The PalliEM Podcast:
Episode 10 –  – with Dr. Tom Sullivan, MD

Episode 10 Production:

Podcast Guest:
Dr. Tom Sullivan, MD
Link to Dr. Tom Sullivan’s Bio

Podcast Host:
Dr. Justin Brooten, MD

Podcast Editing & Production:
Michelle C. Brooten-Brooks

Transcript for Episode 10 with Tom Sullivan, MD (recorded April 2023)

00;00;00;14 – 00;00;10;10 
Justin Brooten, MD: 
This is the PalliEM podcast, a production of PalliEM.org at the intersection of palliative and emergency medicine. I’m your host, Justin Brooten. 

 
00;00;10;10 –  00;00;22;02 
Justin Brooten, MD: 
Today on the PalliEM podcast, I’m joined by Dr. Thomas Sullivan. Dr. Sullivan is an interventional radiologist and assistant professor of radiology at the Wake Forest School of Medicine. Tom, thank you for joining me today. 

 
00;00;22;02 – 00;00;25;07 
Tom Sullivan, MD: 
Glad to be here. Thanks for having me. This is exciting. 

 
00;00;25;07 – 00;00;37;07 
Justin Brooten, MD: 
I was really excited after you came, several months ago, to talk with us on the palliative care team and you mentioned to us a procedure that you do to try to treat pain from spinal metastasis. 

00;00;37;07 – 00;01;03;08 
Justin Brooten, MD: 
And I thought, this is a really interesting concept. The idea that interventional radiology can be used for palliative care. And just as a disclosure, this video is not sponsored by any of the manufacturers  
that make any of the devices that Dr. Sullivan uses. But it’s more really just to kind of get information out there about ways that we can better treat this patient population. So, the first thing I wanted to ask you is how did you get interested in treating people with spine metastases pain? 

 
00;01;05;10 – 00;03;06;29 
Tom Sullivan, MD: 
Well, it goes back to when I was a fellow, a fellow at the University of Miami, and we had this one, one of the faculty, who we often referred to him as a bit of a mad scientist. And so, we would, We would scrub in on his cases and, and do spine procedures with him. And he was one of those guys that was just like, willing to try anything. And this is before a lot of the major data in RFA of the spine came out. This was 2018-2019. So we’re very new. But he was looking at spinal instability scores and opioid use, and the, and the use of RFA and spinal augmentation. And we ended up presenting our, presenting our data at our annual meeting at the Society of Intervention Radiology. And ever since then, it really, and it really started to take off. 

There’s a group in Atlanta that wrote up, actually one of the abstracts of the year for us. 
That’s called the Opus One study, and that really kind of helped us gain some momentum and get us going. But as a fellow, we would scrub these cases, and we’d put these needles in people’s spines, it was wild because they would because then they would get better. And I mean, the cases were a little bit long and a little bit torturous for us fellows because he would just, and we were just kind of watching him or whatever and, oh my God, we’re putting needles and people’s spines and then burning them. And are we going to, are we going to hit the spinal cord or cause a CSF leak or some kind of something horrible? And actually, it’s it’s, it’s just an addition to a procedure that’s been tried and true for almost 30 years called Kyphoplasty. And, and if you have the skill set to do a Kyphoplasty, you can generally do an RFA of the spine. So that’s kind of how I got started. 

 

00;03;06;29 – 00;03;15;25 
Justin Brooten, MD:  
Tell us a little bit about, about kind of how the procedure works and, and what kind of patients this can be helpful for? 

 

00;03;15;28 – 0 00;05;06;19 
Tom Sullivan, MD:  
So, we’re, we’re in the NCCN guidelines for stage four spinal metastases. And so that means anyone with spinal metastases is eligible. And we love it because we like to be partners with radiation oncology. So, we don’t preclude. EBRT [External Beam Radiation Therapy] or SBRT [Stereotactic Body Radiation Therapy]. And you can still have radiation, and you can, you can do it before or after the results are similar. And it’s actually pretty well validated by by, by a couple of different studies that we can cite.  

And so, these are patients with painful spinal or spinal Mets or anywhere in the axialor appendicular skeleton. And what we do is we put needles into the end of, the end of the lesion, and we apply radiofrequency ablation, which is generally heat. It submits actually from a microwave and it just causes local heat. And, and we monitor that heat and make sure that doesn’t travel posteriorly. 

We were actually able to very carefully control where that heat goes and then typically in the spine  we will then then do our vertebral body augmentation, which is a balloon and then cement. And generally, it’s generally people are better within 12 to 24 hours. Once in a while, you get a little bit of inflammation. People with large, with larger lesions I’ll typically mitigate some of the inflammation with Solu-Medrol, but they generally do really well. 

 

00;05;06;19 – 00;05;32;22 
Justin Brooten, MD:  
And what, what are some of the how quickly from the time let’s say that somebody has a patient that they want to have consideration for this procedure for, hat’s the timeframe in trying to get follow up and evaluate them to getting the procedure done, to getting relief? Like, what does that look like? 
 

00;05;23;03 – 00;06;29;04  
Tom Sullivan, MD:  
Well, anytime you see someone in palliative care, I’m sure as anyone knows in this 
audience, you have to manage expectations. And I would never go into a consult…  
And so I see everybody in clinic because I want to get to know them, and I kind of want to, 
and I kind of want to set expectations. And we want to have goals. And those goals have to be, of course, in line with those of our referrers. And then whatever, whatever issue. Issue it is. And a lot of it is actually, side effects from opiates And one of one of my, major goals and one of my follow up markers is opiate, opiate usage. And as we all know that these, these medications work, but they are a little bit dirty. 

And any time we can kind of turn that dial down, you have somebody that’s on an 80-milligrams a day regimen, 100 milligram regimen a day, 100 milligrams regimen a day, and if we can get that down to the teens, that’s, that’s a win for me. 

 

00;06;29;06 – 00;06;43;21 
Justin Brooten, MD: 
And do you? Well, one thing that that brings up, because those of us who manage pain 
with opiates know that if you do things that modify the pain, then there can be a need to really modify the opiates. 

00;06;43;21 
Tom Sullivan, MD:  
[Nods in the affirmative.] 

00;06;43;24 – 00;06;56;13 
Justin Brooten, MD:  
So, what are some, how do you how do you manage that whole transition of treating the pain, getting the actual pain down with the procedure, and then also having to adjust the pain medicine accordingly? 

 

00;06;56;15 – 00;07;40;01 
Tom Sullivan, MD:  
Right. But we have great partners at Wake and we we generally work hand in hand very closely. But because obviously, you don’t want to overdose anybody and then you have rebound effect, we typically will look at their PRN usage first. So, most of our patients are on a long-acting regimen. But with the PRNs. What we do is, the trend that we typically see is their PRN need goes down. And so, they’ll, they’ll get, they’ll be getting their 15 or oxy, four times a day and that kind of goes down to two. And that’s what we watch. And then and then as a team we’ll adjust the long-acting together as well. 

00;07;38;26 – 00;07;47;07 
Justin Brooten, MD:  
What are some of the things you’ve had patients say to you after they get this  done and, and feel the results of this? What is what is some of the feedback you get? 

 

 
 
00;07;47;07 – 00;11;01;18 
Tom Sullivan, MD:  
So one of my favorite stories is, so, I used to be the division director of Mount Sinai Chicago, which is a safety net hospital on the south side of Chicago. And I took the job because I want, because I’m a crazy altruist, and I wanted to address this population that is essentially ignored. And so, I did it for two years. And one of the reasons that I made the switch to academics was, I wanted a bigger microphone because of this patient. And I’ll never forget him. 

He was a 56-year old guy with metastatic lung cancer to T-five, seven and nine and he was almost bedbound. He was able to get up and walk with a walker with a lot of supervision. But he was on a lot of these on like 120, 130 milligrams a day. And I actually was and this is private practice as reading by NMR, and I read his MRI, and I called his oncologist and said, Hey, you know what? I think I can fix this.  Can I see him in clinic? And she said, Sure, no problem, We’d love to have your input he’s maxed out on Gray’s. Radiation oncology doesn’t really have anything else to offer him but we but he got KEYTRUDA and had a great response in his lungs, and so, so we actually had some time and we brought him in.  
We did vertebral body augmentation on our very limited south side equipment, and it took a long time. My techs wanted to kill me. And it was a, it was a 3 to 4 hour procedure that could have been a lot shorter if we had the nice stuff we have here at Wake. But with, you know, anesthesia, we put him to sleep and he got up and stayed the night, where he stayed the night with us. The next day, he was walking  

00;10;01;28 – 00;10;05;19 
Justin Brooten, MD: 
Wow 

00;07;47;07 – 00;11;00;18 
Tom Sullivan, MD:  
And the pain in his spine was gone. For that, for the remainder of his life, he actually ended up dying in the hospital, six months later with the liver metastases. And you know, I actually visited him, when he was near the end at his hospital bed, we had a great conversation. And he and he thanked me for giving him six months of his life back. And after that, I was like, okay, this is you know, this is an important mission and this is this is something that we really have to have to make sure that people know about and have access to. And so that’s kind of become a major area of academic and clinical interest for me, is trying to see these patients and offer something else in addition to radiation and opioids. 

 

00;11;01;21 – 00;12;26;05 
Justin Brooten, MD: 
That is, that is an awesome story. I’m not kidding. I got chills while you were, while you were saying that story and first time, first-time hearing you relay that. And that’s really couple of things. One, I think it’s amazing that you were sitting there reading his films and actually were able to see something, not just not just to identify the pathology, but say, I can do something about that, because that’s one of the things I think as physicians that that energizes us, is finding something that we can do, but not just for the sake of doing it. What you said about him saying he got six months of his life back like that is so awesome.  
 
And one of the things I think that gets overlooked, a lot of times in palliative care, people think about the opiates. They think about hospice, they think about just the end-of-life piece. They don’t think about trying to help people live better. It’s not just about helping people die better. It’s about helping people live better. So, I think that is such an awesome story. And, and for many of us who are interested in this field, it’s the same kind of thing that got us, that got us excited about that. We see suffering and we see it addressed in inadequate ways. And like you said, you know, opiates are useful, but if you’re. if it’s not accomplishing the goal of getting the patient up and moving around and being able to function well, then we need other alternatives. So that’s really that’s a great that’s a great story. i think that’s, that’s awesome. And I’m glad that you’re taking that experience and using it really to hopefully help impact other patients and help get the word out about what’s, what’s possible. So I’m glad you could, you could join us for that. 

 
00;12;26;05 – 00;12;28;09 
Tom Sullivan, MD:  
Thank you. 

 

00;12;27;11 – 00;12;53;12 
Justin Brooten, MD: 
Well, I, I think that that covers a lot of the things that our listeners are going to want or would be interested in. What would within the, certainly we’re going to have to people elsewhere are going to be listening to this. In the Wake system, if anybody has a patient who is dealing with painful spine issues, what is the process they can go about trying to make sure that they can get a procedure like this to address their pain along with the other modalities available? 

00;12;53;15 – 00;14;46;07 
Tom Sullivan, MD:   
Well, I’m absolutely available. I don’t have a full clinic, I’ve only been here a year. So, we’re generally able to get people in pretty quickly. The other, the other point that I want to make is one of my partners, a couple of my partners and I do cryoablation for soft tissue tumors, and we were absolutely thrilled to see Cynthia Emery get promoted a couple of weeks ago to her new role in orthopedic surgery. And I think that’s going to open a lot of doors for us in interventional radiology because we have a great, great relationship with her and her team and starting to see some of these a little bit exotic soft tissue tumors, extra spinal things and we we have a lot of tools in our tool shed, one of those is cryoablation for soft tissue tumors and cryoablation is a is a very different technology from radiofrequency ablation because it cause it causes no inflammation and it never hurts. Like I mentioned, sometimes you get a little bit of a pain flare after a radiofrequency ablation. The cryo is amazing because it just it just shuts everything down and we’re always looking for an opportunity in application for trial. And that’s, that’s, that’s the ice ball. That’s, that’s actually argon gas that is it uses entropy so it is expands. It forms at -20 to -40 degrees centigrade. Ice ball just freezes everything. So we’re doing a lot. But I have a case tomorrow where we’re doing ablation in a lung tumor. So it’s we’ve a lot of very nice tools. 

00;14;46;10 – 00;14;54;29 
Justin Brooten, MD:  
And you do. And you do other interventions. You do other interventional radiology procedures. But it sounds like you’ve really made a focus in treating oncologic issues. 

00;14;55;01 – 00;15;18;21 
Tom Sullivan, MD:  
Yeah. So my partner Brian Corey is, I mentioned, I mentioned this project with him and he he does he does weather ablation, he’s our liver specialist and he turns to me and says, “Tom all my, all my encounters are, are palliative. Do I get to go on a podcast?” [Laughing] 

00;15;14;21 
Justin Brooten, MD:  
[Laughing] 

 

00;15;18;23 – 00;15;47;09 
Tom Sullivan, MD:  
He’s our Y90 and microwave ablation guru and and he approaches it the same way as all of us, you know. And he has a fantastic relationship with the liver oncology group and he’s, he’s been building his practice for over 20 years and coming into this as faculty to partner with him. It has been a fantastic opportunity. well. 

 

00;15;47;09 – 00;16;32;22 
Justin Brooten, MD:  
Yeah, thanks. Thanks for joining us. And it’s really that’s one of the reasons I love being here is just a lot of excellent colleagues to interact with. And just a way to deal with these issues that are cancer patients and not just cancer patients, but patients with other conditions in a comprehensive manner that we have all the different fields that they need to make sure that these problems are addressed. 
 
And I really appreciate what you shared about how, how just that patient encounter and how that made such a, it seems like such an impact on your career and your career trajectory. And then not just that you’re, you’re not just a procedurals that’s that’s reading films and finding patients that need your help, which I still think I think that’s fabulous, especially as somebody who works the emergency room. And I’m frequently having to talk to radiologists, about things that come across the screen. 

 

00;16;32;23 – 00;16;35;20 
Tom Sullivan, MD:  
Yeah! I can fix that. 

 

00;16;35;20 – 00;17;01;02 
Justin Brooten, MD:  
But I, I appreciate the advocacy behind that, that really this isn’t just about just doing your day-to-day job. It’s really about making sure that these patients that are dealing with some really painful conditions and some really debilitating conditions can get some relief and really get that quality of life back for as long, as long as their cancer can be mitigated and they can live, they can at least live with less pain and better function. So thanks, thanks so much for what you do and thank you for joining me. 

 

00;17;01;02 – 00;17;03;16 
Tom Sullivan, MD:  
I really enjoyed talking with you today. 

00;17;03;16 – 00;17;06;27 
Tom Sullivan, MD:  
This is a fantastic opportunity. Thank you so much. 

00;17;06;27 – 00;17;08;04 
Justin Brooten, MD: 
Thank you. 

00;17;08;04 – 00;17;14;15 
Justin Brooten, MD:  
For more information on current topics in the fields of palliative and emergency medicine, please visit PalliEM.org.