, like myself, love being orthopedic trauma surgeons. A common trait amongst the best orthopedic trauma surgeons I’ve met is that they are inquisitive, and they possess the ability to think "outside the box," meaning that they are open to surgical improvisation. Sometimes, that means mixing older and newer surgical techniques, or even finding new applications for older, classic surgical techniques and tools. It’s important to be inquisitive and strive to learn and evolve.
Q: What do you like to do in your off time? Are you enjoying Boston so far?
One of my favorite pastimes has been watching my kids' athletic endeavors and seeing them become adults. My youngest is an undergraduate premedical student-athlete who plays football at Morehouse College in Atlanta. My middle child played lacrosse at Hampton University and is now a Navy Officer stationed in Florida. My oldest was a competitive cheerleader at the University of Florida, and she is also in the Navy.
When I’m not working, I love to go out to great restaurants and visit museums and other historic places. Both my wife and I are budding musicians. She has played the drums for years and is now teaching me to play. We also take dance lessons, and are learning all styles of dance, including standard ballroom (waltz, tango) and Latin styles.
This is my first time living in the Northeast; my Navy career has afforded me the opportunity to live in every other part of the country, including Hawaii. My wife and I are both extremely excited to be here in Boston. Although we've been living here for only a few weeks, thus far, between the people we've met, and the great food that we've had the opportunity to sample, I’ve been impressed. We'll see how the winter goes!