E80 Kenneth Mattox

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Kenneth Mattox

If you’re going to go to Carnegie Hall, you get there with practice, practice, practice. The same with athletics. The same with any business, including medicine. And especially surgery.

Chad Ball 

Welcome to the Cold Steel surgical podcast with your hosts Ameer Farooq and Chad Ball. We’ve had the absolute privilege of chatting with some amazing Canadian as well as international guests over the past year. While the topics have been broad in range, whether clinical, social, or political, our aims for the podcast continue to remain the same. We hope to inspire discussion, creativity, scholarly research, and career development in all Canadian surgeons. We hope you enjoy our second season as we continue to highlight some incredible guests, deliver detailed masterclass sessions on a myriad of clinical topics and introduce some fresh new features such as debate and companion formats. We hope you relish the podcast as much as we do. We feel so privileged to bring you a very special guest today on Cold Steel, Dr. Ken Mattox. We use the word icon within medicine far too frequently. But to be truthful, there is no bigger icon within American or global surgery when it comes to the care of injured patients and kinematics. From his annual review course in Las Vegas to the industry standard textbook on trauma to his course altering peer reviewed publications, he has arguably had a greater impact on the care of injured patients than anyone else in history. As you’ll see, he remains driven, controversial, and committed to any metric one can contemplate. We hope you enjoy this podcast as much as we did.

Ameer Farooq 

Dr. Mattox, it is an absolute pleasure and an honor to have you on the show. You really don’t need any introduction; you don’t really need to tell your life story as the vast majority of our listeners will know you and your reputation. But can you tell us and walk us through where you grew up and what your training pathway was to really put in context for our discussion going forward?

Kenneth Mattox

I was born to dirt farmers in White Oak, Arkansas. Population: 15. The year I was born, most of my relatives were sharecroppers if that. And when I was six months of age, the work ran out. My dad had been chopping cotton for 50 cents a day. And another couple went to California and we were migrant farmworkers for several years. Very religious. And we moved from California ultimately to El Paso, and I graduated high school from Clovis, New Mexico, going to Wayland Baptist College with two scholarships; a music scholarship and I sang in an acapella choir. I also had a ministerial scholarship to be a Baptist preacher or Baptist missionary. During my first year I fell in love with biology, changed my major to pre-med and then decided to go to Baylor College of Medicine which had a reputation of being a tough medical school. I liked that. And I fell in love with surgery. And except for two years during the Vietnam War, I was in Houston for my medical school. My residency was a general surgery residency and thoracic surgery and promptly became a faculty: Michael E DeBakey Department of Surgery. And in about 1989, I was made Chief of Staff of the Ben Taub Hospital. I already was Chief of Surgery. And this year I stepped down as chief of staff. I still have a number of responsibilities at the school. I no longer scrub actively on either elective cardiovascular cases, or trauma cases. I do go to all the educational sessions and participate in many of our conferences. I’m married, I have one daughter, and I try to stay busy.

Chad Ball 

Well, there’s no question you’ve succeeded in being busy. You’ve really been at the center of all thing’s trauma, (you can correct me) but for at least four decades. Your contributions are endless. As Ameer said, most of us, you know, are aware of a lot of them. You certainly informed and molded and have driven a lot of us to do injury care to our core.

Kenneth Mattox 

So let me put this in perspective for both you and Ameer. When I started medical school, the following things did not exist: EMS, emergency medicine, vascular surgery, the American Board of Thoracic Surgery did not exist. Surgical critical care. There were emergency rooms run by the lowest ranking individual in the hospital. Interns. There were no faculty in the house, we had penicillin, but not complex amino glycosides. We had mercury-based diuretics, but we did not have loop diuretics. The volume ventilators did not exist. The fancy ventilators where you added peep etc. did not exist. Intensive care units did not exist. And ambulances were run by the local funeral parlors. That was in 1960. And it was literally in the mid-60s before we began to have dialogue. Trauma systems, trauma surgeons, and trauma as an entity did not exist. Trauma was felt to be a psychological event that describes stress. So that’s where we all started. And today, the enterprise, the integration of the various disciplines and how we work together, and what is available to patients – I’ve had the opportunity to see develop over time.

Chad Ball 

Can you tell us about what some of those initial challenges were in creating a modern subspecialty, such as injury care and a trauma system? Or at least recognition of it? Maybe locally, as well as nationally, internationally?

Kenneth Mattox 

Well, I decided I was going to be a cardiovascular surgeon. Cardiac and vascular were united back then. And in 1971, I finished general surgery and took a two-year thoracic residency, and sort of thought, I’ll stick around as a faculty for a little while. And I determined what organizations I’m going to belong to. Texas Surgical. We were forming and making emergency medicine and EMS organizations. I wanted to be in the vascular surgery societies and the thoracic societies. But then when I looked to see what they required, they all wanted 75% of my papers to be in their discipline. So, I said, okay, I’ll start writing about what everybody else in my department writes about. Well, all the elective stuff, they had written about, and we’re still writing about. And here I was at the bottom of the totem pole. So, Dr. DeBakey wanted me to work over at the Ben Taub, helping the singular faculty that was there. So, I became the second faculty in surgery in 1973. And I wanted to belong to the organizations and to belong, you had to be productive and present papers. And the only papers that people hadn’t presented were injury. But an injury organization didn’t exist. So, I made it my mission to write a paper, a summary paper, a review paper, a chapter paper, ultimately, textbooks on every vascular cardiac, thoracic, emergency and injury that occurred. Because except for a few people, Norm Rich and a few others, there weren’t many papers. So, my papers got accepted at every meeting. And those were then republished, and that became a niche for me, and at the same time, forming a network across the country, for patients to go to level one, two and three trauma centers. Meeting a high bar became the mission of a few people whose names you know – George Shelton, Don Trunkey, Norm McSwain, and on and on. We even had some folks from Canada, who were part of that early club that everyone thought was a bunch of misfits, because it wasn’t a traditional area.

Ameer Farooq 

Sir, you know, one of the things that I think is interesting is the fact that you were able to recognize that clearly, there was a need for something like a specific trauma specialty. So, I’m curious how you sort of saw that. And the second thing is that, you know, I don’t think it’s an accident that you were able to contribute so much to the field based on the caliber, and the high technical expectations that were placed upon you by training under someone like DeBakey. What was that experience like, training with DeBakey? And how do you think that informed your practice and your expertise going forward?

Kenneth Mattox 

Dr. DeBakey expected nothing of anybody that he didn’t produce himself. He loved to work. He thought sleep was a bad habit. It would not be unusual for him to make a phone call at 2:30 or 3:00 o’clock in the morning to talk over something that he was thinking about. And if you didn’t like that, he didn’t understand it. He was a disciplinarian. He expected total attention to detail. He expected pursuit of excellence. And he expected you to know more about his patients and your patients than anybody else. He expected you to know more about internal medicine than any referring doc; more about antibiotics and infectious disease. More about cardiology than the cardiologist. He expected you to look at every x-ray, every lab data and integrate those and he had rotations. Most people only had them once. On his service, that were three months in length, you never left the hospital for those three months. And sometimes they were on the floor with his inpatients and sometimes they were on a new thing he had created called Intensive Care Unit. I had that rotation for three times. You only saw your family if they came on weekends when it was less busy. And you had breakfast, lunch, or dinner with them. And so that was the environment. During those times in the operating room, with Methodist Hospital, Ben Taub Hospital, the Children’s Hospital and the St. Luke’s Hospital, the affiliated hospitals of Baylor, it was not unusual for there to be 75 cardiovascular cases every day. So, Mary looked at the schedule and said, what am I not seeing? What do I need to see? What is it I want to learn today? What is it that I want to learn this week? And it was in that environment where everybody owned their patients. There was this team issue. No one ever talked about burnout. Stress was a pablum of productivity. And I chose that residency because it contained that kind of hard work.

Ameer Farooq

That’s just an unbelievable description of such an amazing place. And again, it’s no accident that you were able to go on and do the things that you’ve done when you were put through such an intensive training environment and training pattern.

Kenneth Mattox 

If you want to go to the Olympics, if they’re going to be held this year in Tokyo, or if you want to go to Carnegie Hall and be a virtuoso on the cello or violin or any other instrument. You don’t do that by working a 20-hour week or even a 40-hour week. You practice, practice, practice. And you excel. And you go to various meets and walk away with the local trophies for you to compete on the national scale. It’s the same in medicine. If you wish to be the doctor, the “go-to” physician, whether it be radiology, psychiatry, surgery, trauma, critical care, in a community – you have got to be known as the person who makes people well. Or is honest for those people that you can’t change because they’re at a terminal event. But if you’re going to go to Carnegie Hall, you get there with practice, practice, practice. The same with athletics. The same with any business, including medicine. Especially surgery. And I don’t think we emphasize the technical expertise that is required to be that “go-to” physician for the president of Exxon, or a person who happens to be hurt in a personal violence in a bar.

Ameer Farooq 

We want to come back to that topic here in a moment, because I think that’s such a critical and important point that you raised there, sir. But we did want to talk to you a little bit about the Ben Taub Hospital and what that environment is like, and how that has sort of shaped you. And how did you actually end up at Ben Taub? And how is that institution, that is certainly a legendary place in trauma, how has that institution sort of changed over time?

Kenneth Mattox

The Ben Taub is the second name that it was applied to the City County Hospital in Houston. The first one was a Jefferson Davis hospital that opened initially in the 1920s and was located very near downtown and was paid for by a combined budget for the city and county and was incredibly low. It was obvious that a replacement hospital would be needed. So, beginning in the 50s, led by Dr. DeBakey, a new hospital was to be built in the Texas Medical Center. And it would be normally adjacent but linked by a tunnel to Baylor College of Medicine. Mr. Ben Taub was a humanitarian in town who was happened to be into property. DePelchin Children’s Home, he imported tobacco, purchased land, but he was the chairman of the city county board that drove Jefferson Davis hospital. So, it was appropriate when it was moved to the medical center to name the hospital after him. It was limited budget. And if I was to put in a heart valve, a vascular graft, or a hip prosthesis, the old ball that would be used for a broken hip, I had to find a benefactor to purchase that piece of equipment that I was going to put in a patient. Mr. Taub paid out of cash before a lot of those devices. Because the budget simply would not pay. It was understaffed, and the salaries were very low. As I indicated for surgery in 1969, well actually 1973, there was one full time faculty and surgery, and yet it had a fairly high trauma volume and elective surgery. Gall bladders, colons, and we were doing lots and lots of operations on biliary tract, common duct explorations, gastric resections. And if you finished general surgery, you are also expected to be proficient in vascular because there was no special vascular training. And so, Ben Taub was the hospital for the people who had no other choice. The VA was here for the veterans. But private patients went to St. Luke’s United Methodist, and other hospital systems around the city. It continues to be that to this day, but the outcomes by using any quality metrics, especially NSQIP, TQIP, and the like. The best results in town are at the county hospital. I’m sure that somebody would question me on this. But I also think that regardless of the specialty, the most intelligent, hardest working, most comprehensive physicians that Bader had is working in the county hospital. Still a hospital that competes, the salaries aren’t the same for nursing and others as they are in the private hospitals. But people who are there are sort of like a mission field. It’s almost a sacred location for them to go. And the happiest faculty, and the most sustained faculty of any of our affiliated hospitals is Ben Taub. I look at Ben Taub as being as…the cost per unit, DRG, or ICD nine code, CPT code, are the lowest cost per diagnosis and is at the Ben Taub. Of all the hundred or so hospitals in the community. So, we are a profit center for the community. If we add some of the other models of the country, where the private hospitals bill the city, the county, the faith-based sources of income, it would cost as maybe four times as much for the trauma and the acute care for the indigence. So, I see the Ben Taub hospital as a profit center for the private community. And yet there’s not an illness tax or a sick tax to those private hospitals. The sources of income are pretty much the taxpayers of those people who are property owners in the community.

Chad Ball 

I want to switch gears here a little bit, you know, we’ve had the pleasure of having both Dr. Moore and Dr. Feliciano on the podcast and I want to talk a little bit about your textbook. I realized that the three of you rotate your editorship of that book, but both Dr. Moore and Dr. Feliciano also called it your textbook and I think that’s appropriate. There’s no question. It’s the industry standard. It’s what we all use as the Bible on the desk. It’s what we teach from, and so on. I’m curious what the initial genesis of that textbook was, as well as how it’s changed over time?

Kenneth Mattox 

In the early 80s, there were a couple of textbooks of trauma. One was written by Tom Shires. And he rarely revised it. And I think he had his residents write it when they wrote it. And Dr. Robert Rutherford, who is a vascular surgeon, has died. From Denver, had a textbook of trauma, and emergency medicine. But remember, emergency medicine was just beginning. And there was really not a good textbook on emergency medicine. It’s one of those opportunities to discover building blocks for one’s future. And I want to get back to that before we run out of time. And so, I said, I’m going to put together using multiple authors, the textbook of trauma, and we’re going to revise it every three to five years. And I contacted a company and they said, well, there’s not a trauma textbook that’s really that good. There’s Rutherford out there. And the sales aren’t that great. If you make a good enough book, it’ll be bought. But this guy, this young guy in Denver is going to do a book with a different company. So, I call Jean and said, you’re putting together a trauma book. Yes. I said, Well, if you do, I’m going to kill you. I’m going to kill you with competition. And I love competition. And I think you feel the same way. So, I said why don’t we go together, and produce a double good book. And then anybody who’s coming along, just simply will be blown away and won’t compete with us. And about that time, David came from Mayo, fell in love with vascular and with emergency surgery and trauma. He wrote very well, had a good analytical mind. And each of us approached problems in different ways and thought we would complement each other. So, we went together and made the book. We agreed we were going to rotate it, and we were going to produce the latest data. And we have had from time to time, about two or three people try to compete. And every time somebody emerged, we doubled our efforts. Go to the heart of danger, near you find safety. Increase the load of work, and there you’re going to improve your product, whatever it is. So that was our driving force. And we all each wrote little handbooks along the way. But the book that you really need to master the field has been that book, Trauma. And as we announced at the Vegas meeting this year, this last edition, is ninth edition. It’s our last edition together. And we will no longer be the lead editors of the book, Trauma.

Chad Ball

Your ability to move across platforms and deliver super high educational content is, I think, unrivaled. I would say unrivaled across surgery, quite honestly. It clearly is something that you are an expert at. I wondered if we could talk for a minute or two on your Vegas course as you point out the trauma critical care and acute care surgery course. Tell us about how that started, how it continues to change as well. And there’s just no question. I mean, it is the preeminent conference on any of these topics in the world and has been for forever.

Kenneth Mattox

Well, it’s back to the principle I brought up earlier. And that is recognize building blocks, recognize social forces that you can take advantage of to satisfy the ego needs of the people who you then serve. I did not start the Las Vegas course. It was started by John Batdorf, Hank Cleveland and Cuth Owens, and Dr. Commack from Las Vegas. And it was started because of a political issue. Yes, political that occurred in 1960. When the United States put an embargo around Cuba. Cuba was the place where people went to play from the United States. And there was gambling, there was prostitution, there was drugs. There was fishing. There may have been the mafia involved, who knows. But that was all stopped. And when the United States created the embargo, some of those forces already were in Vegas, but Vegas overnight became the playground for gambling, for shows, for food. And young surgeons. I named them all ago, led by Batdorf and Commack. They went to Las Vegas, and they became overnight, the oncologic surgeon, the acute care surgeon, the cancer surgeon, the colon rectal surgeon, the proctologist and orthopedist and the trauma surgeon. They didn’t call themselves anything but a general surgeon. And the committee on trauma at the national level got to be a big deal. And so, they put together what they call the Western States Committee on Trauma, because their doctors could not get away. So, in the mid-60s, they put on their first course, some 54 years ago. And that first course, was basically an EMS course, and a CPR course. They discovered Resusci Anne. They filled the Resusci Anne case with booze. They went to a suite that they rented at Vegas, and they gave people booze as they put on a course. And during this while, they started talking about other courses. ATLS grew out of the faculty that were coming to the Vegas course. And the pre, um, PTLS (prehospital trauma life support) is an outgrowth. The Society of Trauma Nurses was an outgrowth. And the disaster course was an outgrowth. It was an opportunity for people to get their education. And the hospitals now are requiring CME credits. So, they came to get their credits, and to learn what you do and don’t do in the ambulance. Remember, I told you ambulance EMS did not exist. Thumper bumpers did not exist. Mass pants came along, and were thought to be good, they were shown to be bad. And so, an analysis of what was good and what would help you with your patients happened. Very quickly, about the time Norm McSwain and I were put on the faculty in the late 60s, early 70s. The one big word of mouth about the Vegas course, was if you really want to learn how to really help your patients: you don’t go to a Chicago or New York or a Boston course to learn what the textbook says. You learn the practical aspects of how to be the go-to doctor in the small communities of America. And so, this was the meeting for the people who came to Vegas. It also became obvious that the committee on trauma was putting on the ATLS and other courses, but a new area of medicine emerged. And that was critical care. Several of us were on the committee to evaluate critical care. And we discovered that there were five or six different specialties: pediatrics, anesthesia, pulmonary, cardiac surgery, and trauma surgery that had courses. They had examinations in critical care. The questions were the same. And trying to fuse them, we discovered that these specialties had different and correct answers for their particular course. Still do. So, we added critical care to what the trauma course was in Las Vegas. So, it was trauma and critical care. And very quickly as the acute care surgeon doing all the acute general surgery in a hospital, we added acute care surgery because the genome of this physician was identical. So that’s what we do now. Trauma, critical care, acute care surgery. Response to that genome provides that ego and provides an answer for how you take it… and data from people who are in the trenches to how you take care of them. And that’s the reputation of this course. And it is that word of mouth that brings people back year after year after year. So, we have to keep it fresh, we have to make sure we give them good stuff. And when stuff is bad. And we gave them something bad last year or the year before, we’ve got to say: the mast kills people. Crystalloid kills people. And even this year, there was new information. It said, use of steroids and use of vasopressors may actually be something that we need to do away with. And we may be making patients worse and killing them quicker by using vasopressors in the emergency room, operating room and in the ICU. And that’s created a lot of setting.

Ameer Farooq 

One of the things that strikes me, Dr. Mattox, is that you understand people in a very kind of profound way, and you cater your educational content and the things that you put out, really to serve people’s needs. And you clearly have a very profound understanding of that. And I think that also applies to the work that you’ve done internationally. And I understand that you’ve done a lot of work, particularly in the Middle East, helping develop trauma systems. Can you talk a little bit about how you got involved with that and what you’ve learned from that experience?

Kenneth Mattox

Well, you should not have missed the point I made in the first minute of when you asked me questions. I went to college, to go into a religious field and either be a missionary, or a Baptist preacher or a gospel singer. If you’re any of those, you’ve got to understand your audience. You’ve got to understand people. So, it had been that background that I started. I had the opportunity to go to Vietnam, to go to Europe, to go to a number of meetings in Washington and in other locations with the military during my two years with the US Army. And I made contacts. And one of my habits was to get business cards and contacts with people wherever I went. And when they had a birthday, whenever they had an anniversary, I would send them a little card. Happy Birthday, Happy Anniversary. If I saw an article that they wrote that made a difference, I would let them know. And some of those people we put on the faculty from time to time at Vegas, in recognition of their contribution. But during my first few years of faculty, remember I was doing all the vascular, all the cardiac at the Ben Taub. I wasn’t writing many papers in those areas because I was writing papers in trauma. But our results in valves, coronary bypasses, we did the first internal memory bypasses done in Houston. Our results with endocarditis were the best in town. Best in town. So, at one of our faculty meetings, about 1978, Dr. DeBakey said, Ken Faisal’s widow approached him at a meeting. He was at in Lebanon. Remember, he was Lebanese and asked him to start open heart surgery at the King Faisal Hospital in Riyadh. Maybe it was 77. And so, we all looked at each other and said, where is Riyadh? And he said, it’s in Saudi Arabia. What language do they speak? Is it near the place to go scuba diving? No, it’s in the middle of the desert. It’s hot. But they have a lot of people who have congenital heart disease and a lot of people with rheumatic heart disease. So, they said, we want you guys to see what it would take for you to go over. We discussed it for six months or so. None of us wanted to go to a strange place. But we then put together a contract thinking they’ll turn it down. Well, they accepted it. And for many years, we sent for three-month rotation two surgeons, a senior faculty and a resident, two anesthesiologists, ICU nurses, OR nurses. And we began open heart surgery. They had cardiologists who were doing CAS at the King Faisal Hospital. We met a lot of people at the middle eastern conferences that we participated with them. And we have maintained that contact ever since. So, this was an early track at globalization. In the meanwhile, military campaigns were coming. And our contacts that we had made in the army were either part of the Las Vegas conference, or read our articles, and we were needing various devices. Actually, prior to my going to Vietnam, I was a participant, very few people know this, in the development of the militaries model of the current G suit, the mass pants, and we thought it was the greatest thing in the world because it was going to elevate blood pressure. And when we got out of the army, came back to Houston, we discovered that what we thought was good in Vietnam, they didn’t have in Houston. When they bought a few and we studied it, we found we increased the mortality. So, we did a very good scientific study and found that we accelerated the complications when we elevated the blood pressure in the ambulance, the emergency room, the operating room, in trauma patients. And we popped the clock. And that led into a lot of other studies, but it was that international link and comparing data in the international link that was one of those building blocks we recognize to say, hey, there’s a difference here. I would like to pause here for a moment and say that there are organizations like east, a Western trauma, that spend a lot of their time talking about clinical practice guidelines. There are even books about practice guidelines. And if you read them, the majority of them are based upon dogma and biased approaches, that something is good. That’s never been studied. 80% probably of what we do in emergency medicine, trauma, general surgery, internal medicine, infectious disease, and even immunology is based upon no prospective randomized study. The word evidence based is used by hospital administrators and nurses. But they’re referring to an article has been written, and no one’s looked at whether the statistics was good statistics. Who is applicable in the statistics? Are the people listening to this talk? Poll the East guidelines. Ask for the data. You’ll find that at least 80% of what we do in medicine are building blocks that are ready to be destroyed, or to be built upon. Some of the things that are good, we have destroyed and remain destroyed. Let me just give you one example. During the early cardiac times, we use a Swan-Ganz catheter. The critical care doctors did not like to put in Swans for a whole lot of reasons. Sometimes they were using them wrong. So that if you used a swan during the 80s and 90s, you were considered to be a lesser doctor. Maybe the 70s. Along came COVID then last year, and the year before. We had a lot of people with hemodynamic instability in the ICU. I cannot find one institution anywhere in the United States around the world that used anything other than ultrasound of the ches.t Transcutaneous ultrasound to evaluate the hemodynamics when a beautiful instrument in COVID would have been the Swan-Ganz catheter. Did we increase the mortality? No, what we did around the United States was create over 20 different protocols, in all the different specialties that applied to the COVID patient in the ICU. And yet, none of them talk to each other about why one did not work, and the other one did, or which one actually did work. We spent a lot of money, but we did not ask the basic questions. Where’s the data? So, the building blocks are there, hidden in the bias of clinical practice guidelines. So, if I’m leaving one message today, it was my ability to sense something doesn’t compute here. And the fact that when we applied mast to trauma patients in Houston, our mortality rate increased. And the other thing that increased was their pre-hospital and emergency room blood pressure. And that became the culprit for us to study. So, it opened the door to evaluate those things. And I’m suggesting there are many areas right there in the ICU, in vasopressors, in vasoplegia, in the fibrosis that we see with COVID disease, and also in the vasoplegia we see in some super sick patients who get certain anesthetics under certain procedures. So, the opportunities are there for the person who likes to climb and walk the high, hard road.

Ameer Farooq

Dr. Mattox, one of the things that I love that you’ve been doing lately is you’ve actually I think uniquely embraced social media. You’ve been using mediums like Twitter so effectively to make the points that you’ve been making today with us. That you know there is dogma, and it’s there to be challenged. I’m really curious, as someone of your seniority to embrace Twitter is really quite powerful and amazing. What made you go on Twitter and become active on that? And how do you see social media interacting with science and scientific research moving forward?

Kenneth Mattox 

I hate to admit this, but it was political. I discovered, and I don’t know how he did it, that we had a president that had some pretty strong feelings. He used Twitter to attack his enemies, or those people who attacked him. And he told them, he said, you go after me, I’m going to go after you. And he also had some political philosophies, whether you agree with him or not, he expressed them and was able to express them in a few short words on Twitter. Now, I did a little research, and I don’t know how in the world, he did anything else in his life. If he wrote all the Twitters that were scribed to his name. So, I think he must have had a team of people that worked with him. But the same is true of raising questions and using the media. And Twitter, Facebook, and the various groups within Facebook are out there. I have created a Facebook group for the surgeons of Mexico, Brazil, Spanish speaking, Thailand, Japan, the Middle East. I’ve created a Facebook page called the quiet zone, a place where people can go – as long as they don’t insult somebody – can reflect just like, a place where you put your feet up at the end of a good operation and talk, what did we do? What do we do right? What do we do wrong? And the quiet zone has become that with several 1000 people. And I posted three things to the quiet zone just this morning. Sometimes I reproduce what other people have written. And these are longer normally than the little Twitter tweet. But it’s to reflect and people to reflect back. And there are many other secondary ways that the social media can be used. And there are some social medias under WhatsApp. And organizations have joined together. And I enjoy reading those, I try not to compete with them. Because they each compete in a different way. But in analyzing them, you can analyze people’s social habits, on how they use it, when they use it. And then take advantage of that when you want to stir the pot and create some controversy.

Chad Ball 

You know, the Vegas course to be honest, for those of us that have attended it, and for the few of us that didn’t get the email from you and Mary to be faculty on it. It’s really the opportunity and the privilege of a career. Really, I think that the highlight moment whether people talk about it or not, though, is that the conclusion of that Las Vegas meeting, your commentary and your discussion, your summary on all the preceding talks that have happened. And this year, you touched on two things in particular. You commented that throughout your travels, which were obviously international and widespread, there’s two things that you don’t see discussed very frequently anymore. The first one was the importance of surgical technique itself. And the second was moving an operation forward in a quick, efficient, but safe manner. In a timely manner. I was wondering if you could talk about that a little bit more to close this out, because I certainly agree entirely. I think there’s been significant drift, even in the past 15 years, per se on those two topics. I’m curious why you think that is, what we should do about it, and where do you see the future going?

Kenneth Mattox

I don’t remember the name of the author. The author is a navy seal. He wrote a book called Extreme Ownership. Extreme Ownership.

Chad Ball

Yeah, Jocko Willink, you betcha. Fantastic.

Kenneth Mattox 

I recommend anyone who wants to excel, read that book. During my career, every patient I operated on was my patient. If they had a complication, I owned it, and I had to fix it. I had to communicate with that patient. There were times I was out of town and someone covered me, but they were covering me. And I appreciated that. But when I got back, I accepted that Extreme Ownership. For whatever reason, it may be the 80-hour workweek, it may be the 40-hour workweek. It may be individual personalities. But it may have been a mistaken description of professionalism. But we tend to practice a team concept of shared responsibility. And a patient and even one of our county hospitals may be operated upon three or four times, five times, take backs, complications, and be operated upon by a different surgeon. And everyone then discusses it: our complication. And it doesn’t take someone to be very smart just to tabulate which doctors have dehiscence, which doctors use staples on a stomach anastomosis. And all of those fall apart. I don’t know what staples they’re using all the time. But there’s a trend that tends to be repetitive. And yet the team doesn’t point a finger and say there’s a problem here. Something else happened at this year’s Vegas meeting that has disturbed me a great deal. Two of our senior individuals, Jane Moore, and Dr. Sise gave talks. Jane Moore on Monday at noon, Dr. Sise on Wednesday morning about the changes in professionalism and what has happened for the availability of the young surgeon to develop that ownership. Both of those individuals were chided for what they said at that meeting. Well, I have never chided anyone for what they’ve said. I praise them for saying something controversial so that it brings it forward so we can talk about it. I actually praise those two for saying thank you for bringing these issues out and go back and reread their syllabus material. And if you record it, listen to what they said. I think ownership, attention to detail, tying the prettiest knots available. Cutting the suture right on the knot that has sufficient tightness in it, so it doesn’t come unravel rather than using a ligature to try zot a vascular structure together. That hasn’t been studied that well. We really need to revisit. Two days ago, a Dr. Jorge Cervantes, (like Cervantes from Don Quixote) died in Mexico. We were born almost within a month of each other. Our careers have paralleled each other. Jorge Cervantes has said it in a number of national meetings, beginning 10 years ago – the master surgeon who is technically adept, and as you watch his movies or her movies, you praise them and the slickness. They’re like a virtuoso playing a violin or a cello. And you’re not only listening to the most world’s most beautiful music, but you’re watching their hands. A pianist whose hands are like magic. We don’t have a co-pilot that’s watching. Like the beautifulness of the flight, like we do in some other areas. So yes, I am pleading that others enjoin this concern, and we do not increase our mediocrity. That we have attention to detail. Attention to the most specific of detail and not having to say, well, I’ll go look it up. I attend many M&Ms and grand rounds when I’m a visiting professor. You look at the protocol, and look at the mistakes, and the lack of internal consistency of complications and death. It almost appears like some of them are, slipshod, put together the night before or the morning of an M&M conference. To be very blunt. If people operate like they put together a protocol, I don’t want to be operated upon by them. I want to be operated upon when I have an operation by someone who has the best results in town, because of attention to detail, and pursuit of excellence, and knowledge of the anatomy. And that is all possible. But it can’t be possible without Extreme Ownership. If you own the problem, it’s our job to fix it. And I see a problem in an evolutionary surgical education that I’ve criticized, and I’ve been criticized for not making everything peaches and cream. Quiet. But I make a point of it because I think it’s a problem. I think our complication rates now exceed those from 10, 15 or 20 years ago. I think the number of preventable deaths is returning. The fix has to be internal. If we don’t fix it, society is going to, with artificial intelligence, catch us at our own game of lack of attention to detail. You have no idea how fortunate I am and how happy I am that you opened this door and this window for me to say these things. But if somebody doesn’t like it, it’s your fault. Because you asked me the darn question.

Chad Ball 

I’ll take that responsibility to my grave, sir. Always.

Kenneth Mattox 

But it’s my time to hand off the baton. It’s my time to give someone else the book. It’s my time for others to have the courage to fail. By taking the room.

Ameer Farooq

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 podcast.cjs@gmail.com, or connect with us on Twitter @CanJSurg. Thanks again.