E30 Alex Poole with Masterclass On Frostbite Injuries and Remote Surgery

Listen to this podcast on SoundCloud

Chad Ball  00:15

Welcome to Cold Steel, the Canadian Journal of Surgery podcast with your hosts Ameer Farooq and Chad Ball. The goal of the CJS podcast is threefold. The first is to highlight the best research currently being completed by Canadian surgeons. Second is to offer educational topics for both surgeons and trainees alike. And most importantly, the third goal is to inspire discussion, thoughts, creativity and career development in all Canadian surgeons. We hope you enjoy it.

Ameer Farooq  00:50

Dr. Alex Poole is a general surgeon in Whitehorse, Yukon. He's had a fascinating career working in many remote locations. And in this episode, we talked to him about what it's like to practice surgery in a remote community. His work on frostbite injuries, and the deadliest animal in the Canadian north.

Chad Ball  01:07

Dr. Poole, thank you very much for for being on the podcast with us. We know how busy you are, how crazy the times with our friend, the COVID. So thanks for that. For those listeners who may not know you personally, tell us a bit about where you grew up and which training pathway was.

Alex Poole  01:24

So I grew up in a small town in Quebec, on the shores of the St. Lawrence River, called Baie-Comeau. No relation to a former prime minister from the same place. And I was the son of a full purpose general surgeon. And I had no idea at the time that I would end up being a general surgeon myself. As most kids in small towns, I went out to CEGEP which is sort of junior college after grade 11. I thought I was going to be an engineer, went to Waterloo did an engineering degree. And one of my work terms was in a biomechanics lab in Toronto, and that piqued my interest in medicine. So then I went to medical school, and lo and behold, enjoyed my surgery rotations, and eventually went into general surgery and ended up in Whitehorse through a somewhat circuitous route. But there had been a long time true general surgeon in the Yukon recently just retired Dave Storey, who would take a few podcasts, I think, to discuss Dave Storey's career. He trained, yeah, he trained in Calgary and that's how I came up here for an elective and so I've been returning ever since.

Chad Ball  02:37

Gotcha. Where did you go to medical school?

Alex Poole  02:41

Calgary, so I did Calgary medical school in Calgary and residency in Calgary.

Chad Ball  02:45

Gotcha. Yeah Dave Storey is a true legend. I think certainly across western Canada what what was it like to follow in his footsteps?

Alex Poole  02:55

It was fantastic. He was a great mentor to me and taught me a lot and no one will ever think that I have a broad based practice. That's the fault of Dave because whenever somebody thinks that I do more than most general surgeons typically do Dave will go he doesn't do anything. Because I you know, I limited my orthopedics to simple plating simple fractures and not doing IM nails. And so Dave thought I wasn't really doing much. So he he did full spectrum for years, often by himself. And so standing on the shoulder of a giant I think now is true for what my broad based practice Whitehorse is like.

Ameer Farooq  03:37

It sounds like you've been working in a lot of interesting and amazing places, not just Whitehorse. How did you what other places have you worked and how did you end up in Whitehorse?

Alex Poole  03:49

So I initially went to work in a small town in BC Nelson BC and then for a variety of reasons they regionalised surgery to a town that was too far away to live and work in Nelson at the same time. So I first came to Whitehorse as a locum and the practice pattern that historically had been set up in Whitehorse prior to me coming was, at that time a solo surgeon two solo surgeons working a variety of schedules on and off, we've sort of settled on two weeks on two weeks off and there's four of us now. So in your off periods, you potentially can do administrative work, research work, hang out with your family or do locums in other places, which some of us have done either to continue our medical education or to go to interesting places and help out. So I have done locums in a variety of northern areas as well because I do like the broad base northern practice. I did locum in Iqaluit, which is very interesting. This is about 15 years ago. And it was very much a different place than a Whitehorse. I mean, it's equally as North but far more remote. So it was a fascinating practice working with the Inuit people was great at the time. I think anyone over 40 needed a translator, which led to some interesting translations. The one that I can remember most clearly was, I was seeing an Inuit Elder in the office, by definition would be a hunter. And I, I most of the interview had been quite short responses. So I would ask the tribe, I would ask him a question, the translator would pass it on to him, he'd answer very briefly. And then I had said something and it was a very long discussion between he and the translator. And I, I said, What was that all about? What did I do? And she says, he doesn't know what orgon abdomen is, he wants you to be more specific. And so I realized that when you're dealing with a hunter, and this is what I've learned in the north, they tend to know their anatomy, if they're butchering their own meat, and so you have to be very specific, or they think that maybe you don't know what you're talking about.

Chad Ball  06:01

Wow, that's fascinating. Alex, let me ask you a bit of a tangential question, for sure. But you're for sure a deep seated family guy. How does your family I don't mean this in a negative way, but how does your family enjoy the ride and go to these interesting places with you and whether it's going from BC to Whitehorse or just the whole the whole voyage?

Alex Poole  06:26

Well, my wife certainly enjoys it. And she's a peripatetic artists. So at times, we've moved the family to various places for her and I've commuted to my remote practices. So it's been a bit of a 50-50 split, who gets to decide where the home base is. And I've continued to work in Whitehorse because of that. And we have lived here full time at times as well. And so the boys have been in many different schools, we have two boys and they, they've been pretty understanding. It's a bit of a challenge now that they're teenagers to move them around. But so much of their social life is online that they've been able to do it. So in some ways, they were ready for social isolation, because they've lived it sometimes before but it's given us great opportunities, which is the beauty of the two weeks on two weeks off pattern that we have in Whitehorse. Because we've I've commuted to Whitehorse from a variety of places, including Nelson BC, Halifax, St. John's, Newfoundland and Iceland.  Can you tell us what, from your point of view the some of the great benefits of working in a smaller community are? Maybe what are some of the challenges? In particular, what's it like, you know, for those of us who are city boys and continue to be so what's it, what's it like when you're the community and you're you're buying groceries, or you're in the hardware store, you're running to, you know, presumably, all these patients on a relatively regular basis? Yeah, the pros certainly outweigh the cons. I think that as far as running into patients, it's not that often that you run into patients, and you both want to acknowledge that they were your patient. So I tend to have to I, if it's someone I don't know, socially already, I won't say anything, because they may not want the other people around to know why they know me. That being said, people who would, I am sure, in a small town that I may have more blinders on that I think there's a good chance everybody knows who I am. But I don't necessarily think so. The big advantage is you're helping your neighbors. And so there's that's certainly fulfilling when you if somebody comes in with significant disease or condition or injury, and you can help them. You certainly feel like you're contributing to the community that way. And it's it's overwhelmingly positive. Sure, it just like any of us that are certain patients that for a variety of reasons, are either displeased with their result or their expectations aren't met. And you don't necessarily run into them that often in town, they more likely will respect to see you in the office if they want to do that. But for the most part, it's it's overwhelmingly positive and you know, to see young kids grow up that you potentially treated for appendicitis, or a fracture or hernia is pretty fulfilling. So overall, I'd say it's, it's positive. And I would agree when you're in a bigger center and you have anonymity, probably what you worry about more is those few times that you would have a loss of anonymity and a difficult patient, but those numbers are pretty small. So it's certainly not a detriment. It wouldn't be enough to keep somebody from working in a small place. But there are some small things that I mean, good advice I got from Dave Storey, again, was to not do parotid surgery in a small town. Which I've never done because if you get a facial nerve injury, you're going to be looking at a facial droop downtown that you're responsible for for the rest of your career. And if they just don't like what their appendectomy scar looks like, you're not looking at it all the time and watching them carry a handkerchief. So there's, you certainly have to tailor some things.

Ameer Farooq  10:12

I think a lot of us in Calgary really enjoyed a talk that you gave a couple years ago at our research day. And it was on frostbite. And you can you tell us a little bit about how your interest in this injury developed and what the scope of the problem is in Canada?

Alex Poole  10:32

Well that's a good question. This is where you'll probably have to cut me off because I tend to go on a bit of a become obsessed with frostbite. The how it happened, there was no intent for me to become the frostbite guy, which seems this my 15 minutes of frostbite, it's gone on and on. But I recognized that I had seen a couple of cases of frostbite. And we weren't doing really anything with them, we were just waiting for them to declare may or may not let them autoamputate or amputate them. So I, I just assumed that people would think that we were good at treating frostbite, because we're in the north, and I thought that I should find out if we should be doing anything different. And then I went down a bit of a rabbit hole, because it turns out that nobody really was, as far as I can tell in Canada, or at least, saying that they were doing anything differently. So it started innocently enough, I just did a literature search. And I found that there were experts in France who were treating it quite aggressively and some in the US. And I cold emailed these people, all based on the emails that they would put on their journal articles, which I've since learned that most people don't answer. I eventually got hold of one Alaskan, who gave me the real emails of the experts. And so that linked me with France, and then I got quite interested in potentially making and doing what we possibly could. So they were using a drug that's a vasodilator and also has some rheological effects on platelets as well called iloprost. And I thought, well, it'd be, we should see if we can get this I didn't realize it wasn't available in Canada. So when I asked our pharmacy, they said it wasn't available. So we innocently enough, not realizing that this tends to be an onerous process asked for special access to use it to Health Canada. And initially, their response was quite quick and said, No, there are therapeutic alternatives available. And our pharmacist was quite crestfallen because we've done a fair amount of work, rationalizing it sent them our literature review. And I said, Well, I don't really care. Ask them what that therapeutic alternative is. Let's get that. And then we emailed them that one question. They said, Oh, never mind, you can have it. So I don't know if that's their standard response initially, when they ask for something special. So then we more or less based the protocol of how to use that drug and what they were doing in Europe. I didn't realize no one in North America had done it. So then I was encouraged to publish our first two cases which the CMAJ was kind enough to take, which caused a bit of a storm across the country, that I now get calls from all over Canada, which initially, people wanted to send me patients from the south, which I tried to tell them that medical transfers usually go downhill from the north to the south, and not the other way around. So through a variety of means me giving talks at certain national events. And I think the embarrassment of some of the bigger cities being told, if they didn't take a patient do something they were gonna send them to Whitehorse. It's kind of caught fire across the country. And so more and more people, including Calgary now have an aggressive protocol for frostbite. The second part of your question of what the burden of disease in Canada is unknown at this point. We see two or three bad cases a year, which if you can imagine if there's two or three surgeons working, you may only see one a year and so you don't think the problem is necessarily big enough for you to figure out if you should be doing something differently. So I suspect that what we need is a national registry, which I may get involved in trying to set up. Because there's some there's some clear questions that need to be answered. We're currently treating the most significant frostbite grade four out of four, with both of basil dilator and a thrombolytic. And there's no clear evidence that combining the two is necessary or even using the thrombolytics at all is necessary, which is common in the US. They don't do any vasodilation. They do the thrombolytics and the big centers that treat frostbite aggressively, which is mostly Minnesota and Utah. So I think there's some questions we could answer or somebody who knows what they're doing from running trials could answer if we had a national registry which I think would be great. Because I imagine that there's places like Calgary, Edmonton, Winnipeg, which are big cities that have cold climates must see a lot more frostbite than maybe they think. The advantage that we have is that we are seeing a disproportionate number of adventure athletes who may be young and healthy otherwise. And are coming in with their first episode of frostbite. If you have a bit of an urban practice, where you have people that live on the street, that may not be the first time they have frostbite. And so though, and those injuries, I believe, are harder to deal with if they've had secondary freezing events or yearly freezing events. So it's harder maybe to make a difference and therefore identify that you've made an intervention that can have a difference.

Ameer Farooq  15:44

So when you get a...

Alex Poole  15:45

Lot of unanswered questions in frostbite. Sorry, that's what I mean, I could go on forever.

Ameer Farooq  15:49

No, it's, it's it's really, like you said, a lot of us really found the topic totally fascinating. And, surprisingly, none of us really even thought about it, even though obviously, we live in a cold place. Can you  can you walk a little bit through like, how do these patients present? How do you manage them kind of summarize what you talked about in that CMAJ article?

Alex Poole  16:15

Most of them will present within 24 hours. The main changes that are classically described with frostbite are a reperfusion injury. So the people that get the blisters, the bloody blisters, the cyanotic changes, those are usually a post rewarming phenomenon. The people that present frozen that we have to rewarm are potentially people that have been rescued. Often they'll do or unless which we now have a fair amount of public education in Whitehorse. So people recognize that they may have frostbite and come in. So if they're not rewarmed, we rapidly rewarm them. And then what's probably becoming evident in frostbite is if you are going to treat them aggressively, the next step is to try and decrease their warm ischemia time. Because the reperfusion injury that they get is appears to be vasoconstriction and thrombosis. And so they're getting an ischemic injury downstream from there. So that the earlier that you can give them either the thrombolytic or the vasodilator, potentially both, the better. And so there's some work out in Minnesota, showing that time is money in the sense that they do better the earlier that you intervene, possibly even earlier than you could arrange if you're in a bigger center, an angiographic study or a bone scan, which is useful because if the bone is not perfused, then you know, there's no perfusion anywhere in that digit beyond that. So we treat them aggressively, they get a five-day intravenous protocol, which is really well tolerated. For most patients, if they're ambulatory, they'll get their first course of it in hospital, they're monitored because the vasodilator but we no longer admit them to the ICU often monitor them as an outpatient. Now, if they tolerate the first course they will come back to the hospital, they'll get their whirlpool the suite of physiotherapists, their dressing changes, get their six hours of an infusion, and they'll go home and do it all again the next day. So it's pretty, it's an efficient way of treating these patients. And when they're given five days of the protocol, the five day there's no magic to the five days, it's based on what they were doing in France. Again, if we had a real study, we could figure out do you really need to do five days, should you do more? Should you do three? But we do five and most people tolerate though well. The most common complication is headache, and it's usually a dose response. And often if you turn their their rate down for a little while that'll go away and and get that under control. And then we follow them out to resolution, which in my experience seems to be at three weeks, you know, what's gonna survive and what isn't. And then the question is, if you could know sooner, if you could do a surgical intervention, if someone inevitably is going to have an amputation, then you would potentially save them and the system a lot of time and money by getting them healed and moved on as opposed to dealing with a chronic wound waiting for the spring for it to declare.

Ameer Farooq  19:19

That segues really nicely into my next question, which is, where does surgery fit into this pathway? And how do you know when or do you know if someone's salvageable or not?

Alex Poole  19:36

That's a good question. There was some evidence before people were being treated aggressively. We did some good work in France, where they did a retrospective analysis of all the patients that had had bone scans. I think it was at 48 hours, and the bone perfusion accurately predicted what their ultimate amputation level would be. So this is before they were treating them aggressively. And that's what we're trying to change is that prediction. So you can, there is a natural history prediction that you can probably make it 48 hours of what is going to survive. What we and I, my experience with about five years of this now and over 20 cases is we're probably cutting that amputation rate or level by 50%, with our aggressive treatment, so the more is going to survive. But certainly it's three weeks clinically looking at them, you know, what's going to survive? And then the question is, is how where surgeons could come in at that point is how to preserve length. Because anyone that's done revision amputations of the fingers or toes, the main issue is usually skin coverage. So you may have circumferential necrosis at an area, but you have to cut the bone back to get the skin to close over top, which if you go through a joint now you've lost a significant amount of more mobility, and usefulness. And so if there's a way of maintaining length, whether that's moving flaps, or temporarily, I read an interesting article recently about temporarily embedding the fingers into the skin of the abdominal wall to revascularize the area maintains length. So I think that as we salvage more, if we get really aggressive with length, and that's where surgeons could practically get more involved as well.

Ameer Farooq  21:17

You know, you took this protocol from France, but what were the iterations for you to actually develop it in Whitehorse. And how did that what did that look like in practice?

Alex Poole  21:29

Well, it's certainly an interesting journey to do that. There are a lot of I mean, the protocol we took from elsewhere really was how to dose the iloprost. Then I tried to identify what evidence there was for certain treatments, the a lot of the changes. Here's an interesting journey from the history of medicine as well. For instance, what is the deal with the blisters turns out in Chicago in the 80s, they aspirated 10 patients with blisters felt that they were prostaglandins within the blister fluid that they knew from plastic flaps were bad actors thromboxanes. So they decided we should be treating these frostbite patients with an antithromboxane regimen, which is where aloe and ibuprofen come in because where they hit on the arachidonic pathway, they blocked the bad thromboxanes. So unfortunately, they made two changes, they started a protocol and they gave them both aloe and ibuprofen didn't separate them so. And then did a large series of patients and demonstrated a decrease in their amputation rate. And so that is why everybody gives the patients the ibuprofen for the frostbite. So though it's based on a large number of patients that they intervened with, it's based on just aspirating 10 patients blisters, which is I thought was pretty fascinating. As a consequence, we give everybody ibuprofen and aloe based on that. So that's an example of everything we do for because we're in a small town. And if if we're developing a protocol that no big academic center has, we have to be careful that we're not just making this up. So everything that we do in our intervention, either has evidence that it does no harm, or there is actually some rationale physiologically with evidence that it works. So that includes our rapid rewarming. And the temperatures we use for our we rewarming and our ibuprofen and aloe vera. And the iloprost. And it's it's funny creating a protocol, I've learned a lot about sometimes they're very logical ways why people do things. The best evidence that I could find was that most people were rewarming at 37 to 39 degrees. So I picked 38 when I first wrote the protocol, and the very first time I was in the trauma bay, we were rewarming a patient, and we have these nice little rewarming whirlpool tubs that have an external heat source. And then it's just they have a circuit contains circulating thing in the bottom so you can't actually burn your feet on this. So I saw the nurse pour cold water. She filled the tub, right from the tap in the trauma bay. And she's pouring a liter of cold water in the tub. And I said what are you doing? She said, well, it comes out of the tap it's 39 degrees, it turns out and I'm trying to get it to 38. And I said if it comes out of the tap at 39 degrees we're changing the protocol to 39. It seemed ridiculous. So you have to be careful when you're dealing and the nurses are extremely good at to their credit of following a protocol. But you have to be careful what you put in your protocol.

Chad Ball  24:39

That example is so good and it's it's so repeatable it happens so often no matter what we're doing. Alex many years ago, you were doing a locum at the Children's Hospital here doing pediatric surgery which again speaks to your your broad breadth of talent and training and and you made a comment to one of my co-residents at the time that you guys were doing, you may not remember this, but you were doing a groin hernia, standard, straightforward, nothing special. And, of course, this individual on this rotation had done a zillion of them. And you were hanging out. And you said, you might know this procedure better than I do right now. But in six months, I'm going to know it a lot better than you. And that comment, we all thought was interesting, because it kind of spreads through the ranks. And that was cool. But it's clearly more and more and more true, the longer you practice, can you tell our listeners what you meant by that maybe? And, and especially with your practice, starting and stopping and starting and stopping and moving in and out of these locations, you know, in terms of your view on skill maintenance, and CME and, and, and that whole kind of world.

Alex Poole  25:46

Well, I don't remember saying that. But I can imagine saying that. I haven't studied the theory of education. But I certainly noticed as I was going through my medical training, that there was a whole lot more that was just going into my short-term memory than was going into my long term memory. And I wasn't acutely aware of it at first. And pediatric hernia would be a perfect example, when you've just you've done a couple of weeks of them, you've done a couple of days, it's a pretty easy operation, you just reach in, there's the hernia sac and you divide it away from the cord and cord structures, and you do your high ligation and move on and you can chat during the procedure. And then a few months later, if you're on a different rotation, if someone gives you a pediatric hernia, you would ask yourself, Oh, where did we put the incision, again, like it would be from a start, it wouldn't even necessarily be a process of the operation. And if you as you know, as a surgeon, if you put your incision in the wrong place, and everything looks different from then on, so it's just snowballs. And so I think what that speaks to is that if you know what your ultimate goals are, you have to somehow recognize when something is simply, you know, wrote temporarily, because you're doing it repeatedly. And if you're going to have to pull it out, every now and then then you sort of have to have an approach for how you're going to do that. Whether that's you're making notes or educating or even consciously making it into your long-term memory. When I when I came to Whitehorse as a resident, there was no CT scanner here. And every case we dealt with in Calgary in rounds, we were often talking about the CT scans, and I can remember, as a resident, we'd be reviewing a CT scan, and I consciously say to myself, what if I'm in Whitehorse, and we don't have a scan? How am I going to deal with this issue? So I was making plans for that. Of course, when I came to Whitehorse, the staff, they just bought the CT scanner. So all those plans were perhaps for not unless the CT occasionally goes down, which does happen. But I think you have to, you have to recognize that it's going to happen. And it's certainly easier now with online resources. If you don't have your textbooks, you can look something up. I remember being amazed, sitting with a plastic surgeon at the Children's and I was a resident, and they were asking me that day, what cases we had for their elective list. And I asked them at what point they no longer check the list obsessively because they wanted to see if they needed to look up how to do something. And I think they said about 10 years, which seems about right. But unfortunately for my practice, there's so many things that I do in frequently or have to as I recently stated, I'm a high volume, low volume surgeon. I do a lot of operating and stuff that I don't necessarily do often. So there's still things that I will look up. What I found particularly useful as a resident who used to save all my dictations. Because a resident dictation of meticulously how to do a thyroidectomy would still be useful to me if I had it now for the steps of the operation. I don't know if that answered the question, but those.

Chad Ball  29:08

Yeah. There's so much insight and wisdom in terms of what you just said, it's, it's perfect. The other thing I was wanting to talk to us about is a couple years ago give or take you were out in Australia and hung out giving a talk to our colorful when absolutely fantastic colleagues in Darwin, Australia, North Side, north tip there and they asked you to come and talk about, I think initially polar bear injuries, but I'm sure your talk was more broad than that. Can you tell us about that and what some of the content of the talk was?

Alex Poole  29:37

Yeah. Well, that was fascinating for a variety of reasons. And thank you, Chad. You're the one that suggested me to them. And I think we we both enjoyed the experience myself and the Australians. So that was for the 50th Annual Provincial Surgeons of Australia meeting and that's their term for rural or remote surgeons is provincial surgeons. Which was telling you from the start. Because I don't think we've ever had a one in Canada and I was at their 50th.

Chad Ball  29:38

Yeah, exactly.

Alex Poole  30:08

I thought that was telling for their support of rural and remote search. Now they wanted me to try, they were fascinated with bear attacks. So I was coming from the Yukon, they wanted me to talk about bear attacks. So when, so I looked it up and in the whole country, and the Yukons numbers are similar, we have a fatal bear attack every two years on average. So in a decade, there would be five. So the bottom then the numbers are pretty, pretty low. And the day I landed in Darwin, the newspaper on the front page in the newspaper was that some local fishermen had been eaten by a crocodile. So their crocodiles are way more dangerous than our bears. So of course, I'm giving this was a pretty August gathering of the surgeons on Australia. And turns out it was also their Royal College meeting. So the city surgeons were there too. So I didn't want to go talk off the cuff. So I decided to look into our data. So I had our medical records people in Whitehorse, who were very good at tracking all the admissions to the hospital emerge and otherwise or even just the people that pass through the emergency department. So they pulled up all codes that involves animals presenting to our emergency department. And so I gathered the data on animal injuries and I wanted mammal large mammal injuries in the Yukon. And I was pretty sure I was going to tell the Australians that the by far the most dangerous mammal in the Yukon was the moose, which I assumed was from car crashes into moose. Because the moose has been destroyed. It's been designed to destroy a car. It's extremely top heavy, it's tall, you take the legs out of it, they fall in your lap, so they're a danger. So I looked this up and there are at least two moose for every human in the Whitehorse in what in the Yukon. So there are a lot of moose. There are about 6000 bears, I believe in the Yukon. So I was pretty sure it was going to be the moose. So I went through the data. And turns out we have about I think it's 1000 bison and 1200 domestic horses. And what shocked me was that horses were by far the largest number of injuries. Even when I then went through the charts and screened out the people that have simply fallen off a horse rather than they would say in Calgary thrown off the horse. Just from attacks either being kicked or bitten, the horse was overwhelmingly a higher number than bear the moose traffic accidents, or even bison gorging so we have in the Yukon. So it turns out that by far, they had a much lower number. This isn't this is sheer absolute numbers, and they have 1/10 of the population of the large mammals the horses. So unquestionably, the most dangerous large mammal in the Yukon is the horse. Which you should worry about that Chad because you're in Calgary, you're right in the thick of it.

Chad Ball  33:00

Yeah, exactly. Well, we certainly published a few papers on equestrian injuries and it's it's always interesting to to hear from riders, you know, what, why they got injured. And certainly the more experienced the the rider was, or the equestrian was, the more often they blame the the injury on themselves as opposed to the animal which always fascinated me. It's , it's it's funny, we, you know, if you when you think back to your top 10 sort of injury stories, one of my very favorite ones without question in Calgary here was a guy that, that that came in as a what we call level one so and you remember this, you know, hypotensive super sick come now sort of thing. And the page which has, of course, limited, limited texting, characters on it, had said gunshot, blunt, and bear. So this this poor guy, of course, who should remain nameless, was out hunting deer with his one day previous father-in-law, like just brand new. This is like sort of like the honeymoon. And long story short, they, they, they shot the deer and they were tracking it and one guy gets attacked by this bear. And the son-in-law, here's the kerfuffle and comes flying around the corner and sees the bear on top of his new father-in-law. And just starts shooting him. And it's just, you know, the both the guys were great. They're straight out of a comic book. And then he did he did fine. But yeah, some of these stories are fantastic.

Alex Poole  34:29

That is awesome.

Chad Ball  34:30

Yeah, that's good stuff. But let me ask you maybe in closing, Alex, you know, it certainly sounds like I didn't know this about you. But it certainly sounds like you were thinking about the sort of career path as a remote surgeon really early and, and addressing it, you know, as you went through your training pathway, but what what sort of advice would you have for a general surgical resident maybe who wants to pursue some of the things that that that you've done in general?

Alex Poole  34:58

Well, that's a good question. I think to have this sort of practice you do it would be hard to live in an academic center. So I think first you'd have to want to live in an area in either the north and more remotely in the south. And then I would just follow your passion. You have to really enjoy what you're doing, get as broad based in education as you can. And even if you don't have rotations, like I'm not sure they do plastics, rotations, or neurosurgery rotations, or orthopedic rotations, or general internal medicine, which were all in value to me invaluable to me and I use many of them daily, if not weekly. You can ask questions, you can be interested, you can poke your head into a case and see what's going on. And it'll build from there. And if you're interested, there certainly are ways of designing your practice to get continuing medical education. I think before you returned Chad, I took a month and I hadn't operated on a liver trauma for a long time. So I just hung out in Calgary and scrub down about a billion cases for a month, a few years back and just little things that you can that to pick up your experience and skill set is invaluable. And so I think if you're interested in what you're doing, and you want to live in a smaller area, then I'm sure it can still be done. And if you know where you're going to go, and you need to tailor it to that, then that's fair enough. So you can just pick up the skills that they're asking for either before or after there's no rush.

Chad Ball  36:27

Yeah, that's I mean, that's an amazing comment. And I think it's something that we've heard with a lot of our guests, whether they've been, you know, iconic, famous American trauma surgeons or whether they've been military surgeons, or now from you remote surgeons that, you know, we shouldn't probably be bashful about asking our colleagues to maybe help us update our training or to show interest in them because, you know, almost almost across the board, general surgeons have a culture. You know, we we love that. And we get as much out of it as as, as the person that's, that's helping us update our skills, you know.

Alex Poole  37:03

And people, people are supportive. Because of COVID I have to learn how to do my first tensor fascia lata flap for big trochanteric ulcer last week, because I just couldn't send the patient anywhere. And the response I got from the plastic surgeon Duncan Nickerson, who you know, well, was what I asked him what this patient needed. He said they needed TFL flap, and he said, but I can't take them because if it's COVID and then  he paused and he goes, but you self taught much more complicated stuff than that before. Why don't you spend a week and learn how to do it, do it. And so with his help, remotely I learned how to do it, we did it and saved the patient a lot of time and grief and closed his wound.

Ameer Farooq  37:54

You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. So feel free to email us at [email protected] or connect with us on Twitter @CanJSurg. Thanks again.