How Spray-on Skin Helps LSU's Dr. Jeffrey Carter Improve Trauma Outcomes
December 07, 2023
In this episode of “On Par,” hear from Dr. Jeffrey Carter, professor of surgery for LSU Health New Orleans and the Medical Director of the Burn Center for the University Medical Center New Orleans. He and his team developed a spray-on skin called ReCell, which has helped reduce the length of hospital stays and the mortality rate from burns by more than half. He’s a biomedical innovator and researcher who aggressively pursues healing and is passionate about teaching.
Jeffrey Carter, MD, is a professor of surgery for LSU Health New Orleans and the Medical Director of the Burn Center for the University Medical Center New Orleans. He serves on multiple health-related boards regionally and nationally and has been recognized with numerous teaching and research awards including the ABA Moyer Award His research interests include innovative technologies that advance burn care, healthcare economics, disaster preparation, and enhancing the burn workforce. Dr. Carter trains other doctors on burns and using the spray-on skin technology, which he began developing more than 10 years ago under a grant from the Armed Forces Institute of Regenerative Medicine, or AFIRM.
[00:00:00] William F. Tate IV: Welcome to On Par with the President. Today, I am joined by Dr. Jeffrey Carter. He is a leading burn care expert, professor of surgery at LSU Health Sciences New Orleans, and the medical director for the Burn Center for the University Medical Center New Orleans. Not only does he help Louisianans and burn victims around the world, he and his team helped develop a spray-on technology which is reducing hospital stays and mortality rates. Thanks for joining me.
[00:00:31] Dr. Jeffrey Carter: Thank you. It's my pleasure to be here today.
[00:00:33] William F. Tate IV: Well, doctor, you have an impressive background and resume in medicine and surgery. Was there a reason that you chose this field?
[00:00:42] Dr. Jeffrey Carter: I, I had excellent mentors and one of the things that really attracted-- made this feel attractive is that, uh, trauma and burns, a form of trauma is a leading cause of death and mortality from age one to 44. It's the thing that takes our children from us, it's the thing that also takes the young adults and, uh, it's also the leading cause of disability in the United States. So it's, it's an area that needs a lot of work.
[00:01:05] William F. Tate IV: It's my understanding that you didn't start your career in medicine, that you actually were a math and science high school teacher. How did that experience shape what you do today?
[00:01:15] Dr. Jeffrey Carter: It taught me how much passion I had for teaching and that I wanted to do that throughout my entire career. Uh, but it's also, it's a --burns is a numbers game. You calculate the size of the burn, you calculate the fluids are going in, calculate the nutritional needs of the patient. A lot of it is very mathematical.
[00:01:32] William F. Tate IV: Tell us more about your education. What was your journey like and how did you become a part of the LSU family?
[00:01:37] Dr. Jeffrey Carter: My great-grandfather actually went to medical school at LSU and, uh, was unable to finish his medical school due to an accident. And then my grandfather went to college at LSU and held the track record here for over 20 years, and, uh, was drafted in World War II and he never got to finish his LSU experience. And then, I actually had a scholarship to come to LSU for college. And then, um, an accident happened back home, and I had to go back home and help my dad start his company and go to a college in Mississippi. So, I've always wanted to come back to LSU and finish the story.
[00:02:06] William F. Tate IV: Well, we're glad you're here. Now, you serve as the Medical Director of the University's Burns Center in New Orleans, which is a very, very, um, impresive place. I've had the chance to visit. Describe what some of the unique services that you provide to the community at that center.
[00:02:22] Dr. Jeffrey Carter: We treat the patient in a, in a comprehensive fashion So, everything that the patient needs from counseling, to nutrition, surgery, to rehabilitation, reintegration We do it all there. We do prevention education in our community. And it's really one of the few places in America where you can go and you can on one floor of one hospital, you can have everything you need from research all the way through fancy reconstructive surgery. Um, and it's because of the incredible team that's assembled there. And I really have to give them that kind of credit.
[00:02:54] William F. Tate IV: Well, let's talk about innovation. Innovation is a very important part of the biomedical sciences, and you had a chance to be part of a group that developed the spray skin. How was this innovation created? And what's so special about this technology?
[00:03:12] Dr. Jeffrey Carter: A little over a decade ago, uh, one of the departments in the federal government realized that we were very vulnerable as a country to burn injuries. Burn, blast, biologic, as we saw with COVID, radiation. So, they began investing into different fields, and one of the fields they decided to invest in was burn. And, in fact, they've put almost a billion dollars of research into the specialty in the last 10 years, which is more than all the other funds added together in the history of this specialty.
[00:03:37] And so it's been transformative for burn care. And probably one of the things that's been most interesting is the spray skin. It was invented by a surgeon in Australia, who I had dinner with last month, and we've remained good friends. Um, and when we brought it to the United States, it was studied from the Department of Defense, but also from a civilian perspective. And those funds were originally brought at my former institution where we began those studies. And when I moved to New Orleans, we brought those studies with us, and we began to continue the studies there. And we knew that there's going to be a really special return in this community because when we do the spray skin, we not only spray the cells that make the skin come back, we also spray the cells that make the skin have pigment or color. And a lot of the people in our community have skin pigment. And so when they get burned, it's a very noticeable deficit from 30, 40 feet away. And with this technology, we can help minimize those deficits so that they can heal more quickly and heal with better pigmentation.
[00:04:35] William F. Tate IV: So, can you give us an example of how you've used this technology, the spray skin technology, on helping people?
[00:04:41] Dr. Jeffrey Carter: Sure, sure. So, uh, we did a case just yesterday, as a matter of fact. We commonly have people who have burned faces, hands. And what we do is to combine it with standard surgical techniques to reduce the amount of skin that's needed or reduce the amount of pain.
[00:04:56] Um, we've seen that in our patient population, we get three times the number of trauma patients as the average burn center. Meaning we get patients with more severe injuries. We admit patients with three times larger burns on average compared to other verified burn centers. And we get them out in about a third less time. And oftentimes, our patients have less resources than compared to other burn centers. So, it's really a game of numbers, going back to that, where we have to cause less harm to be able to help the patient. And surgery is one of those unique fields where you have to assault someone to make them better. So, it requires a high degree of confidence in both yourself and the team to be able to make that kind of change.
[00:05:31] William F. Tate IV: Well, like anyone who is aggressively pursuing, uh, healing, which is what you've just described, there have to be some challenges in that where the innovation of technology is limited, and you have to figure out something new. What, what kind of challenges do you face? And are there any ideas in your mind about new innovations that might spin from the challenge?
[00:05:55] Dr. Jeffrey Carter: Sure. I mean, this is where the educator comes out. So, the hardest person to teach in the room is not the student. It's always the teacher. And unfortunately, sometimes that is the physician. So, it's been hard to teach people to embrace a big change in their practice and to believe in something that they can't see, because you're literally spraying like what a form of, like, almost like stem cells for the skin down. And so it's not-- it's different than putting a, a graft down. It's the same way if I said, "I'm going to paint your house, but you can't see the paint. Just trust me. It'll be there tomorrow." It's a big change. So, that type of education has been a challenge. Uh, and we've been able to overcome that with good evidence, large center trials and then doing long-term studies and looking to get the outcomes that have come from that.
[00:06:38] William F. Tate IV: Speaking of clinical trials and looking at outcomes, your research spans a few topics. Obviously, the innovation related to spray-on and burn, burn care in general, healthcare economics, disaster preparation. Talk to us about some of the exciting things you're finding in the research that you're engaged in.
[00:06:58] Dr. Jeffrey Carter: Probably the thing that's most exciting right now is artificial intelligence, and I know this is a hot topic for LSU right now. So, we have two different studies: one that's funded by the Department of Defense at over 9 million, and then an even larger study that's funded through BARDA with an industry partner. And the artificial intelligence is helping us do two things. One of them is helping us teach better. It's helping us use adult principles of learning to make artificial intelligence-guided education, so that learners can have the time in an asynchronous fashion, meaning not in a traditional classroom.
[00:07:28] The other one is a, uh, really exciting technology where it uses visible and non-visible wavelengths of light to very quickly take a picture of the wound, and then to determine whether it's going to heal or not heal. In clinical practice, we're able to decide if someone has a heart attack with greater than 99 percent accuracy in an emergency room. Unfortunately, because you're looking at a burn wound, making a decision and very complex things, you know, old, young, comorbidities, other diseases, location, type of the burn mechanism. It's very hard to predict. And unfortunately, in about a quarter of cases, doctors make an imprecise decision, meaning they offer someone surgery that didn't need it or they withhold surgery and delay it, causing more pain, delays and suffering. This type of artificial intelligence, we've just completed our first large multi-center trial, and with over 240 patients leading over 11 centers, including, you know, really a lot of the Ivy League schools, but leading it down here from New Orleans, uh, we found that we had over 92 percent accuracy with this type of artificial intelligence.
[00:08:24] William F. Tate IV: Wow. Um, AI is, is quite powerful. Uh, now you mentioned that, you know, you're working with really talented people at your burn center. The burn workforce is something that we would be very interested in at LSU. We want to make sure we have great biomedical care. Um, it's also one of your research interests.
[00:08:48] So, what strategies and initiatives, um, have you thought through, through your research, or that come to mind in terms of building a strong and skilled workforce for this field?
[00:08:57] Dr. Jeffrey Carter: I'm very fortunate that I have a great team and great partners. Dr.-- Dr. Phelan, Dr. Shane are just two extraordinary people that I'd let them care for me and my family anytime. But that's not like that in the rest of the country. And what we have found, we did an analysis through the American Burn Association, and there's only about 250 full-time burn surgeons of the 82,000 surgeons in the U. S. And there's about 130 burn centers in the 6,000 hospitals. So, it's not a-- it's not a specialty that's offered everywhere.
[00:09:26] And what we've done is to begin to look at number one, how big is the problem? What is the problem? And then number two, how can we help distinguish burn professionals? In other words, if you have a burn injury, do you want to be cared for by someone that specialize-- specializes in this? And so I'm very proud to announce that Dr. Phelan and I just got notified last week that we are now, uh, we've become fellows of the American Burn Association. It's a program that was started to recognize people who excel in education, patient care, research, rehabilitation, and injury prevention.
[00:09:55] William F. Tate IV: That's pretty awesome. I, I know that, um, we're excited that you all have that expertise, but it raises a real question about the rest of the country and what kind of access to care people have that might actually facilitate, you know, better outcomes.
[00:10:09] Dr. Jeffrey Carter: Yeah, you're exactly right. So, in the last year, we've been working with, uh, different groups to be able to look at big data. So we've been buying large data sets, building data sets from it, and what we're looking at now is how access to care impacts outcomes. Because while there are many health disparities, the health disparities that we should probably be the most concerned about are when we have a time-sensitive illness.
[00:10:31] And like I mentioned earlier, trauma is a leading cause of death for people 1 to 44, but other things that are time-sensitive like stroke and heart attack. And so, how does access change with those outcomes? And what we're learning now is that probably more than anything else, it changes with whether or not you are seen by that specialist.
[00:10:47] So what we've done is to, number one, build a large dataset called the National Injury Resource Dataset. We hope to work with some of the departments that are actually on this campus that specialize in geographic mapping. Uh, and what we're looking at is where patients are getting care. So, we're getting data that doesn't tell us who the person is, but it tells us if they had a trauma or a burn injury and then where they got their care. And then later we're going to be looking at the outcomes from that care, both the financial consequences, but also the clinical consequences that come from that to be able to really try to build a better model.
[00:11:18] That's going to be several years worth of work, hopefully several supported grants for that work. But it's where our passion is beginning to turn because if you know how to do it, and you know when to do it, or who needs it, the question is how do you make sure that they get the access to that care.
[00:11:32] William F. Tate IV: You're describing the life of a physician scientist. I don't think many people really understand that life. Why do you think it's important for us to actually produce more physician scientists?
[00:11:45] Dr. Jeffrey Carter: That is a good question. So, I learned a long time ago that it's more important to know why you do something than it is to know what you did, because the "what" will change as technology changes, but the "why" is what's really important. And what's happening commonly now in medicine is that people are learning for a test or they're learning for an answer, but they're not necessarily learning the "why." And so, the research is really the "why" and that's where the beauty and the exploration comes in. That's where the discovery, the "Aha!" moments really come.
[00:12:15] That's also where you're able to learn how to ask questions and be able to resolve them. So, a lot of the push that myself, my partners are doing, is to work with our students and our residents. And I'm proud to say that just last week at the Southern Burn Region Competition, we had an LSU student who won in the oral presentation category. We had an LSU resident, Anna Garboff, who won first place in the resident competition. Our research associate who's applying to medical school came in third place. And then, our pharmacist even came in second place. So, we swept the awards, but it's really about that mentorship and helping them discover research.
[00:12:48] William F. Tate IV: So, as evidence evolves, what do you see as the primary challenge in your area of expertise?
[00:12:56] Dr. Jeffrey Carter: Wow. So, this kind of gets to where I think my second career is going to come, where I really would like to study behavioral economics and implementation science, because people might know the-- how to do it, but they don't know how to get to the--they don't know when to do it or how to do it, necessarily.
[00:13:10] So, how do you help people make that change? Like we were discussing earlier, when a new topic comes out or a new technology comes out, a lot of that's going to be through really effective education. Uh, we're very fortunate that, um, LSU is building a, a large simulation lab there. They're really reinforcing it. We plan to bring more doctors to that community and do that. We do a lot of outreach and education right now. Education is changing how we do it. Uh, we used to do a lot of simulation in controlled environments, and now we're going to the forefront. We're going to where they are. Um, and this started back when I was an intern. We raised three and a half million dollars and I built the first little simulation lab at Wake Forest and then it grew from 50,000 to one and a half million square feet, and it's quite productive. And now, we're doing something similar to that down here.
[00:13:52] We can't do it without embracing education, but also embracing research. And that's also where some of the DOD funded research comes in, too. Where, what's the most effective way to do it? Is it a PowerPoint? Is it a tablet? Is it a hands-on trainer? And, so we're really learning what's the best way to teach doctors how to learn.
[00:14:10] William F. Tate IV: I just have to say this, for the record. I try to make the case wherever I go that without research, people will die. I mean, they're going to die no matter what. If it's a natural course of life. But in terms of intervening on trauma, without the evolution of research, we're just not going to be as effective. And for many people, research is such an abstraction, right? So, I appreciate what you do.
[00:14:34] Now, I have a harder question for you. It seems like your life is very much, uh, emerged in research, teaching, and you're a director, which means you're a leader, in a very complex organization. Health-- healthcare is a very complicated financial, as well as clinical matter. How do you make sense of all this? How do you balance it all to make it work?
[00:14:57] Dr. Jeffrey Carter: Well, the first thing is having a good team. When you have an effective team, you can delegate and you can know that they can deliver. And I've been very blessed to have that. Uh, the other one is that-- setting priorities. There are things that other people can do sometimes with the clinical care that-- where I need to focus my time administratively.
[00:15:13] And right now, in the United States, healthcare is 20 percent of the GDP. That means that of all the money that comes in the United States that it's not-- 20 percent is not going to bridges or education, it's going to caring for people. And we've got to figure out a way to make that more effective. And one of the tools we use is looking at value. Nobody wants low value care, and it's one of the few things that everyone can agree on, whether you're the patient, the payer, the provider of the hospital. And when we look at value, we look at, uh, in the formula that we use for this going back to the math teacher ideology, is value equals quality plus service divided by cost. And so, if you, if you increase costs, you got to increase quality or increase a new service. But we don't want to compromise this. And so, we always want to have the highest value care we can offer. And that's one of the approaches that we take.
[00:15:57] William F. Tate IV: Now, in the evolution of all your duties, I'm going to, I'm going to really tax you here. I always think the best researchers are the ones who can see the field before things really emerge and find that space. Now, there are some who do incremental work and incremental work is extremely important, as you know. But if you were going to project out today, what's the next big space in terms of research in burn care, what would you predict?
[00:16:25] Dr. Jeffrey Carter: What we're learning now is that we can create polymers and mix them with someone's cells so that we can actually create suspensions and cover wounds and heal things that we never thought could heal. What we're learning is that you don't necessarily need hot lights and cold steel, like an operating room, to heal everything. And this is changing our field dramatically. And that billion dollars that I mentioned that BARDA put in, those things were studied in isolation. So, there's a small group of us in the U. S. that are beginning to put those things together. And when we put that together, the results are outstanding. Things that used to be 30 days in the hospital, we can turn into three.
[00:17:02] That's a very different world. And the other thing that we look at with this are the consequences of those actions. In many ways, burn, because it's your skin, it's what other people see, it's how you interact with the world, you feel, you touch. it's, it's a chronic disease, it's not an acute disease, it's not a broken bone that heals. It's something that you deal with from a scarring, from a public, and from a personal perspective. There are scars on the outside and the inside. So our, our next step is to combine some of these new technologies, maybe look for some things that are really close in our grasp from a polymer standpoint, but then to look at the long-term impact that they have. Because I think that'll help us economically. That'll help us find the best value in the care, and it'll help us, you know, educate patients so that they can make good decisions for themselves.
[00:17:46] William F. Tate IV: Some folks would tune in to listen because of your expertise in the area you work in-- medicine, research, innovation, technology, and they may aspire to work in those areas. What advice would you have for them if they want to jump in and make a difference in the field of health care?
[00:18:04] Dr. Jeffrey Carter: I got lucky in the sense that I identified an area of renaissance, and I got to ride the front of the wave, and I'm enjoying that till today. But most importantly, I found something I was passionate about. And when you have that passion, then the opportunity to look for answers or questions and to solve them is there. And so, find what you're passionate about, what's important to you personally. We wrote a paper many years ago called "For Love, Not Money." And it explains why choosing careers doesn't always make sense financially if you don't follow the ones that you're passionate about.
[00:18:36] So please, find the things that you're passionate about and pursue them.
[00:18:39] William F. Tate IV: Well, Dr. Carter gifted us with this wonderful cup. And on the back, it states "What we lost in the fire, we found among the ashes." That's pretty powerful. Why don't you talk to us a little bit about what that's about? What does it mean to you right now?
[00:18:57] Dr. Jeffrey Carter: So, you know, part of that excellence and having that distinguished team is, uh, them being able to get certified. So, we had the very first nurse certifying exam for Burns, and there were 400 nurses that took it, only 165 passed. Of the 165, 10 of them were in New Orleans. So, something we wanted to do special for all those nurses was to have something made for them that they could take home, they'd use every day. And we had that made.
[00:19:23] And the reason why we put that quote on there is because they see people, patients, who are in their, in their worst times, who are hurting, they've lost their homes. And we have to be hope for them. Hope that their wounds are going to heal, hope that they're going to find a solution to the devastation that they've gone through. And what that cup is there for, that quote, is to remind us all that, uh, it's our resilience that counts. In that, like being a great athlete is how quickly you recover. And so, that's really part of the-- why we put that quote on there.
[00:19:56] William F. Tate IV: Well, Dr. Carter, the mission of LSU is obviously teaching, research, service. Some people forget, um, clinical practice is extremely important part of our mission. And today, we got to hear from you, and it's quite clear you're contributing to all four of those areas. And thank you for what you do for the state of Louisiana. Thank you for what you're doing that actually is applying not just in Louisiana, but across this country and in a global fashion. We call that flagshipping up here in Baton Rouge, and you certainly are representing a flagship perspective on medicine and health care. Thank you very much.
[00:20:34] Dr. Jeffrey Carter: It's been my privilege.