E11 Masterclass with Neil Parry on Trauma Resuscitation, REBOA And Mentorship

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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

Hello, everyone. From everyone at the Canadian Journal of Surgery, I just wanted to extend our best wishes and hope that all of our listeners are doing well during these unprecedented times with COVID. In the interim, we’re going to keep on putting out podcasts for you to listen to. In this episode, we interviewed Dr. Neil Parry. Dr. Parry is a trauma surgeon at the University of Western Ontario. And we have a wide-ranging discussion with him, ranging from REBOA to pelvic packing, to really some high level concepts such as how to run a trauma. We hope you enjoy. Dr. Parry, thank you very much for joining us in the podcast and taking time out of your very busy schedule. You’re flying all over the country, it seems and going all different meetings and giving talks all over the place. So we really thank you very much. I think we just wanted to start off a little bit by asking you a bit about your training, where you did medical school and how you ended up coming to Western.

Neil Parry  01:49

Sure. So I did medical school at Western. I got in on the second round wasn’t a first pick but managed to get in and then did residency here. I must say when I was thinking about residency, it kind of came down to probably at the time my top ones I was thinking rather Edmonton or London and was mainly from Dr. Duff, who was our chair at the time and Dr. Jurati, who were both big influences and reason why I wanted to stay in London. Did five general surgeries here and then went down to Atlanta to do trauma critical care at Grady Memorial through Emory University with a great group they are led by Dr. Feliciano and mosaic. And then back on staff in London, for a long time now it seems since 2003.

Chad Ball  02:49

How did you pick surgery specifically, Neil? Why not gastroenterology for example?

Neil Parry  02:54

That’s a good question. You know, it’s funny in clerkship back when we did med school, you really never get exposed to any surgeons, you didn’t do any clinical, really until your third year when you started your clerkship. So I actually went into clerkship thinking the physiology of the kidney, and I am just a little kid inside. So I like pediatrics. And I thought that’s something I was going to do. So I started my clerkship with surgery. And low and behold, it opened my eyes. I just sort of fell in love with it. That was really the team aspect and the immediacy of it all, that really drew me in and I kind of mold around between plastics, ortho, in general. And then as a nice, influential clerk that I was, I was a senior resident, I had my medicine rotation, similar scenarios, you want to look after sick people, and you want to do surgery, you got to do general surgery. And that’s kind of how it all happened wasn’t a big eureka moment in anyway.

Chad Ball  03:59

It’s interesting, it’s true for so many of us say, you know, everyone, you come in knowing exactly what you’re going to know, rarely is that the case. Having known you for a long time, you know, from the outside. And I think we talked about this a little bit. It seems like you’re having a ball in life, and that you balance so much stuff so well. We’ve also talked about, what balance means and how it’s different for different people. But, you know, you have a great family, I hope you don’t mind mentioned we have three fantastic kids a fantastic wife. You clearly have an academic footprint. You’re on lots of national international committees, you come to lots of meetings, we see each other all over the place. How do you kind of maintain that balance? And more importantly, how does that interact with kind of how happy you seem as an individual.

Neil Parry  04:51

It’s a challenge, that’s for sure. As we said before, a lot of smoke and mirrors to make things work out. I’m not one really dwell on little small things that, not descend to, I don’t know who they are. But with regards, there’s no point really dwelling on a lot of negativity. So I try to be positive about most things because I just think putting your energy there is going to be so much more fruitful than then being negative about things. And, as you said, my family’s been remarkably supportive, as have all my colleagues here in London, to allow me to do these things. And, I really do enjoy most of these things, I like to my committee work outside the hospital more than maybe I shouldn’t say that. Take that out now. But I know I enjoy all the committee work, the camaraderie and I really enjoy always learning from other people and how their systems or just individual things that are being done. Getting the balance again, it comes back to the support that’s around you, and then just trying to keep things positive.

Chad Ball  06:15

That’s such a good piece of information to me, you guys in the in the trauma and critical care, acute care surgery group in London have such an amazing group you’ve recruited so well. The group dynamic, at least from the outside seems absolutely amazing. We probably don’t thank our partners enough, quite honestly to do that a lot of this stuff. It’s amazing to see a group like yours and how you guys leverage off of each other and support each other and the general morale being so good. It’s fantastic.

Neil Parry  06:49

I just want to echo that again. You’re absolutely right, Chad, like the group that we have, it’s worked out very well again, you know, holistically, and even selflessly, it’s made my life so much easier. It’s just fantastic people to be around and work with. It makes again, it gets it just makes it positive. It’s just that a good vibe, a good energy to be able to allow people to pursue what they want to pursue.

Chad Ball  07:18

There’s no doubt I mean, to go off on a tangent, maybe the recruiting people’s hard recruiting great people harder. How did you guys manage to attract and recruit such great folks that fits them?

Neil Parry  07:31

It’s a good question. I think we’ve been fortunate that London always sort of had this reputation as being a hard ass general surgery place, people get beaten and worked into the ground and that sort of stuff. That’s clearly not true. Yes, we work hard, and so does everybody everywhere. But there’s a really good sense, and I think that’s come historically from Dr. Duff, draughty Ken lezlie, these leaders that have just demand respect and responsibility, and it comes down to treat everybody equally. And it just comes down that way. So with that, it comes down to the residents, the residents are fairly happy. I think, again, that’s just my outside look. But, we’ve been able to engage a few residents that really liked, fellowships at great places and have come back and have added just tremendously to the programs, we’ve been fortunate to be able to recruit them back and not get the stolen away somewhere else.

Chad Ball  08:40

That’s amazing. That’s such a great group. You and I often see each other at lots of different events nationally, internationally. And I was wondering what your take on, especially for trainees, whether it’s medical students are more commonly residents, and occasionally fellows and junior staff, what’s your thoughts are on how you target a particular society to join? So what’s important, what do you get out of it? And then similarly, really the same question for associated conferences, maybe either general surgical or subspecialty wise, what do you think of all that? If you were to give those folks advice?

Neil Parry  09:18

I think that, early on in our training, and then as we move along, through our careers, they change and so early on, I think it’s, to be able to meet other people and connect, just to try to get some feelers out and to get a lay of the landscape and really, just to learn how these systems work. So the premises have always it has to be something that you’re really interested in. There’s no point in going trying to join a conference because Wow, someone told me this is a great one, I should join but that subject doesn’t interest you. So there has to be that passion there behind it at first. So I think, early in the career that’s the main reason why. Then it really as your career develops, and you find a clinical or an academic interest, which doesn’t have to be just in surgery could go around from there. And then that would really sort of drive where you go. And of course, you know, your own mentors provide great advice as to where to go. And certainly, open doors for us all. That’s for sure. I’ve been very fortunate that way. And I think that’s, it’s almost the same as long with conferences, I think, with the societies, that’s one and most societies have their own conferences, and then depending on what your academic band is, or the clinical band that one has, the other one have joined some committees that you think may be able to actually make a difference and because they certainly do that has a lot of these societies, and then also if that’s where the academic side is that you want to present some of your research or to partner up and link up with other people, other groups?

Chad Ball  11:05

Yeah it’s so true. I mean, it’s interesting to watch a lot of the societies change over the past, I’d say, less than 10 years, there’s really becoming a culture of volunteerism, and all associations. as opposed to having to wait until you’re saved mid-career to even walk onto a committee. And that’s really become the culture and a lot of different societies. It’s interesting.

Neil Parry  11:28

I think that there people are, most societies now are acknowledging that you don’t have to be, you know, mid end career to be able to get onto this committee or that they seek out younger staff, and rightly so bright and energetic that’s the first thing of course, but also, because the culture has changed a lot. And it has to be more dynamic and diverse.

Chad Ball  11:59

I think you see societies as you as you pointed out change over time, too. I mean, the reality is, there’s 1001 societies, it’s too many. And there’s always someone saying come to this and join that. But people speak with their feet. And certainly societies become increasingly or decreasingly popular over time for that reason. No doubt. That’s really great advice.

Ameer Farooq  12:22

I wanted to ask you, Dr. Parry, speaking of conferences, we actually interviewed Kelly Vogt at the last CAGS meeting. She talked a lot about returning back to this idea that you guys have such a great group at Western. She talks a lot about how powerful it was, as a young staff to come back and have really good mentors. And we often ask, young surgeons, they always talk about having good mentors, but I kind of want to pick your brain like, what do you think it takes to be a good mentor for young and upcoming surgeons and what are you guys doing that has made that so fruitful?

Neil Parry  13:06

That’s a good question. We do have mentorship committees. Now, in the last, probably five, seven years or so we’ve established those. But I think that’s more something to double check and make sure that people are on the right track. It’s a formality, I think the real mentorship that occurs is much more on the informal level. And whether you go on to formalize that or not, I just think that’s me just moving the deck chairs, but I think that’s where it really starts. You learn from your own mentors, right, just so much of that is environmental, and if there’s a good environment for that, and you’re very thankful of how you’ve been trained and how things have gone, then you tend to pay that forward. I really do believe that. So, Kelly, she might have been excited to come back but we were ecstatic. The fact that she was coming back to work with us. So, it’s pretty easy to be a mentor to help somebody along in their career in that path. I don’t think there’s anything really super specific about it, though.

Ameer Farooq  14:28

It’s certainly not an easy question that I’ve asked you and I don’t think there’s any secret sauce, but it kudos to you guys for being trying to make that Western such a great place to come and work. If it’s okay with you, then I’d like to switch gears a little bit and hit you with some clinical questions because a few of us have a little quiz coming up at the end of the year.

Neil Parry  14:36

I know nothing about that.

Ameer Farooq  15:01

Exactly! So, here’s a question and I kind of have a few different layers to it that I’d like to pick your brain about. So, the scenario is that there’s a 40 year old female, brought in by EMS after suffering a head on collision. She’s unstable and trauma being tachycardic and hypotensive on primary survey. It’s clear that she has a significant blunt pelvic injury, a binder is applied and she is resuscitated. I think the first question I want to ask you about isn’t specifically clinical. But, I’ve seen what the trauma bay are like in Calgary and unfortunately, they’re often quite chaotic. No matter how much our trauma staff really tried to have meetings and sit down, it really seems quite challenging sometimes to maintain a certain sense of order, while still keeping some urgency. What sort of tips and tricks do you have for maintaining some control over a tough situation like that?

Neil Parry  16:12

I mean, that’s for sure. I think that happens everywhere. There’s lots that have been has been written in attempted in order to sort of decrease the mayhem with, you know, stickers, different colored gowns, that people wear different color hats, whatever, perimeter tape you can’t come around. I think you have to have somebody who’s a good leader. So the person who’s the trauma team leader needs to be able to take control of the situation. That doesn’t have to be the general surgeon or the trauma surgeon, if someone’s sick, like this, I think should be the one who takes control. So that’s the first thing, you need somebody who can do that. With that, you know, as I tell our residents and fellows and that sort of thing, you can be respectful, but we’re not there to make buddies with everybody down in the trauma bay. You’re there to save that patient’s life. So, we respectfully say, okay, who’s not involved? No, you, okay, stand back and or get out of the room, please. And then, everybody should have an assigned task. We’ve recently just gone to the stickers, so people will know who people are. So who’s the trauma team leader who’s from general surgery, anesthesia, or so emerge, that kind of stuff. And I think that helps, just with communication within that area when it’s sometimes chaotic, but it has to be a good leader to be able to take control of the situation.

Ameer Farooq  17:46

That’s awesome. I’ve seen obviously, I’ve worked with Dr. Ball in the trauma surgeons area and everyone’s a little bit different. Where do you stand? How do you talk like, are you someone who wants everyone to verbalize things? Tell me a little bit about how you actually run a trauma?

Neil Parry  18:09

Sure, so I’d be ready at the end of the bed. Usually, the foot of the bed as layered trauma bays are set up. So if you’re there before the patient gets there, have a little bit of a fill in the team as to what we know about the patients and what potential things we may need to do and what things we may need to do very expediently. And then once a patient arrives, usually we get them over onto the stretcher or under the trombey, and then get a bit of a handover from our EMS or whoever’s there. Then I would ask, someone else, depending on the severity of things, that someone else to act as the TTL, and I would sort of stand back and sort of just watch how that person does. If they’re doing a great job, perfect. If they need a little help here and there, I’ll let chirp in from the cheap seats, I don’t have a problem doing that. And then I do like it when the person who is doing the primary and secondary surveys that does speak, I don’t like a lot of people talking in the trauma bay. There always are more than what you’d like but you have to bring the volume down and just wait to hear what’s going on. But that’s generally the way I would run it. I don’t tend to get my hands involved unless somebody else is acting as a trauma team leader. And they need me to do that. Or if somebody you know, struggling with something, but generally, you’d be sort of at the end of the bed.

Ameer Farooq  19:36

Gotcha. Okay, so, the next question I had related to this scenario is sort of the whole question about resuscitation because I think that has really evolved in the last little while. People are talking about whole blood, you know, different ratios. And, and so what are your thoughts? What’s your choice of resuscitation fluid and sort of along those lines? Do you think Canada’s ever going to get to the point logistically where we can give people whole blood?

Neil Parry  20:08

So, I agree things have changed a lot from the days on, as a resident and resuscitated with crystalloid, leaders and leaders, trauma patients are bleeding and bleeding, patients need blood, and they need to get back in the way that they lost it. So, you know, we do need to have a balanced transfusion. Most centers have some type of massive transfusion protocol. Even some smaller centers do and regionally, they have the ability for that in Ontario, any small community hospital or even, very, very small hospital has at least two units on scene or at the hospital, so we can use that. We can activate our massive transfusion protocol before the patient arrives. So, we can have blood and FFP in the room prior to arrival. So, I think that you want to minimize, I totally believe that we should, as you know, we just said need to resuscitate with blood, the exact order of the products, again, is now being looked at quite a lot recently, and whether we should start with, our plasma, there’s some evidence to suggest that may be beneficial. But I think that’s really getting into the weeds right now for this question. But, you know, a balanced transfusion would be the way to go and get that blood ready for when the patient hits the door? With regards to whole blood?  I don’t know. I mean, that’s just never mind, just from the medical point of view and I’m not sure if that’s exactly what needs to be done. But just the logistics, political and economic climate, which Canadian Blood Services, I don’t know, really how that would all play out.

Ameer Farooq  22:17

Okay, that’s a great overview, I think of how resuscitation has really changed. So, let’s go back to the patient that we have in the trauma bay. And let’s say she arrests in the trauma bay, and I kind of wanted to get a little bit into REBOA. Are you someone? Are you are using REBOA at Western? And if so, what sort of scenarios are using REBOA?

Neil Parry  22:43

So we used it I’d say now three times. And we have exclusively just for the hemodynamically unstable pelvic fractures, and deployed in zone three. We don’t have the seven French when we still have the Old Quarter catheter, we don’t have the Primetime one here. So, it’s a bit of an ordeal, we set this up with our vascular surgeons. And we keep the kits actually up at the OR desk. So, someone has to bring them down to the trauma bay to get them done. Once we decide that we’re going to use REBOA automatically that books the operating room as what we would have as in a case for an emergency case, vascular surgery, the fellow’s pace at the same time, and then he or she comes in and we’ll do the REBOA cap along with the general surgeon who’s on or the trauma surgeon who’s there. And then we transfer the patient right up to the OR with generally both place in the emerg and then get them right up to the OR. So, we only done it three times successfully on two out of the three one was an older guy who had really torturous and atherosclerotic iliacs and we just couldn’t get the catheter in. But he was in the OR at this point. So, we’ve not used it a lot.

Chad Ball  24:18

Neil, let me ask, you know, REBOA. I guess we’ve talked about it for a long, long period of time in North America and some centers are certainly leading the way and really, certainly overusing and trying to figure out its true utility doubt. I would argue probably Canada, we’re a little bit behind in terms of using it and certainly the second catheter that you mentioned with the seven French introducer should help that. What are your thoughts on who actually deploys it and who managed it and it sounds like, as you said, the vastra guys are heavily involved at your site. At our site here in Calgary, the Foothills, we don’t have that we don’t have vascular at all. I’ve been personally deploying quotable ends and the number of investments for 10 years probably. Sometimes very well, and indicating maybe sometimes not. But certainly they’ve been helpful. So what do you think about it in the in the pre hospital context? You look at London, England, for example? Have you put all that together?

Neil Parry  25:21

You know, I don’t know, I think that this pendulum is swung still really far for verbal is super cool. And we should all do it, I think it’s gonna swing back, I’ll preface that in a sec, there’s a there’s a really interesting paper that someone had a friend of mine had forwarded to me, they just came out of the Royal Albert and in Melbourne. And looking at it they have a very, very mature ECMO program there. So they wanted to look at their feasibility of doing REBOLA and they have a really incredible, inclusive trauma system in the state. And really, basically just go to one of two hospitals, as you know. They were receiving about 3000 trauma patients a year, generally is greater than 12, that sort of thing. They thought maybe REBOA the years, and they’re looking at the data prior to the study and say, seven to 10 patients that may have been helpful. So they wanted to implement a team to have 24/7 deployment of REBOA they use the quota. And they said, Okay, we’ll do it and patients that whose blood pressure is 70 or less, and they present. And in that they had up I think 13 patients or so that came and none of them had REBOA deployed successfully. And so the conclusion of all this is one, even with the very tried to get a mature team to deploy REBOA, they couldn’t really get that working as well. And then two, the patient population just weren’t sure if really, that would have helped with any of them. So I thought it was very, like a really interesting way to look at it. And so I think it’s gonna swing a little bit around. As far as how it all goes, but for us, and I think for every other center, it has to be local and has to be local culture and from interactions with or different specialties, whether you need to have vascular or not. With us, we have a great relationship with our vascular surgeons, they’re at the same hospital, of course, which makes it much easier. So we just opened the door and said, this is what we would like to try to do. And there’s little hesitancy initially, and then we came up with the protocol and went forward with it. And there hasn’t been any issues with it. Although, again, we haven’t found exactly who the right patient would be that requires ripple, I don’t think either.

Ameer Farooq  27:59

Kind of goes along with many new things in surgery where there’s a lot of initial excitement and then it’s always much more challenging. In real life when the rubber hits the road to actually figure out, where does this get best deployed? And there’s all the practicalities of getting the right team and everything.

Neil Parry  28:20

And depends on your access to the OR. If you can get to the OR right away, do you really need REBOA? If it’s delayed a little bit will that be helpful. So, there’s all these little nuances, which are really, really difficult to tease out, I think there is a rule for it. I just don’t know what it is yet. My bias would be just the patient that you’ve mentioned that the team did an unstable pelvic fracture. In our protocol here in London, we would not put it in somebody who’s arrested. Now I know that it’s being done a lot. But we didn’t feel that we wanted to start with that.

Ameer Farooq  28:55

Gotcha. The last question I wanted to ask you about related to this particular patient and scenario is a lot of people, particularly some centers in the US, talk a lot about pelvic packing. Is that something that you find helpful? And where do you think that should sort of fit in?

Neil Parry  29:20

I do believe it for sure. I think, again, you can look at, you know, online and you’d be able to find probably half a dozen of very reputable evidence based as best they can, algorithms for management of human dynamically, unstable pelvic fractures. So when there’s that many there’s probably not a right way to do it or not, but my bias is, certainly if someone comes in who’s got an unstable pelvic fracture, regardless of everything else, it’s easier if they’ve got a positive facet and whatever else but if they if they just have the bone fracture, I think they should be resuscitated in the operating room. So, we’d get them up to the OR. Again, depending on how your relationship is with orthopedics, your interventionalists, if you have a hybrid suite that you can use or not, that’d be the ideal place for it again, our vascular surgeons have that here. And we do use their OR if it’s available, if they’re not currently in it, we can use that for these unstable power fractures.  What we would do is, whatever what the pedic surgeons come up, you know, as we go to scrub it, depending on who it is, if you’ve got one other stuff, guys that are here, they’re fantastic. If they can get on an X fix in a couple of minutes. As they’re doing that, then, we prep out the abdomen, and then I would do preperitoneal packing after that. I like them to do the x fix first. Because if we prepared your pack, I’m always I don’t want to do the Xbox afterwards and then we sandwich in and then get some sponges caught in between the bone fragments, and then see how the patient does. If they’re stabilize off from there, and okay. If not, then we’re actually if we’re fortunate to be in the hybrid groomed and shoot an angio. So that’s kind of the way we do it. That would be my sort of algorithm, or extrapolated from various others, that we would that we tend to do here somewhere other partners would do something differently. Perhaps they may go to Andrew Moore, first, but I really think the backing is very, very helpful.

Ameer Farooq  31:34

Can you just describe briefly, your technique for doing that for those who haven’t done much?

Neil Parry  31:41

Sure. So if there’s not another indication for laparotomy then you just to a lower midline incision, start a few centimeters below the umbilicus and get down to the synthesis. Get down through the fascia without going into the peritoneum. And then once you’re in that precarinal space and space of ritziest will be a huge cloth that’s in there, you’ll be able to really just the blood does all that dissection, and you can scoop out the cloth, being careful not to touch your fingers, because that’s pretty easy to do. And then I leave the packs, your laparotomy pads or packs, whichever you want to call them. Then fold it up, and you can usually get in three to five or so per side. And then I would, just stitch up the fascia, or you can put it back over whatever, but if you can get the fascia closed, I think it provides a bit more tapenade. And, and then, bring them back when their physiology starts to correct a bit more, and then to remove them. But not have to repack twice interestingly enough, with these. Generally, you’re successful with just the packing of them once and you can get the packs out and then be able to close things definitively. If the patient had a need to do a laparotomy, then you can truncate your incision to just below the umbilicus and then leave a bit of a bridge to do a lower midline or probably what’s even easier is to do a pfannenstiel type incision in that case., Then be able to do your preparing and packing through it.

Ameer Farooq  33:21

So you do your laparotomy, you leave a bit of space so that you can actually still get into that prepared kneel, plane.

Chad Ball  33:28

Yes you need to have that.  People will describe doing a full laparotomy and then entering the space of wretches from within the abdomen getting down, but you can’t really get a good vector packing that way. The same way you can from coming into the above us, you know what I mean? So, I would do two separate incisions if that’s what I thought. Also, if someone’s got a bad pelvic fracture, if you go straight down through there, and then just kind of begin to bleed out like crazy. Well done that before they bleed a lot from the core part of the room because it’s coming up to the edge of pregnyl. What do you guys do in Calgary?  It would be similar. I mean, because the Raptor room is kind of all ready to go. It just depends on instability. usual thing, like if we were waiting for him to come up or come in, and they’re really in trouble, same exact thing, or fix them and pack them and invite time. Sometimes they’re there in the middle of the day real quick. So, you don’t need.

Ameer Farooq  34:35

So, switching gears, once again, to a very different scenario. So, this time, we now have a 25-year-old male with a seatbelt injury and a positive fast unstable. And for some reason, every CAGS exam I’ve ever written has this scenario. So that’s why I’m bringing it up and I’m never sure what’s it is.

Neil Parry  34:58

Full disclosure. I don’t write the CAGS but I do participate in writing your big exam in the spring. All right?

Ameer Farooq  35:08

I know who to blame then. Okay, so this 25-year-old has a positive fast. So, you take him to the OR and he has clearly as a duodenal injury, but there also seems to be an injury to the pancreas with pancreatic fluid leaking, and the patient is now stable and has been resuscitated in the OR. So, I thought I’d ask how and that is perfect because we have Dr. Ball on the line as well, too. How do you guys approach a possible pancreatic ductal injury? How do you delineate that? And then how do you try to manage it?

Neil Parry  35:49

So I guess one, the patient’s stability in Western with these pancreatic or pancreatic, duodenal injuries as often major vascular injuries involved as well. So that all depends., But in this scenario here, where patients stabilized when you need to be able to identify if there’s a duct, if you see, you know, a clear transection and you think that it could mixed in with the blood, if you’re ever so lucky, then that’s obvious, I think that when it gets very difficult is when you’re unsure. Your eyes and your fingers are better than any other tests you can do in the operating room. So, if the gland has a big central area of maceration, or it looks like it’s been transected, more than 50%, or obviously transected, right in half, then you go on and do your resection, depending on where it is. If it’s to the left of the mesenteric vessels, that you just go into distal pancreatectomy most likely splenectomy at the same time, you can’t do splenic deserving if they’re super stable, and nothing else is going on. But most of times, that’s what we would do. With a duodenal injury, with this type of scenario, most likely be a blowout injury. Those for the vast majority of those, you can just bring back the edges and repair those primarily, I don’t think any of these fancy maneuvers of all the different types of to drainage is exclusion, and all that type of thing is really necessary. Where it gets really, really tricky, obviously, is when it’s right in the head, or it’s just to the right of the mesenteric vessels. Then that makes it much more challenging. Again, the principles there would be to just stick with the lifesaving maneuvers from the examinating hemorrhage, control that and  in my hands, that’s what I would do, and then probably drain and then call assign like Chad Ball and say, Hey, dude, you know, somebody’s got significant expertise in this area, where you may have to do a stage Whipple down the road. Again, if you start out like that, and then we get to hear what Chad says, but it’s a little different when it’s a part of your everyday life in your elective surgery practice, and shadow. Say it for sure but the group that’s probably contributed to this the most in the literature is the South African group and many of them what I think three Chad are HPB surgeons as well? And, they have the sort of the biggest sort of series on doing traumatic levels and with excellent results. But that’s because of who they are and what they do in their everyday trauma or everyday surgical lives.

Ameer Farooq  39:04

Dr. Ball, do you have anything to add to that?

Chad Ball  39:08

Not a lot. I think that’s beautifully said. Neil, for sure. Nuance I see most clinical things exactly the same way just bigger. But I think the overriding take home principles, whether you’re doing an oral exam or a written exam, or you’re maybe working in a community center, and one of these you know, you’re unlucky enough one of them comes in or exactly what Neil highlighted. So, number one, you know, you have to stop the immediate threat to that patient’s life which is going to be bleeding. And that can be venous, it can be arterial, it can be a combination of both. So that’s number one. Number two, I think there’s no running principles. Get help the best you can. Now if you’re in a small rural Alberta town that might not be possible except over the phone. But certainly, if you have access to more experienced or just educated hands, that’s huge. And number three is don’t try to do too much don’t try to do stuff that will change the trajectory of that patient. Sometimes less is more until, as if all Africans would call the patriotic cavalry arrived. And I love the fact that Dr. Parry brought that up. The group in Cape Town is exactly right. They’ve published more on this in the last 15 years than anyone else. On the HPB side, they’re led by Professor Kreig, who has just recently retired, but as he was retiring did a full PhD in pancreatic injuries. That’s where a lot of recent papers have come from. What you see when you go there, and you’re friends with those folks, is that the interaction between the HPB surgeons and the trauma surgeons is almost like nothing I’ve seen anywhere else in the world. They are very, very close and very tight. And they deal with those injuries together. There’s no question that the pancreas surgeon is going to think about it differently than the trauma surgeon and vice versa. And sometimes you need both of those voices to provide optimal care, because I think, in terms of the eventual plan, sometimes the trauma surgeon will under treat that patient. And sometimes they may over treat them. But that discussion is if it’s respectful and knowledgeable, is quite amazing to be a part of.

Ameer Farooq  41:26

On behalf of the other poor souls that have to write their final exam this year, I really appreciate that discussion and it was a very good overview of some fairly frequently tested and real-life scenarios that we might have to deal with.

Neil Parry  41:46

I think we could also think, Chad would agree with this as well, but you’ll read some interesting things that are still in textbooks on how to identify duodenal injuries and they’re just silly. That’s all I’m gonna say.

Ameer Farooq  42:02

Exactly. Asthmatics would say the printed page can tolerate anything but patients. Yeah.

Chad Ball  42:10

It’s very true. The only thing to that I would add potentially is in some penetrating injuries, particularly stabs, the ultrasound is a beautiful tool. And although granted, 99% of surgeons are not looking at pancreas, or pancreatic ductal anatomy with an ultrasound, it’s a pretty simple task. As long as the gland isn’t super beat up. If it is super beat up, don’t even waste your time. But it’s another skill that a trauma surgeon, maybe just pop into HPB surgeon’s room once in a while, have them show that to you. When they’re doing a pancreas case and it’s a skill that can be very helpful and that’s a wonderful scenario like you described.

Ameer Farooq  42:53

Fantastic. I have one last question for you, Dr. Parry and that is, as someone who’s about to enter into the great blue yonder. If you had one piece of advice for trainees that you wish someone had given you, at my stage, what would that advice had been?

Neil Parry  43:14

I think Roy, one of my mentors, when I went for my fellowship, he sort of said: Hey Neil, I got a piece of advice for you. It’s eyes and ears open and mouth shut, you will be just fine kid. And it sounds kind of silly but it’s true, you got to keep your eyes and ears wide open for everything, not necessarily some health shut part. To go into it. You’re just finishing five years of very tough training, you are going to be arguably the most book smart that you ever will be for the rest of your life, just before you write those exams, I’m sure they’ll do that quickly. But you have to maintain. You’ll have to maintain and be humble. And try, definitely try to find a senior partner or where you’re working that you can talk with openly have established that good relationship and quite frankly, that could be a rate limiting step for where someone would decide to go or not. I think it’s really, really important to have that. We talked about mentoring before and as, you know, more senior surgeons go along. I think it’s certainly in my mind, it’s our duty to be able to mentor younger colleagues and again whether we do this formally informally it’s debatable but that’s what I would look for as you’re just going out into the, into the route so called the real world.

Ameer Farooq  43:47

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.