EPISODE 63

The Reality of Practicing Alone with Dr. Scott Nelson

Episode Transcript

Dr. Randy Lehman (00:00):

Welcome back, listener to the Rural American surgeon. I'm so lucky and happy to have Dr. Scott Nelson, colorectal surgeon from Oregon with me. Thanks for joining us, Dr. Nelson.

Dr. Scott Nelson (00:18):

Thank you for having me.

Dr. Randy Lehman (00:20):

And we had the chance to sit together at the dinner at the North American Rural Surgical Society, and you're working with the residents in Grants Pass Oregon as a colorectal surgeon, right?

Dr. Scott Nelson (00:33):

Yes, that's right.

Dr. Randy Lehman (00:34):

Yeah. And so it's funny because in my mind it's one of the big powerhouses in rural surgery training and the dedicated year at Grants Pass. As a medical student, I just read all about it. I was really applied, had it really high and top of mind. And then of course didn't get an interview. So what are you going to do?

Dr. Scott Nelson (00:58):

Well, neither did I. So there you go.

Dr. Randy Lehman (01:01):

But did you have anything to do with starting that residency program?

Dr. Scott Nelson (01:06):

Yeah, no, I didn't. I came here in 2009 and the program had been up and running for probably five years, so I've been a part of it for almost two decades now, and it's been a great experiment. I'd say it's more than an experiment at this stage, but we had some forward thinking surgeons who really took advantage of some opportunities and convinced the hospital that this would be a good thing and worked with OHSU and put it together before I got here.

Dr. Randy Lehman (01:34):

Yeah, very cool. So you're not outside of just being a clinical faculty, you're not a PD or anything like that, right, with the program. You don't have to do any paperwork. That's good.

Dr. Scott Nelson (01:47):

I just have the fun part,

Dr. Randy Lehman (01:49):

Right, which is great. So we really appreciate what you do. Usually I like to start with an introduction. So just tell us a little bit about your background, your training, and your current practice and along the way, the high points.

Dr. Scott Nelson (02:01):

Sure. I did my medical school training in Kansas City, and then I did my general surgical residency in Marshfield, Wisconsin, which is a very tiny town and has a very large hospital. It's the regional referral center for most of northern and central Wisconsin. And that's where we really fell in love with rural medicine. That was not really what I had anticipated doing. I grew up in Southern California, just a little east of LA and I'd always lived in large cities my whole life, but once we went to Marshfield, just that small town feel and being in a smaller environment, we really enjoyed that. So when we finished, I did a two year fellowship in colon and rectal surgery in Omaha, but we began looking for a smaller community to raise our family and live, and we found Grants Pass and we've been very happy here. I've been here for almost 20 years.

Dr. Randy Lehman (02:54):

How'd you find that job in the first place?

Dr. Scott Nelson (02:58):

Well actually, actually it's kind of crazy. I was just looking around the country at positions for colon and rectal surgery, and I stumbled upon a name of a gentleman who was here working and he was part of the Northwest Society of Colorectal Surgeons. His name was Bob Ulrich, and I just sent him an email and said, Hey, are you looking for a partner? And he emailed me back and said, I'm about three years away from retirement and yes, come on out. So I flew out to Oregon in my best suit and tie and showed up and he was wearing overalls and had hay coming out of his boots in his office, and he took me to his house where he had a hundred acre farm and raised Longhorn cattle, and we fed the cattle in my suit and tie because that was part of my role there and I was hooked and I have been here ever since. So kind of a fun story with Bob. He's a good man. I'm

Dr. Randy Lehman (03:52):

Going to take this time, I don't have any sponsors or anything for my show, it's just me producing it. So I'm going to unashamedly give my listeners a shout out from me because probably in the next two years or so I'm looking to recruit a partner. So if you're interested or of somebody that might be interested in type of practice that you've heard me talk about on this show, please don't hesitate. Go to the rural american surgeon.com and just submit an online submission there. And then I will get back to you and let's carry on to the next segment of the show that's called Why Rural Surgery. So what draws you to it? And I know you said raising a family there have a place to settle. You fell in love when you were at Marshfield, but why does this still matter and relevant in 2026?

Dr. Scott Nelson (04:35):

Well, rural America is huge and it's underserved, and I just found that we were able to do the things that we wanted to do as a family that really fit the lifestyle that we were looking for in a smaller environment. And I think that's the thing that drew us to that area. As a colon and rectal surgeon, it was a little bit more challenging because most colon and rectal surgeons only work in large cities. And so when I came to Grants Pass, I quickly realized that I was the only colon recal surgeon for about a 300 square mile radius. So there's about 15 of them in Portland, which is four hours north of here. There's three or four in Redding, California, which is four hours south of where I am. And then there was no one in between. And so I recognized that I had an opportunity to do something where I was the monopoly. There wasn't another colon and rectal surgeon, but that it was also a very needed specialty in the area, and it has provided a lot of wonderful opportunities and some significant challenges as you work by yourself in an area. So it was the right fit for our family, which is probably the most important. But then I also found the work rewarding. There was just me, and so you get to learn how to do it really well. Well, because all by yourself,

Dr. Randy Lehman (06:00):

What were one or two of the biggest challenges, unexpected challenges that you came across as you were developing your practice?

Dr. Scott Nelson (06:09):

Well, the first was when I joined my partner, Dr. Ulrich. He was in private practice, and so that I thought was going to be a good opportunity, but then unfortunately he developed liver cancer and passed away within a year of me coming. So all of a sudden I found myself in a brand new practice running my own business and trying to figure out how life works. And so that was an unexpected challenge that we had. The other was that I didn't have a lot of mentors. So once Bob passed away and quit working, obviously then it was me and I didn't have a lot of resources. I had trained in the Midwest, but I didn't know anybody on the west coast. I hadn't met a lot of the other colorectal surgeons, so I didn't have those resources to turn to. I could call my program back in Nebraska. I could email some of my attendings from residency who were colorectal surgeons. But the reality was you were kind of stuck out in the middle of nowhere trying to figure out actually how to run a practice at this point and had to do a lot of challenging things that you felt very confident about as a resident, but all of a sudden that confidence goes away when you're a new attending. So

Dr. Randy Lehman (07:20):

I feel all of that stuff coming at it from a general surgery perspective. By the way, how much general surgery call have you had to take throughout your career?

Dr. Scott Nelson (07:27):

I took until last year we were taking general surgery call. I would take it anywhere from three to about eight times a month. So my practice has just specifically gone to colon and rectal at this point, which took a few years to make that transition. But I would still continue to take general surgery call. I took it for almost 15 years while we were here,

Dr. Randy Lehman (07:56):

Still fixing strangulated hernias, and

Dr. Scott Nelson (08:00):

I did all that now we developed an EGS program at our hospital, so I don't have to take call anymore, which has been the best thing ever at this stage my career. Yeah. Did that include trauma? Yeah, I took trauma call. I refused to do any vascular. I just didn't feel like I was going to do a good job with vascular surgery, but I would do all the trauma, all of the emergency general surgery things, and then all the other things that a rural surgeon has to take care of all the way down to doing some of the orthopedic things if they wouldn't come in and we couldn't transfer somebody out. So yeah, it's been an adventure because it really made you develop and keep all your skills from general surgery residency while you were still trying to do a subspecialty practice.

Dr. Randy Lehman (08:47):

Sure. One more question before we go to the how I do it, and you mentioned didn't feel like I was going to do a job, good job if I did vascular. Say a resident comes to you and they're four or five and getting ready to go out and practice, and they say to you, how do I know if there are things in my practice that I shouldn't do? How would I know where my limits are?

Dr. Scott Nelson (09:14):

Yeah, I think that's a great question because at some point you have to jump in and just figure things out. If you didn't do everything that you don't feel comfortable with, you probably wouldn't do a lot your first year In a rural practice, that's not always an option. So I'll give you an example. When I came out, I hadn't done a lot of endoscopy. I had done a lot of colonoscopies, but I hadn't done a GI fellowship. I didn't do GI bleeds. That was not my wheelhouse. But when I came to this practice, there's no gastroenterology in the city, so I became the defacto gastroenterologist. So when I was on general surgery call, they would call and say I'm at a foreign body in the esophagus. Well, I hadn't been trying to take care of foreign bodies in the esophagus. And so for the first several months I said, I don't do that. I don't feel comfortable with it. And then I quickly realized, well, they can't send them anywhere else, so somebody's got to take care of it. And so I said, well, I've got to learn how to do it. And so I just jumped in and started doing that. And then as I got more comfortable, I am doing the GI bleeds, I'm doing all of the things that I didn't necessarily feel comfortable with, but

(10:23):

You have to do it. I think one of the things that's important though is if you're a new resident and you're starting to go to a place and there's a practice, you need to have somebody who can back you up. You need to have a mentor there, and if you don't feel comfortable with something and it still needs to be done, you need to talk to somebody about that. Ask a partner to come in. And at least for my first year, I did have a good partner who would come in and give me a hand if something wasn't right. But it is a balance trying to figure out what can I do that's safe and yet what do I not feel comfortable with? And you're going to have to figure that out. Experience will then lend itself to becoming more comfortable doing more and more things. So you need to be wise in your choice about what you're willing to do, but at the same time, that's a really good question and it's just something you have to work through as you start your practice.

Dr. Randy Lehman (11:19):

One more very tiny follow up thing, privileging. So when you submitted for your initial privileging note, did you submit for esophageal foreign body in your privileges or was it part of a general surgery core? And then how do you, for example, I've personally decided that the volume of my thyroid practice is so low and there's certain pieces of equipment I don't have. It's not that I never want to do thyroids again for my life, but right now in 2026 for me, I'm not doing it. That would be a great thing for a junior partner to come on and we could double scrub. They could be the thyroid guy, maybe we could focus on building a practice, but I've got other things like for gut that I'm focusing on. So I still have privileges to do that at all the hospitals, obviously I'm not going to, but at the same time I'm saying no to a consult for it. So how does that privileging versus your operation play out?

Dr. Scott Nelson (12:22):

Yeah, I mean, I think that's probably the best way to go. I didn't select foreign bodies in the esophagus as an example, but I quickly realized that you know what? There's a million of these, I'm going to have to learn how to do it. And so I had to go back to the credentialing committee and submit for that, request that privilege. And so it is easier to give up a privilege than it is to get it. So as you're starting in a practice, you can click all those boxes. However, for example, a thyroid, if you are only going to do one or two thyroids a year, I would say that's probably not something that you want to then try to build up in the future because if it's just not a procedure that you do often, I don't think you should do it. I think foreign bodies in the esophagus, I was going to do that all the time.

(13:11):

I didn't click thyroid or thyroid surgery because I knew I wasn't going to do that. I had done very little of it over the last several years of my training because I was doing colorectal surgery and while I enjoyed head and neck surgery, it was like, I'm just not the best person to do that. I think that should go to somebody who's an expert who's doing it more often than I would. So I think you're going to have to look at your practice and then figure out what am I going to do? And this is one of the hard parts when you start a practice and then you decide I want to move to a different area because you get in grooved or ingrained into what you do on a regular basis for what the needs of the area are. And if you go someplace else, you're like, well, we need somebody to do thyroids or we need somebody to do nisson, and you haven't done a lot of that. You then have to build up that skillset again. And that can be really challenging as you do that. So there's just a lot of things to think about in the span of your career, but I think having a good mentor, being willing to say, Hey, I do need someone to watch me so that I can do this safely and learn the rules again and know the steps, that's going to go a long way and helping you be successful as you have to transition into doing other things.

Dr. Randy Lehman (14:26):

Let's move to how I do it section of the show. So this is usually I ask questions, the potential risk of making myself appear stupid, I ask the question that I do or don't know. And we have talked about colon cancer, everything that you do. I would probably love to talk about inflammatory bowel disease and colon cancer and all the other things, but really practically because I have a colorectal surgeon and it's something we all have to deal with, I was hoping we could talk about perianal disease in terms of tips and tricks that you have for the rural surgeon. So everything that comes to us is hemorrhoids, whether it's rectal prolapse, actually hemorrhoids, fistula, fissure, abscess, they all come as a hemorrhoid consult. So I guess the first thing is take a history and take a look, but anything else in terms of you get a patient on your list as hemorrhoids or ER consults as hemorrhoids that you're always having your spidey sense up about?

Dr. Scott Nelson (15:34):

Yeah, I think that's a great point. I mean, I wanted to do a study and publish the results to say how many times do I get a consult where it says hemorrhoids and it's something else? And then the next part of my study would be how many times does the referring provider actually look at the anus and try to make a diagnosis? And the answer is likely less than 10% of the time. And so as a general surgeon, you should just know that whenever anybody is sending you hemorrhoids, it's probably not hemorrhoids and you really do need to talk to the patient and then do a good physical exam and figure out what's going on. I can break down most of the diagnoses for anal rectal disease into probably five things, anal fissures, anal rectal fistulas or abscesses, hemorrhoids and pruritus an nine. And then, well, I guess those four things are the most common that I run into.

(16:29):

And so if you understand at least those four disease processes, you probably have 90% of everything that you're going to need to worry about figured out. So I actually give a talk to all of the emergency room and family practitioners in our healthcare system about what is anal rectal disease and how do you diagnose it? And we just go through the questions to ask and then the simple things to look for so that they can at least have a diagnosis before they send it to me. I can say it's been not helpful at all, but at least I feel better. I'm trying to change the world in some little way, but if you understand those things, then you'll probably be just fine at making a diagnosis and then figuring out what to do.

Dr. Randy Lehman (17:12):

When you're asking your history, is there any special great question that you always ask every perianal thing that really helps to differentiate or is it just kind of a general history?

Dr. Scott Nelson (17:24):

Well, I always ask, is there pain when you go to the bathroom, right? Because pain with going to the bathroom, having a bowel movement is not hemorrhoids. It's almost always an anal fissure. So if there's pain with bowel movements, I'm looking for an anal fissure. I always ask if there's tissue that's prolapsing, because if there's tissue that's prolapsing, it's usually going to be an internal hemorrhoid, or if it's an elderly woman, it's going to be er rectal prolapse. But then that helps me kind of know is this internal hemorrhoids? And then my mind goes, am I going to band it? Am I going to offer surgery? What's going to be the best thing in that regard? I then ask if there's anything that's draining. So if they have an anal fistula, it's going to be something that's draining. If I walk into the room and they're not sitting down because they're hurting, I know it's in a rectal abscess, right?

(18:12):

I mean, those are just the things that I look for without asking for anything else. I always ask the question is if they see any mucus in their stools because mucus is either prolapsing, internal hemorrhoids, large rectal polyps or cancer or inflammatory bowel disease. And so if there's mucus, then I'm going to a colonoscopy or doing some other kind of form of workup to figure out where the mucus is coming from. So those are the basic things. If they come in complaining of itching and burning, we're talking about pruritus, anai and that lecture on how to fix those problems. One of the common mistakes that I see general surgeons make is that they don't listen to the patient and they just assume they take the diagnosis of hemorrhoids at face value and then they go do a hemorrhoidectomy. And that usually ends up with disastrous results for an individual.

(19:07):

And I see that more often than we should. And so that's where I think general surgeons can really save themselves is if they will just ask those basic questions and then get the diagnosis upfront, then the rest of our training should take it from there. But if you're just taking it at face value and you go take their hemorrhoids off, then we're talking about anal stenosis, chronic pain fissures, all sorts of things that then get sent to my office not getting better, and then that's when patients get angry. And so those are the hard things that we have to work through sometimes.

Dr. Randy Lehman (19:45):

Very good. Talking about history and everything, we hit the chief complaint, we hit the HPI. Let's go through anything. Obviously you got IBD, family history, colon cancer, personal history of colon cancer, probably smoking, things like that, maybe sexual activity, whatnot. And then you do your physical exam, and then I'm going to walk through the other things after. But any specific tips on the physical exam?

Dr. Scott Nelson (20:12):

Well, yeah, so a couple things. I examine all of my patients in the pro jack knife position, so I have them kneel down over the table. I just find it personally, it's a lot easier than having them lay down and trying to look. I use a bulleted, an aScope, and I examine both internal and external, and I spend some time really looking on the outside trying to figure out what is it and fissures, fistulas, pruritus, eye thrombosis, those should all be seen without having to do any internal exam. And so if you kind of what you're looking for, you should be able to just get the diagnosis just from that. Really, the internal exam helps you if you're looking for prolapsing, internal hemorrhoids. So if you are looking for that internal hemorrhoid disease, again, hemorrhoids is painless, rectal bleeding or prolapsing tissue, that's the internal component. And so the anoscopy can be helpful for that. The digital rectal exam can tell you if there's a cancer there, at least a few centimeters up. And then oftentimes if I look with an endoscope, if they have inflammatory bowel disease, you'll see a lot of those changes in the lower rectal mucosa when you're looking at it. So that's how we do the exam.

Dr. Randy Lehman (21:30):

And then of course for the infectious stuff, like we're looking for labs, there's nothing else really fancy there unless I'm missing something. I mean barring CEA for colon cancer and whatnot. But let's move to the other part of the objective, which is who needs a CT scan? Who needs an MRI who doesn't need any imaging at all? Hit me.

Dr. Scott Nelson (21:53):

Yeah. I very rarely order any imaging for anal rectal things because I think a good physical exam tells you most of what you need. If I have a really challenging anal fistula, I will order an MRI, and those are the ones that I can't find the internal opening for. And every once in a while I'll take somebody to the operating room and they clearly have an external opening and there's no extravasation of fluid back inside. You do all of your tricks and you can't find an internal opening. That's always frustrating. I'll get an MRI for that. If I feel like a presacral mass, I will get an MRI or a CT scan, but those are rare. I've done maybe six or seven of those in my whole career if I don't have a good explanation. Yeah, six or seven. I got two teenage daughters, so there you go. But imaging studies really are not overly helpful for 95% of all the things that I'm looking for on the anal rectal exam.

Dr. Randy Lehman (22:51):

Okay. So say you got a good anoscopy in the clinic or ER setting, wherever you're looking at them, which I got to say I don't do that so often, but what percentage of those patients do you have a nice confident diagnosis if you got the anoscopy, is it like high nineties percent that what's going on and you're making the plan right then and there?

Dr. Scott Nelson (23:16):

Yeah, I mean, I can be honest. After 15 years, I can tell you pretty much what you've got just by listening to your story.

Dr. Randy Lehman (23:22):

And

Dr. Scott Nelson (23:22):

I can do an exam and I know exactly what the diagnosis is, but that's what I do day in and day out. I've listened to 10,000 different stories and I think, so there's the advantage of being the subspecialist as opposed to the general surgeon who sees hundreds of people a year as opposed to thousands of people a year. So employ all the tools that you need to get the diagnosis, whatever that is, is the right thing for you. But when I listen to them and I do an exam, I would say 95 plus percent of the time, I feel very confident that I know what we're doing and I go from there.

Dr. Randy Lehman (23:56):

So where I was kind of going with that is who needs a true anorectal exam under anesthesia where you're kind of going not really a hundred percent sure what you're going to find?

Dr. Scott Nelson (24:08):

That's a great question. So if I walk into a room and the patient's standing and they won't sit down and I look and I don't see an abscess, I take them to the operating room. That means that we've got a deep post anal space abscess and I need to do a more thorough exam. If someone won't allow me to examine them because of discomfort, then that's someone else that then needs to go and I look at them and decide, is it right now we've got to go or can I set you up tomorrow or the next day? But if I can't get a sense of what's going on, then that's when I would do an examiner anesthesia. Most of the time I can talk people into allowing me to at least figure things out, but if they're so uncomfortable that they won't let you examine them, then that typically means there's something wrong and you need to go look.

Dr. Randy Lehman (24:57):

When you go in and do your anorectal examiner anesthesia or any other perianal surgery, do you always position the same way? Or if not, why not?

Dr. Scott Nelson (25:10):

I would say I do 90% of my work in the prone jack knife position, and I do that for a couple reasons. One, it's a lot easier for me to stand as opposed to sit and try to see into the anus too. When you put them in lithotomy, that's placing the rectum kind of in that most dependent position. So the hemorrhoids tend to swell up and things get in your way. They bleed a lot more if you're operating. So unless I have something that's directly posterior midline and I want them in lithotomy so that I can work down on whatever it is, if I'm doing a transanal excision, I almost always put them in the pro project knife physician, and that's a personal preference. I know a lot of people always put them in and they're worried about anesthesia putting them prone, and so those are all legitimate concerns certainly. But I've been doing this long enough and I have an anesthesia and my or crew is comfortable enough that we put everybody in the pro jack knife position, and that for me is always more helpful when we're trying to work on the anus.

Dr. Randy Lehman (26:14):

Yeah. Do you put some silk tape and tape to the bed, or how do you do your exposure? Yes.

Dr. Scott Nelson (26:21):

Yep. I use silk tape. We get as much exposure as we can. I'll use the lone star if I need extra help getting in. I use the Lone Star a lot for my altmeyer repairs for rectal prolapse if I'm doing those cases. I also have a set of clear anus scopes, which has saved me a number of times. They come in various sizes and they help you get up if you need to remove a lesion in the low rectum, those have kind of gone out of favor nowadays. We have a robot or they have the laparoscopic instruments that lets you do a lot of that stuff. But those are all the little tips and tricks that I've picked up over the years of just trying to get into the rectum and take care of things.

Dr. Randy Lehman (27:01):

Perfect. So let me go through just a couple of the conditions. So starting with hemorrhoids. So say the patient's predominant problem is internal and external hemorrhoids and they're bleeding and you do fiber for six weeks and they're still having problems. There's still a lot there. I mean, is that fiber thing essential? You got to normalize their stool and then if you're going to take them for the operation, what operation do they get?

Dr. Scott Nelson (27:27):

Great question. So I don't have a limit. I don't make people do fiber for six weeks and come back. You can look at some hemorrhoid disease and go, it's just not getting better. So I always recommend fiber to all of my patients. We want to normalize the bowel movements, and in some cases, if their hemorrhoids aren't bad, that's what I would recommend. But if we're deciding that yes, we need to go to surgery, then all of the other medical management is important, but I am not going to wait for that in assumption that it's going to make things drastically better. I always tell my patients that they don't have to have surgery. Hemorrhoids don't kill you. And so this is an elective procedure, and so when they're ready to fix them, I'm ready to help them have them fix. And that's kind of how I approach hemorrhoids.

(28:18):

I have tried all of the operations for hemorrhoids, from stapled hemorrhoid, opexy to the doppler, suture them down to hemorrhoidectomies to everything else, banding and sclerotherapy and infrared coagulation. I have settled on two things that I think are the most helpful. If I'm just going to do something in the office, I'll put a band on a hemorrhoid and I always band above the dentate line so that the patients don't have a lot of pain. If you're getting a lot of pain when you're putting bands on, you're not putting the band on the right spot. However, I tell my patients that bands bias several years, but bands do not last forever. So if their hemorrhoids are smaller and we've got one little one or whatever, and I think, yes, this is going to be helpful, I'll throw a band on. But if somebody has significant disease, I just offer them a hemorrhoidectomy. And after having done all of the other options, I will tell you that the recurrence rate on all the other options was so high that I just stopped doing them. A hemorrhoidectomy done well, fixes the problem forever. It's a miserable surgery to recuperate from. It's about two weeks, and I just lay it out for everybody. This is going to be rough, but you'll never have to worry about your hemorrhoids again. It does fix it if you do the surgery the right way.

(29:40):

I don't have too many people that say no to that. They're usually wanting to get that done. So problematic.

Dr. Randy Lehman (29:46):

What if they have three really a three

Dr. Scott Nelson (29:48):

Quadrant hemorrhoidectomy?

Dr. Randy Lehman (29:50):

I

Dr. Scott Nelson (29:50):

Do three quadrant hemorrhoidectomy, they got three incisions and I numb it up really well. I send them home with plenty of pain medication, stool softeners. They can have some ointment with lidocaine, which I don't think really is helpful, but it gives them something to do. And then warm showers I think are very helpful. I see everybody back at two weeks and they almost always say the same thing. That was the worst, but I, I'm feeling better. And then by the time we get out four to five weeks from the surgery, they're like, that was the best decision I ever made. And I've been in practice now long enough that I see all my patients back for colonoscopies and things and they have great results. They don't come back. So that's where I've just settled on just do it once, do it the right way and then move on as opposed to all of these other things.

Dr. Randy Lehman (30:38):

Yeah, most of 'em, they end up being internal and external hemorrhoidectomy then majority. Yeah. How much normal mucosa do you need to leave to prevent stenosis?

Dr. Scott Nelson (30:49):

So when I do a hemorrhoidectomy, this is how I teach the residents. I'm really just trying to take all the redundant tissue. I take a grasper and I just fluff it all up in the anus scope and I say, this is the line. This is what we want to take so that when I'm sewing it, we're just leaving that the normal tissue, the redundancy is gone and we're just bringing the two bottom edges back together. So I'm leaving, I'm trying to leave all of the normal mucosa together. We're just taking out that redundancy, so I don't make wide flaps when I do it. I take very narrow flaps and then that really prevents that stenosis. I think where people get into trouble is when they take a lot of tissue, they have wide flaps, and then they do three quadrants and then four or five months later, the people are anal stenosis and I see that all the time. And so you just want to make the narrow flap. You just want to take off that redundancy. And I do it in all three quadrants and thankfully most people do well.

Dr. Randy Lehman (31:49):

Yeah, and then also you mentioned taking it out and stitching and close, but specifically what do you take it out with and then how do you close it, man, a lot of people have gone to just leaving it open, and so what do you think about that?

Dr. Scott Nelson (32:06):

Yeah, I mean, so you have open and closed techniques. I think in Europe they usually leave them open and in America, historically we have closed them and I was trained to do a closed hemorrhoidectomy and I do close them. I think the literature would bear out that you have less bleeding complications afterwards. They do say that there's more pain when you close them. I don't know if that's true. I think the operation is just terrible and it's going to hurt to poop whether you have it left it open or you close it. Most of the wounds do open over time anyway, but I have had just a few bleeding complications and I think I attribute that to just closing the wounds. I can't imagine just leaving them open. I think you do have a lot more bleeding involved. I do think that closing that also helps you gauge how much mucosa you're leaving, and that also is a good thing. I also use a large fan LER anus scope, which really opens up the anus, and that actually helps protect you because then you're only able to take the redundancy. You're not able to take more than that. And so that's another trick that I use to really just try to make sure we're not taking too much tissue.

Dr. Randy Lehman (33:18):

Okay. And what suture do you close it with and what technique is it running?

Dr. Scott Nelson (33:22):

Yeah, I just do a running three Oh Vicryl and then I'll put some interrupted three Oh chromic in. And that seems to do the trick.

Dr. Randy Lehman (33:30):

Do you close it all the way out or do you leave the last centimeter open?

Dr. Scott Nelson (33:35):

Nope, I closed the whole thing all the way up.

Dr. Randy Lehman (33:37):

Okay, so that is first off validating. So thank you. Any other tips for hemorrhoid disease before we move on to the next disease process?

Dr. Scott Nelson (33:49):

No, I think if you're just upfront with patients about what they're going to experience, then I think it's a much easier problem to manage. I have found that if you set the appropriate expectations for whatever surgery you're doing, life is a lot better for the patient and for you if you don't spend the time setting appropriate expectations when it becomes a real miserable experience for everybody.

Dr. Randy Lehman (34:12):

Yeah. I guess I did have one more question. Do you follow the textbook Thrombosis, hemorrhoid 48 Hours Management, or do you find yourself taking those patients for hemorrhoidectomy incision and drainage? What do you typically find yourself doing?

Dr. Scott Nelson (34:29):

I don't follow the 48 hour rule. I follow the how is the patient doing, because I've had some people that have come in at a week and they're miserable and I'm like, let's just take it out. And other people at 48 hours have this giant thing and it looks terrible, and they're like, I'm feeling better. I'm like, let's just leave it alone. So I just really, I look at the patient and I talk to them and we kind of assess where they're at and that's how I make the decision. I

Dr. Randy Lehman (34:54):

Think 48

Dr. Scott Nelson (34:55):

Hours is a good guideline, but it shouldn't be a hard and fast rule.

Dr. Randy Lehman (34:58):

Is it an incision or is it an excisional hemorrhoidectomy for you?

Dr. Scott Nelson (35:03):

I usually just take the top off the clot, the skin off the clot, and then I will shell out the clot. And then if I'm in the office, I will take some silver nitrate and just cauterize the base and then I just leave it open and let it heal. If I'm taking them to the operating room, which is pretty infrequent, then I will try to take out all of that tissue and I'll do a hemorrhoidectomy.

Dr. Randy Lehman (35:29):

Have you ever done any external hemorrhoidectomies in the clinic under local?

Dr. Scott Nelson (35:33):

Yeah, I do. I find it challenging, not just because they're awake and it's a rough area to work, but when you put the local in, it plumps up all that tissue. And one of the advantages of doing it under general anesthesia or under a spinal or however you choose to do it, you can remove it and then the tissue hasn't been edema by all of the local that you put in. Then you're able to put it back together so it looks nicer, and then you can inject the local. And so a lot of times you're working on a young woman who doesn't like some large tag after a delivery, let's say you start putting all that local in and then it's like you've just made this tag that's two centimeters, four centimeters, and then you're cutting off a lot more tissue and it just makes it a little bit harder to make that cosmetic effect that they're looking for. Nice.

Dr. Randy Lehman (36:23):

Yeah, I can think of one guy in his nineties who I didn't really want to put to sleep, and it was purely external and it was just one of 'em, and I'm like, we can just take that. So yeah, it's good to have different options and to think about things. I'd like to talk a little bit about fistula. So fistula and anal, starting as an abscess, I generally tell patients that when I explain an abscess, we got to drain it as close to the anus as possible. So if you do have a fistula, it's as short as possible. And I tell 'em about a third of people will have drainage at six weeks, and that means that you have some sort of ongoing fistula. Those people then need an exam under anesthesia. Sometimes we put a seton, sometimes we need a fist. Kind of how I tell them, I don't know if that's been a true third in my practice, but what do you think about those recommendations? Would you change them in any way?

Dr. Scott Nelson (37:16):

No. If we drain an abscess, I give everybody about six weeks to declare themselves. If they're still draining at six weeks and by and large I would say you have a natal fistula and then I would recommend an exam under anesthesia. And I do tell them that I don't always know what we're going to do until we get in there. And the determining factor for me is how much of your sphincter muscle is involved. If it's a high trans enteric anal fistula, you're going to get a non cutting seton and we're coming back for a second and sometimes a third operation. If it's a low lying fistula, you may get a fist otomy or a cutting seton, but it's all dependent on how much muscle's involved and what I think their outcome's going to be if we cut through whatever we're seeing. And I'll be honest, fistulas are probably some of the more challenging issues that we take care of. I'd rather take care of colon cancer and low rectal cancers than I would really bad anal fistulas. Some of them are terrible. And I have a group of probably 10 patients in my practice that I have tried everything on and I still haven't been able to get them to heal up. And so those are frustrating problems for everybody.

Dr. Randy Lehman (38:25):

Lemme focus on that cutting Seton for a second. So say you got a low Seton, do you open the skin under where you're tying your cutting seton? Do you use a 2.0 silk as you're cutting Seton? Those are my initial questions.

Dr. Scott Nelson (38:39):

So if I feel like there's not that much muscle or enough muscle can be sacrificed that the patient isn't going to have any undue effects, I will put a 2.0 silk stitch in as a cutting seton. I will cut the skin and I will just leave that portion of the muscle exposed. So I just make a vertical incision just in line or parallel incision in line with the fistula tract, and then I will put a silk stitch in and I will snug it down pretty tight. I don't do the hangman's knot where you're coming in and tightening it up all the time. I just feel like that can be problematic and really painful for people. So I let it just sit there for probably four to six weeks. Most of the time the fistula or the seton will fall out at that point and the fistula will close.

(39:23):

If it doesn't, then I will take the patient back or I'll do it in the office, but I'll do the second stage fistula because usually there's just a little bit of tissue left. And again, I set these expectations for the patient so that they know there may be a second operation, we may have to do something else, and then that way everybody's kind of expecting it. I learned really quick if I didn't explain it and then I'm like, okay, we got to go do a second surgery. People are angry that, well, what do you mean? Why didn't this work? And so just laying that groundwork up front saves you hours of pain afterwards. So that's how I approach kind of a low line fistulas. If

Dr. Randy Lehman (40:05):

You're just putting a Seton to delineate the track for a higher fistula, what do you use? I use a vessel loop and then tie it to itself with a silk stitch. That's what you like to use too?

Dr. Scott Nelson (40:15):

That's exactly what I do. So I use a blue astic vessel loop and then I just tie it in a circle just to itself. I don't like tying it end to end like this. I think that then it's always just rubbing and getting in the way. So I found that putting it as a circle seems to be more convenient for the patients. I guess for general surgeons, one of the thoughts that I would say for fistulas is if you don't know what to do, just put a non cutting seat on end and then send it to somebody else. That's always helpful because regardless of what we're going to do, we almost always want a Seton in just to mature the tract. If you're going to do a lift, I use a laser, I do plasma injections as if I'm going to do a flap closure, I want that Seton in place for several months anyway. So if you don't know what to do with a fistula, just put a non cutting seton in it, send it off, and then somebody else can, then that first step is already done and then they can make a determination on how else to tackle that.

Dr. Randy Lehman (41:16):

Yep. Okay, very good. So there's lots of other things we could just keep talking about each one topic forever, but you mentioned pruritus a nine, and I was hoping that you could give us some treatment tips for that disease condition.

Dr. Scott Nelson (41:35):

Sure. I found that pruritus is usually caused for two reasons. Either one, you have a patient that likes to polish their bottom, so they're very fastidious about hygiene and they just rub the skin raw. And the other is usually the gentleman who just don't clean themselves very well. That is 90% of it. Very rarely do we run into these weird other conditions. And so I talk a lot about appropriate hygiene. I tell the women mostly, look, you need to stop polishing your bottom. Keep it clean and dry. Get rid of the loofah, get rid of your special wipes, just clean and dry. That's all we need. And then my favorite ointment is epting, and I have people put epting on the area at least two or three times a day, and I ask them to do that for about six weeks, and then I have them come back if they're still having problems. And that cures most people, not everyone, but it does fix most of the people. I try to stay away from the steroids and things. If people come back and we haven't made any progress, I will take a biopsy. It usually comes back as osis or dermatitis, and then we'll try some steroids and even some tacrolimus if things are bad. But that's a pretty unusual scenario.

Dr. Randy Lehman (42:51):

Yeah. Alright. And then fissure. So optimizing bowel movements, fiber, and then what do you do for creams and then who gets a lateral internal sphincterotomy? Anything else besides that?

Dr. Scott Nelson (43:11):

Yeah, I've tried everything for fissures as well. I've just settled on Nifedipine ointment is my preferred choice, and usually you have to have a compounding pharmacy that does that. We've actually found a number of compounding pharmacies that will just mail people the ointments. So I've just gone to doing that. It's a lot easier than always trying to fight with the pharmacies to make it. For us nitroglycerin gives most people headaches, and the two are about equivalent when you look at the data. So it's either, we either use edine or we don't use anything just because of the side effects, soft stools, fiber, et cetera. I won't bore everyone with those details, but that's always a key ingredient into trying to help people get better.

(43:56):

Botox, I've used Botox in the past. I have found it to honestly be no better than the ointments and creams and most insurance companies won't pay for it. So the patients were having to purchase it out of pocket and it was typically 800 to a thousand dollars. And so if you're investing that much money and then it doesn't work, that's always really frustrating for everybody. So I don't recommend that as a treatment because the literature and my own experience just doesn't bear out that it is actually all that much more helpful than the ointments lateral internal Phi Atomy I think is an excellent operation to offer. I think if it's done carefully, it's a very safe operation. I've done it many, many times in my career. I'm very careful about how much of the muscle that I take. And I think the literature, again, would bear this out, that if you do a limited lateral internal swing atomy, you can achieve about 90% success rate with very little risk of incontinence.

(44:56):

And that's of course what everybody's worried about. So when I do the surgery, I do an open technique, a number of my colleagues like this, the closed technique, but I will make a small incision in the inner sphincter groove. I identify and isolate just a small portion of the internal sphincter. I usually try not to make it any larger than the size of the fissure, and that's really all the muscle that you need to cut, which is kind of maybe the best gauge that you have. But I just cut a little bit and then I test it to see how relaxed does it feel. And if it doesn't feel relaxed, I'll cut a little bit more, but I won't ever take more than the length of the fissure. I put one stitch of chromic in there, I tell everybody, you should be about 80 to 90% healed by the time you come back to see me in two weeks. And that's usually the case. And then I think I just tell them the biggest risk is that it doesn't work because I'm not going to take that much muscle. I'm going to be very careful. I haven't ever had anybody say that doesn't sound like a good plan. I want you to take it all so that this seals up. Nobody wants to be in common.

Dr. Randy Lehman (45:58):

Yeah, that makes sense. But

Dr. Scott Nelson (46:00):

That typically is all you need to do.

Dr. Randy Lehman (46:02):

Very good. I have one last question then if you had any other things to add, Mike? One other question is, working in one IU hospital, they won't let me have exparel. Should I refuse to do perianal disease in that hospital?

Dr. Scott Nelson (46:16):

I used EXPAREL for several years, and I'll be honest, I found it to be more of a marketing ploy If the got 24 hours, I was lucky most of them were taking because I would ask them all when they would come back, and most of them were taking narcotics before 24 hours and the company claimed 72 hours, which I mean, if that were true, I would be their biggest advocate. But most people were taking narcotics within 24 hours. And so while it is better than just giving straight local, it lasts longer. It was not what was advertised, at least in my experience as I talked to my patients as they came back to see me. So our facility actually took peril away. They were charging the patients $2,300 for it, and they were not getting reimbursed for it. So they said, we're not using xprl anymore. And it hasn't really changed my practice.

Dr. Randy Lehman (47:11):

Okay. Don't forget, if you do inject xpr, you have to use a big enough needle. So it doesn't break up the liposomes too for the listener because some people, nurses try to hand it to you with a 25 gauge needle on it, and then all you're going to do is just, it's going to be just bupivacaine. So don't do that. Any other tips? Thank you. You're such a natural teacher, so thank you so much for all of this.

Dr. Scott Nelson (47:35):

I mean, there's always more stuff I guess we could talk about. We didn't really talk about anal cancer, a IN rectal prolapse. I mean, the list goes on and on. So I can come back and we can chat about all the other things if you want in the future, but there's a lot.

Dr. Randy Lehman (47:50):

Yeah, then we can do it justice. So that's perfect. Let's plan on it. How about tomorrow? No, I'm just kidding. So let's move on to the next segment of the show, which is the financial corner. So do you have one financial tip, maybe learn from experience that you have for our listener?

Dr. Scott Nelson (48:10):

I don't think I have anything that people probably haven't heard before. I think so I have seven children. That's a lot of college to pay for. And our goal as a couple when we came out of residency was to get out of debt, pay those off, get a house that would fit the family and pay that off. And then really, I think the best financial advice I could give someone is, look, you make a lot of money and you want to put yourself in a position where as a surgeon, you're able to generate enough income that if used wisely, you can get out of debt, grow that wealth, and then have enough to retire on and do the things that you want to do. But you do need to be fiscally responsible to do that. And I've seen a number of physicians come out and they buy the big fancy cars and the houses and whatever, and they get into trouble financially. I even have some of my partners who live paycheck to paycheck and they make a good salary. And so spend less than you make, always set stuff aside. It is just the basic things. It's really just applying it on a daily basis and then continuing to do that through a career. And if you'll do that, you generate enough income that you'll be able to retire and be just fine.

Dr. Randy Lehman (49:28):

Love it. Thank you. Do you have any classic surgeon's lounge, rural surgery stories, just something crazy that's happened either recently or just memorable from your career?

Dr. Scott Nelson (49:37):

Well, just last month we had a gentleman come in who was homeless, who was living out in the camps, and he had a lipos sarcoma that he weighed 125 pounds. And the lipos sarcoma was probably a fourth of his body weight. And he looked like he was nine months pregnant. And he got sent to my office because he had rectal prolapse because it was so large, it was prolapsing out the rectum. So I took one look at him and his CT scan and we realized he was dying. He was having abdominal compartment syndrome. This was not something that other people were going to want to take care of. So I enlisted one of my partners who is an excellent surgeon, who's a general surgeon, and we took the man to the operating room. We took out 26 pounds. He was less than a hundred pounds by the time we got done.

(50:27):

And it was a fun case to do Once we were done, I think during the middle of the case, I was sweating bullets. There was a few times when I thought this was a really bad idea, but he did well and is now back living in the camps on the streets or wherever. But I had to run to the homeless shelter actually to take his staples out because he left a three days after his surgery. So we had to track him down in the community and get him taken care of. But he did great. But those are the types of things that I think we don't always appreciate that in rural America, you're going to see things that you just wonder, how in the world did you let this go so long? At times, I think, man, we're back in the 18 hundreds here. So those are some of the fun things I think that happen in rural surgery. But it's also a challenge because you're it or you and your partner are it. You're going to have to figure it out.

Dr. Randy Lehman (51:21):

What's your best colon parasite story?

Dr. Scott Nelson (51:28):

So I had a gentleman who had a terrible metastatic cancer and I had to give him a colostomy while we were starting his treatments. And I don't know where he lived, but when he came in, he had maggots all inside his colostomy bag, and he was claiming that he picked it up while he was in the hospital. But these were some really big maggots. And I was like, I don't think so. But I've never been as grossed out as I was watching all of these maggots crawl around in his colostomy bag. That was probably the most disgusting thing I've seen. But thankfully, I don't have too many other stories other than people bringing me in some worms. But I'm still waiting to find my first hookworm or something during a colonoscopy, but I haven't found anything yet.

Dr. Randy Lehman (52:13):

Right. Hey, actually that's one more question on patients that are going to go for hemorrhoidectomy. Do you demand that they have an up-to-date colonoscopy before you do anything perianal wise?

Dr. Scott Nelson (52:26):

Well, I mandate that they've at least been screened in some way. So if they're average risk and they've done and they're up to date with their fit testing or whatever, then I accept that. But if they haven't been screened or they're not up to date, then I do tell them that they need to have a colonoscopy. And for me, I won't do that because let's say in a bad situation they have a rectal cancer, and now you've done a hemorrhoidectomy either open or closed, the last thing you want is unfortunately for maybe some of those malignant cells to shed into the anus. And that just changes everything. And while I think that would be very unusual, there's just nothing wrong with ensuring that people are being up to date on their screening. So I do mandate that for my patients, and I haven't had too many people say, no,

Dr. Randy Lehman (53:10):

That actually happens 100% of the time when you forget to do it on the oral boards though, right?

Dr. Scott Nelson (53:20):

Yes, absolutely.

Dr. Randy Lehman (53:21):

Happens

Dr. Scott Nelson (53:22):

Every time. So yeah, when you take your boards, you just always remember in the back of your mind, colonoscopy, colonoscopy, colonoscopy,

Dr. Randy Lehman (53:30):

The last segment of the show, resources for the busy rural surgeon, maybe colorectal specific resource or else take it wherever you want, far as resources that you think every rural surgeon shouldn't be without.

Dr. Scott Nelson (53:46):

Well, this may sound a little funny, but I think you really need to have a good relationship with your hospital administration. I think far too often surgeons come out being trained, at least I know I was, that your hospital administrators are the enemy and they're trying to, you and I have found over my career that really is very unhelpful when you're trying to get things done. And if you will be pleasant and kind and work well with your hospital administrators, they oftentimes will get you the things that you need in order to do your job. And so I guess, I'm sure many other guests have said, well, you have to have a good mentor or someone to call. And I agree with all of those things. I would just add that I have found that if you have a good relationship with your administrators and with your staff, life just goes so much better for you. And so I've really, I learned that lesson the hard way when I first started because I was trained that they were the enemy. And over my career I've realized that was a very naive approach. And if you can find a way to really ingratiate yourself with the administrators, they will do whatever they can to help you be successful.

Dr. Randy Lehman (54:58):

I think I have some smoke coming off my back right now. So strong

Dr. Scott Nelson (55:03):

Preaching there. But I say that because, well, I say that because I've watched enough surgeons come through who, and I have felt that way. That's how we were trained. And I've just recognized that I, that's a very immature approach to doing the work that we do. And I think we as surgeons oftentimes take the approach that we're the surgeon we know best. You should just do whatever we want. And we don't always consider all of the bigger picture items. Now, I work in administration, I work with administration, I should say I'm not at a hospital administrator, but I have grown to appreciate that if you approach them in a kind, respectful way, they will do whatever they can to help you. And when you act like we were trained to act, at least

Dr. Randy Lehman (55:53):

How

Dr. Scott Nelson (55:54):

I was trained to act, life's just become so much more challenging. So

(55:59):

That would be my advice to folks is they're coming out, especially in rural hospitals, I mean, they love their surgeon. They want their surgeon to be successful. In some cases, if the surgeon's not there, they close. So yes, you are kind of God in that sense is that they have to have you. But if you will, I guess treat them well and be respectful and recognize that they have priorities that they have to meet and work with them, you'll be much more happy in your career and in your ability to get things done than you would've been otherwise.

Dr. Randy Lehman (56:37):

Yep. I love it. Well, thank you so much for joining us, and I just really appreciate you taking this time to do it and across time zones and everything. So this has been so helpful for me, and I'm sure it will be for the listener too.

Dr. Scott Nelson (56:49):

Great. Well, as I said, I'm happy to come back and chat about all things colorectal or whatever else you'd like to chat about. So

Dr. Randy Lehman (56:55):

Very good. Well, I will take us out. So thank you to the listener for being here on this episode of the Rural American Surgeon. I'm your host, and I'll see you on the next episode of the show.