E130 Homer Tien on Ornge, Emergency Transport, COVID19 Vaccine Distribution & Leadership
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Chad Ball 00:12
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 masterclasses 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.
Ameer Farooq 00:42
Dr. Homer Tien is a trauma surgeon at Sunnybrook Hospital in Toronto. We were so excited to have him on the show because of the incredible work he has done in multiple leadership roles; most recently, as the president and CEO of Ornge, Ontario's air ambulance and transport service. Largely because of the amazing work he had done with Ornge, Dr. Tien was also made in charge of the COVID-19 vaccine distribution task force back in April of 2021. This was a conversation about trauma care, paramedic services and air ambulances. But even more importantly, we got to hear Dr. Tien's insights on leadership. Can you tell us a little bit about where you grew up and where you did your training?
Dr. Homer Tien 01:23
Sure. I originally grew up in Hamilton, Ontario, and then moved to Toronto for high school. So, I did all my schooling in Toronto for general surgery and did medical school at McMaster, did general surgery in Toronto and did my fellowship in trauma in Toronto, as well.
Ameer Farooq 01:49
What motivated you to go on to do trauma surgery?
Dr. Homer Tien 01:52
You know, it's interesting; I actually was relatively undifferentiated up until my senior year in general surgery residency, but what happened was a couple of things: I was on my trauma rotation at Sunnybrook and was really enjoying it. And then I was there during 9/11. And because I was funded by the military at the time, I remember thinking, "Hm, with 9/11, I'm sure that we will be going to war," and I thought, I'm enjoying trauma, I think trauma would be a good thing to be doing as a subspecialty.
Chad Ball 02:34
Yeah, that makes a whole lot of sense. You know, as you bring up, Homer, you've been involved with the Canadian Armed Forces for a very long time. We're curious what took you into that pathway initially? And I certainly know that a lot of the stuff that you've done over the years, you can't particularly talk about, but what has that experience overall, contributed to how you practise surgery and how you think about injured patients?
Dr. Homer Tien 03:00
You know, I like to say that probably joining the military was the best decision of my life, professionally. And the reasons for it were as mundane as the fact that I needed to subsidize my medical training. And so I needed a way to pay for medical school. But what happened was, originally, we only had 3 years of obligatory service. I did my time as a general practitioner in the military, as required, and I really had an amazing time, met some amazing people and really learned a lot by watching others about leadership and Canada's place in the world and some of the things that we can contribute. So I ended up staying in, and it really gives you a way of, I guess, leading both — as surgeons, we're leaders in the operating room at the hospital, and the military gives a different perspective on how we should be leaders.
Chad Ball 04:05
Yeah, I can only imagine what some of those experiences were like, based on talking to you and certainly knowing some of your colleagues. Are you still involved in the military now? And if so, what does that look like for you?
Dr. Homer Tien 04:19
Yeah, it's been quite the evolution. So, I did spend 5 years as a general practitioner, and in those years, I deployed quite a bit. I was with the 1st Battalion, Royal Canadian Regiment, and then a Canadian Special Operations with Joint Task Force (JTF) 2 and spent a fair bit of time in the former Yugoslavia and elsewhere. And then as a surgeon, I deployed numerous times to Afghanistan, to Kandahar. In those roles, I was able to work as, sort of, what we call the National Practice Leader for trauma, and so my job was to give advice and help develop the trauma system for the Canadian Forces during our time in Afghanistan; really looking, planning the system for point of injury in Afghanistan back to repatriation to Canada. I retired from the regular force in, let me think now, 2015. But I stayed on as a reservist as the Chief of Reserve as a medical and surgical specialist, and still do some work with the forces in that capacity. Wow, that's really, really neat. And, you know, the whole JTF lore, I think from a civilian point of view, is always interesting to think about and realize that we have some pretty incredibly special folks helping look after us, like you and your former JTF colleagues, so we all thank you for that. I'm curious, in this particular pathway of discussion, my last question would be something to the effect of: What are some of the most challenging areas that you see in integrating military and civilian care? Particularly, I guess, injury care? How does that colour or temper what you do in your current and previous roles, both with the air ambulance system and as being the boss of Sunnybrook? That's a hard — there's a lot of components to that question. I guess what I'd say to that is, I think they're interrelated. When we first, in the military, went to Afghanistan, we had a lot to learn from the military, which was that Canadian Armed Forces hadn't really been in a shooting war since the Korean War. So, our trauma system and our medical and surgical specialists were really out of practice of caring for critically ill and critically injured patients. And so the good news is the forces had the foresight to position our specialists in large academic trauma centres. And so, for the most part, the medical and surgical specialists of the forces were actually fairly well-trained and up to date in modern critical care and surgical management of the injured patients. Then we went there. And then I think, as you know, in these sorts of war situations, there's really a high influx of critically injured patients. And so some of the stuff that we learned there would help inform practice in Canada, so it's really a synergistic relationship. So, things like the use of tourniquets pre-hospital, the use of different transfusion strategies really came from that military context. So, I think it's quite a synergistic relationship as practitioners in the civilian world go to the military and then back; I think we learned from those experiences.
Ameer Farooq 08:15
You've done some amazing work on a number of different fronts, both on a leadership perspective, but also on a research perspective, as well. You published this really amazing paper in The Journal of Trauma almost 15 years ago now that talked about the causes of mortality from a Level 1 trauma centre, and it really highlighted the fact that pelvic fractures were a big source of mortality for [inaudible]. Can you talk to us a little bit about the genesis of this paper and what you found?
Dr. Homer Tien 08:49
Sure, and I think the great thing about clinical epidemiology — I did my master's in clinical epidemiology — is that we try to solve problems that we see in clinical practice. And the problem that we see is that patients that are bleeding to death from pelvic fractures, there isn't necessarily the same initial, "This is what the problem is, and this is what needs to be done". So for example, obviously, if someone is in hemorrhagic shock, we put an ultrasound on their abdomen, and if there's a lot of fluid in the abdomen, we can prioritize the belly. But there are these cases where it's a little complicated by either the — with a pelvic fracture, all you see is the pelvic fracture, and you don't necessarily confirm that they're bleeding in their abdomen. And so what we realized was that there was really a delay to hemorrhage control in those with massive bleeding from pelvic fractures, and we were really just trying to figure out how we can best expedite it. And some of the reasons were that sometimes you have pelvic fracture — extraperitoneal bleeding that leaks into the abdomen — and that confounds you, because you prioritized the abdomen and you get to the operating room, and then you realize, "Oh, we prioritized the wrong place. We really need to go to angio[inaudible]". And so, I think it really speaks to the need, and I think Calgary was the leader of this, sort of, having a 1-stop shopping area where you can go for a laparotomy, go for pelvic embolization, you can do all the aspects of hemorrhage control in 1 location. So you don't have to pick between 2 different locations (i.e., the operating room and the angiography) and then sustain a delay in hemorrhage control if you picked wrong.
Ameer Farooq 10:50
I think that's a really neat thing that's been highlighted. And you were prescient, because I think a lot of people have then gone on to do some work on figuring out [inaudible] factors. You know, one of the things that we were so excited to talk to you about today is the work that you've been doing at Ornge. So, you're the President and CEO at Ornge. For the few people that might not know what Ornge is, can you tell us about the organization?
Dr. Homer Tien 11:16
Sure, Ornge is Ontario's air ambulance and critical care transport provider. So, that means in Ontario, all air ambulance transfers — so either helicopter or fixed-wing aircraft — are either performed or organized by Ornge. But then, all critical care transfers, whether by air or by land — so, we have our own land. Ambulances that are critical care–level are done by Ornge as well, and they're done by paramedics. And so, we have a group of highly trained frontline paramedics and pilots that really do the interfacility transfers and the scene trauma calls in Ontario. And it's really been — I was recruited to Ornge as the Chief Medical Officer in 2015, out of the military, and it's been an amazing experience working with a great group of professionals.
Chad Ball 12:15
Can you give us a sense, Homer; how big is Ornge? Like, how many aircraft? How many employees? How many pilots? Those, sort of, metrics.
Dr. Homer Tien 12:23
Yeah, sure. So, we have about 670 employees, and of that, maybe almost 200 frontline paramedics, and we have about 160 pilots, both helicopter and fixed-wing pilots. You know, and people think about us, really, as a helicopter company. They see the orange helicopter flying around. But one of the things is that one of our core pieces of businesses are fixed-wing aircraft, because we provide service to many of these very small and rural and remote communities in northern Ontario, particularly the remote Indigenous communities that are fly-in only. And so, we're their only way of getting medical care, access to emergency medicine and trauma care. So — sorry — and so we have 8 operational helicopters at any one time. And so we use 12 helicopters to staff 8 operational [aircraft], and we have a fleet of 8 fixed-wing aircraft to staff 4 operational aircraft, 24/7.
Chad Ball 13:40
Wow, that's a phenomenally big and complex organization. That's tremendous. You know, you kind of highlighted it, there, in terms of the geography with which you guys touch and service those communities, and I can only imagine how challenging that is, particularly with somewhat unpredictable factors, like weather. I was wondering if you could talk to us a little bit about how you pick — what modality, I guess. Do you send a helicopter? Do you send a ground ambulance? Do you send a fixed-wing [aircraft]? I recognize that the far, far geography is probably quite simple — again, weather-dependent, but is there a certain distance for those listeners who don't deal with this every day; that you would choose one modality over another? What sort of factors go into those complex decisions?
Dr. Homer Tien 14:36
Yeah, for sure. Ontario actually has certain published guidelines. So, Ontario has published an air ambulance utilization standard. And so, there's a standard for scene trauma calls, and that is about 30 to 45 minutes' drive time to a trauma centre that we use, and the reason why it differs is different jurisdictions use a different time. So, as we know, it's often beneficial to patients to bypass smaller community hospitals and go directly to the trauma centre. So, the idea is that if someone is injured a 30-minute drive time from a GTA hospital, they will dispatch in conjunction with — land EMS will dispatch a helicopter if recalled if they meet field trauma triage guidelines. In different areas, like the Ottawa Valley, the time is about 45 minutes, mostly because the hospitals [are] a little further apart, and the ones in the Ottawa Valley are relatively small, so different times are used. For interfacility transfers, the distance in the standard is 240 km for an interfacility transfer, or if they need a critical level of care. So if, say, they're 120 km away, but they're vented, and they're on pressors, and speed is of the essence, we might use a helicopter, weather permitting and other circumstances permitting, as well.
Chad Ball 16:14
Oh, that's really interesting. So, about 4 hours is, sort of, the line in the sand, eh?
Dr. Homer Tien 16:22
I guess that's if you drive really slow. So, 240 km, so maybe a little more than — just a little more than 2 hours.
Chad Ball 16:35
Exactly. Okay. I got you. Sorry, I thought that was minutes. And I was thinking, "Oh, that's interesting".
Dr. Homer Tien 16:42
That's quite far, yeah.
Chad Ball 16:44
Yeah, that's great. You know, I can only imagine the complexities and the challenges that you would deal with running an organization and leading an organization like that. Where do you see pre-hospital, particularly air ambulance, care going, say, in the next decade? Is there any things that need to be improved? Is there any big developments coming down the pipeline?
Dr. Homer Tien 17:08
Sure. I think there's 2. I mean, 1 in terms of the actual care we provide, because I think we have some really advanced practitioners, and as you know, for trauma care, there's a push to push care out further and further in the pre-hospital realm. So, the starting of blood products; in the field, the use of ultrasound in the field; I think, in different jurisdictions, they're experimenting with things like, ED thoracotomy is in the field, ECMO in the field. So I think, the idea is that we're trying to push, as the practitioners become more advanced, more advanced care to our patients earlier. So, I think we'll see that more and more. The other thing, I think in general, about air ambulance, though, is [that] in Canada, there's a lot of issues from a health care system capacity point of view, postpandemic. And one of the things that I think we see with air ambulance and transport is that we're like a little special operations force for the health care system. And so, when there's areas that have very little medical care, and there's an emergency, we can deploy quickly and supplement care in remote areas. And an example that we had during the pandemic was, we organized the COVID-19 remote vaccination program for the remote Indigenous communities. And when there's a lack of capacity, right, you can use transport to create capacity. So there's a regional surge; you can use transport to move patients to other places. So in Wave 3 of the pandemic, I think we moved about 1000 patients to different hospitals in the GTA and further, to create capacity for the areas of Peel and Brampton, which were really under fire from surges in pandemic cases that were overwhelming their ICUs. So, I think we'll see an increased interest in air ambulance and critical care transport as a means of creating capacity, both remotely and in certain circumstances in built-up areas.
Ameer Farooq 19:27
Certainly, the pandemic has forced us to think very differently about the way that the health care system is organized and really try to think about where we have capacity in some places and not in others. Dr. Tien, when you were appointed to CEO in charge of the COVID-19 vaccine distribution roller, which I think at first glance, if someone, you know, heard "Oh, well, it's a trauma surgeon to be put in charge of COVID-19 vaccine distribution," people would be surprised. But I mean, I think listeners now having listened to you speak and all the work that you've done, realize that it's a very, very obvious choice to have you doing that. Can you tell us a little bit about how that occurred, that you were put in charge, and what that experience has been like?
Dr. Homer Tien 20:17
Yeah, sure. And I appreciate the obvious when you said the obvious choice, but let me tell you, it didn't seem obvious to me at the time. And I was scared to death. But I think it really came with the the completion of the remote vaccination program. So, when we finished the remote vaccination program, and I think people were a little nervous that that wasn't going to go well, and I think, relatively speaking, there was a sense that that program went well. And then they were in need of a new Chair for the vaccine task force, and so they asked me based on, I think, the success of the the vaccination program for remote Indigenous communities. You know, it's a large organization that was responsible for vaccinating Ontario. So there were all the different public health units, there were Ministry of Health Officials, Solicitor General officials, and I think it really was setting some strategic direction with all stakeholders, understanding what our mandate, was listening to what all the public health officials are saying, and in all the different public health units, and trying to chart a strategy because, you know, when you have such a large organization, you can only make fairly large swings in strategy. Like, let's focus on the hotspots where there's the highest risk of transmission, or fairly large decisions like that. The goal is not to get into the weeds at each public health unit. And so, I think a lot of the lessons in leadership in the military were useful in that exercise.
Ameer Farooq 22:08
You clearly held a number of leadership roles in the military at Sunnybrook, and now with Ornge and in the vaccine roll-up, could you tell us what are some of your major leadership principles? If you had to distill down your principles for what makes a good leader and what good leaders should do, what would those principles be?
Dr. Homer Tien 22:31
I think some of the principles are, you really have to think a bit about what the situation is. So, I mean, when people talk about principles, I think there's both leadership and management, and I think we sometimes confuse the two. So the leadership principle is: the leader is the person with the vision of, you know, the strategy and what the whole enterprise might look like. The manager is the one who really gets into the details of how do we turn that vision into something concrete? And I think we tend to focus on the leadership and the person with the strategy and the vision, but that managerial role is also of critical importance. Like, what are the actual steps and the techniques of turning that vision into a reality? And I think sometimes we don't focus on that as much in medicine; in the military, they really think about that. And so how do you make an operational plan? How do you communicate that plan to everyone? So, I think both principles are equally important. So if you have a great leader, with no management, I think it's hard to get the job done. And I think if you have a manager that's just yelling at people, no one wants to do what that manager is saying, because they don't inspire or create a vision. So I think both are important. And I think it's important to, I guess, have a basis for how to proceed, both as a really good operational manager and as an inspiring leader, and I think there's a bit of a science to both.
Chad Ball 24:21
You know, Homer, quite honestly, that might be the best description of a difference between leaders and managers and the interdependence on both of those groups that I've ever heard. That was succinct, and I'm so glad you said that. I wrote an editorial a couple years ago in the [Canadian Journal of Surgery] about those differences in particular, and part of that came from frustration in a lot of our local environments and our local hospitals where, you know, that nuanced view and understanding how those 2 pieces are equally critical and work together, really at all levels; up at the top level and then in the trenches. Well, sometimes you don't find that in health care. So I'm curious what some of the strategies that you've employed and that you've developed over time and all these different, amazing leadership and managerial positions you've held across all these domains. How do you use those skills? And how do you frame your goal when you end up in an environment where maybe 1 of those 2 sides is a bit lacking in the health care environment?
Dr. Homer Tien 25:27
Sure, I think that's the trick, really, and I think we're all practitioners of that, trying to do our best to figure out the best way, I think. What I try to do as a leader is, you know, you have to have the strategic vision, but one of the things that — I think we see this in the pandemic — is, you need to make sure you look after your people. And so, obviously, in the military, on deployment, and in health care, in the middle of a pandemic, people are put in harm's way to do the job that they have to do. But I think it's very important that people think and know that their leaders have their back. And I think that is something that we need to continually focus on in crises. Otherwise, I guess, our frontline people lose faith in their leaders. I think in terms of managers, I think trauma surgeons and surgeons in general are, you know — we have an advantage in that when you think about the conduct of an operation, there are a million different steps that we as surgeons have to be able to see our way through. There is no, you know, the 30,000-foot view; someone has to actually do all the steps to make it happen so we can actually plot a roadmap. And even if we don't see a roadmap, we see the beginnings of a route. And we have to make it happen. And I think in a complex operation, in a management operation, it's the same. There are certain principles that we follow as surgeons. There are certain principles that a good manager needs to follow in developing the plan. And it's not enough to have the 30,000-foot view, because you'll never get to the end if you just say, "Oh, just take the tumour out," or, "Oh, just stop the bleeding in that area". You have to actually know techniques and principles of making that happen into reality. So I think the military will teach you a way of planning operationally, and I think any good business school will teach you that as well, of: when you have a mission or a problem, how do you approach that in an organized way to come up with a plan with your stakeholders and how you communicate it to everyone? And I think we need to be more deliberate about things like that.
Ameer Farooq 27:58
Speaking of COVID-19, you must have been under immense pressure from so many different factions in terms of how to roll vaccines out, where to roll them out. And I'm curious; when you're dealing with input from many different stake-holders, all of them believe that they're correct. How do you balance those different stakeholders and opinions and still make a decision that you think reflects the best interests of the people you're serving?
Dr. Homer Tien 28:28
You know, that was a challenge in all aspects. And I think some of the principles are: people want to be heard, and I think they need to be heard. But then you have to present some of your principles of what your decision is being made on. For example, when one way of distributing COVID-19 vaccines in a time of vaccine shortage might be: we're going to distribute it equally to every community by population; another way — a lot of people where there was a lower incidence of COVID-19 in their communities might say that might be the way to do it. Another way to do it might be by an equity lens of where they need it the most. So if there's a neighbourhood where COVID-19 is basically exploding, you might say we're going to put the vaccine there more, knowing that the vaccine's not going to get you out of the outbreak quickly — it's really public health measures that stopped the outbreak — but it might accelerate the downward trend and protect against future waves in that area. So, I think it's important to communicate what your principle is, and people can disagree with it, but in the end, you have to pick a principle by which you're making your decision. And unless the situation changes, sometimes you make your decision, as we do in surgery, and you have to stick to it.
Chad Ball 30:08
Yeah, that's very well said. Now, let's switch gears here just a little bit, Homer, if you have a little bit more time with us, and ask you about a manuscript you wrote talking about, essentially, handover of patients from paramedics to the trauma service. I'm curious what led you to pursue that particular avenue of research and thinking, and I'm also always thinking about that particular manuscript and that work in terms of how to improve that process. Because, you know, I assume, like a lot of places, but, you know, I can certainly speak locally, we continue to struggle with all elements of the things you talked about, whether that's communication from the pre-hospital group to the hospital before arrival, as well as communication once they get here. It's a continuous work in progress, and I think we struggle with it here in particular.
Dr. Homer Tien 31:02
Yeah, sure. And I think, I won't take credit for it, really, was the brainchild of a lot of my colleagues, Luis da Luz being one of them, Adrian Nathan's another, but, you know, because I work at Ornge, I was able to help with some of the details of this, which is — handover is a period of risk, right? So you have these highly trained professionals who started care, they have a sense of where the injuries are, and they've started the resuscitation, they have some data from the crash mechanics or the pre-hospital injury mechanisms that might be very useful to the team. And really, it's something that we learned in kindergarten, right? When someone is speaking, and they have important stuff to communicate, people do need to stop and listen for a bit. Now that's also balanced by the acuity of the situation. So sometimes it needs to be abbreviated, because the patient's in extremis. But most of the time, you have a minute or so to listen, to actually hear in a structured way what the team has to tell you2, and I think it's really about how do you communicate these things quickly, in a structured way, and you have a way of abbreviating it, if they're in extremis. And I think we need that in intrahospital transfers and handovers, as well, and there's obviously a lot of work being done on the, say, the handover from the trauma team to the intensivist. This is a piece of work on handover from the pre-hospital transport providers to the trauma team.
Chad Ball 32:41
I'm curious, in Ontario, and in particularly, you know, your work in the GTA at Sunnybrook; how do the paramedics in the pre-hospital setting communicate with you [inaudible] as the trauma service? In other words, someone is shot or stabbed, or there's some incidents X number of blocks away; is there a mandatory time at which point they need to call in, like as soon as they pick up the patient? Or, sometimes they're too busy and don't call at all? How does that front-end process work? Because I think, again, based on talking to a lot of our colleagues across the country, some of our systems don't do that very well, and we continue to struggle.
Dr. Homer Tien 33:24
No, and, you know, in Ontario, it's really very much a work in progress right now. So, speaking about Ornge and, say, you're in a helicopter enroute to Sunnybrook with a critically injured patient. There's no 1, sort of radio net that all public safety providers can speak on. Like, in the military, you might have an operational radio net, and more of a combat support radio net, where everyone can call in on that radio frequency and communicate, so Eric can communicate to ground, and so forth. We're trying to do that in Ontario with a public safety radio network, where we can call on the same radio frequency to the land EMS providers when we're landing on scene and to other hospital providers, as well. Right now, it's by cell phone or by indirect communication through our communication centre, so it really is still a work in progress right now in Ontario.
Chad Ball 34:34
Yeah, that sounds similar to a lot of places, and I think you're right; there's a lot of room for improvement there. I just wanted to swing back before, maybe, we move towards closing, and touch again upon your comment about some of the more — maybe aggressive is the wrong term — but, higher and potential for care in some of these injured, and even just critically ill, patients, in general, further out in more remote areas, and for sure, not only in the civilian, but in the military, domain that's being pushed quite hard. Which one of those things are — or, how many of those things do you see as real-world possibilities that may, in fact, become standard of care? For example, roadside [inaudible] thoracotomy at that point, it's a roadside thoracotomy — seems a little off to me when you look at that London data, for example, and you talk to those folks, but that might just be my bias. There's a lot of really interesting things and certainly I sit back and a lot of our mutual colleagues that work in the US and look at some of the things that they report that they're doing on large, military, longer range aircraft in the air itself are unbelievable. So, what things do you think we'll end up actually using more extensively in this civilian world?
Dr. Homer Tien 35:58
So, I think it really depends on a couple of factors, which is, you know, the geography that you work in, the provider in the air ambulance, and really, the type of air ambulance. So, you know, the London, England, helicopter EMS experience is really — they're in downtown London, and they're doing ED — or, as you say, roadside thoracotomies, and presumably, the transport time back to the trauma centre is quite small. Like, for us, we did our annual report, and we were looking at the kilometres spent on a fixed-wing mission. On average, our fixed-wing aircraft will fly 1700 km for 1 mission, and so, when you think about that, like, there's no — even if they could do an ED thoracotomy, there's a lot of time and stuff that has to happen from the time of that ED thoracotomy in the field, where maybe you decompress the tamponade, to going back for definitive care and repair of the heart, or whatever you have to do, and closing of the thorax. And so, 1700 km is quite a distance to overcome for that. Now, that's there and back to base, so maybe it's 600 km for just that 1 leg to the trauma hospital, but it's still a considerable distance with a transport by land from the airport to the hospital, as well. The provider obviously matters because, you know, it's one thing to be a FRCSC surgeon or an [emergency doctor] with years in their belt; it might be different if it's a paramedic base to do ED thoracotomies. And, you know, when you look at the military experience, they're flying Chinooks, where you can basically have a large team in the back doing a resuscitation. You know, in the civilian air ambulance system, we're flying much smaller aircraft, so it's hard to get a large team to do a massive resuscitation. I think, usually, the resuscitation is started at sending or in the field, and then they're transported and packaged and brought with ongoing blood and fluids running, but hopefully with less surgical intervention happening when you're in flight. So, I think a lot of things in the military setting aren't directly translatable to the civilian section. I do think things like far forward blood, ultrasound technology and telementoring, and maybe REBOA [resuscitative endovascular balloon occlusion of the aorta], now that they have these, as you know, these smaller catheters, there's a lot of different possibilities. And who knows, with robotics and haptics, of having a telemetric procedure done in the field by someone remote, if there's enough bandwidth and satellite communication. I think there's a lot of options. And I think Canada is a large country with a lot of remote and austere — a lot of remote communities where you'd have to practise in austere circumstances. I think there'll be more and more interest in this particularly, you know, when we have the call to actions for truth and reconciliation, of how to improve access to care for our remote Indigenous communities.
Chad Ball 39:36
I think that's well said, and it's certainly a reason to be optimistic about that topic in particular. We know how busy you are, and we can't thank you enough. A lot of us were really excited to be able to talk to you today and it's really been a thrill. I was thinking back — you know, I met you in 1997, when I was a first-year medical student, and I can honestly say, over the years, every time that we interact, I learn something from you. I think of you a little bit like Yoda, not because you have big ears and are short, but because your commentary and your advice is always so sage and thoughtful and measured and calm, and I thank you over a long period of time for all of that. One of the things we try and close the show with, always, as you may know, is asking our guests: If you were to go back and give your earlier self, maybe as a trainee or as an early faculty, some of that sage advice, what would you tell yourself?
Dr. Homer Tien 40:42
I think I would tell myself — and I believe this — I tell new trainees this, is that there's no hurry. I think I remember when I was in [medical] school thinking that I wanted to be a surgeon, but because of financial reasons I had joined the military and I had to do some time as a general practitioner. I thought, oh, boy, that's going to delay me, I'm going to be behind. And, you know, at the time, I was a little nervous, little stressed by that. You know, and I think, you know, in retrospect, I think that's absolutely silly. I think we learn something from every experience that we have in medicine and in life, and I think there is no hurry. I think as long as you get the most out of it and put your best into it, I think it all helps in making the surgeon that you are and the person or the leader that you are.
Ameer Farooq 41:35
You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you like what you've heard, please leave us a review on iTunes. We'd love to hear your thoughts, comments and feedback, so send us an email at [email protected] or tweet at us: @CanJSurg. Thanks.