E18 Matt Kaminsky On Cook County, Trauma Simulations, and Finding Your Path

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Ameer Farooq  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.

Chad Ball  00:50

Dr. Matt Kaminski is a trauma surgeon at Cook County Hospital in Chicago. He talked to us in this episode about what it is like to be a trauma surgeon and one of the busiest trauma centers in the US. He also talks about his unlikely journey from Winnipeg, Manitoba, to Chicago and what trainees at all levels can learn from that experience. Make sure to check out our YouTube channel for the Canadian journal Surgery where we have posted Dr. Kaminsky short yet very effective trauma mini simulations. Links are in the show notes and enjoy the episode.

Ameer Farooq  01:22

Dr. Kaminsky, thank you very much for taking time out of your busy schedule to come and chat with us on Cold Steel, we really do appreciate it. And for those of us who don’t know you as well, can you tell us a little bit about where you grew up your training pathway and how you ended up in Cook County?

Matt Kaminsky  01:39

Yeah, so basically, I’m a Winnipeg, Manitoba kid. So that’s where my initial formative college years were, did medical school there at the University of Manitoba, followed by general surgery residency there. I came to Chicago after that to do a trauma surgery fellowship here at the Cook County trauma unit and then I subsequently went back to Winnipeg to critical care fellowship. Although I went back for the critical care, I kind of never left Cook County after trauma. I took a job here after and have been enjoying it ever since in Chicago.

Chad Ball  02:34

There’s a few iconic public hospitals in the US, I would argue being biased about. Grady in Atlanta would be one Bellevue in New York City would be one, maybe even LA County in LA. It’s certainly Cook, as a member is not above that crowd. So tell it for people who maybe haven’t been there and haven’t had the pleasure of visiting and certainly training there? What’s it like to work at Cook?  How would you describe it, maybe even put it in the context of Canadian hospitals where you know, most of the listeners would have been working?

Matt Kaminsky  03:04

Well, it’s neat, working at a legacy institution, or legacy trauma unit. I guess it depends on the person, but I really, really enjoy looking at the old building on Harrison street here, like the old Cook County Hospital and looking at the old roster, just the hundreds and hundreds of people that have rotated and learn through here. And I find that you have this weight and you’re on the shoulders of giants. Everyone’s heard that term before, but you really are. With that comes experience from an institutional perspective in your group. When we do things a certain way, there’s usually a pretty good reason for it to be like that and it’s out of experience, as opposed to just someone deciding to do something a certain way like that. And obviously, North America has many legacy institutions and even locally. For example, the Winnipeg General Hospital has a lot of really cool history. If you look back in the rosters of any major Canadian hospital. I think that the, the biggest thing is that you have over 100 years of a huge roster of people coming through and training here. I think at one point in North America, roughly a third of surgical trainees had either trained directly at Cook County or rotated through so at one point, virtually everybody had trained and in some way shape or form at the Cook County Hospital. So, again, you might not feel it on a day to day basis per se, but it is neat how you have this weight behind you when you do things kind of hilarious as well, some legacy trauma units get into a certain frame of mind, and it’s hard to move them. So they may not be as adaptable as newer or other trauma units. So there’s, maybe some negative sides to it, or depending on where but I said Cook County, we’ve always been trying to maintain the leading edge of trauma care. And we’ve always felt that that’s the most appropriate way to do things. And that’s been how we’ve done it since day one, Cook County being one of the first organized trauma units in North America. We try to continue that legacy to this day.

Chad Ball  06:13

It’s interesting, when you walk into Cook, and you walk into Grady as two examples, you really, honestly, independent of your level, whether you’re there’s a visitor a trainee or navigate this who’s not working there, you feel good. That’s exactly what you’re saying. You feel that weight and even more importantly, I think you feel this almost overwhelming commitment to patient care. That seems to be  unique, it’s palpable. Do you feel that on a daily basis at Cook? And how do you process that kind of privilege and that kind of commitment in amongst your colleagues in the institution?

Matt Kaminsky  06:57

Yes, for sure and I think it depends on the individual, there’s some people that just walk in, and it’s just like any other hospital but if you open your eyes and you look around, and you look at the legacy wall and the history, immediately, I personally get that feeling that is very palpable. With that, I feel almost comes a responsibility to maintain the mission. Again, the mission here has always been to provide care to the people that can’t afford it, and we save the people that nobody else wants to save. That’s been the mission since day one, actually very Canadian, and I feel very, very much at home. So on a daily basis, working here is very much in tune with my frame of reference for the world. So it’s very easy to come to work and to continue on this mission is not a problem, it’s not a job to me, it’s like all of this is fun. So going to work is like going to play on a daily basis.

Ameer Farooq  08:25

Can you for those of us like myself who haven’t ever been to Cook County? Can you tell us a little bit about like, what is the setup like for trauma is it similar to how things are set up, let’s say in Winnipeg or in an other Canadian hospitals, in terms of the trauma service, the emerg or is Cook County very different than other places you’ve worked.

Matt Kaminsky  08:45

So Cook County, unlike most other trauma units in North America is essentially a standalone department. So it’s not a section of general surgery or of surgery. It’s its own department, as well as its own ER for that matter. So we manage people from start to finish as a completely independent unit within our hospital. So with that comes it’s actually a lot easier to see patients right from the start of their care, all the way to their rehabilitation plan and discharge planning. So we’re not consulted down to the ED to see someone already five to 10 or 30 or hours into their care. So we see them right from the start. In order to be admitted or sent to the trauma area you have to meet the injury criteria. So it’s not like we see slips and falls and minor orthopedic or, or minor cuts and bruises. You have to meet a level of injury to be sent to the, what we call the trauma front room or the trauma ER area. There the attending on call myself and my peers, we work with surgery residents as well as ED residents under our supervision. We manage all aspects of care, including all of the airway, central access, etc, etc. So we don’t need to shove other practitioners out of the way, we are in the driver’s seat right from the start. So it’s quite easy to manage a bunch of people like that. We don’t have to be unnecessarily consulted or occasionally, as happens in other EDs, your consultant, possibly a little bit late in the patient’s care and you feel like you’re behind the eight ball for the rest of the day or for the rest of the time that you’re working on this patient, you might think if only I had known an hour ago or seen the guy right from the start, we could have avoided a particular outcome.

Chad Ball  11:22

So it’s interesting. It means that the structure, you describe it very eloquently, nonchalantly, but it’s  such a challenge in Canadian trauma care. Not that collaboration with, emergency room physicians and the emerging General, a general emerge is not great but there’s certainly examples of delays to care that really challenge our ability to achieve some good outcomes in those sickest of the sick patients.

Matt Kaminsky  11:50

Yes, and I don’t think people do it intentionally, or people have egos, you know, everyone wakes up in the morning and goes to work wanting to do a good job, nobody wants to, you know, not do a good job or not do a good service to patients. However, in the moment, practitioner, you’d be surprised how very smart people and a trauma team can fumble the football in a high stress moments. And, I find it fascinating, like, why is that? Why is it when a particularly stressful event, or patient comes in that needs to be managed promptly. It seems like practitioners’ decision making, or team skills can fumble. And I’m always curious why that is. I find it quite reversed here where as soon as we have a very sick patient. It’s unfortunately quite common here. But the team locks in and the resuscitation and the whole process can be quite calm and collected. And there’s no egos or fighting, decision making. Elbows ever punches and depending on when happens, but it is nice to have a straight border of command here. And things can be actually quite calm, and I think, overall, we do a good job of it here. I think that other places, depending of the relationship between the ED and the trauma service, maintaining a level of collaboration, just so you know that who’s in your back pocket so that you can have a good outcome for the patient, particularly in the stressful environment, or the stressful high acuity and a type of patients.

Chad Ball  14:10

Yes, it’s so true. And the reality is that the challenges that you described become larger, of course, when your volume probably gets less. And if you see a really severely injured patient, based on your shift work pattern or your practice, once a month or once every couple of months. It’s hard not to reinvent the wheel and it’s hard to achieve that flow in that calmness and in particular the quietness and the trauma. I think that’s something that we certainly struggle with in Calgary and in your volume centers and say yours No, doubt.

Matt Kaminsky  14:47

Yes, I guess the assumption question is, how do you optimize the team for that? So an area of research that I kind of do is very, very simple tasks. We have a laminated card with a picture of stab wounds to the cardiac box and I just grabbed my residents and nursing colleagues actually just the whole team and they say, pretend arrest is coming in, and we go to the trauma area. I just put the card on the table and describe the situation and we basically go through an intubation, the intubation doesn’t go well, so we have to correct the patient, then the patient arrests and we have to do a thoracotomy and it, the whole thing takes about five to 10 minutes. And it’s basically like a critical systems walkthrough. As well as a systems check, so if we have to correct somebody, the resident physically looks at where we have the knife and the Craig kit. So that we know where it is, you’d be amazed how just seeing and touching and just confirming we have all of these critical systems within a few hours or a few days, we end up using all of these items. It’s great when the team on call, has confirmed these items and they’ve confirmed the team, especially when we have the nurses with us. The whole process takes five to 10 minutes. I think every institutions are different but a few simulated case scenarios, particularly in the actual environment that you’re going to be working, to do a few little dry runs, it doesn’t have to be a long simulation, where everybody sort of rolls their eyes. Everyone has work to do but you can do these things fairly efficiently, as a critical systems check, a team check. It only takes five to 10 minutes and it’s a very small investment of time that pays dividends, should you actually you need to use these items.

Ameer Farooq  17:09

We can’t not have you on the podcast and not ask, what’s your greatest or craziest story from working at Cook County?

Chad Ball  17:17

The greatest story that you can tell publicly on a podcast is what you meant!

Matt Kaminsky  17:27

Yes. You know, I have to admit I’ve seen it all. If you were to scroll through my pictures on my cell phone, you’ll see again, crazy gunshot wounds and things that you thought would be impossible; ligate at IVC aortas. Thor Academy’s various implements, through body parts, everything. Then as you’re swiping through them, there’s pictures of my kids or my car trips. it’s kind of hilarious if you were to just scroll through my pictures, I think you’d have just an absolute, that’s my life. But it’s a whole crazy mix of all kinds of insane events.

Chad Ball  18:22

It’s so funny you say that, Matt, you and I were talking about this, but since I was down Chicago with you, John Kordick. Certainly, for those who don’t know him, the Canadian leader of trauma. He was just recently on a plane and they pulled off when he landed back in Calgary, they pulled off all the essentially middle aged Caucasian males and they pulled them through security and they looked at all of their laptops and their phones and he was only guess what they were looking for. But he says after about 10 minutes into looking through all of those pictures because they were exactly the same as yours and mine and all of us crazy injuries and kids. All the security guys were all huddled around the computer with their minds blown apart. It was fantastic.

Matt Kaminsky  19:09

Hilarious. Yes and I think in my literally last case I did yesterday, gunshot times 21 to 21 holes. So he came in peri-arrest, thoracotomy, his heart’s beating, OR and it’s amazing and Chad you’re at this skill level but you have a Cattell Braasch, Mattox everything exposed. I’m not kidding you within 60 seconds and it’s done. I’m not a cancer surgeon. So I do all of this with blunt or with a curved male scissor, but it’s unreal how once you’re in this business how fast you can get and when your skills are just honed in and this guy had a last Reno sort of blow out right at the aorta, we got some clamps on it and control the bleeding and he came to the ICU damage control. Unfortunately, just physiologic exhaustion, and he ultimate expired, but he was alive for 12 more hours and had he not been transferred from another outlying facility. So I had I got them. Honestly, I think if I got them 10 minutes earlier, I would have saved them. But perhaps it’s just neat, where you could see people go to that physiologic point of no return on a regular basis and you’re trying to pull them back and save the 1% that would not make it anywhere else. We’re trying to save the people that are right at that brink and I feel quite fortunate that I can have a part in this person’s worst day ever but you’re trying to work on it. I’ve seen it all I can think of particular cases, I’ve had gunshots to the heart asymptomatic, bullet emboli. Again, gunshots to the head and the guy’s GCS 15 wasn’t even aware that he was shot. And then just the hilariousness that can happen on a busy night. In a busy American trauma unit. You name it, I’ve probably seen it a couple times.

Chad Ball  22:05

Now one of the things that we’ve noticed, it’s kind of a bit of a pattern and it’s certainly not to say it’s it’s everyone that we’ve interviewed and talked to you. But there’s no question there was a significant group of folks that we’ve talked to that really have special partnerships with their sub specialty group. From the outside having met you guys, I would certainly classify your trauma group at Cook is that description. We’ve heard from you about the structure and the volume and the content. But tell us a little bit about your partners and what makes your group so unique and so special?

Matt Kaminsky  22:39

Well, you know, I think what’s very empowering here is that, because we see so much surgical pathology, the philosophy here again, and this has been since day one is that we can manage everything surgically and absolutely everything. And we have the ability and support from our sub-specialist is that we can go into any compartment in terms of damage control, or anything. I do cardiac surgery, I do vascular surgery. I could go in the neck and chest. I won’t do brain surgery but if I had to I could do that and I do minor orthopedic stuff. So from our sub specialists, the understanding is we’re allowed to do that. And they support us for that because they’re elective surgeons and so there’s a difference between being an elective cardiac surgeon and being a trauma surgeon. The disease process is different. So by any means we are not consultologist. So we don’t give up our surgical procedures to sub specialists unless we specifically asked for it. Obviously, orthopedics and neurosurgery, that has to be done by those procedures but it’s done after we consult them for those specific items. I think 50% of my case logs are in the chest. I’ve always enjoyed thoracic surgery. It’s really cool that we get to do all of this, all of these things. And even in the postoperative course if we have to do Avast or video, torches, scopic drainage. I’m very well versed in that replating. So it’s fun that I’m not just doing appys, choles, hernias. I get to do thoracic surgeries and again gunshots to the heart or perhaps to the heart, very comfortable around these compartments as well as, major vascular liver. My hepatobiliary skill sets are probably different than yours, Chad. Every time I’m in that area, it’s usually dog meat, but I can usually control the bleeding but I might not be as eloquent as you.

Chad Ball  25:30

I don’t know about that dude. What I want to talk to you about is, as you’re aware, Morad Hameed published to sort of surgical magazines called ROSCOE and you were involved  in an article that talks about the spike in the violence epidemic and really gunshots in Chicago. I think it’s probably quite a bit a little bit now you can correct me if I’m wrong, but for those who maybe didn’t read that really superb article, I don’t really know a lot about what was going on there and what was Chicago like at that time.

Matt Kaminsky  26:05

Yes, and no one knows exactly, or everyone has various theories. So in 2016 was one of the most violent years in Chicago in a very long time. I think generally, for example, Chicago was averaging maybe low 500 murders a year, most of it by gunshots. In that period, we were around that 800 murder level, so a huge spike in murders and along that, you can imagine just how many people were shot or severely injured. Again, most of this is all gunshot wounds exactly what occurred, I don’t know if it was a drug wars, different fads of drug use or something. It’s, a bit unclear. But that winter, going into 2016, we knew it was going to be a bloody summer because usually, even in Chicago in the wintertime did things slow down, and we’re on a different pace. But the pace was relentless at that time. So we had, at any given time before ICU, or our trauma, ICU is 12 beds, it was full all the time, we had half of them open abdomens in various phases of their trauma, laparotomies enclosures. And we just kept on getting them. So it was really relentless. The cause is unsure. Again, these are these crazy things that happened in Chicago where it’s a railroad city. And a container from the Ruger I think was the Ruger bin manufacturing company. One of the containers got broken into and so into the South Side of Chicago, a container full of high-powered military rifles were released. So in 2016, most of our stuff is low, low velocity arms, so test flows and, and occasionally, shotguns and stuff. But we were having essentially military wounds during that period. It’s quite quieted down since, but two gang factions were going at each other with high powered arms. And so you can imagine the injury patterns of that. I’m not a military surgeon at all, I’ve never been in military combat, but during that period, we were getting military type of injuries. It’s just night and day, the difference in wound patterns and the severity that occurs with these types of wounds. The initial question of why I have no idea if someone knew they can try to fix it. It predates President Trump. So this was on Obama’s watch the violence in Chicago, but it says since subsequently gone, gone down. But we can’t blame President Trump, on any of those years.

Chad Ball  30:07

One of the things that you and I have talked about is sort of accessing amazing places or people or training programs. In our case within trauma from where you start. And by that, I mean, was an Alberta boy coming out of this province. The training that I received in South Africa, Colombia, and eventually Atlanta, really, there was no local link to those places. That was something in my case, I had to figure out. You have really the same story about coming out of Winnipeg, there wasn’t a friendship or a link between those institutions. So I wondered if you could maybe talk about doing that a little bit and provide some advice to maybe students or residents and fellows that are in those scenarios across Canada, it’s I don’t think it’s uncommon across the board is certainly not uncommon outside of trauma as well.

Matt Kaminsky  30:59

Yes, well, in typical Winnipeg fashion, my path to Cook County started with a frozen battery in a car that wouldn’t start. I was on a, I think, a cardiac surgery, rotation. As I was going to the parking garage, at the end of the day, the cardiac anesthesiologist was coming back into the hospital, grumbling that his car had frozen over and wouldn’t start. I drove him home. As we were chit chatting, I said, I was interested in trauma, I was PGY2 or so and he had trained at Wash U in St. Louis, and was co fellows with a trauma surgeon at Cook County and he forwarded me, her contact and I subsequently arranged a resident, elective rotation, here at the PGY3., Loved it and then, again, apply for the fellowship and my direct path to Cook County was a frozen battery. I probably would have looked it up and cold, called some places, but having rotated at a residence as a resident, it made me know what I was going to get into if I were to choose this fellowship. I knew the staff and everything and really wanted to be here for my trauma fellowship. So I think that it’s just amazing. I know, residents often want mentorship, which is very, very important. But also to look for the opportunities within your network of people you know, because if you think of it, the medical and surgical community, actually the surgical community, specifically, pretty small, if you think of it, and so everybody kind of knows each other. But look at who you know, and to capitalize on opportunities, even to backtrack, just to look for those opportunities, should they ever  occur. Because you’d be surprised how your cardiac kinesis knows, trauma surgeons in the US or your faculty in a small town in Canada somewhere might know some big people, or at some big institutions and it’s amazing how just a quick email and a good word can get you a life changing rotation as a resident.

Chad Ball  34:06

Yes, it’s so true. I think we all have to keep in mind as we’re coming out that most of these quote unquote, big or iconic people or places, they’re in it for the right reasons. They love to train keen, enthusiastic folks from anywhere in the world. They usually are quite approachable once you’ve figured out how to link in with them, whether that’s no excuse of cold calling them or a connection or emailing them or whatever. People shouldn’t be nervous about that. They should pursue that and be motivated by it. For sure.

Matt Kaminsky  34:35

I was just gonna to expand on that. Occasionally, people, I think, a residents or students feel that their mentors will make their career better. Or if I know this guy, it’ll make my career better. I think ultimately, the residents are still responsible for their career. And if you’re passionate about whatever area you’re interested in, that just lights up your mentors and your contacts to just make things better for you. And so if you see a brilliant individual that loves trauma surgery and is just gushing it out, it motivates your mentors and all the people around you to make things happen your way, if you’re a future hepatic biliary guy, and you can see that it’s not hard to motivate a guy like you Chad to just like, value your spectacular we got to get you, you got to go talk to this person. But ultimately, it’s that resonance. And I think, whatever you specialty, or whatever you’re passionate about, if you’re if you exude that, it’s very motivating for the people around you to make things good things happen for them.

Chad Ball  36:06

At the trainer level, right, it’s such a selfish pleasure to be around those people that are so motivated, it’s rejuvenating. It’s fun, for sure. The last question, I want to ask you, Matt, before we let you go, because I know you’re busy today. You know, surgical education is clearly a 30,000 foot term. And many have a bit nebulous means different things, different folks. But you’re clearly a guy from Winnipeg, through your fellowship, of course all the way to the end, that really, I think got the most out of your training environment, you’re sort of touching on that or dancing around that right now. But what would your advice to trainees of all levels about getting the most out of your training and the mindset with which you will mostly succeed?

Matt Kaminsky  36:57

I think, again, from a 30,000 foot perspective, you know, always to be true to yourself. I know that sounds very cliché, but occasionally you’ll see residents focusing on a specialty and I think they like the people that are in that specialty, but they may not. Or it appears that they may not really, really be passionate about that area. So to just be cognizant of that, the reason should always be really focused on what they enjoy on a day to day basis, whatever that may be. That could be very bread and butter, general surgery and or rural surgery. It could be on the critical care side, it could be breast, whatever it is to ask yourself, do I really enjoy this and I really want to focus on an area that they really find easy or enjoyable, to capitalize on that you don’t have to be anything in particular. Subsequently, I think, use your or, I guess, the other thing is your five years of surgery training or your residency. Consider it the five year interview. People that are your teachers are within the hospital, to be cognizant that in a couple of years, these might be your partners. To capitalize on your relationships and maintain a good relationship with all of your faculty members, even ones that you as a resident, you might feel have no immediate means to your fellowship or your goals. You’d be surprised how, like I said, everybody knows each other and to maintain those constant contacts. And then the last thing I think a positive can do attitude is really important. The medical world, the hospitals is basically like in surgery in general is just a series of frustrations, back to back to back and how you manage that. A positive resident, and a can do attitude can be quite refreshing. Those are the people that hospitals want to hire, people that are looking to make things better in a positive way. There’s no shortage of things to complain about but people that get hired are the ones that have that skill set or that attitude that will change things for the better.

Ameer Farooq  40:16

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.