E88 Walt Biffl on Clinical Guidelines, Blunt Cerebrovascular Injury (BCVI) and Pancreatic Injuries

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Chad Ball  00:12

Welcome to 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 brought 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. This week we were joined by the Dr. Walter Biffle of the Biffle score for blunt cerebrovascular injury. Dr. Biffle is a trauma surgeon at Scripps Memorial Hospital La Jolla in San Diego, California. We picked up Dr. Biffl brain on this episode, and yes, the plan was definitely intended. On what goes into generating good clinical guidelines. We then delve into his work on blood cerebrovascular disease. And finally, on pancreatic trauma. As always, send your questions, thoughts and comments to podcast.cjs@gmail.com or to Twitter, at our Twitter handle @CanjSurg.  For those very few people who don’t know who you are. Can you tell us about where you grew up and what your training pathway was?

Walter Biffl  02:02

Oh, yeah, well, I was born in South Florida in Fort Lauderdale. We lived there just a few years before my father’s job moved us to Buffalo, New York, kind of the opposite of South Florida. So, I grew up there, grew to appreciate a good Blizzard and became a big fan of the Buffalo Sabres who could never win the big one and the Buffalo Bills who could never win the big one. But that was a fine place to be a kid. But when I was old enough, I went away to college and went to Duke University in North Carolina, and then George Washington University for med school. So, I was in DC for four years. And then I moved out west. Did my residency at the University of Colorado and the middle of it, I did a two-year research fellowship in gene Moore’s lab. And I was fortunate enough to join the faculty and work with him and initially, his brother Fred. His brother Fred left before then, but at Denver health Medical Center on the faculty of University of Colorado.

Chad Ball  03:06

So can you tell us a little bit about what it was like to have Dr. Moore as a mentor during your training? And, and how did that shape your career trajectory?

Walter Biffl  03:14

Oh, he was amazing. And I don’t know what my career would look like if I hadn’t been, at that program working under him. I remember, still when I was a med student there on my interview, and when you went to the Denver General, and all the applicants are in his office and he’s sitting there in his scrubs, his bulging biceps and his big moustache and surrounded by hunting trophies and bullets and all these things from around the world, his world travels, the journals and everything in his office talking about how this is going to be a rigorous program and we’re going to push you and you’re going to learn you’re going to stay on top of the evidence and that’s the way the program was.  Alden Harken, our chairman and Gene would push us to know not just what to do but why to do it. And it was a daily thing there in the programming and Gene, as a faculty and then as a colleague, he always set the pace for not just clinical productivity, academic productivity, everything living life to the fullest and he set a bar so high we just struggle to keep up all the time. Really an amazing guy to work for and, and to get to know.

Chad Ball  04:41

Such a neat description. I’m sure you do the same for all your trainees. Now. You know what you’ve done so much in sort of a medium length of time if I can put it that way that it’s hard to talk about it all, but maybe our starting point if you’re okay with it would be, just a conceptual discussion surrounding how clinical practice guidelines are generated, and obviously I bring that up because you’ve done so much work with the WSES and the WTA. I don’t know what exactly what you think but for me, in the world of guidelines and trauma and critical care in general, the WTA ones are always, always at the top of my list. They’re always the most practical and direct and really well done. Obviously, I’m biased. But my favorite or favorite of all of them, of course, is your pancreas guideline. So, I was curious if you could walk our listeners through how these CPG get generated, who’s invited, what that process actually looks like?

Walter Biffl  05:41

Yes. And it’s interesting. I wasn’t part of the committee when they started WTA, the current President Robert McIntyre, and Gene and Fred Moore and the several others created that committee and ran it for the first several years and then I was fortunate enough to get appointed to it. But you hit it right on the head there. The practicality of the WTA algorithms is what sets them apart. And you also mentioned WSES, which is more of the classic evidence-based medicine format. As you know, in trauma, there is so little high-quality evidence, just no Center has the volume, even multicenter studies like the pancreas study we just completed, you don’t have the level one evidence to say this is definitively the way to do it. And so, the WTA decided that we wanted to provide a practical approach. And not just these are your options. But here is an algorithm to follow. Explain why each decision is made the way it is, let’s say this is a safe approach. You can follow all these steps, you can support it, and we think it’s safe. And it was based not just on available evidence, but on the experienced members of the group who had been there and done it. Now in contrast, you have EAST guidelines, which are very valuable, everybody refers to them and in the world Society of emergency surgery guidelines, they’re all valuable. But I agree with you, I am biased. But I think that having that step-by-step approach is very helpful. And if you contrasted with, for example, resuscitative, thoracotomy, you have the East practice management guideline and evidence isn’t very good. So, you only have out of six different scenarios. There’s one strong recommendation and the rest are conditional like, well, okay, I got a patient dying here, I don’t need a conditional recommendation. But you pull out the WTA guideline, and that’s got clear parameters for futility. We pronounced him dead and walk away or you cut them, and this is what you look for. And this is what you try to correct and go from there. So, I do think that they’re helpful and have at your bedside.

Chad Ball  08:07

I think your description of the comparisons is absolutely perfect. And I’m curious, what is it about the WTA group that’s able to avoid some of those pitfalls? Because not my experience in CPG committees, sometimes, not always, but sometimes. It’s certainly that you have eight people in a room and there’s eight subtopics within that umbrella and probably every single person in the room is really passionate about one of those eight things. In the absence of, as you point out, level one, high quality evidence, the person kind of pushes all their chips into the table on their particular sub section. And that’s kind of the way that guideline flows. And certainly, I think we’ve all seen guidelines get lost a little bit. So how did you guys on the WTA group prevent that? And how do you avoid some of those pitfalls?

Walter Biffl  08:56

Well, you’re always going to have a lot of discussion and there’s one that stands out that was ended up more like you’re talking about the pelvic fracture algorithm, it was done initially, early on Jim Davis and others, Jim might have been the first author but several years later, it came up for renewal and I think Nick Namias was leading it and everybody in the Denver group had started pelvic packing at that point and others were promoting angio. So, Nick Namias comes in and says: It looks like a wagon wheel. There’s no clear pathway here. It was hard. Everybody had an opinion, nobody had the most compelling data, but in the end the group works, because we do find a way to come to consensus and just focus on creating a usable document and we do get a lot of feedback from the membership. It’s done in a small room, but then it’s brought out and presented to the entire group and questions are raised. And it goes back for more revisions. So, there’s a lot that goes into it. But somehow, we’re able to, to get them done.

Chad Ball  10:12

They really are remarkable. Almost too perfect, to be honest, from guidelines to guidelines. They’re fantastic. If you were to give advice, then in terms of an overall framework, like let’s say, in Canada, we wanted to write a guideline on the utility, the role of hybrid operating suites. How would you recommend that the one or two or three people in charge are tasked with that? How would they create a committee? And how would they move forward and in a relatively structured way?

Walter Biffl  10:44

Well, I think the keys are, number one, getting good literature and getting subject matter experts to the extent that you can. People who have used it, who know the pitfalls. Because we’ve seen some of these things fail when somebody who doesn’t have a lot of clinical experience with it, will just go and read what’s published. But you’re dealing with publication bias, not the greatest quality evidence, sometimes you can go down the wrong path if you’re just relying on what has been published. So, the expertise of people who’ve done it, and the best quality literature and the experts are the ones who can interpret the literature. And I think initially keep the group pretty small, and then go from there to start working toward consensus.

Chad Ball  11:38

That’s perfect. That’s wise advice. Yeah. I’m curious. I remember, quite early on training in Atlanta with Dave Feliciano and Grace Rozycki, we’ve also had them on a podcast. I remember, Dave Feliciano saying, Oh, yeah, no, see, CPG are great guidelines. You’re welcome to come off the guideline, but you better not be wrong. And so, I always remember that, and certainly, I think we all, to your point, with increasing experience, and given patient, will navigate away from them, and back to them and so on in that pattern. But I’m curious with that framing, then, how do you view trainees, surgical trainees or surgical fellows, using guidelines and placing them within their sort of study pathway and their knowledge acquisition?

Walter Biffl  12:29

I think it’s the way to go. And I’ve always been a big fan. In fact, that’s how I prepared for my boards. As I drew out algorithms on index cards for all the potential clinical problems. I think a great starting point is to map it out. And then as you acquire more knowledge, or experience or new things are published, then you can change the decision tree a little bit. And it happens as we read the literature; things continue to come out that are going to change our approach to various problems. But I think if you start with an approach and have the rationale for it, then you can take everything that’s published, its new and put it in context.

Ameer Farooq  13:16

Sort of along those lines. Dr. Biffl, you give a really thoughtful presidential address that was published in the American Journal of surgery. Where you talk about evidence-based medicine in surgery. And one of the things you talk about is some of the limitations of EBM in surgery. And one of them being that guidelines and evidence do change. So, in your experience, working with committees on guidelines, multiple iterations of guidelines, how do you sort of think about changing the guidelines in light of new evidence, particularly when, I’m thinking for example, the colorectal world where mechanical bowel preparation and oral antibiotics, that pendulum has swung back and forth so many times, it’s hard to keep track. How do you think about changing guidelines in the light of new evidence? And how often does that scenario seem to come up?

Walter Biffl  14:06

Well, first, I need to correct you. I haven’t been the president of anything. So, it was an invited lecture. And I’m glad that somebody read it. It’s really interesting, and it’s something that we have to deal with. And when you think about evidence-based medicine, first of all, I encourage it, I think we should all be following it. I like to get guidelines to get everybody on the same page and using current recommendations and, and I think it helps trainees. It does change though. And a couple examples that I had in that lecture, that paper. Well, the steroids for spinal cord injury when I was a resident, that was a standard of care. In fact, I was named in a malpractice suit in the US. It didn’t go anywhere, but it was considered a standard of care and they said we didn’t give them, but we actually had. As you know, now it’s consider the wrong thing to do, to give them. In preparing this lecture, I was curious about some of the most popular, or most cited clinical trials from New England Journal of Medicine, I think that’s the most influential journal in the world. Something comes out in that, and it’s pretty quickly adopted, like the NASCIS-2 trial. But I looked, you can search the most frequently cited trials and when I did this, out of the five most frequently cited trials ever in the New England Journal, three of them, were in the field of critical care, and were all published in 2001. One was an Early Goal-Directed Therapy, the River study. One was the tight glucose control in critical care patients, and one was a study on Xigris for severe sepsis, all those things were incorporated into the surviving sepsis guidelines. And none of the three lived to the third iteration of the surviving sepsis guidelines. At at least in the form that they were published. So, things do change over time. We have to keep up with literature and change with it. Another thing that I think is important, is when you’re looking at new literature, or something that comes out that might change your algorithm, it’s incredibly important to make sure that it applies to the patient who’s in front of you, before you extrapolate it. Is it asking and answering the question that you want answered? And I think that’s a pitfall that we get into a lot of times when something is recommended or done, say, well, wait a second, that wasn’t who they were studying in that trial. And there’s reasons not to do it for this patient. So, I think that when you look at the literature, that’s a big thing to consider.

Ameer Farooq  17:04

For our listeners, I’ll point people to a book that I found very helpful, which is called the Ending Medical Reversal. Vinay Prasaddo and Adam Cifu do a great job of doing exactly what you did in your address Dr. Biffl, which is going through all these different interventions that were initially thought to be helpful. And actually, one more evidence came out actually were shown to be sometimes not helpful, it’s actually sometimes harmful. And so, you kind of have to take all these things, as you’re saying with a grain of salt. One of the things that’s challenging though, in surgery is that expert opinion does have a role. In your address, you kind of talk about this scenario where you have this retro hepatic cable injury and you call in Dr. Moore and he says, while I just been reading about this, we should try vino bypass and cannulate the SMV, and the patient did really well. And you actually went on and published that case report. In surgery, maybe unlike cardiology, or some other fields where you have a medication, you give the medication, you know that it doesn’t matter who gives it, it doesn’t matter, which cardiology says this is a good medication or not, you just do the trial. But in surgery, it’s not really like that. Expert opinion, when you have someone who’s has a huge expertise in doing something that does really matter. And so, I’m curious how you think about incorporating expert opinion into clinical guidelines and into evidence?

Walter Biffl  18:30

That’s a great point. When evidence-based medicine came about that field, it was stated that they were minimizing the influences of experience and intuition, and those things in it and wanted it to be about the most high-quality scientific evidence and you hit it right on the head. That’s true when you’re treating hypertension or MI but the surgery and trauma are very different because every patient presents with a different set of circumstances. And that’s why I think with the WTA guidelines, there’s so much experience and judgment that goes into creating those, that’s what I think sets them apart and makes them more helpful, because you’re not just saying, well, okay, here’s the best quality evidence is level 2B and this is what we think. Here we say, we’ve been there, and this is what we recommend. So, I think there’s definitely a role. It’s not the thing that evidence-based medicine zealots would promote. But in our field, it’s very helpful and on a related note, everybody’s familiar with the parachute analogy, nobody’s ever studied parachutes and the original paper said all these people who are fanatics about evidence-based medicine ought to be first in line to study the efficacy of parachutes. And you may have seen the actual prospective randomized study that was done using parachutes. And this gets at the point of the conditions of the study and who it applies to. They found that parachutes didn’t make a difference. And they randomized people jumping out of an airplane with a parachute versus an empty backpack but they were planes that were on the ground. So, when you look at that, they were equivalent, but they’re not jumping for 30,000 feet and jumping from six feet. So, it just reminds us you got to pay attention to the conditions that they’re studying.

Chad Ball  20:47

Yeah, but the role of evidence-based medicine and its evolution over the years is particularly interesting from a Canadian perspective, because it works. Gordon Guyatt and his group in Hamilton are really credited with that initiation. And he’s certainly had some really fun and intense debates over the years with some of the anti EBM orthopods. And some really great scientists to be honest. It’s, been great for sure.

Ameer Farooq  21:13

How do you think this EBM all plays out now in this world with social media, the development of visual abstracts and you talked about the idea of spin, I think, as well in your address. Obviously, that’s common in abstracts and titles, but there is a very big potential for that with visual abstracts and in general on social media. So how do you think EBM in surgery interact with a world where, like it or not social media is the driver for promulgation of new research?

Walter Biffl  21:51

I think there’s a lot of pitfalls. I think it’s great that people are informed. But it’s not regulated. And you get one person in favor of something and they start spreading the word. And then soon you have everybody asking for a treatment that really isn’t helpful, may go against my recommendation. And it takes a little more time to counsel those patients away from what they heard about from a friend or read on social media. And, I think it can be problematic.

Chad Ball  22:28

There’s no doubt. A couple of other things we wanted to touch on Dr. Biffl if you’re okay with it, is some of the tremendous work you’ve done on both pancreatic injury which we’ve,  danced around a little bit as well as blunt cerebrovascular injuries, of course, if we if we start with the pancreas side of things first, I’m curious how you frame these injuries in particular, in terms of recommendations or thoughts, maybe at a high level for the general surgeon who has to deal with these. Let’s say they’re in a city like Red Deer, which is equidistant between Calgary and Edmonton. And they’re forced into operating on a patient at damage control scenario. And they find varying degrees of pancreas injury, just as one example. How do you frame pancreas injuries for the general surgeon? And where do you take it from?

Walter Biffl  23:23

Well, for any listeners who don’t know, you are the expert in pancreas here, not me. But I think that for those of us who practice trauma general surgeons who are doing it, there’s a couple key things. One is, you don’t want to miss a main duct injury because that’s where the morbidity comes from. If you encounter one, drain the pancreas and if you’re not experienced or comfortable with doing a resection, then find somebody who is. But draining it, is always safe. The worst second half in there is they have a pancreatic fistula, which could also happen if you operate it or it could be worse. But I think damage control is a great initial strategy. And I do think that once you start getting into resections, as you know, it can be pretty complex. And the outcomes are great in many cases.

Chad Ball  24:25

I guess one of the beautiful things at least I think from years of my point of views, to your exact point, that the pancreas injury, in general terms of it being an isolated problem, is not really a big deal up front, right? We can always as you said, drain that and send it out or think about it and consider it and take the patient back. It’s really, of course the higher-grade injuries with maybe a complex duodenal and ampullary injuries plus or minus, of course, the associated vascular injuries. So, I’m curious how you frame those, two scenarios and what you like to do or not do.

Walter Biffl  25:03

Yeah. So you know, in the high grade injuries, the worst ones, clearly, damage control is the best approach and stop the bleeding. We add in this multicenter style trial with we just did on the high grade injuries, they were about 18% of patients who died early. And that most of them were bleeding deaths. And so you don’t really die of a pancreas injury in the first 24 hours. So, controlling the bleeding, doing damage control, and draining it gives you time to stabilize the patient and come back and start putting things back together.

Chad Ball  25:42

For sure. And it also of course, gives you the time to invite an experienced colleague back in with you or transfer that patient out as well. No doubt. If we shift gears to blunt cerebrovascular injuries and I think you know, all of our listeners know this, but what’s become the double AST BCVI scale, no one really calls it that, everyone calls it the Biffl scale. You have a biffl for grade 2 or a biffl for grade 4 or something like that. I was always curious at that level, how in your case, Dr. Biffl you felt about everyone using your last name every day in every ICU. But you know, independent to that. I was wondering if you could walk us through really the origins of that and how you came to study that?

Walter Biffl  26:27

Well, first of all, I’m not comfortable with that terminology. I’d prefer they called it Grade because I certainly didn’t create it. I was fortunate enough to be able to be the first author on that paper, but Gene Moore and Jon Burch and others put the brains behind that. But at the time, well, I guess to talk about BCVI in general, I was exposed to it pretty early on actually the first case I saw, I was an intern. This is 1990. And at the time, if you open a trauma textbook and read about bloodstream vascular injury, said, Well, it wasn’t cerebrovascular. It was carotid and said, well, a patient who has a stroke without any finding on the CT scan has had a blind carotid injury. That’s how you diagnosed is when they had a stroke. And I had a patient who had a stroke, Denver general when I was an intern. And when I was a more senior resident, there were Fabian study came out from Memphis, showing that heparin was effective therapy for carotid injuries. And in that study, over 90% of the patients had symptoms, either a Horner syndrome or lateralized, in deficit something and we had started a study, this is at the time again, when you were doing arteriography to look for a torn aorta, in trauma patients. So there Gene and Fred and others had an interest in carotid injuries from some WTA study. So, in the mid-90s, there was a study going on to look at CT versus arteriography for torn aorta, and they did some arteriograms in the neck to look at the carotid arteries, and found that about 4% of the patients had carotid injuries that were unsuspected. And so, in late 1990s, or mid-1996, we started screening asymptomatic patients, we had a protocol and you didn’t need to have a Horner syndrome or a lateralized deficit. We started screening them in the first paper, we call it the Unrecognized Epidemic of carotid artery entries, because we found them in about 1% of patients, which was 10 times more than what was reported in all the multicenter studies before. And it just grew from there. And one of the early things we did, Gene had always been involved in the WST, organ injury scale grading papers and said, you know, this should have a grade that goes along with the outcomes. And we sat and thought about it and said, well, okay, grade one injury, that’s just a little mild internal irregularity, there’s no narrowing, that’s going to cause any flow limitation. So, we arbitrarily said, well, that’s going to be something that’s less than 25% narrowing. The artery wall looks irregular, so that’s a great one. A grade two is one with the more significant narrowing not completely occluded, but from 25% to 99%. narrowed, plus the visualization of an intimal flap, or intraluminal thrombus. Those were all lumped is great two, pseudo aneurisms were graded as grade three occluded arteries were grade four and those that were transected. With bleeding, we’re grade five, and those are fortunately rare. And they did in fact correlate with stroke rates in a carotid artery so that helps. And it’s held up over time. There has been, a couple of papers that try to subdivide them based on the degree of narrowing and grade 2, for example. But so far it seems to hold up and you can generally use it to assess the risk for the patient.

Chad Ball  30:22

There’s no doubt it’s held up there, for sure. I mean, it’s really become the foundational way that we look at these and then and then use that grading scale to treat all these interesting, I think globally. Certainly, though, I think, hopefully, you’d agree that the detection side of it, the diagnostic side of it, though, is changing. And, you know, I don’t think it’s in a too distant future where, really these injuries are screened in that initial first CT scan out of the gate in almost everybody. What are you guys doing at your center, who are you screening and who are you not, is that ubiquitous?

Walter Biffl  31:01

We are not screening universally, that’s been interesting, looking at those couple of papers that have been put out, one group found a report, I think it was from Medical College of Virginia, they found injuries in about 3% of patients and they do CT on everybody, they did pan scan with CTA. And then the other side in Birmingham, they had almost an 8% incidence of the BCVI, which was I don’t understand how it was so high, but clearly finding more. And we’ve always known that the more you look, the more you find. 8% seemed high, I don’t know if it has something to do with their patient population, or if they’re over reading some cases of spasm, or how many a grade one injuries. But nevertheless, I think that right now we use the expanded or modified Denver criteria, but I see definite advantages to doing it with the first scan. So, you don’t have to go back to the scanner and give another dose of contrast. And I think that’s the biggest reason to do it. One thing to note in the MCV paper, they had looked at the value of the Denver and Memphis criteria. And every patient that had an injury that wasn’t picked up by the Denver Memphis criteria was in a motor vehicle crash. So, the higher energy mechanism would be part of the picture. And so, I think if you’re going to start screening more and more people definitely the high energy mechanisms, then you have another body of literature saying that the elderly who fall from ground level or have a higher-than-average rate of injury. So, you come back to doing it to everybody. We’re not there yet. Are you doing it at your place?

Chad Ball  33:03

You know, across Canada, some centers are, some centers are not. We’re not at this point, we’re using exactly the criteria, the extended Denver criteria that you comment, plus or minus some mechanistic alterations. But I really struggle with it. And I think, amongst so many cases that we all see, these ones in particularly for me personally have struck me hard. I guess that’s how you know it’s random, something clusters. But I remember, a two-week run, close to 10 years ago, where we had three young ladies who were all motor vehicle crash victims, and we didn’t screen them at that time. And honestly, probably two of them maybe should have been but in hindsight, but didn’t get screened, and all three had huge strokes. And it was those were harrowing conversations with these young gals parents who came in the next day and sort of said, Well, I left last night and things were good and now I can’t communicate with my daughter. And I think we treat lots of things based on a bit of emotion and hopefully not often, but we do and it’s so easy to fall into the low of, if I don’t look for it, it’s not there. And I don’t see the clinical consequence of it. But this seems to be one where, the miss rate maybe is not worth, I don’t know where the equation sets, but I certainly am biased by those experiences.

Walter Biffl  34:29

Yo, yeah, absolutely. We talk about evidence-based medicine, but nothing means more than the cases you’ve personally had. And I think that trumps what they published in Denver or Memphis.

Chad Ball  34:45

Yeah, for for good or for bad. Maybe. If we switch gears again, I was hoping to take you out of the clinical realm and Ameer and I certainly know for many people about your legendary knowledge and love of wine in general, I was wondering if you could talk to us about that and where that comes from. And I think you know, for me, I’ve mentioned to you, I’ve been to Napa once and outside of running into Dave Matthews in a in a store in his hometown there where he lives. The second most impressive thing to me was just the amount of knowledge is mind boggling. It seems like it puts the surgical body of knowledge at Child’s Play compared to what I don’t understand about wine.

Walter Biffl  35:37

Well, it’s a fun and expensive hobby. I guess I was a beer drinker from my early, earlier years. My first trip to Napa was in the mid-90s, I guess, while I was in the lab, and my brother graduated from business school at Stanford, and we went up to Napa and I went around mainly Sonoma Valley and got a bunch of red Zinfandels and took them home and had a big party or a dinner party. And really enjoyed it. And I joined a couple wine in the month clubs and started tasting different things and a couple more trips. And, when it really got to be a problem for me. I say that the wine buying thing when I moved to Rhode Island and the food and wine culture there is great. And Bill Shafi was my chairman and he got me in his wine tasting group, and I got to be friends with a guy who owned a wine store and specialize in Italian wines because that’s the big influence in Providence. And I just started learning so much about Bordeaux and Burgundy and Italian wines. And I liked everything and started learning more about it. So, it became a real expensive hobby for me. But it’s fun. My wife and I we get a bunch of magazines; she likes to cook a different meal every night and I picked the wine to go with it and it’s fun. We’ve been fortunate to go to Tuscany a couple times and we’re actually going to Napa in March hoping that things are open again for tasting. I haven’t been to Washington State yet I want to visit some wineries there, but we were in Willamette Valley and Oregon, visiting some Pinot Noir places. So, it’s fun to go around and learn about it. Wine Spectator magazine is replaced by medical journals on my bedside table.

Chad Ball  37:38

I grew up with a guy and actually went to medical school with him. His sister, she lives in downtown Toronto and she was the first woman to win the sort of world Sommelier championship and we were always sort of messing with her. And she was always schooling us and embarrassing us. And we had four or five bottles of wine. And she said to us, you guys open those up, I’ll tell you, the year, the whole thing. And that always boggled my mind. And so, we’re, the first one, she nails it first, just smelling it. The second one, she nails it. And the third one, she gives us this answer and we start laughing and giggling like children. And we say No, you’re wrong. And she’s like, I’m not wrong. We’re like, yeah, even though you’re wrong. And she’s like, okay, let me taste it again. And she said, there’s only one possibility that I’m wrong. And she said, in Niagara, there was a freeze at the wrong time of the year, this particular year with this particular winery, and they had to bring in grapes from Bordeaux or somewhere in Europe. And they mixed it with their preceding ones. And so that’s the only other thing this could be in the world. And she was dead, right? Oh, I was just like, it’s almost like financial advisors that are great, right? It was like, I can’t even start this. I can’t even walk into it. There’s no way. It’s great.  You know, one of the questions we’d like to end our podcast with is to ask you, if you were to go back in time and give your younger self a piece of sage advice, what would that be? And before you answer, you’ve obviously done so much great clinical work and you’ve been such an impressive contributor to trauma critical care acute care surgery in the surgical world in general and we can’t thank you enough for having been on the show again.

Walter Biffl  39:28

Well, thanks Chad. I yeah, there’s so many things I would like a second crack at, but I think that the big thing is to always put everything into it. It’s Carpe Diem, but not just to have fun, but take advantage of the opportunities that are presented. If you have a case to present an M&M, just read the last paper written on it. Read everything you can find. Learn from it and teach other people as much as you can. One thing I didn’t mention about Gene Moore that really influenced me, was the emphasis on understanding the history of the problem that you’re writing about or learning about. And it was always important, you can’t write about something without understanding where it was coming from where it was before. And I think that when you’re trying to learn about something, go as far back as you can trace it back to try to figure out how it got to where it is now. And that’ll help you understand why it’s there and what might have to happen for it to change moving forward. And I think just taking advantage of the opportunities of the people you can learn from, the things you can do, and experience and they’ll be more fulfilling.

Ameer Farooq  41:07

You 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.