E111 Sam Minor on Trauma Simulation and Practicing in Halifax
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Sam Minor 00:00
Certainly, you look at a high-volume center team and the way that they function. It's impressive. And it's an impressive machine that requires a lot of oiling, a lot of practice. And we knew that we didn't have the numbers to achieve that. But we aspired to.
Chad Ball 00:27
Welcome to the Cold Steel podcast, hosted by Ameer Farooq and myself, Chad Ball. We consider it an absolute privilege to bring you guests from around the world who are truly experts in their craft. Our mission is to offer you a combination of not only master classes on clinical surgery topics, but also insights into achieving personal growth, productivity, and fulfillment as both a surgeon and perhaps more importantly, as a human. How do you create a high functioning team that is prepared for clinical scenarios that you might not see that often? In this episode, we had a great conversation with Dr. Sam Minor on this topic. Dr. Minor is a general surgeon in Halifax, Nova Scotia, and he has developed in situ trauma simulations that help not just residents, but also the staff surgeons themselves prepare for major traumatic injuries. Dr. Minor also tells us what it's like to practice in Halifax and about some of his other research interests.
Sam Minor 01:26
Yeah, I grew up in small town Ontario, you know, northern hick boy, Peterborough, Ontario, the home of the Peterborough Petes, and home of the highest lift lock in the world. And I'm sure the first question you're having is, what is a lift lock, it's really not that important, but it is the tallest one in the world. So that's what distinguishes us in Peterborough. And from there, I did University at the University of Guelph. And that was just simply following my best friend and a girl that I really liked. So that turned out pretty good. She ended up marrying me. From there, I went to University of Toronto for med school. And then I went to Queen's for general surgery. And at that time, you could sort of combine critical care fellowship with your residency. So, I ended up signing on to my fellowship and critical care in my third year, and then sort of bundled all my elective time in my fourth year towards critical care. And then what that meant was, I was able to shave an entire year off of my critical care fellowship. So, I finished sort of a combined critical care-general surgery training after 6 years. And then, you know, I very much wanted to be in academic medicine, that was a big goal of mine. And I'll tell you, what an experience for anyone that goes through that, it's daunting, because really, when you get down to it, there's - for an English-speaking person that doesn't have French, you know, you only have 12 places in the country that are potentials. And it's all a matter of timing. You know, and for me, I was looking for 2 jobs. You know, I wanted to continue operating and being a general surgeon. So, trying to find a position for a general surgeon without surgical fellowship training - that was a challenge. And a spot in critical care medicine was a tall order. And as it turned out, you know, the only places where there was even potential for work was Halifax. And there might have been some opportunities in Edmonton or Winnipeg that didn't really get fully realized, at least there wasn't a full "no," in the discussions, but I went right across the country. And it was actually my wife - that she grew up in Toronto, but she would get carted off every summer to Newfoundland, and her entire family identifies as Newfoundlanders, that's where all her relatives and so on came from. So, when she had the opportunity to go back out east, there was a big pull for that. And it just all worked out. So, for the last 14 years, I've been an East Coaster. I've been here longer than anywhere really. But I will always be considered a CFA, which is a Come from Away. Unless you're born and raised here. You're never entirely an East Coaster. But we enjoy it very much here and that's the story.
Ameer Farooq 05:00
I love it. I love it. You know, just to geek out on this topic here for a minute, because it does bring us back around to medicine in some ways. I was reading a book about the building of the Panama Canal. And how central that was and initially, I guess there was a French influence in that they owned that land. And they had tried to build that canal for years. And they lost so many workers, like essentially all of their workers to malaria and other infectious diseases. They just wanted to offload it. So, they sold it for next to nothing. Obviously, it was the eventual landowners south of us, who finally built that, but it's unbelievable, you know, some of these engineering feats that we see around the world and the impact that infectious disease has on their ability to get done in the duration of it, too. That's fascinating stuff.
Sam Minor 05:52
Yeah. Oh, yeah, the Panama Canal story is fantastic. Interestingly, the whole lift lock analogy is a nice little teaching point in critical care medicine. It's the role of PEEP and managing air trapping and airflow obstruction. Now they call it the waterfall effect, but whenever I teach it, I call it the lift lock effect.
Chad Ball 06:14
You know, Sam, your pathway to your job is interesting. And it reminds me a little bit of Andy Kirkpatrick he did very much the same thing in his surgical residency to achieve that critical care, fellowship and shorten his training. You have a lot of passions and a lot of talents, you know, you're in a lot of different areas. But I'm curious if you could talk to us a little bit about your passion and talent, in particular for simulation. How do you define simulation? What does it mean to you? And how have you applied it in your in your practice?
Sam Minor 06:46
Thanks, Chad. Yeah, I have spent quite a lot of my educational focus on simulation and continue to do so, both surgical, using surgical-grade cadavers. We have an amazing cadaver program on the East Coast and the cadavers are prepared in a very specialized way. It's becoming more common now, but when I first got here, I think the anatomy team we had was really front runners and this at least in Canada, and they have a process by which the cadavers maintain their tissue elasticity. You know, when I did anatomy in first-year medical school, they were plasticized and tissues dissected out - I mean, we used the back end of the scalpel just to sort of like chisel away or basically liquefy the tissue to leave the important structures to learn from. The surgical grade cadavers cut and maintain tissue integrity, just like a real human body. The only thing they don't do is bleed, although we have developed models to even make them bleed in certain contexts. So, they are really quite amazing. And so, I've definitely taken advantage of that; our residents have greatly benefited from this program. And so that is one aspect of simulation that I put a lot of time into. From an ATLS standpoint, it's been amazing teaching. That's how we teach all of our ATLS courses now is using surgical-grade cadavers. But we also have SimMan 3G. And we use that more for critical care stuff and resuscitation crisis resource management. We do run the general surgery residents through it, sort of doing trauma scenarios and decision-making using crisis resource management. So, I have quite a bit of experience in that regard as well. You know, in terms of the role of simulation, I've really always thought of it as anyone who's done high-level sports knows that you have to practice, practice, practice. You know, the reality is that we have to practice. When you're first starting off with a skill you have to practice even more. And one can argue even as a staff, you know, should we be practicing if our volumes aren't sufficient to maintain a high level of performance? And certainly, that simulation gives you that opportunity. It also allows you to do it in a way that's consequence free. When you talk to the lay person, they're just fascinated by this idea that you could have someone in their first year cutting them, and by fascinated maybe the better word is horrified. And by using simulation, getting them over the hump, I really think has been an essential tool in advancement and medical education. And it's something that I see will continue to evolve, for those obvious reasons.
Ameer Farooq 10:20
There's, there's a lot to unpack there. But I think one of the interesting things that I like about your simulation work has been some of the emphasis on some of the nontechnical skills, particularly the work that you've done around in situ trauma simulations. Can you talk a little bit about what an in situ trauma simulation is?
Sam Minor 10:39
So first of all, just to place the context, Halifax is designated by ourselves, not by any sort of accreditation, but we call ourselves a level one-trauma center. We are the only level-one trauma center in Atlantic Canada. And even the emerg is called, you know, Trauma Centre. But the reality is, is that our volumes are very low. And we do about one major trauma a day. And really, that is not enough to maintain your skills. It's not enough to be a well-oiled machine. And you know, certainly you look at a high-volume center team and the way that they function. It's impressive. And it's an impressive machine that requires a lot of oiling, a lot of practice. And we knew that we didn't have the numbers to achieve that, but we aspired to. And so, in order to increase our ability, we adopted this in situ program. And basically, we just activate a trauma, completely the normal way that we would do. But when the team gets there, it's SimMan 3G instead of a patient. And we run it with the seriousness that we would run an actual trauma. And then, at the end of it, we do thorough debrief with all members of the team, everyone from RT, nursing, residents, staff, paramedics, they all get to talk about what they just did, from their own perspective and share it with a team. And that's where it's very much more powerful, I feel like the bang for the buck of doing an in situ trauma with that 20 minute debrief is maybe worth 10 actual traumas, in terms of the learning that occurs. I also feel that it contributes a lot to team building in the sense that we are all working together and understanding each other's perspectives that would typically only come from doing this so many times of the day over and over and over together, I feel like we bump ourselves up on the curve. The other thing about in situ and doing it in the actual environment, with the actual people, in the actual team is that from a system and equipment standpoint, you really get to suss out some major details in terms of latent safety errors. And that's been extremely powerful for us as far as a QA tool. On average, we're identifying about 6 major potential safety errors a simulation, especially when we first started, and then what we would do is put that into the QA/QI loop, we would try to break down where we went wrong, come up with the solution. And then we would rerun a simulation focused on that particular aspect that was identified to see if we'd fix the problem. And as someone, you know, in a leadership role, there, it's incredibly frustrating how, you know, you look at maybe 4 or 5 hours of committee work and, you know, developing the solution, and then you run it, and then you realize that nope, it's still a problem. And so, then you've got to figure out well, why didn't it work and redo it again. And on average, it took us about 3 times before it sort of went away and consistently went away. Every now and then when we had identified one of those, we would incorporate it into a scenario - maybe 2 or 3 down the road and see if it was still holding up. But I really feel that for a center our size, you need to be constantly on this stuff. I think there's good evidence out there that if you just leave it alone, eventually it will disappear and it will resurface because of the same attitudes and maybe issues right at the very, very root that led to the problem being created in the first place. And maybe that's something that you just can't get out - sort of like weeding your lawn, you know, you just got to be constantly at it unless you want it to come back.
Chad Ball 15:20
You know Sam, one of the amazing things I think about our emergency general surgery, or ACS trauma communities, whatever moniker you'd like to use is, is that we benefit from a closeness across the country, like many subspecialties, to be honest, that I think is tremendously helpful in many, many different ways. And I was curious if you would comment on that group and the relationship and the reality that, you know, emergency general surgery, no matter what your subspecialty, with the exception being the liver transplant, is really what binds all of us together.
Sam Minor 15:55
Yeah, it's been an amazing experience, Chad, and you know, I really have a split feeling on this where emergency general surgery is evolving as a specialty. It's happening organically, and you might want to fight it. Or you might want to encourage it either way, I do believe it's going to happen just on its own volition. But having said that, it is the thing that unites us all - going in in the middle of the night, to a patient who has septic shock, and peritonitis, and you decide to take them to the OR, without knowing what you're getting into, going in and figuring out the problem and saving that patient's life. I mean, that, for me, is what got me addicted to general surgery. And it's still what excites me and drives me. And whether you're a pedal biliary surgeon or a colorectal surgeon, I still think that that moment is what thrills us, and also unites us. And at our center, everyone in the divisions has to do general surgery call. So, we do share that common experience. And it's important that we all maintain our skills within that. As far as getting into it as a specialty, that has been an incredibly rich experience for me. The Canadian Acute Care Surgery Group, newly minted as the Canadian Collaborative on Urgent Care Surgery or CANUCS, which is just about the most brilliant acronym ever, has been an incredible professional and personal development for me, just an amazing group, full of incredible characters and all working collaboratively to generate some great research and further our understanding in this burgeoning field. And it's very exciting to be involved at this time. I really feel that we're similar to the way trauma surgery was maybe 30-40 years ago. And I think the potential for its development is very similar. So, it's just been a great group to be part of, and it's great to have these friends and colleagues from across the country to share with.
Ameer Farooq 18:53
I like to switch gears a little bit if you're okay with it and talk about what it's like to actually practice medicine and live as a family, you know, on the East Coast or the Maritimes, so to speak. I don't think it's a secret. You know, Amir and I are from pretty far west of you, but, you know, as you pointed out, being an Ontario boy, what are some of the realities both fun and maybe not so fun of living in the East Coast, and what are the patients like, how do you think they differ from the rest of the country? Because I, you know, for those of us that live far west, I think we come into Halifax and have a great time at a given surgical conference or maybe some of us, you know, travel nationally and played hockey when we were younger or something to that effect, but you certainly hear lots of stories, but I don't think we have a great sense in the rest of the country what that experience is really like.
Sam Minor 19:45
You know, anyone that comes to Halifax I think the thing that really defines it is if you can make your way down to the lower deck and onto the waterfront there. It's an incredible vibe, a lot of great live music, great energy, a lot of university students here, tourists - well - used to be. But it's just an amazing city in terms of its vibrancy and energy, a lot of fun. And that's definitely, you know, when I came for my interview here, that was my picture of Halifax and certainly very excited to come here. Of course, you know, just like, if I defined Calgary by my experience at Cowboys, you would probably say that that wasn't the typical thing in Calgary. So, what is life, you know, day in-day out here. It's a neat place and that most physicians live right around the hospital and walk to work. Most would be within a 5- to 10-minute drive and choose not to drive most times ride their bike, whatever. It's a very livable city. You know, if you look at real estate compared to Calgary or Toronto or Vancouver, I mean, it's very, very affordable. You know, your opportunity as a physician to get some sort of ocean view or something like that is not unobtainable. The hospital itself and now this is sort of getting into the negative aspects, you know, Nova Scotia is a have-not province. It's about a decade behind in terms of trends. So, you know, we just recently gave up on Windows XP and upgraded to Windows 7 on our computer system. We do not have an electronic charts system or anything like that. They've been talking about it for over a decade. We do handwritten orders. It used to be not long ago on carbon copy, actually; they got some sort of new system where we got rid of the carbon copy, but it's handwritten notes, handwritten orders. So, everything is about 10 years behind. Now, I've been told that that can be a bit of a blessing, all sorts of problems with electronic medical records, and maybe we've avoided some headaches there. We're a 2-hospital system that's trying to pretend that we're one. So, the hospitals are separated by about 500 meters, I would say. And you can imagine it's quite a headache trying to pretend that it's one hospital with Division of Services. You know, one hospital has a blood bank, the other does not, that can be a problem when someone has an exsanguination hemorrhage. There's all sorts of problems in terms of coordination of care, having patients split between 2 different hospitals. And then this has been compounded by the one hospital, which is ancient. And it's basically at the point where it's uninhabitable. I think, at least now, 3 years ago, we actually had to do a mass emergency mass evacuation of our ICU because of a huge leak in the ceiling above. And I kid you not. We have video, it was actually like a heavy rainstorm in the ICU, the entire ICU. So, you can imagine at one o'clock in the morning, you know, all this water starts to pour out onto all the patients and ventilators and everything and people are throwing sheets of plastic and plastic bags over the ventilators and just rushing the patients out of there into the hallway trying to find a warm environment. And we were without an ICU at that hospital for 6 months or so. And, you know, basically we had the environmental engineers, they basically said, "Well, this space is uninhabitable now because everything's wet and mold, infection control, and who knows." Apparently, the problem that caused the leak was a potentially repeatable event. And so, we were like, okay, we can't come back to the space, but wherever they went, they were like: "Oh, no, this place was actually condemned 15 years ago." There's asbestos all over this space and so on and so forth. And this went on for several months and we ended up right back in the same spot that we started, but the roof has been blown off during a hurricane. My office has been flooded 2, 3 times - all the office furniture was ruined from floods, it's just in a constant state of crisis. So, they do have plans to build a hospital. I might be retired before that's done. But that has been a challenging aspect. But to go back to the good, you know, you have to think of the [inaudible]. The people here are wonderful people. The patients, you know, I would say on average, are extremely grateful. They seem to have more realistic expectations than maybe other extremes within the country. And the environment here, I would say is very positive, in spite of the challenges. The patients here are big. That's definitely a challenge. From a surgeon standpoint, we have some of the biggest people in Canada. And so definitely, I had to up my game in terms of going to the gym and getting my retractor skills going - and gallbladders - I definitely feel like we could take on the rest of Canada for the worst gallbladders in the country. That would be a neat contest. So yeah, I sort of rambled on there. But lots to be said about Halifax; I really encourage anyone that's got the opportunity, come, it's great fun, a great place for a conference. And if you ever think about moving here or want to try something different, it's a great place to live and work raise a family.
Ameer Farooq 26:45
I did a 2-week elective in Halifax as a medical student and did some call at the main hospital in the infirmary. Is it still as crazy as it used to be like, it almost felt like you would take a year off your life every time you do call there - it was just nonstop, just wall-to-wall action every night. And you know, in talking to trainees who have graduated there, they all talk about the same thing. Is it still that crazy? And there any sense that that's going to get better?
Sam Minor 27:19
Yeah, it's, you know what, we call it our acute care surgery service we call surgery e. And to be honest, I think it's our crown jewel. It is very busy. You know, in doing the study that Kellyboat did, you know, we have the data to show that we're one of the busiest acute care surgery services in the country. It is just a machine 24/7. It's very well resourced. We have our own OR every day 7:30 to 5:00, and we keep it busy. It's got very good utilization. Most weekends, you're operating most of the weekend as well. It can be a real challenge for the residents. And again, it's this 2-hospital model, the entire division is actually over at the other hospital. And so, we manage with one surgeon, and often as the staff surgeon, you're in the operating room most of the time. So, what that means as a senior general surgery resident, you're in charge of running traumas, of seeing all the consults, of manning the floor. And so, you know, I just finished a week there we had 40 inpatients, 6 off-service consults we're following and just a full OR day every day. And then you know, covering trauma whenever it came in. So, it's really where our residents cut their teeth. It's trial by fire. It can be a sink or swim experience. But for those who manage to swim, I think it's one of those things that they look back on their training and feel like that's where they made huge leaps forward in becoming a true surgeon. You know, Andrew Beckett, who's now at St. Mike's, you know, I think he looks back on that experience. Fondly, he comes from a military background, and he created this big stein that still hangs there to the day - beautifully done, but it looks just like from the show M.A.S.H. And it says, "Surgery e - best care anywhere," because it really does just feel like a mash unit.
Ameer Farooq 30:01
You recently published a report about using antibiotic beads in conjunction with a biologic implant for hernia repairs. Can you tell us a little bit about this? What got you started on this?
Sam Minor 30:12
As a general surgeon without a surgical fellowship, how do you contribute to your division? I've basically taken on abdominal wall reconstruction as my surgical subspecialty, as many people in critical care and acute care surgery have. And you know, it's really been an interesting area to be in. I love the problem-solving and all the options that are available for these massive hernias. And particularly, I've developed an interest in hernias with contaminated fields. So, these are patients that are presenting with infected mesh that needs to be explanted, and then you have to find some way to restore abdominal integrity after you've pulled out this 20 x 30-centimetre mesh. Patients who have fistulas with the mesh that they have eroding into their bowel. And our patients who have stomas and you're not really certain that you're going to be able to keep the abdominal wall clean when you're implanting your device. So, the infection rate is quite high - although extremely variable when you look at the literature, and this is one of the things that's so difficult about hernia surgery is that you don't know what's real, and the margins of what's being reported are all over the place. But when you sort of average it all out, you know, this group of patients with contaminated wounds, you know, you should be looking at about a 25% rate of wound infection. And obviously, if the mesh gets infected, this can be a real problem especially, you know, having done a component separation and placed a large form material in there. So, this product, which is calcium sulfate antibiotic beads, you can basically imbibe it with any antibiotic that you want, you just mix it in with the powder, and I use gentamicin as my binding agent, along with powder vancomycin, so I have gram negative/gram positive coverage, and it was originally developed for use in infected bone and infected bone implants. Then there were some reports of some vascular surgeons trying to salvage infected vascular grafts with it, some plastic surgeons have salvage some, some breast implants with it. And so, I was like, well, you know, like, hernia mesh is really not that much different. So why don't we start using it in that scenario? And so, we're building our data set with that. Preliminarily, it looks favourable, small numbers. But I think in our paper, we are reporting around a 10%. So, you know, this is the problem, it's all trying to look at very messy data in terms of the literature about what our baseline should be and then having small numbers, which, you know, when you're looking at large abdominal wall reconstruction and setting of contaminated fields, all the data, all the studies are small numbers. So, we suffer from the same issue. It's hard to know if we are actually on to something or not. But to be honest, I don't think you'll ever really get to a randomized controlled trial for this type of patient. But, you know, for minimal cost and for what looks like possible good effect, the one thing I can definitely say is that we haven't seen any concerning complication. In fact, I haven't seen any complication whatsoever. These beads dissolve after 6 weeks. We've done post-op levels on all the patients, and they have minimal systemic absorption. So, you know, just from the philosophical standpoint, you got absolutely nuclear levels of antibiotics locally on the craft, which is what I'm trying to prevent mesh explantation from, and no systemic absorption. So, for my peace of mind and the minimal cost associated with it, I think I can make an argue in the absence of good science that we may never get, but yeah, it's definitely a real interest of mine.
Ameer Farooq 34:58
So just to be clear, these beads are incorporated into the mesh or how does it actually logistically look when you're ...
Sam Minor 35:06
Yeah. So, during the operation you make the beads themselves. So, it just comes as a powder and you throw in some vancomycin powder and you pour in the gentamicin liquid and you stir it all up, and there's great buy-in from the surgical team, I sort of feel like I'm in a Betty Crocker kitchen and everyone likes the baking and you put it into the mold and about 10 minutes later, you're pop, you know, these nice little beads. I put about half the beads on top of the mesh. And then I put the other half within my subcutaneous spaces where I do an external component release for the really big hernias. And so, I put them in my lateral release area where there's quite a bit of undermining of subcutaneous tissue.
Chad Ball 35:56
Sam, I'm just curious, have you ever used them in the context of synthetic mesh as opposed to just biologic?
Sam Minor 36:01
Yeah. So, we published a case report in The Journal of Hernia where we used it to salvage a piece of infected polypropylene. And so, we've pulled that stunt off 3 times now. So, you know, that's evidence. It is an option. And what we do in that situation is, we just debride the piece of mash that is like, you know, just sitting at the skin and completely open with no tissue over it. We raised subcuticular flaps, basically sew the polypropylene part that we've cut out together, so you don't get a recurrent hernia, and then pour these beads on over top and then close the skin or back over top. And, you know, these are patients that we were looking at. One lady, she had, like two 20 x 30, polypropylenes sewn together like it would have just been a massive explantation. And doing this, we were able to get away with not having to explant the mesh. And the other one was a Ventralight mesh. So, you know it again, you don't lose anything, it's a 1 OR not a big OR. And I think the beads are about 1000 bucks. So, it's something, you know, if you're looking just at a bad situation where an explant is going to be a huge amount of tissue destruction and morbidity. I think it's worth it go.
Chad Ball 37:39
Yeah, there's no doubt. I mean, when I read your report, I thought it was genius. I thought it made so much sense on so many levels. And maybe I'd just push you back in an encouraging way. I think you could do a small randomized controlled trial on this; you know. We're just finishing one in Calgary that's a little bit bigger, just well over 100 hernia patients with the 2 biologic industry leaders head-to-head. But I think you could probably show an effect. I bet she was a lot smaller numbers than that. So, food for thought. I don't know what the cost is of that antimicrobial bead. I'm sure it's not much, but I bet that's something that industry would be supportive of as well. Because if you really think about it, I mean, that would be a whole entire game changer. There's no doubt.
Sam Minor 38:25
Well, it's funny that you said that because I did talk to the company. And you know, the interesting thing for them is, so they got approval - Canada Health approval - for use in infected bone and infected bone grafts. For them to engage in a study where it's been used in an off-label way, it is an incredible amount of investment on their part to pursue that. So yeah. They really weren't keen; they're a small company. They don't have a lot of money to throw at this thing, but they were very encouraging that I continue on.
Chad Ball 39:13
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