E142 Masterclass with Dennis Kim (Trauma ICU Rounds) on Fascial Dehiscence
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Chad Ball 00:06
Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball.
Ameer Farooq 00:27
This week, we're joined by trauma surgeon and podcaster Dr. Dennis Kim. Dr. Kim, among many other things, hosts the very successful and highly educational Trauma ICU Rounds podcast. We in Canada are extremely lucky to have him back on Canadian soil. And so this episode we talked to him about his experience moving back to Canada from a successful trauma career in the United States and coming here and collaborating to develop a trauma system in Victoria, British Columbia. We then delved into a masterclass on fascial dehiscences with Dr. Kim, ranging from closure techniques to prevent them from happening in the first place, to strategies for dealing with them when they happen. Dr. Kim, thank you so much for joining us on Cold Steel. We really appreciate you taking time out of your super busy schedule to join us on the show. It's a double pleasure to have such an esteemed surgeon, as well as a fellow podcaster, on the show. So thank you again for joining us.
Dennis Kim 01:26
Thank you so much, Drs. Farooq and Ball. It's truly a privilege and honour to be here with you guys. Love the show. I know how much work and effort and time and planning it takes to, sort of, host the hot podcast, and so I really appreciate this opportunity.
Ameer Farooq 01:42
Right back at you. We're big fans of trauma ICU Rounds. Tell us a little bit about where you grew up and where you did your training.
Dennis Kim 01:50
Yeah, so I'm originally from Ontario. I was born and raised in Toronto. And growing up, I wasn't ever really too sure that I wanted to go into medicine, although my mom is a nurse and so I heard a lot of stories from the hospitals and she worked with a lot of different surgeons. And as you can imagine, not all those stories were necessarily good. But after going through a few different career paths, I ultimately decided on medicine and eventually surgery. And so I ended up doing medical school at McMaster, followed by residency as well as a Critical Care Medicine fellowship at the University of Ottawa. And towards the end of my fellowship, I think one of the things I realized was that I hadn't really gotten a lot of intra-operative trauma management experience or training. And so, much like Dr. Ball, I headed down to the US for a fellowship, because that's what you do when you want to get operative trauma experience; you head down to the US. And so I ended up at the University of California, San Diego for 2 years, where I met my career mentor, Dr. Raul Coimbra, and he had a big influence on my career, and I spent my first 10 years at Harbor-UCLA in South Los Angeles before coming back to Canada.
Chad Ball 03:09
Dennis, that's an awesome pathway and pedigree. You know, obviously, in Canada and BC and in the West in general, we're so thrilled to have you back and call you our own. That's wonderful. So you must have worked with a few really good guys, eh? Like, Ali [inaudible] would have been down there and a bunch of great guys.
Dennis Kim 03:29
Oh, absolutely.
Chad Ball 03:30
Yeah, yeah. I mean, he's a close friend to a number of us, Ameer and myself as well. He's such a good guy, amongst many others. And, you know, it's such a different environment in LA, and in the US, in particular. What brought you back to Canada? What was that driver for you?
Dennis Kim 03:47
Yeah, you know, when we went down there, we kind of went down with the plan that we would go to our fellowship, maybe come back. And once we got down there, we really fell in love with the west coast as well as academia. I wasn't the most academically productive resident when it came to publications. And so during my second year of fellowship, that's when I really found a passion for clinical research and presenting at meetings, getting involved with professional service. And always having a strong inclination towards education and teaching — not just residents, but medical students — I really wanted that first job to be in a busy academic environment. And when the opportunity to take up a faculty position at Harbor-UCLA came up, and the academic appointments [inaudible] UCLA. I just felt like I really couldn't pass that up. And so I spent the first 10 years there; really got so much wonderful hands-on experience and met some fantastic mentors. But deep down inside, you know, we always thought, just like many Canadians, you know, we're very proud of our heritage and of our nationality and proud of our country and being Canadian. And so we always kind of knew in the back of our minds that we would be coming back, it was just a matter of when and where. And so over the first 10 years of my career, occasional job postings or openings would come up in places like Toronto and Vancouver, even Ottawa. And it was just never really the right fit. Unlike the US, where if you're a surgical intensivist, you're doing ACS, you're doing trauma, and you're rounding in the ICU. One of the things about canvas, especially as a surgeon, is it's maybe a bit more difficult to get your foot into the ICU. There's always trauma surgery jobs, although they're few, and not as many are voluminous as in the US. There's always general surgery ACS jobs, but it's really getting that ICU job. And so when the posting for an ICU position here in Victoria came up, I knew that it was probably not the right fit, because they weren't looking for a surgeon, there was no mention of trauma, and then when I found out that there was no actual trauma centre and a complete lack of a trauma system here on Vancouver Island, and they were looking for a trauma medical director, it just seemed like the perfect opportunity in terms of the next phase of my career. You know, the first few years, you're really learning to be competent, get comfortable in the OR with challenging cases, and really figure out who you are and get your footing. As I head into, sort of, the mid-phase of my career, I think one of the things that really attracts me about this job, and what I've loved so much, is really working with others, collaborating, leading and developing a system, which is exactly what we're doing.
Ameer Farooq 06:50
Congratulations on really developing the trauma system in Victoria, and you've really been successful at doing that. What does that been like setting up a trauma system in Victoria and on Vancouver Island? What kind of goes into something like that, like, as you know, as an outsider, I would have no idea what actually goes into developing a true trauma system. So what goes into that? What was that experience like?
Dennis Kim 07:16
Yeah. So, I think one of the things that American trauma centres do, especially organizations like the American College of Surgeons; they have their verification review committee, and obviously, every few years, you're going through that accreditation process. So you really start to learn, as you participate in these updates as well as these re-verifications, the importance of quality, as well as patient safety, peer review, and the importance of various systems and operations and how they can support the actual trauma centre as well as trauma system. And so, very early in my career, that's something that, well, it's hard to avoid, you know? When I started out as a very young surgeon, I very quickly took on the role as the ICU medical director. And so you're very quickly, sort of, immersed into the importance of patient safety, quality, and, you know, focusing on things like structure, process and outcomes, all with the sort of end-goal of improving value and patient safety. And so, having learned those lessons, it was almost, sort of, the next step, but looking at it at a larger scale. And I have to say that we've been very fortunate; they've been trying to get a trauma program off and running for more than the last 10 years here. And we've had so much support from our friends at places like Vancouver General Hospital, who had been wanting to work with us and liaise with us here on the island, to develop the provincial system. So there was already a lot of pieces in place. It just really took someone to, kind of, pick up the ball and carry it across the line. And fortunately, we've had so much wonderful support, not just from hospital administration and leaders in British Columbia health care, but also our community. And so it's been great. We've been collaborating with not just folks and friends from within the emergency room, anesthesia, all the various surgical specialties, but across disciplines, nursing, restorative services, and then liaising with other partners across the island. And so, back in November, we went live with our trauma service at Victoria General Hospital, and I'm very proud and excited to say that as of January 1, our neighbours a couple of hours north of us in Nanaimo launched their 24/7 trauma MRP service. So we're slowly building the system and developing capacity, we're working on destination guidelines, we've implemented monthly peer review, monthly systems and operations, and things are really starting to flourish. So we're very excited.
Chad Ball 10:04
Dennis, that's awesome to hear. And, you know, the fruits of all your effort and labour are certainly clear to the rest of us in the country. So congratulations.
Dennis Kim 10:12
That's too kind. Thank you.
Chad Ball 10:14
Yeah, no, it's true. I mean, you know, the challenges of doing this are not insignificant. And I know, you know, no one likes to perseverate on the difficult piece of this, and to be fair, you're partners with some tremendous people and surgeons in Victoria. I think the whole country knows that. But there's certainly been speed bumps for you in trying to, you know, achieve this endeavour, I have no doubt. Can you tell us a little bit about what some of those challenges have been? And, you know, the second part to it is, we asked this question to a lot of our guests and how do you assess challenge? How do you deal with the problematic administrator or colleague or department? How do you break through to the other side towards that common goal?
Dennis Kim 11:03
Great questions. And definitely, I think anytime you're trying to get a program or service off the ground, there's going to be numerous speed bumps, and there's, you know, there's always resistance to change, right? Change is scary, and the status quo was comfortable. It's known. And so one of the first things I did really was to make sure that I didn't speak too much. It was really more just about MBWA: management by walking around, talking with people, asking them what challenges they faced, and what were some things that they noticed around them in their day-to-day work, we're in need of improvement. And time and time again, it always comes back to patient care. Patient care, patient safety, and I think, coming out of this pandemic, we're starting to realize the importance of taking care of ourselves and each other. And so coming on the scene, I think I made a huge effort — I kind of told myself, I'm going give it 3 months, right? Don't say anything. I don't impose my end vision, my ideas. I'm just going to listen and identify what the key problems are, and then identify those, sort of, low-lying fruit; things that we could do something about immediately, where you get that immediate satisfaction, and people can see that you're effecting change. And then think about the long-term picture and establishing not just the mission, but vision for the program. And, obviously, without the support of hospital leadership and administration, and everyone is vying for resources, you know, even in specialties or in programs where you think, jeez, they've got, like, 40 faculty in that program. They've got all these resources. People are always looking for more. And as we all know, across the country, those resources are in critical supply, and they're quite limited. And so again, I think one of the big things we did was really just offer a solution. We looked at the problem, and what we found was that our length of stay within our health authority was quite long. We also noticed that some of our outcomes were not as good as some of our other health authorities — and this is objective data. The 1 great thing about trauma that we do so well is we do patient safety quality, and we have a trauma registry with dedicated registrars. And so it's hard to argue with the objective data, you know? And you're always being compared. I mean, you look at some of the efforts by ACS with teak whip and [inaudible] whip. But there's benchmarking, and you can see who the outliers are. And unfortunately, for many, many years, we were outliers. And so I think taking that and emphasizing the importance of patient safety, the importance of protocolization, adopting guidelines and ensuring that we're making every effort every day to improve delivery of value care that seem to resonate. And again, there's always going to be the naysayers. There's always going to be the late adopters. I think you can't worry too much about them. People just need to see that you're showing up every day, with a good attitude, looking to solve other people's problems. And eventually you start to rally and you build your village and your tribe and spread that positive mission moving forward.
Ameer Farooq 14:25
Well, congratulations, again, for all the really amazing work that you're doing. And we're looking forward and excited to seeing what you'll do next. Speaking of amazing stuff that you've done, I mean, you can see it right in the picture there on the video. You know, you're a podcaster, and your podcast, the Trauma ICU Rounds, has been immensely popular. You've won a bunch of awards for the work that you've done. How did you get into the world of podcasting, and what has that experience been like for you?
Dennis Kim 14:57
Well, probably a lot like you guys did, I'm sure. Deep down I think most of us who are into free online-access medication, or FOAM, and podcasting, specifically, usually we're very dedicated educators. And over the years, I've always made every effort to be involved, whether it was in simulation or classroom teaching, teaching ATLS. I think I find no greater joy outside of taking care of patients than really teaching the next generation of surgeons how to doctor and how to be the best potential surgeons and safest surgeons that they can be. And one of the things that I did find is that year in and year out, you'd have the same sort of courses, where you'd give the same old canned talk and interact with students, and oftentimes it would be on a very small scale. So maybe 10 students, 20 students. And, you know, it just came to the point where I really felt like I wanted to have a larger reach. And I wasn't an early adopter of podcasts, but certainly, there were a number of podcasts throughout my residency and fellowship that I found very, very helpful. You know, it's just so easy. You're going to the gym, or you're on your way into work, and you can listen to something and conceptually understand, especially when it's well done, the ins and outs of what would otherwise be complex issues, and then apply that at the bedside. And so that, for me, was very attractive. And so yeah, I did a little bit of research in terms of what was involved. I very fortunately, had a good friend of mine, Tim Horeczko, who has a podcast, the Pediatric Emergency Medicine Playbook, and he does monthly episodes. He's been doing it for years, and he was a really great resource for setting up your equipment and thinking about show notes and episode, sort of, list. And so it certainly helped to have someone help guide me early in the process. And then you, kind of, just fall in love with it, you know? You guys know this; I've seen some of the incredible guests you've had on Cold Steel. And you get to build bridges and relationships and talk with really cool and wonderful people that you might not otherwise have access to. And then to share that knowledge with others is just — that, in and of itself, is a wonderful gift. And so it's been a great journey. I've been a little away from the show over the last few months as we've been getting the trauma program here up and running, but already have my episode list for the next year ready to go. And so, [it's] time to get back on that saddle.
Ameer Farooq 17:42
That's fantastic. You know, like, I'll echo some of the things that you said, like, I think some of the connections that you make through this is really neat. Like, I love the episode where you had Sharmila Dissanaike and Christian — I hope I'm not butchering your last names — de Virgilio, and a bunch of other guests come and talk and debate with you about what's your approach with a difficult gallbladder. You know, should we be opening? Should we be doing subtotals? It was fascinating. I think so many people listened to that and enjoyed those types of episodes, and you have episodes ranging from, you know, really common medical things that you'll see in the ICU to very surgical things. So, you know, just something for everybody. You know, I'm curious, having done this work, where you think the future of medical education is going in the future, because it still boggles me a little bit that we have all these resources, right? Like, we have things like Trauma ICU Rounds, we have things like Behind the Knife, we have hours and hours, thousands of hours of videos on YouTube, you have things like the Toronto Video Atlas, and yet, you know, we still give the same — we still get asked to give lectures to the medical students about diverticulitis, right? So I'm curious, where do you think the future of medical education is going, as someone who's a podcaster and has their finger on the pulse?
Dennis Kim 19:14
Yeah, I mean, I think there really is something to be said about multimedia resources and surgical education and on-demand learning, you know? I think, when I think back to undergrad and going to these huge lecture halls with hundreds of other students and taking notes in class, and it being a very, kind of, cold, non-personal way of learning. I think these days, across podcasts, video-based education — and you've mentioned some great resources already — simulation, and I think VR, or virtual reality, I think have tremendous opportunities not just to teach concepts and theory, but for the pragmatic aspect of being a physician; working with others, thinking about things like crew or crisis resource management, how to lead a team, how to communicate and close the loop, and focusing in on key patient safety initiatives. So I think that that's where we're at. I do still enjoy the the small-group learning and case presentations as a way of really kind of assessing learners' grasp of key concepts and things like that, versus the kind of talking at them and lecturing. And I think on-demand learning for the younger generation is really the way to go. You know, let them learn at their own pace, using a variety of different resources. And instead of us just talking at them when they do come to meet with us, it's like that flipped classroom model, you know? What questions do you have? Let's apply what you've read and learned to a particular scenario. And then putting it into context. You know, you look at the first 2 years of medical school in most medical programs, they're spending so much time learning about mitochondria and cell biology and physics. And honestly, I mean, I'm sure some of that is relevant, but so much of it isn't, you know? It's not until their third year, they've already done 24 months of education, that they're finally starting to interview a patient, you know, and thinking about things like emotional quotient and EQ, and the importance of empathy and communication, you know, spending so much time just not at the bedside, and then not really understanding what's truly relevant, you know, to one's day-to-day clinical practice. So I think the sooner we can get our students and learners at the bedside, taking care of real patients with adequate supervision and real-time feedback, I really think that's the way that we should all be kind of moving towards.
Chad Ball 21:53
I like that message a lot, Dennis. You know, we had a guest on who I'm sure you know well from McMaster, Paul Engels. And we talked about, specifically trauma education at the residency level across Canada. And I want to drill down on that a little bit with you, because you're such an expert in this space. You know, in the Canadian Journal of Surgery, Paul's article will be coming out in the next couple of months, I believe. And it's a powerful — I have to be careful what I say here, because I don't want to ruin the discussion and the release of it, but it's a powerful message in terms of concerns across the country, both with regard to tremendous heterogeneity in structure in our programs with regard to trauma education and experience and exposure. And then secondarily, just purely volume. So, structured volume, which, you know, is true of a lot of things. And I don't know, you know, when these conversations come up, at least when I'm involved in them, sometimes somebody will say something about, say, an open cholecystectomy or conversion to an open cholecystectomy, and I'll sort of say that, to me, it's apples and oranges. Like, you can always back — almost always — back out of a [laparoscopic cholecystectomy] and send it to me in the Foothills Hospital in Calgary, and I'll take care of it as an HPB surgeon, but you can't necessarily back out of what shows up at your door that's critically injured. So I'm curious how you see Canada, how you compare that to, of course, the US, and what are some of the tools and the ways and things that we should be thinking about moving forward in this country?
Dennis Kim 23:33
Yeah. That's a great question, and I think that's something that's even outside of Canada in the US. I mean, so many times when we think about operative trauma, you think of the US and any major urban centre or core and you're thinking, oh, you're going to get great trauma experience. But to be honest with you, if you look at the number of verified trauma centres throughout the US, there aren't that many that are doing day-in, day-out operative trauma. You know, you think of places like Baltimore, you think of places like Chicago, Los Angeles, Denver, Miami — Emory, you know, where you trained. But outside of some major centres, they're doing a lot of non-[operative] management, and they're seeing what we're seeing; it's going to be gravity-related injuries and old people on anti-thrombotic therapy. I think that's one of the major, sort of, pushes or reasons why the acute care surgery model has been pursued. It's another way of ensuring that once our residents graduate, that they get that operative experience to deal with sick septic patients with intra-abdominal catastrophes, but you know, I struggle with that as well, because I feel like at the end of a 5- or 6-year residency, you should be a good acute care surgeon, hopefully. You're able to manage open abdomens and know when to bail. But it's true; we are doing a lot more non-operative management, and so I think a lot of our learners aren't getting that hands-on intraoperative experience and decision-making that's required to deal with complex and challenging cases, especially those that involve operative intervention, and I just think of any foregut surgery. And, you know, recently we were supposed to chat earlier this month, and we had a very complicated patient in our ICU who had an injury to the second portion of the duodenum, which leaked and caused us a lot of headaches and a lot of, you know, sort of, improper decision-making and technical challenges went into fixing this person's IVC, removing their kidney, and then sorting out through multiple repeat surgeries how to best deal with this recurrent anastomotic breakdown. And so, again, I think there's a number of things that we could be doing. There are certain organizations, not just the American College of Surgeons Committee on Trauma, but EAST [Eastern Assocation for the Surgery of Trauma], AAST [American Association for the Surgery of Trauma], Western Trauma Association, and then, of course, within Canada, we have CAGS, but, you know, I think a lot of these programs are focusing on ensuring that there are very clearly laid-out objectives as well as goals for those of us who are interested in pursuing trauma and acute care surgery. I think participating in the American College of courses outside of ATLS, which include things like ATOM, or Advanced Trauma Operative Management, and ASSET, or the Definitive Trauma Surgical Course [DSTC], are also really great ways for us to get the least some hands-on intraoperative exposure using cadavers as well as live swine models, to really practise skills like performing a cardiorrhaphy or suturing a heart or repairing an IVC. And I think those courses are available throughout the country. You know, trauma and general surgery, for me, go hand-in-hand. And it has been so interesting to see the rise in minimally invasive surgery and robotics. And I look at some of my junior colleagues and they're so comfortable and they work those chopsticks so well. And then when it comes time to opening, you can see there's this hesitation; whereas, for, you know surgeons like in our generation, that would be my go-to, is just to open and be completely comfortable setting up my [inaudible] here to ensure I've got the best possible exposure. Open [cholecystectomies], you mentioned; that's my absolute favourite operation. And anytime someone tells me that it doesn't give you a better view than a laparoscopic approach in a difficult gallbladder, I think to myself, boy, like, are you not setting it up properly? Like, I've never had difficulties opening and then understanding the anatomy and knowing when to bail versus not. So a bit of a long-winded response, but I think it's a multi-tiered approach that begins early in medical school. And really, that curriculum through undergrad and graduate education, I think, should be building on each other.
Ameer Farooq 28:12
I saw a tweet from one of the colorectal surgeons at UMass recently that said, maybe we should do a course, not doing so many courses on [laparoscopic] approaches to rectal cancer; maybe we should do a course on open approaches to colon cancer. I thought that was an interesting tweet and certainly generated some discussion. So we could talk about this all day, and I think there'll be lots and lots of thoughts to think about and ways to move forward. But we wanted, you know, as the trauma ICU guy who delivers such thoughtful rounds and such thoughtful podcasts, we wanted to do a clinical topic with you. And I thought it'd be a neat discussion between, you know, you, Dr. Ball, and maybe I can chime in a little bit here. I'm going to talk about something that comes in, and unfortunately, we all have to deal with a bit on call, which is that kind of dreaded fascial dehiscence scenario. I'll tell you about a patient, just to set the scenario, that I had in fellowship. So it's a guy who, you know, we have a big, sort of, homeless or unhoused population in in Vancouver, the Downtown Eastside. And this gentleman had had a resection in the past for cancer and then, of course, he developed a stricture that was very, very low. You know, long story short, he came in with large bowel obstruction and really needed an APR [abdominoperineal resection] and that was really the only definitive operation that he could have to sort this out. And so, he was kind of malnourished but we hadn't really been given a choice given him being obstructed. So we do his APR and, you know, 7 days later — 6 or 7 days later, we're rounding on him and, you know, he coughs, and there's a big gush of fluid that comes out from his wound. And of course, this gentleman, you know, has poor hygiene, you know, I don't think he, probably, had a bath in a month prior to us seeing him, and he'd lost a bunch of weight. He had abused fentanyl in the past. And when you examine his wound, you could clearly feel that there's a defect in his fascia. So, maybe, just for our medical, sort of, listeners or our junior resident listeners, how do you define what a fascial dehiscence is?
Dennis Kim 30:36
Yeah, a great scenario. And unfortunately, something that I think we've all encountered as surgeons. That gush, the 7-day mark, are all pretty classic hallmark features, at least in terms of timing and presentation for patients with a fascial dehiscence. And what is a fascial dehiscence? You know, any time we close an incision, whether it's a midline laparotomy, a transverse incision, oblique incision on the abdominal wall, there's going to be a number of factors that can predispose towards weakening of that incision. And any time the abdominal wall tension overcomes either knot strength or integrity, and fascial strength, you have the risk for a potential fascial dehiscence where the incision comes apart. And it may be partial, like in this case, or complete, and obviously, when it's complete, and someone's entire, for example, midline incision dehisces, well, then we're looking at complications like evisceration, which I think most surgeons would agree is a bit of a surgical emergency. Unfortunately, these are fairly common. Usually less than 5% of incisions will dehisce, but as we've already alluded to and you've so clearly alluded to, I think there are a number of not just technical factors, but patient factors and host factors that may result in an increased risk for dehiscence. And so malnutrition, use of corticosteroids and a number of other perioperative factors really plays into the potential risk for dehiscence, including obesity, COPD, anything that's going to increase intra-abdominal pressure has the potential to predispose towards a fascial dehiscence. And, like any good surgeon, we want to look at our, sort of, procedure as well as our technique, because oftentimes you can trace things back to something we potentially could have been done differently. Although when you look at most risk factors for fascial dehiscence, I think a lot of them do have to do with intraoperative and patient care factors. Although we talked about the importance of square knots and knot integrity, I think when you look at most dehiscences, it's not so much that the knot comes undone; it's usually the suture tears through the fascia. And the question then becomes, well, why would it do that outside of those patient and host factors? And one thing I always emphasize to our residents and learners is the importance of very good hemostasis at the end of the case. So there are no hematomas or seromas within that wound bed. And the importance, especially with midline incisions, is opening them truly in the midline. You know, there's nothing worse than trying to bring together a midline that's not midline, and so you're suturing rectus muscle to each other, it's tearing the muscle, and you know that muscle doesn't have strength. So yeah, in a nutshell, any time the tensions across the abdominal wall are too high, we do put patients at risk for dehiscence.
Ameer Farooq 33:45
So when you're assessing someone, and you're perhaps worried about someone who has a fascial dehiscence, what are some of the key, you know, findings that you're looking for on exam, or what are some things that really would trigger in your mind that, hey, maybe this person has a fascial dehiscence?
Dennis Kim 34:06
Yeah, I think this really comes back to good daily rounds and assessments of our patients' abdomen as well as incision. You know, so often, you know, it's a hassle to take down the dressings, and you're in a rush, and it's 5 in the morning and the room's dark, but really being mindful and paying close attention to the physical exam as well as the patient's symptoms. Any time you have a wound that is leaking fluid, that's always concerning. And so that gush that you have was a pretty pathognomonic kind of presentation for fascial dehiscence. But even before that, I think again, it comes back to a lot of host and patient factors, as well as things related to your initial operation. You know, I kind of mentioned the importance of excellent hemostasis, but one of the other things that I think can contribute to fascial dehiscence is infection, whether that's a superficial, deep or organ space infection. And in trauma, we see a lot of patients coming through with hollow viscous injuries and in patients with, for example, colonic injuries — destructive colonic injuries, let's say, from a gunshot wound. At the time of closure, I always ask myself, should we be closing the skin? You know, should we be putting this patient at risk? And what are some other possible options to immediate primary closure? Yourself, Drs. Farooq or Ball, what are your thoughts in terms of appropriate closure techniques in patients with hollow viscous injuries?
Chad Ball 35:42
Yeah, I agree, Dennis. I think, hopefully, a lot of us think the same way. You know, the other part of it is, you know, what procedure you're doing. And as you point out, what are the comorbidities and the risk factors of that individual patient. So, you know, when someone is shot and they have stool all over the place, up in their chest, through a diaphragm, into their wound, you know, that's a scenario where you're not going to set up a protective plastic covering on the skin, and you're not going to have a wound protector, and you're not going to have a, you know, an antisepsis bundle and the right temperature, and a lot of the things that you may or may not believe in, you know, from case to case. But yeah, I agree; slowing your brain down towards the end and really paying attention to that closure. You know, it's interesting, and I think it's — I hope this comes across without judgment, but we all know that there's, sort of, 2 groups of surgeons, I think, and I don't think age or experience necessarily plays into it. You have, and they wouldn't mention it or wouldn't be upset if I mentioned them by name, but you have John Camerons, Keith [inaudible], Dave [inaudible] on one side of things, who really will be there until the last staple goes into the skin. So closing the abdomen, to them is a critical part of these procedures, whether they're emergency or scheduled. And then, you know, there's other surgeons who routinely will do the complex parts of the operation, perhaps, and sneak out and let a trainee or somebody else close those wounds. And I think it's clear to all of us, you know, as long as you're honest with what you're doing, and accepting risk one way or the other, there is a difference in in wound outcomes in those patients. And it comes back, I think, to your comment about before you finish, really think about each of those steps, technique matters. It matters, as you said, staying in the midline; it matters. Using the curve of the needle; it matters, in terms of selecting the right stitch, you know, the top and the bottom of a long, midline laparotomy are closed differently. All of these subtleties and, I think no matter for the trainees, where you train, there will be a group of surgeons, which may be larger or smaller at your institutions, who really do care about how these abdomens are closed. And, you know, sometimes I think trainees are like, well, why is, you know — and Ameer can speak to this directly — but why is Dr. Ball all over me about this closure? You know, I know how to close an abdomen; I've done it 150 times so far in my residency. Try and flip your brain around, like Ameer always did, and said, okay, I'm going to try and learn a bunch of new stuff here from somebody who is so OCD about closing it — let's go. Because the nuance and the technical nature, I think, is probably, at least in my mind as a bit of a technocrat, probably 90% or 95% of the challenge.
Ameer Farooq 38:41
So let's stay on this topic for a second and just get very technical about it. So, you know, my practice is obviously very different in the sense that when, even though I deal with colon and small bowel all day, every day, you know, it's a very controlled — I have my Alexis there, it's a small wound, it's often minimally invasive surgeries. It's a very, very different scenario. But you know, even then, I still think that those principles that you guys are talking about are extremely important. So when you guys are closing the fascial, you know, when you're doing a fascial closure, what kind of suture are you using? What kind of bites are you using, especially in the emergency-type setting? Are you guys using VAC [vacuum-assisted closure]? I know in the colorectal world, you know, nobody's really been able to show that something like a VAC changes outcomes, but obviously, you know, it is very different to the elective-plan setting for a VAC versus not a VAC. So Dr. Kim, can you talk just a little bit about some specific things: suture choice, how you take your bites, and perhaps [inaudible].
Dennis Kim 39:55
Yeah, great question, and I think we do have some data to guide us in this regard. But again, you know, keeping with the principles of evidence-based medicine, whenever you interpret a study, ask yourself: What are the results? Are they valid? And do they apply to my patient population? And so, probably the most widely cited recent study is the STITCH trial, looking at closure of the abdominal wall or fascia using smaller, non-absorbable suture like a 2-0 proline, and versus how we used to be trained, taking a centimetre back from the fascia, [inaudible] centimetre apart, we're doing smaller bites and closer together. And, you know, I kind of think of the analogy of a jacket. You know, you have 2 ways of closing a jacket; you have 1 with a zipper — a winter jacket — or 1 like a tea coat, where you're putting the buttons together. And which seems to be more secure? And you would think, well, it's the zipper; it's the, kind of, continuous, small bites is going to be more secure. And in fact, when you look at sort of 1-year outcomes, which again, I'm not sure that that's the right outcome for trauma surgeons or acute care surgeons who are doing emergent surgery, you do find that the incidence of ventral hernias are higher when you're using bigger sutures with bigger bites. So theoretically, I think that all makes sense. The other issue outside of just the suture type, whether it's absorbable versus non-absorbable, larger versus smaller, and the continuous versus interrupted debate. And I think that's something that comes up at M&Ms monthly, right? Well, how did you close the abdomen? And you're going have that camp that says we only do interrupteds with #1 Vicryls and I've never had a dehiscence. And then the other camp where they're always talking about the importance of doing continuous sutures. You know, it got to the point, about 5 years ago, where I just decided that I'm going to do both; I'm going to do continuous in every 10 centimeters, I'm sticking in an interrupted. So these days, I've actually moved a little bit more towards the smaller, closer bites. I think a lot of it will depend on the particular situation. I do like to put in interrupteds as I go, as well. And I think, as Dr. Ball mentioned, so much of it has to do with the technique. You know, the less tissue trauma and sawing through and pushing of needles and sutures that you're doing, the better. You want to make sure that you're atraumatic when you're handling the fascia. And if you think, you know, in that particular patient we talked about to start off this discussion, you know, they're malnourished, maybe they're immunosuppressed, and they're already at a high risk for potential fascial dehiscence. Is there a role for things like retention sutures, which for me, I still use fairly liberally in the right patient subset, but I know many people have moved away from retention sutures, don't even know how to set up retention sutures, but I think those can be helpful. Regarding the use of VACs, similar to the colorectal literature, at least when it comes to acute care surgery, the outcomes from studies looking at prophylactic use of VACs — skin VACs — really haven't been that impressive in terms of decreasing the incidence of superficial or deep surgical-site infections. So that's not something that I utilize routinely, that's for sure. It's usually on a case-by-case basis. But I do you think there is something to be said about small bites, continuous running sutures from both above and below, and then excellent attention to hemostasis.
Ameer Farooq 43:46
I will put a little plug in for something, Dr. Ball. What I would do at the end of every case where you, kind of, take your dirty fingers out of the wounds, you tell them to keep your dirty fingers out of the wound. I would rub the the edges of the skin a little bit vigorously with a sponge just to see if there's any points of bleeding and then diligently take even a little — all these little bleeders on the skin and make sure that even those little skin bleeders wouldn't be a source of a hematoma; that's something I do quote. I have many balls, and that's one of them.
Dennis Kim 44:18
So I've got to say, just as you said that, I've got to interrupt because, you know, I joke about this every single time we're closing the incision with students and residents, but I always get my Asepto syringe, I take my suction or [inaudible] off. I instill the wound with my Asepto syringe; I go through it with my suction tubing. It'll actually show you areas that you thought were hemostatic that aren't. And then I do the exact same thing; I go buzz, buzz, buzz, buzz, buzz. And I always joke that you don't need an RCT; this 100% will decrease the risk for wound infection and dehiscence, and people look at me like I'm crazy. But I know there are other surgeons out there that do that, and we don't need the data to support [it].
Ameer Farooq 45:01
Clearly, clearly, great minds think alike. Dr. Ball, any comments? Suture choice? Bite size? Mesh? Oh, and we didn't even talk about this. Are you guys ever thinking about mesh specifically? And we'll get to it, we'll deal with this in a little bit, but if you have an incision that you think is at high risk, you think it's reasonably clean; are you guys ever putting in prophylactic mesh?
Chad Ball 45:28
Yes, it's a fun discussion, and there's a lot more opinion than science. Having said that, as Dennis has said, there is a number of RCTs, and there is a number of tangential manuscripts that really tell us, probably 1 single thing, like everything else in surgery, is not going to make or break the bank. But taken as a bundle, or as a collective, they really do start to matter, whether that's prophylaxis or infection prevention, or whether that's, you know, a critical care issue way down the road, it doesn't matter a ton. And things like wound protectors, covering the skin, changing your gloves, redosing your antimicrobials when appropriate, are all really important. And, you know, I think probably we tend to forget, particularly in these longer and more complex cases, so we need systematic reminders in some way around us to help us not fall down when it comes to that. If you asked me specifically, like you have, about suture choices, you know, we can tear apart the STITCH trial quite easily. And as you may or may not remember when that trial came out, at least for our institution in Calgary on the HPB service, we tried a bunch of them and had some really bad issues very quickly, so we kind of threw it away. I think at the end of the day, it probably doesn't matter whether you're, you know, a science-left or a science-right guy, when it comes to your suture choice. What matters to me, again, is technique. And I would challenge anybody watching someone else close, to critically look at every single bite that someone takes, or somebody of me. And your brain has to be switched on with every single bite in full capacity, not to skive here or miss a little bit there or get short, you know, over here; that technique matters. And I think that the strong suturing technique matters more than the actual, probably, suture that you're choosing. And it's probably reflective of a whole bunch of other things in the operation, not unlike, you know, we know blood loss is a clear indicator of quality, not only oncologically, but in terms of outcomes in general in longer cases. It's sort of the same, the same philosophy or principle, I think.
Ameer Farooq 47:49
Yeah. I mean, we didn't even really touch on this, but things like hypothermia, fluid management, those things also clearly matter for fascial dehiscence. So be a good surgeon, I think, is 1, perhaps, takeaway. I want to come to the actual management of the person who has the burst abdomen, as they love to call it in the UK literature. But, you know, if you — let's say you have that scenario where you have someone on the floor, it's day 7 or 8, and they — you identify, it does seem like there's a little gap in the fascia. There's clearly fluid coming through. They don't have an evisceration. Are you ever — Dr. Kim, are you ever managing these patients conservatively? And I have seen this done where someone says, well, just close the skin real tight, and, you know, they'll have a hernia. That's okay; we'll come back and fix that later. Are you ever managing someone, you know, non-operatively?
Dennis Kim 48:53
Yeah. So, we definitely have done that. Definitely. I think any time you see that, though, you have to ask yourself why. So for me, that's usually some sort of infection, again, whether that's a superficial, deep or organ space. So provided that the patient's hemodynamically stable, they're not frankly eviscerated, they're not peritonitic, those patients I'll usually send for a CT scan to get a better sense of the underlying anatomy and to identify whether or not there's an undrained pelvic abscess that should be drained operatively versus percutaneously. And so yes, I think it's totally reasonable to manage patients with a partial fascial dehiscence, particularly with high-risk features, conservatively, and understanding that you will be back to fight another day to fix a ventral hernia in the future. Whenever it's possible to potentially fix it, I think it's not unreasonable to do so; again, most of these due to fascia being torn. And so you're going to have a lot of necrotic fascia, torn fascia, that's going to predispose to further infection. So in general, I do like to debride that fascia and not leave that tissue hanging around. And again, getting back to the technical aspect of closing, so many times you'll see people as they're going through. The person who's assisting is like really pulling on that suture as hard as they can and strangulating that fascia, and that's really not necessary. Oftentimes, [inaudible] patients will develop edema, fascial edema, and so this whole idea of approximating, not strangulating, I think is so important. So yeah, short answer is, absolutely, you can manage fascial dehiscence conservatively. You definitely want to get some coverage, whether that's skin only, and where technically feasible and possible, if you can fix it, debride the healthy, debride the fascia back to healthy edges, that might be reasonable as well. Oftentimes, though, at about a week out, [it's] probably not the right time to start thinking about anterior component separation, or a TAR or any other fancy means of closing that wound. And certainly, if there is exposed bowel, and you're going to proceed with, sort of, non-primary closure of the fascia, that's where I think using the VAC can be very helpful, particularly laying down that white sponge on the bowel, and then slowly helping that wound granulate in, and maybe a delayed primary closure of the skin.
Ameer Farooq 51:25
So let's drill down on there. So let's say this is not the wound — ours was certainly not the kind of wound that we could, unfortunately, sit on. It was tried, and, you know, when there was bowel sitting in the [inaudible] a day or 2 later, it became clear that that was, that was not an option. So we took the patient back to the operating room, and as you described, the suture had really torn right through the the fascia, and you know, it was really, really low quality. There was an element of some, you know, a bit of an abscess, as well, that I'm sure had contributed to things. So you talk a little bit about the situation that you're going to debride some of the dead, kind of, fascia back. How do you approach now closing this fascia and this dehiscence? What are some of the principles and techniques in terms of how are you going to bring those edges together, especially if you feel like there's significant amount of tension on it?
Dennis Kim 52:24
Yeah, so, great question. I think there's a number of different options to this. Number one, when you've got exposed bowel, you've got to get coverage, and you've got to protect that bowel, because the last thing this patient needs in addition to fascial dehiscence is development of an entero-atmospheric fistula, or enterocutaneous fistula, which we know are just riddled with issues, not just for surgeons, but moreso for the patients. And so, depending on the size of the defect, and you know, ensuring that you're debriding that fascia back to healthy bleeding edges, if they're left with a defect that you cannot bring together without undue tension, I think those are patients where considering VAC therapy might be very, very helpful. And what I like to do with that, depending on the size of the defect, is once you lay down your Apthera, oftentimes, in order to prevent those edges from further spreading apart at the time of closure, just making sure you get, like, a number 1 nylon or number 2 nylon, and do almost, like, a vest-over-pants or a figure-of-8 to keep that fascia together. And that's something that can be serially tightened as you bring them back to the operating room every 2 to 3 days. And in those case scenarios, oftentimes, the 1 thing you're looking for is just preventing further injury to the bowel. And then development of healthy granulation tissue; skin-only closures work there. You can also think about things like skin grafts, depending on the size of the defect, but I think: Do no further harm. And where you can achieve reasonable fascial closure without undue tension, do it. But in this case, it doesn't sound like that's something that's going to be possible.
Ameer Farooq 54:14
So, just so I'm clear, for any listeners who might be listening to this. So what you're actually doing is you're actually putting a piece of the VAC sponge overtop of your Apthera, and then you're actually putting some sutures overtop of that sponge, and then bringing them back serially for closure. So that, you know, I mean, I'll just comment that that requires a lot of diligence and effort that you, you know, that you want to get this patient closed. You know, anecdotally, it's a challenge because, you know, if you're the surgeon on call, you don't want to be doing that case at like 10 or 11 o'clock. It's like, oh my god, I've got to do that fascial dehiscence or whatever. It's not, like, anyone's idea of a fun case to do at 10 or 11. But if you don't have the diligence to do it, you know, that person is never going to get closed and they will have those issues that you talked about. Dr. Ball, I know you certainly have some principles that I've learned from you over time, in terms of, like, getting that difficult-to-close fascia together. Can you talk a little bit about some of the principles? You know, particularly, 1 thing that I do like to talk about is where you put those sutures in terms of the top of the incision, the middle of the incision or the bottom of the incision?
Chad Ball 55:36
Yeah, my pleasure. I'm so pleased to hear Dr. Kim talk about so much of this. It seems like we were trained in the same place and with the same people. So it's wonderful. Yeah. You know, my first 30,000-foot comment, Ameer, would be — and I think we all know this intuitively — but probably is helpful to state it. If you're taking your or another patient back because of some technical failure, you're pretty silly if you use the same technique again. That's a moderately arrogant viewpoint of it. So you're going to employ some sort of different strategy. And hopefully you've trained in a place where you've been taught, and you've seen enough patients, to have a number of tools in all these regards in your belt. So you're going to try and pull out a different tool to to try and deal with the problem. Yeah, I think what you're asking me is some of the the technical pearls, which really, for me, in addition to what Dr. Kim has said, you know, you've heard me say this both locally, when we train together, as well as nationally and internationally: I think almost all abdomens can be closed. I think we all believe that now, and we've learned that through the last 20 years, quite honestly. There's exceptions — necrotizing infections, close-range shotguns, and so on — for sure, but in general, that should be your mindset. And your ability, in general, if you believe that mindset, to close an abdomen means that the ability to close it is directly proportional to surgeon effort. So I don't mean that in a nasty way, but these patients in general need a champion. They need you or someone like you, who is going to take the bull, proverbially, by the horns, and you're going to take that patient back yourself, the same person, every other day or every day or whatever the cadence of progress you're making demands. It's really hard to pass these patients off to partners to have them understand what you're trying to achieve, not to have been there the preceding 3 operations and seen progress or understand progress. But the concept, though, is you want to make a little bit of progress at minimum every time you go back. You don't want to trash the fascia. So there's a thousand different cheap ways to do this. There's a thousand — maybe not a thousand — but there's dozens of commercial, expensive, more expensive ways to do this. But you want to keep (A) maintaining the domain on the inside; keep that stickiness away, and (B) keep moving the abdomen closer and closer together. The other comment would be, don't, you know, as I said, don't mess with the fascia. So if you're putting in sutures, you can put them superfascially; you can be superficial to the fascia. The fascia will follow what superficially comes together. Obviously, if you can use a wound VAC, like Dr. Kim has talked about, that's helpful to nursing and for fluid control and to a whole bunch of things. The, you know, the 2 large companies that make most of our negative-suction, open abdomen products will tell you that there is a midline tension generator with those sponge products. I'm not entirely sure that's true, quite frankly. And my last comment would be, you know — I saw this this week — surgeons confusing the idea of making progress at the top and the bottom of a laparotomy room as helpful, meaning I'm going to put 2 or 3 sutures in the bottom, and 2 or 3 stitches in the top — that is a critical mistake. You're converting the geometry of a torso of an abdomen from an up-and-down, rectangular, or certainly oval, structure into a circle. And if you can close a circle, almost anywhere in life, I would love to learn how to do that. I know how to close ovals. And so, you want to maintain that length. You want to increase tension and approximation in a very logical, serial way, time after time. Don't be tricked by the older-school technique of a little bit at the top and a little bit at the bottom, or we've got an extra stitch — you end up with this big circle that needs a skin graft and it probably didn't need to, didn't need to be there.
Ameer Farooq 59:52
That's great. Thank you. Thank you to both of you. You talked a little bit, Dr. Kim, about the use of retention sutures. When are you using retention sutures? And specifically we can talk about, if you're using them, how do you put them in?
Dennis Kim 1:00:08
Yeah, so again, retention sutures I usually use in a prophylactic fashion. So when I have that malnourished patient who's immunosuppressed, on steroids, complete temporal wasting, and you just know they're at a super high risk for fascial dehiscence, that's when I'm usually doing that. So I'll place them typically about 10 to 12 centimeters across the length of the incision. I usually for this, I used to do full-thickness abdominal bites. Now, I'll try to avoid the skin. And so, just start in the subcutaneous tissues and make sure that I take very generous bites very far lateral of the entire abdominal wall minus the skin, typically with a number 1 nylon or a number 2, so the big harpoon, and as you bring that up through the superficial aspect of the incision, I still just utilize 14 or 16 French red rubber catheters that I'll cut in a way that it sits nicely at the level of the skin. And so it's just another added, sort of, layer of security. Most of these patients I'll also have in a binder. Again, that's just my own personal preference. I think it's just another layer of security. Whether or not it's actually going to prevent any form of dehiscence, probably not, but I feel better than I thought about it, and patients feel a little bit more comfortable, a little bit more secure, as well. And so yeah, it's not something that I'll utilize frequently. But every few months or so, I'll have patients with retention sutures.
Ameer Farooq 1:01:46
And, you know, you'll read about and you'll see in textbooks, a whole bunch of other different techniques, like, you know, sewing a piece of mesh as a bridging mesh, for example, to the fascia, and then using that to try to pull things together. You know, not to get, you know, drag on and on about this, but I do think, as you both have alluded to, having some tricks in your back pocket is helpful. And so that's why I'm picking both of your brains for pearls. Are you ever putting some mesh up to the edges of fascia [inaudible], something to kind of pull things together? And alternatively, when are you actually thinking about — When are you accepting, for example, that this is not an abdomen that can be closed and I'm going to do something like a bridging mesh?
Dennis Kim 1:02:34
Yeah, again, as Dr. Ball already mentioned, I think most abdomens can be closed. And in addition to the technical aspect of things, you know, there has been a couple of studies looking at hypertonic saline as an adjunct. I just saw that there was a recent trial showing that it actually doesn't help at all in terms of decreasing visceral edema, but it is something that I still do. I feel like, you know, theoretically, it makes sense to decrease some of that bowel edema. I think I don't usually like to sew in mesh, and as we've already heard, you know, trying to avoid beating up on that already beaten up fascia is important. Certainly in the past, I have used devices like a Wittmann Patch, but again, you're sewing that, you know, velcro device onto the fascia and then [inaudible] that towards the midline. I think it does address some of the issues in terms of avoiding that circle, because you're really putting tension across the entirety of the length of the incision. And of course, the length of the incision is going to predispose one towards a fascial dehiscence. There are other devices. I think, you know, the more lateral you can get, avoiding that midline fascia for your final definitive closure is important. And trying to stay out laterally by the semilunaris line is important. And so, whether you're using something like a Canica device, or some of these other, sort of, transabdominal-wall anchoring systems, I think is very helpful as well. So Dr. Leah Tatebe, at the University of Chicago, has a great presentation and, sort of, has shared with us their guidelines and their sort of set up for these sorts of transabdominal fixation traction devices, which do seem to be very helpful.
Ameer Farooq 1:04:20
Is there one in particular that you seem to gravitate towards, whether that's — and I'll just say, for our audience, we don't have any affiliation per se, with any particular product or company — but is there any one thing that you guys, kind of, your go-to, whether, you know, and some of these are expensive, like the ABRA, etc., but is there something that you, kind of, gravitate towards, a go-to when you're really in trouble?
Dennis Kim 1:04:44
No, I'll be honest with you. I think, when you have that burst abdomen, big, open abdomen, again, we're talking about the soufflé-, not the pistachio-type abdomen. I think it's important to, kind of, use a number of different techniques, but to be honest with you, like, where I am now, we don't have access to ABRA or any fancy closure devices. And so, for these patients, oftentimes it's a labour of love. I think, you know, you mentioned coming back at 10 pm. That's when these cases are going to get done. There's no time during the days to get these done, so it's going to be the open slate, it's going to be in the evenings, but being dedicated to that every 48 to 72 hours, coming in and making a little bit of a change, I think is critical; it's that dedication.
Ameer Farooq 1:05:34
Dr. Ball, any comments, any particular devices or techniques that you're going to use? Do you ever use something like an ABRA? Do you ever use mesh? Your thoughts?
Chad Ball 1:05:48
Yeah, no, I agree with Dr. Kim. I don't use any commercial product whatsoever. I use the litany of cheap and effective tools that he's talked about, which cost about $9 a pop, which is helpful to do a health care system anywhere in the world, hopefully, and it's certainly, you know, transportable to anywhere in the world. So I continue to do that. And I don't see a lot of benefit, quite honestly, to a lot of the expensive products. As far as — you know, you asked it earlier, too — prophylactic mesh. That's a very interesting question. Prophylactic biologics is also another interesting domain. I think, in general, the answer is no. And it's no across most places and most specialties and subspecialties. There is some high-volume hepatic transplantation programs in the US, a couple in Germany, that do put in prophylactic biologic in those patients, because their hernia rate is so high, obviously, because of the immunosuppression, amongst other risk factors. But the evidence for that is certainly not randomized nor prospective, and it's not great. But outside of that, you know, that's a big cost to a patient in a sketchy, sort of, case scenario. So you should probably think twice about it. You know, and, you know, as you probably remember, when we had Mike Rosen on — and it's something that Mike and I talk about offline a lot — we probably jumped to using mesh, just in general across general surgery, too often, is the honest truth. And, you know, a lot of patients maybe don't need to be reinforced in the same hardcore, traditional way that we've thought, and in some patients, it's worth a try. And if they have a hernia recurrence, and obviously, you're going to change your technique for the second time there, potentially use a mesh to reinforce it. But it does require, you know, case-by-case thoughtfulness and realizing every patient is different, both anatomically as well as physiologically, from a risk factor point of view.
Ameer Farooq 1:07:49
Well, thank you to both of you again for all your thoughts. And Dr. Kim, thank you so much for joining us once again, and in the evening on a Friday night so, [it's] much appreciated. We always like to ask our guests, you know, this classic question that we always end our podcast on. And the question simply is this: If you could go back in time to when you were a chief resident or perhaps an early attending, knowing what you know now, what is the 1 piece of advice that you'd give yourself?
Dennis Kim 1:08:31
Yeah, it's a great question. I think, you know, we get so busy in the day-in and day-out of rounding and examining patients and developing operative plans. And I think 1 thing that I've come to really appreciate, especially as someone who deals with patients who are sick, dying, really, if I could go back, I think I would just take a little bit more time to spend that little extra minute or 2 at my patient's bedside, really getting to know who they are. Now, what I love most about my job is getting to know the people that I'm operating on, you know, my patients, and I think that that relationship, for me means everything. You look at all my patients here, they've all got my cell phone — amazingly, they never actually call or text me. You know, I'll get calls or dings over the holidays. And, you know, I have a number of patients who stay in touch via email, send YouTube videos over the holidays. But for me, that's what medicine and being a surgeon is all about. It's those relationships that you develop with your patients. And I think as surgeons, we have a certain level of intimacy with our patients that you just don't get unless you're actually operating on people. And so yeah, I think if I was talking to my younger self, it would be just to take that little bit of extra time to get to know your patients. I think that relationship, that rapport, can have a huge impact in terms of patient outcomes, their outlooks and yeah, really makes this job worth doing what we do.
Ameer Farooq 1:10:27
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 or feedback, so send us an email [email protected] or tweet at us @CanJSurg. Thanks again.
Posted March 20, 2023