Surgery in Small Spaces
by Maryann Brinley

Pediatric surgeons spend up to 10 extra years in medical training and are rare. According to Bethel, there are only about 25 new ones who complete their
educations annually. Yet, “This was the only medical specialty for me. There is nothing else that would have made me go through the five years of general
surgical residency, three years of research, and then fellowships.”

Bethel graduated from Harvard University in 1983, cum laude and in three years, with a degree in chemistry. He almost went into engineering. “I never thought of medicine until the very last minute. Like many Caribbean parents, my family
considered education so important and really emphasized education, education,
education.” While growing up, he was told, “Get out. Get ahead. Get an education. That’s what counts.” He completed medical school at Columbia University’s College of Physicians and Surgeons and then went on to Yale University, the University of California at San Francisco as well as Ohio State University’s Children’s Hospital. One of his post-doctoral fellowships was spent at the Lawrence Livermore National Laboratory’s Department of Biomedical Research, a federal research facility.

“A lot about Livermore was top secret,” he recalls, “We had to have government background checks and it was a big deal.” In order to qualify for a competitive pediatric surgical residency, research was required and as a result, Bethel’s bibliography of scientific publications testifies to his interest in metabolic
disorders and genetic anomalies. “This work was based on the fact that fetuses diagnosed with lethal or potentially life-threatening problems could be treated before birth by transplanting them with normal cells. Fetuses don’t reject foreign donor
tissue,” he says. Bethel hopes to see a day when this technology may become a widespread reality.

In fact, what attracted Bethel to pediatric surgery were the “neonates and premature infants — the tiny, tiny babies — and intensely delicate surgical procedures. Because the babies are so small, getting to the area that needs to be operated on is pretty quick,” he explains. “Once you are there, it is an intense experience. Quick, short but so intense because it requires a lot of focus on tiny details.” Pediatric surgeons like Bethel care for children of all ages and treat a broad range of problems, including inguinal hernia, appendicitis, gastroesophageal reflux, as well as a host of birth defects like a blocked esophagus, an intestinal misconnection (atresia) or biliary atresia, “where the entire bile system draining from the liver scars down in the first few weeks after birth.” Incisions may be more like little
puncture points and some surgical instruments are smaller than a drinking straw. Using tiny cameras inserted into the little patient, Bethel may use a computer monitor for guidance.

What also energizes him is that his specialty offers such a range of options. “It is one of the last areas in medicine that remain general in the sense that we can operate on the head, neck, chest and abdomen.” While general surgeons may be
limited to certain areas, “we specialize in congenital problems anywhere in the child’s body.”

For Bethel, another draw has always been his patients’ general health status. “For the most part, we are dealing with a healthy little person with just one organ system that needs to be fixed.” In general he doesn’t have to worry about factors such as an individual’s smoking habits, alcohol consumption, blood
pressure, heart disease or diabetes, conditions that could loom large before any adult surgery. “These babies bounce back really fast.” He finds it amazing to operate on a child and afterward in the recovery room, in spite of what may be a huge, abdominal scar, that baby will try to crawl off the stretcher or stand up. “An adult wouldn’t want to move,” he says.

Even children long past infancy have shown Bethel a spunky wisdom unequalled by many adults. One patient in particular comes quickly to mind. When he was 13, this boy ended up in a neighboring hospital with severe abdominal pain. “I got a call from a surgeon there who had operated on him the night before,” Bethel recalls. Black and necrotic, his intestine was almost entirely dead and they didn’t know exactly what had happened to the healthy young teen. Apparently, he had undergone a malrotation where the intestine twists on itself, cutting off blood supply. Called a volvulus, “it can happen very suddenly and if not recognized — symptoms can be vague or like the flu — you’ve only got a six hour window before the intestine dies,” Bethel explains. After the boy was transferred to UH, the surgeon performed eight to nine operations during the course of the next year, salvaging tissue to rebuild the boy’s intestinal tract from the one healthy section, about a foot long, that had been left unscathed. This boy had to be supplemented by a feeding tube and overall, “We were facing a situation that was just not compatible with a good quality of life.”
What makes this patient stand out in Bethel’s memory, however, are not the medical details. “I remember his wisdom,” he says. “Some kids who are very sick tend to have an adult sense of maturity. There is this wise quality and I don’t know where it comes from.” Just two weeks into his hospitalization, he was reading a physics book when Bethel walked into his hospital room. “He’s a high tech kid, whose mother is Ethiopian and whose father is from Louisana. Education was so important
to them.”

That was eight years ago.

Good news arrived just recently and not long after Bethel had written a letter of recommendation for his college applications.

“Genius kid. Gets into Princeton University!” Bethel says. “He’s brilliant.”

While Colin Bethel’s work is always technically challenging and he thrives on the intensity in that operating room, holding the power to give kids a future, is clearly rewarding. He smiles easily just thinking about this patient.

The very first pediatric surgeon to practice out of UH, Bethel started in July 1997, when surgical coverage for pediatric cases was “scattered and provided by outside specialists on an as-needed, or emergency, basis.” Arriving here in Newark, straight out of his last training fellowship in Columbus, Ohio’s Children’s Hospital, he says, “I grabbed the opportunity to lead a program and to be in the New York area.”

A member of the UMDNJ-New Jersey Medical School Resident Education Committee, Bethel also enjoys his role as a teacher. “I love working with the medical students and using the Socratic method. Nowadays, med students don’t always like this approach but I’m not asking questions around the room — the kind they may not be able to answer — to be mean or to intimidate them.” For Bethel, it’s about learning the material and remembering the answer the next time.

“Think about it,” he asks. Having the relaxed freedom to simply look up an answer in a book is not as dynamic a learning experience as being put on the spot. According to this surgery teacher, those missed answers are never missed again.

His dream is to have a hospital in northern New Jersey devoted to children’s care. “The state really needs two or three of them. Traveling to all these other hospitals can be a problem.” Not only is Bethel moving from day to day but other pediatric experts aren’t in one centralized place either. “If we could pool resources and specialists, and have one free-standing children’s medical center, it would be much better for the kids. That’s what’s on my wish list.”

In the meantime, he’ll be on the road again tomorrow and not on his way to Burma. “It’s a routine day. I’ve got several cases over at Beth Israel Medical Center in Newark.”