From Neurointerventional Radiologist to ‘Grey’s Anatomy’ Sonographer

Welcome to “Medical Mavericks,” a series from MedPage Today featuring interviews with healthcare professionals working in unconventional fields of health and medicine.

We spoke with Darren Orbach, MD, PhD, co-director of the Cerebrovascular Surgery and Interventions Center at Boston Children’s Hospital, about his experience making a guest appearance on the hit TV series “Grey’s Anatomy” (season 20, episode 4). Orbach appears in a scene featuring a groundbreaking procedure — conceptualized and spearheaded in real life by Orbach and colleagues — to treat a fetal vascular malformation in utero rather than after birth when the condition becomes potentially life-threatening.

Through the episode and conditioned media coverage, Orbach hopes that recognition of the innovative treatment approach and clinical trial will grow.

This interview has been edited for brevity and clarity.

Could you share an overview of your medical background and current position?

Orbach: I am a neurointerventional radiologist, meaning I use imaging to treat vascular problems in the brain and spine, usually with catheter-type procedures. I did a combined training program in neurology and radiology and neuroradiology, but interventional neuroradiology is sort of a sub-specialty on top of that. What’s a little off the beaten track is that I practice at Boston Children’s Hospital, so my practice is really exclusively pediatrics.

When I first moved to Boston back in 2006, I was at Brigham and Women’s covering the children’s hospital and coming over here increasingly frequently to do procedures. A few years into it, Children’s just hired me outright to be here full time. I still technically have an affiliation at Brigham and Women’s, but I really don’t do adult procedures other than fetal stuff, which is what we’re here to talk about.

Yes! Can you tell me about the procedure that was featured on “Grey’s Anatomy?”

Orbach: There is this particular condition that we treat a lot here (as an international referral center for the condition) called a vein of Galen malformation, which is a very high-flow, very aggressive vascular anomaly in the brain. It’s congenital, and these days it’s usually diagnosed in utero on screening ultrasound and then MRI. The standard of care is that we always admit the newborn to a NICU [neonatal intensive care unit] right after birth because most of them get extremely sick right away.

They actually go into heart failure even though the problem is in the brain because it’s such a massive malformation with so much flow that the heart can’t keep up. It’s actually, multiple times, the entire normal circulation of the body just going through the malformation. So, they usually crash pretty quickly after birth. They get a breathing tube in, and then we do these very complex, urgent procedures to try to reverse that.

It’s clear that the standard-of-care approach has some real gaps, so there is a significant mortality rate. And even among the survivors, there’s a significant rate of brain injuries, seizures, all kinds of problems, even at the most expert centers in the world.

So, that led us to think about whether it’s possible to change that paradigm and do a treatment before birth. Because, interestingly, in utero, the fetuses are not so sick. The malformation is still there and they have increased flow, but the heart and the brain actually seem to be protected from these injuries that occur after birth, probably because the placenta is in place. But then when the baby is born and you clamp the cord and the placenta is gone, all of a sudden that full burden is on the newborn’s heart and brain and they get sick. So, the idea is to decrease the flow and the malformation before birth. Then when they’re born, hopefully they’re fine, or not as sick, and we can lower the mortality and morbidity rate.

This has been a project we’ve been working on for years, and we got approval to run a formal clinical trial. We treated our first patient successfully about a year ago, and the baby was born perfectly fine. It was actually incredible. A little bit like, you know, baby from the 22nd century fell into our NICU. No medications, no intubation, no postnatal urgent procedures, and just did great. We wrote this up and it was published in the journal Stroke last year.

Did “Grey’s Anatomy” find your study and get in touch?

Orbach: “Grey’s Anatomy” evidently has at least one physician working for them whose job it is to read the medical literature and find interesting stories for episodes. He saw the Stroke paper and reached out to ask if I would do a Zoom with their writers because they decided to dramatize this first patient and wanted to get the science right. So I did that, and then they asked me if they could send me the script to review the medical aspects, which I was happy to do.

Then, completely on a lark, I asked them if I could have a cameo on the episode because I thought that would be incredible fun. I expected to be the guy who sort of arranges the scrubs on the shelf in the background, but they decided to make me the sonographer during the procedure. Then, also on a lark, I asked if I could bring my son along because he grew up a huge fan of the show. They said sure, and made him the anesthesiologist at the end.

So, in January, the two of us flew out there and we went to the studio in Hollywood and it was an incredibly fun and surreal experience.

Is it common for “Grey’s Anatomy” to have a physician consult?

Orbach: It sounds like they frequently consult with relevant specialists to get details right. My impression is they don’t have many cameos, but depending on what specialties would be involved in whatever procedure is being featured, they reach out and talk to the appropriate people. The producer who worked with me is actually a surgeon and he operates 1 day a week and then works the rest of the time for “Grey’s Anatomy.” So, he’s in the field, up to date, and he’s able to help them with most things, but I believe they get supplementary advice as needed.

I got to see the supplies they have in back, all the medical stuff, and it’s actually really impressive the lengths they go to. Even for this episode, they literally bought the catheters and wires and coils that I use and had the device company rep there during the filming. It was above and beyond. I was sort of telling them, I don’t think you need to go to these lengths because I don’t think anybody watching is going to have any idea of what catheter we’re using, but they really wanted to get all that right.

So the way they portrayed the procedure was pretty accurate then?

Orbach: It was. In fact, they also got permission from the patient and the hospital to use the actual images from the procedure on the show. That was also an incredible experience for me, just walking into their OR and seeing my patient’s images there on the screen. It was kind of even more surreal than just being on “Grey’s Anatomy.”

I had also sent them a PowerPoint of a talk I give about this procedure, and during the scene where Arizona [a surgeon on the show] is talking to the interns and asking them about what a vein of Galen malformation is, behind her head you can see my slides, which was also a blast.

Do you have any prior experience acting?

Orbach: I do not. In fact, my son and I had to create centralcasting.com logins, which was hilarious to both of us. Neither of us is, in any way, an actor. I learned a lot. I was amazed, first of all, at how many people are involved in a production. It was probably 75 or more people, with all the camera crew and the lighting team and several sets of actors who actually go in and try the lighting out and then they’ll pull them out and put another group of people in. That was number one.

Number two, the amount of work it takes to produce one scene. We basically filmed from 7 a.m. I had to leave at 7 p.m., but my son stayed overnight and they kept going until 11 p.m. just for that OR scene. It’s a lot of work and they re-shoot everything many, many times. So, the actors are repeating their stuff with the same facial expression, same voice. That was definitely educational.

In what ways, if any, are acting and medicine similar?

Orbach: In medicine, sometimes you need to process what you’re thinking. There are a lot of possible ways to talk to different families and patients depending on their background, what they bring to the table, their emotional state. So, I wouldn’t say you’re acting when you talk to them, but in the sense of having a filter and sort of thinking through the best way to present something, that’s an area where being able to control how you present yourself would be helpful.

But in my experience with acting on that day, it really struck me how professional it is in the sense that when you’re watching an episode, it looks like people really having conversations and having these emotions. And then in filming, you watch them do it 25 times in a row and you realize it’s literally a skill that they are honing. So that’s pretty different from medicine, I would say.

Going back to the in utero vein of Galen procedure, has there been an uptake in hospitals performing it?

Orbach: It’s brand new and we tried to be very responsible by doing a formal clinical trial. So, it’s approved by our hospital IRB [institutional review board] and also by the FDA, and there are very strict inclusion and exclusion criteria. And we have calculations for how many patients we need to treat and how many have to go well compared to the natural history of the condition.

That’s usually not the way new procedures in medicine happen. Usually there’s a tough situation and some innovator tries something new and you see how it goes the first few times. And then maybe you brought in the indication, you write a first case report or you write a case series of the first few patients and then other places try it. It often takes a while to do a formal clinical trial — it is usually a later step.

So, I think our approach was a more scientifically rigorous way to do it. And certainly, the hospital and the FDA insisted on it because it’s a fetal treatment, which is higher risk, and with any innovative fetal intervention they want to be super careful. So, I think that’s all totally appropriate. It does make it more challenging though, because we have to find exactly the right cohort and we’re locked into the protocol that we put in place. So we can’t really vary much during the procedure.

What are the main challenges in growing recognition of this approach?

Orbach: The main thing is the condition is rare. It’s not the most rare thing I treat, but it’s about one in 50,000 births. So, finding the right subset of patients who are candidates in a subset of a rare condition. That’s been the most challenging thing I would say: getting the word out and trying to recruit patients.

There’s been a lot of excitement in the field of fetal surgery and neurosurgery and maternal-fetal medicine and all that. So, when people hear about it, they’re motivated to send patients. But I’ve been working hard to try to get the word out, giving talks to the Society for Maternal-Fetal Medicine and such. So that’s a message I would love to get out to help spread the word about the trial.

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