EPISODE 29

The Case That Changed Me

Episode Transcript

Dr. Randy Lehman [00:00:11]: Welcome to The Rural American Surgeon. I'm your host, Dr. Randy Lehman, a general surgeon from Indiana. This show is tailored around the nuts and bolts of rural general surgery practice. You'll find topics such as practical surgical tips, rural lifestyle, finance, training, practice models, and more. We have a segment called Classic Rural Surgery Stories, where you'll get a feel for how practice in the country differs from the city. If rural surgery is your passion, this show is for you.

Dr. Randy Lehman [00:00:42]: So now that the Chloraprep has dried, let's make our incision. Welcome back to another episode of The Rural American Surgeon. I'm your host, Dr. Randy Lehman. Today, I have an excellent episode for you. It's a solo cast, and we're going to be talking about the case that changed me. This is a personal, very close to my heart experience that is a true story that actually happened. It clarifies resource limitations in a small hospital.

Dr. Randy Lehman [00:01:14]: I learned so many lessons in somewhat embarrassing fashion, I would say. You know, I received excellent training, Mayo Clinic, five years. I was really trying. My heart is in the right place. I'm trying to do the right thing. Yet there were some exposed blind spots from this case, and it turned out okay. But it wasn't. I guess it just depends on how you spin the story.

Dr. Randy Lehman [00:01:44]: I'm trying to be as realistic as possible to sort of expose my own blind spots and just be vulnerable and share with you guys. It wasn't even my patient. So let's get into it. Basically, it's a Saturday night. I'm living in a small town in Indiana, 1,200 people. My grandparents live in the next town over, about 25 minutes away. That's where my wife and I attend church. I get a call on a Saturday night.

Dr. Randy Lehman [00:02:16]: This is maybe four months out of residency, right? So everybody kind of knows I'm back, and I'm practicing general surgery and whatnot. I get a call from my grandmother, and she says, "Hey, Randy, I don't know if you heard, but Grandpa's been kind of sick all week." First, he was just kind of not feeling hungry, feeling sick, a little feverish, having some belly pain. Urine was kind of dark. But now, in the past day or so, he's really not been able to get out of bed at all.

Dr. Randy Lehman [00:02:47]: Now he won't drink anything, and he's not actually making any sense. He doesn't know who he is or where he is. I just checked his fever, and it's 103. So I was just wondering if tomorrow, when you're going to come over here and go to church, maybe you could just stop by after church and see him." And so, of course, I said, "Graham, I'm already in the car; I'm on my way." This sounds potentially catastrophic, and it was.

Dr. Randy Lehman [00:03:18]: So I headed over there, and I get there, and he's laying in bed just like was described, doesn't really have any idea who he is, where he is, what's going on. Clearly has not been out of bed for some time. He's got basically a urine sample there, which is quite dark and quite malodorous. He didn't specifically complain of any pain, but I washed him up a little bit, got some clothes on him, and told him the deal.

Dr. Randy Lehman [00:03:51]: My grandpa, you have to understand, he doesn't want to see a doctor, obviously, unless he's dying. So he has basically put this off a little bit, and it requires some coaching and coaxing, I would say, just to get him into the car. At that point, I'm loading him up, and he doesn't have any recollection of any of this. But we got him dressed up, loaded in the car, and said, "We're going to take you to the hospital."

Dr. Randy Lehman [00:04:21]: I took him to the hospital where I was working, a small-town Critical Access Hospital. Took him to the emergency department, called them to give a heads up that I'm bringing him in. We bring him in; his white count is 37,000, he's febrile, his heart rate is 140 sustained, and blood pressure software, lactate, whatever, four and a half, something like that. I thought he had urosepsis, probably would be a common thing.

Dr. Randy Lehman [00:04:53]: Especially because there were some specific urinary complaints. He gets a CT abdomen, pelvis, and it turns out he's got acute cholecystitis, severe acute cholecystitis, and obviously septic. I was pretty proud of our hospital. This is exactly what we're here for—to make this diagnosis and to make a difference in this person's life. Now it's my grandpa, and I'm back home, and I'm in the middle of it. I just love that I was not on call.

Dr. Randy Lehman [00:05:25]: Obviously, I would not operate on my own grandfather. But it's also fortunate that I wasn't the on-call surgeon. So then I called my partner, who was on call, explained the situation, and he said, "Well, you know, it sounds pretty bad." He made it very clear, "Do you want me to do this? Like, do you want me to consider operating on your grandpa here? Is that what you want?" Because the veto power he was given to me, which I thought was very wise, allowed us to separate further from the personal component of this case.

Dr. Randy Lehman [00:05:55]: I said, "Yes, I do." Then we were talking about his fitness for surgery. This is where I exposed my blind spot. This is an example of, I would say, clouded judgment. They were asking, "What's his functional status?" I said, "He's healthy, takes no medications." One of the stupidest things I've ever said. My grandpa had a motor vehicle accident, and he had an injury that kind of messed up his leg, and what his baseline status actually was.

Dr. Randy Lehman [00:06:26]: He didn't look unhealthy to me, but I never saw him walking down the street or anything, right? He moved around his house with essentially a wheeled chair or walker thing. But I kind of thought that was because of his leg. I didn't really think about, "Okay, can you walk a block without getting short of breath?" or "Can you walk around your house without getting short of breath?" If it was somebody else's grandparent, or if it was now, I would say I would have a much better understanding of physical fitness and cardiac fitness.

Dr. Randy Lehman [00:06:57]: I have a lot of patients that come in, and I talk to them. I said, "Can you walk up a flight of stairs and walk a block without stopping now?" They'll tell me, "I never get short of breath, but I have arthritis in my knees, and I can't walk." Then you kind of get a sense of whether that's true. You can always give them a chemical stress test, and then you'll find those types of things out. Maybe they do have a good heart, and they truly just have arthritis.

Dr. Randy Lehman [00:07:27]: In this situation, I think if you would have asked, probably my grandpa would get short of breath with minimal exertion and never sees a doctor. Just because he's not on any medications doesn't mean he's healthy; it means he's never seen a doctor. So he has potentially untreated chronic illnesses, anyway. I think I guided a lot of that decision-making with my own sort of just sort of clouded bad judgment.

Dr. Randy Lehman [00:08:29]: What then happened is my grandpa got two liters of fluid and some antibiotics, and immediately he was awake and oriented, sort of confused about what had happened. But he knows what's happening now, and he knows what's going on with his gallbladder. He's asking me very appropriate questions about that. Then also, to the point where he says, "Hey, you know, like my elbow's been hurting me for about 13 years. You think while I'm in here, they could just get an X-ray of it?" So like, back to his old self, basically, is what I'm trying to say. And obviously, we didn't chase down the X-ray elbow problem. Right. Still not with a complete awareness of his overall septic picture. So, anyway, the patient, my grandpa, was admitted to the PCU status. We gave him IV antibiotics and fluids and resuscitated them overnight.

Dr. Randy Lehman [00:09:31]: With a plan for the next morning, Sunday morning, a laparoscopic cholecystectomy by my partner. The other big thing that we did not do a good job on in this case is clarifying and communicating. And this totally should have been me, of all people, that did this, but clarifying my grandpa's wishes if things didn't go according to plan. And I'm much better about that. I mean, generally, I'm good about that with my patients. But, you know, there's all these other little pieces when it's somebody close to you. So you're thinking about all these other things, and that basic thing sort of got away. I wasn't thinking about it going bad. And I think that's the reason why you don't operate on your family members is because it's different. It's totally different than when you're operating objectively on another patient and you're thinking about the regular routine things that you normally would do. In rural surgery, you can't not operate on anybody that you don't know, you know, just because you know them. You kind of have to know that, I think, in your own head: am I able to maintain objectivity in this scenario or not? And like, for me, I guess it would depend on the case, and it would depend on the relationship. So there are close friends, you know, that I wouldn't do much on, and then there are family members that are a little further related from me that I probably would, you know, and so it all depends on the relationship. And then whether there's anesthesia or not, that's probably the big determining factor in the case. Obviously, lumps and bumps and skin things and stitching people up are just, I guess, a joy of being able to provide that service for your close friends and family members in a small town. But once it gets to putting somebody asleep for anesthesia, doing major abdominal surgery, especially emergency surgery, that's something you obviously should stop and think really hard about and probably not do. So, long story short, we didn't have a goals of care discussion. It was just obvious: you've got acute cholecystitis, that gallbladder needs to come out. By the next morning, the white blood cell count was significantly improved. His vitals were significantly improved. He was feeling much better. Basically, he said he felt pretty much fine. Pain was very much improved. So he went for his operation. I'm waiting in my office with my grandma. Some time goes by, and all of a sudden, I hear "Code Blue, the OR" over the speakers. And I'm like, okay, Grandma doesn't know what this means, you know, so I'm like... And then I hear it called again, and I'm like, all right, I can't just sit here. I'm going to go down. So I walk down there, and I go in, and, you know, there we are doing chest compressions, coding my grandpa. And it's quite an experience, a Sunday, you know, so the regular hospital crew's not around and the skeleton crew's sitting there coding your grandpa. So I tried to, you know, I just kind of asked them, what can I do? And they said, well, you know, what are his wishes? Which I didn't really know. And so they said, you know, why don't you go tell your grandma what's going on, and let's have a conversation. I can't remember if I went there with my partner or just by myself or how it was, but basically, we went and talked to my grandma, and they continued the resuscitation. The reason why that happened was because they were done with the case. The gallbladder was gangrenous, so that was converted to an open operation. And then there was...well, you know, it's just terrible, like a bomb went off in the gallbladder fossa and everything. By the time the operation's over, then the extubation occurred. After extubation, you know, there are lots of things you could say about the whole entire scenario, and I don't want to say anything bad about anybody except for my own judgment, right? In the scenario, obviously, anytime you have an M and M, there are probably 10 or 12 things that you could say, well, I could have done this or that differently. That's always going to be true. But anyway, he coded after extubation. So then the re-intubation was performed, and then, you know, chest compressions and chemical coding were done according to ACLS protocol. So I go back there and talk to my grandma, and we call my uncle, who my grandpa works with on a daily basis. Both of them are like, well, this isn't good, because not only is he dead and they're coding him, but he never would have wanted this. And I'm like, okay. So, you know, and they say, well, every day he says, you know, if I die, you let me die, and I don't want CPR. If it's my time to go, it's my time to go, and I'm ready, and I don't want any mechanical support. I basically want to be a DNR, although that wasn't communicated and put in place before the operation. So we kind of decided we don't think he would want that. And so I walked back over there, but by that time they got him back. And so we were like, okay, well, you know, let's carry on and see how this goes. Get him to the recovery area. So they took him to recovery. We go back and kind of talk again with my uncle, and then all of a sudden I hear "Code Blue in the recovery area" over the speakers, right? So then I go down there, and we're talking again, and we're like, well, we think he might want to be a DNR. But we still weren't 100% sure. That was a relatively short-lived code. Then they got him back again. So we're still gathering the family and trying to communicate about things. Leave him there, but we're getting more clarity, and we're like, we think he probably is going to want to be made a DNR. Meanwhile, I go back to my office. We talked to the doctor, the hospitalist who has come in now, who's going to be assuming the care of the patient. And he's a good friend of mine, we started the same year, and he wanted to be clear. Well, sure enough, we have a third code. And now, in the middle of the third code, we kind of decided, we really don't think that this is what grandpa would have wanted. So we decided to stop the code. They stopped it, shut off all medication, shut off the IV, shut off the monitors, and they have him on the vent. We decided to gather the family and essentially come pay our last respects to grandpa before we extubate him. And this is in the middle of COVID, right? There's, like, maybe three other patients admitted in the hospital. One of them's mine, and he gets admitted. We start calling, and it's Sunday afternoon, and everybody comes, and because it's Dr. Lehman's grandpa and the whole situation, the whole family comes in. We've got, like, 40 people. My grandparents had eight children, and there's... I think, last count is it's above 60 in terms of my first cousins and the rest of the family all combined. And it just... Now it's just, like, blowing up the family, because, of course, we're all having our own kids. It's a huge family. My grandma... Grandma and grandpa on my dad's side actually became quite close with them. Always were, but especially after my mom passed away. And they often come to family events, and so they even came to the hospital. We're all gathered around Grandpa's bed, and he's just laying there with no medication, unresponsive, on the vent. It's kind of sad, but if you know my family, they're hugging each other, supporting each other. They're in there singing songs. I hear from my patient that was admitted to the hospital the next day, "Yeah, it was kind of chaotic over there, and I don't know what was going on, but we were hearing, like, singing and everything." Well, sure enough, about when we get a critical mass of all these people in the room, Grandpa opens his eyes, and he starts looking around at all these people. He kind of half-smiles, you know, with the tube and everything. And of course, the family is just, you know, confused, looking around, like, what's going on? They ask me, you know, "What's happening?" And I was like, well, you know, we're all just gathered around here preparing ourselves to terminally extubate Grandpa, you know, and they said, "Well, okay, what are we going to do now?" I'm like, I mean, I don't know. And they said, "Well, what would you want?" And I said, "Well, if it was me in his situation, I would want someone to ask me what I wanted." And they're like, "Oh, well, could you do that?" And I said, "Yes, sure." This is literally as clear as day. I go up to him and I said, "Grandpa, here's what happened. You had a heart attack. After surgery, you coded. We had done three rounds of chest compressions, and we thought you were dead, and we thought that wasn't what you wanted. So we shut everything off, and we were basically preparing to pull this tube out and thought that you were going to be pronounced dead. If you want to be treated further to live, you need to go to a place where there's a cardiologist and you'll have to be transferred. It'll probably be an ICU for quite a while and it'll be a long recovery. Is that what you want?" And he just emphatically nods yes, you know, with his whole upper body, basically, because he's still intubated. And I was like, okay. And of course, I got my uncle who works with him and has to hear about it, like how "I don't even want to drive in an ambulance if my, you know, my life depended on it" and all this stuff. He's in the back corner, and he goes, "Even if you have to drive on a bumpy road to get there?" And my grandfather just, you know, of course, like, he didn't respond to that. But, you know, when faced with the dire straits, you know, it feels different for the individual. So basically, coordinated for the nurse to come in. And of course, the nurse asked him all the things. "Would you want chest compressions?" Yes. "Would you want longer-term intubation?" Yes. Would you? Basically, full press, full court press, you know, is basically what he agreed to, which is totally different than what he's been saying for 30 years to the rest of family, which makes it hard. And that's why you should have the discussion with your family members. And certainly, that has changed my discussion with some of my family members. So we decide, okay, we're going to ship him. Well, now all of a sudden they didn't want to take him now intubated or something, I can't remember, at the nearest referral center, which would have been in Lafayette. And they have a cardiac, you know, on-call team and everything. And he seemed to be sort of stabilizing. So they get some stuff. And there, there was going to be a hassle to sort of transport him intubated anyway. And so he was looking so good now that the decision was made to extubate him and stay the night and then go down there the next day. I can't remember all the details in retrospect. Obviously, it seems like a bad decision, but we were making decisions on the fly. Long story short, we extubated him. He's talking, he seems to be doing okay. They're kind of like lining things up, getting another set of labs and everything. And I'm in the room, and a couple of minutes after extubation, I'm just sitting there watching him. All of a sudden, his eyes go real big and his mouth purses into an O. He's just real still and not breathing. And I said, "Grandpa." Nothing. No response. I'm like, "Grandpa, can you hear me?" Yes. He gives me a big body nod. I go, "Grandpa, are you in pain?" Yes. He's nodding. I said, "Grandpa, are you having chest pain?" Yes. He's nodding again. I'm like, "Guys, pretty sure he's arresting again, so come back over." Yeah, he's not breathing. He's not. He's legit arresting. So you re-intubate him. He did not require, I don't think he required any more chest compressions at that moment. But of course, then the decision was made, we're going to fly him down. No, they didn't fly him down. I take that back. I think weather prevented flying. That was part of the problem. So we put him in an ALS ambulance and shipped him. That was part of the problem, sorry. So then I called my other buddy, who's a physician in town, and he was just coming back in from being out of town, and he came in and sort of helped us all just mentally and actually rode down in the ambulance with my Grandpa, as well as one of the nurse practitioners from the hospital. This sort of thing again, like, this is a small town and the atmosphere. Then I chased the ambulance down there with the car, and by the time I got there, he'd been evaluated by cardiology, and he went for an angiogram. On angiogram, he had essentially 99% stenosis all over. They said his coronary arteries are a block of calcium. There was no stent that could even be placed, no minimally invasive intervention that could be performed. The only answer would be a bypass operation. That couldn't happen right now because he's basically too sick, and he would die from the operation anyway. So all we can do is supportive care in the cardiac ICU. So they put him in the cardiac ICU, and they started whatever antiplatelet and the best cardiac treatment. My buddy and I went to IHOP, and I just felt like the weirdest sensation, like my life was just buzzing around me. I went home, and I was pretty sure that he's going to die from all this. And I kind of felt, first off, in the middle of it, like I was personally responsible for my own Grandpa dying. I mean, he was in pretty dire straits, but I was involved. Then we just waited, and it was day after day, and he's kind of stabilized in the cardiac ICU, and he got better. Eventually, he left the cardiac ICU and went to cardiac rehab, and he spent, I don't know how long, but well over a month in the hospital. Then he was able to discharge home. That was in 2020. We're in 2025, coming up on a five-year anniversary, and he's still kicking back to his baseline, using the same wheelchair to get around his house. All he's kind of left with is an incisional hernia, which we're just going to watch and never fix. Of course, he refused cardiac bypass surgery after he was out of the window and it was offered to him. Basically, you know, he's back to his usual state of health, which, you know, according to this idiot, is healthy and takes no medications. Thank goodness he didn't die. And thank goodness it was my grandpa and not some other patient in my community, because I can tell you that story now, and it's not painful so much. I mean, it's not a great story, but because of the outcome, it worked out. And I—you can't—I mean, I hope that you, especially if you're a resident or a junior attending, can just kind of imagine yourself in my situation. And then, when we talk about resource limitations, a single CRNA practice, right? A hospital with no cardiology, hospital with no dialysis, hospital with no nephrologist, you know, there's things that we don't have and the risk stratification of these patients ultimately comes down to the responsibility of the surgeon. And you're trying to have an educated conversation. A lot of these patients, they do not understand or do not believe in modern medicine to begin with, and they're untreated, they have untreated diseases. It is our responsibility to work them up appropriately before surgery and to be aware of the medical things that are going on. And that's why a lot of us went into general surgery, at least I did, because the general surgeon of all doctors is the doctor that still is the surgeon that's still the doctor. We'll put it that way. And if we, you know, I like to be a technician, I like to do the technical work, I like to be efficient, I like to crank cases out. But we need to have some sort of process to evaluate the medical fitness of these patients, especially the ones that we're putting to sleep and to really understand on the inside what their cardiac condition specifically is, as well as pulmonary, and what effect that has on their overall risk for surgery. So that's the case that changed me, I would say, of all the cases that I've done. And it wasn't even my case, but it made it really personal. It also makes it very easy for me to relate to my patients and to think about how they're going to feel if they're confused about end-of-life care for their patient, how they're gonna feel in terms of stranded when the patient is having a bad outcome. I've had almost no situations like that in my practice. Largely, I would say, because of that experience, because I'm not a cowboy. Discretion is the greatest part of valor. I use a lot of discretion and a lot of preoperative cardiac consultations and testing and optimization and turn people down when it's not the right thing to do. It's not a black-or-white thing, but you can try to develop some protocols and guidelines for yourself. I'd encourage you to talk to your anesthesiologist about that and have just basically checkboxes for when you're going to say no and why, whether that's weight, comorbidities, and it's a balance. Because I don't want to not offer something to my community. I understand the burden of travel on these patients. The purpose of my existence is to provide care in the hometown of these patients to help support the hospital so that it can stay open for both emergency and elective indications. But when a patient dies in a small town, except for maybe coming in, and a patient's already known to be end-of-life, and facilitator comfortable death for them, those kinds of scenarios are a little different. But especially if you have an elective case that goes bad and then there's a death, the community and the people don't look at it the same. I'm thinking OB as well. It's like it's okay for the patient to go to the big city and die in the big city, but when it happens in the small town, it's not okay. Honestly, I don't want to have my patients dying anyway. For me, the practice that I have, which is largely elective patients, largely do well—they're generally not Whipples, they're not esophagectomies, they're not liver resections. They're not big operations that patients are going to really have a large physiologic insult from. In some ways, my practice is kind of like a dermatology practice for a surgeon, except, I mean, I'm doing real surgery: colons and hiatal hernias and breast surgery and abdominal surgery, hernias and gallbladders, appendix and hysterectomies, but then lots of lumps and bumps and carpal tunnels and lipomas and trigger fingers and things like that. So it's a nice operation. I get to operate, a nice practice to have all ages, both men and women, all throughout the body. It's like everything you would want from surgical oncology specialty and also from a pediatric surgery specialty. That's one reason why people like to go into those specialties, I think, because they operate on the whole entire body. But at the same time, it's like all the positives of an elective outpatient dermatology practice because most of the patients do well, and you can kind of sleep a lot of nights uninterrupted. At the same time, you're providing such a service to your community by keeping the care local. It's this fine line, like I said, between not offering the thing, going down that rabbit hole of cancellectomies and saying no to people, and also, like, never wanting to be unprepared, ever wanting to be a cowboy in the rural scenario. Rural surgery is different because, as we've talked to people from rural Canada on this podcast, you know, the rural mountainous west is a little different than rural Indiana, where I'm at. I do have a hospital with cardiology 45 minutes up and down the interstate, either direction, 45 minutes to an hour. So that's a little different. Helicopter ride, maybe 20 minutes. What I'm doing, maybe, is not realistic everywhere, but those are the thoughts that I sat there for five years in residency knowing where I was going to go. Well, like four years, I would say, signed my contract with maybe three and a half, four years to go. Every case I did, I imagined I'm going to be in this austere rural environment. How am I going to do the case differently? I remember being on vascular surgery, talking to Dr. Kalra, and we were doing a AAA and I said, okay, this comes into my hospital. What am I doing, how am I doing it? You know, step by step, just like I do how I do it here on the podcast. You can do that all you want in training, but that case made it real for me and it made me really understand other things that I didn't quite get. Like all of the pre-op testing, all of the anesthesia PAMI clinic that we had in residency, what was actually being done. If you're a resident, I would encourage you to go spend a day or two on the PAMI clinic and really talk about things and maybe before you start practice, crystallize or early on in your practice, crystallize. Here's what I'm going to do with these conditions and how they all affect the risk and look at the risk models that anesthesia is using and cardiology is using to determine surgery risk in terms of the level of the case and the level of the anesthesia risk as well. I hope that you gained something from this crazy experience that I had. If anything good can come out of it by some other patient having, you know, just a thoughtful surgeon considering perioperative risks. There are so many other options besides what was done. You know, we totally could have done a percutaneous cholecystostomy tube, transferred the patient. ICU percutaneous cholecystostomy tube probably never would have coded. You know, get yourself to cardiac workup ahead of time, angiography, ahead of time stress testing, cardiac interventions, and then an elective operation might not have had to go open then, you know, or whatever. There's lots of different ways that could have been handled versus destination cholecystostomy. But the thing is, when you're sitting there, and it's your grandpa in front of you, and you know how much he's going to hate having that drainage tube stuck out, you think, "Well, we just get it out." But once you choose surgery, like I tell all my patients, you can't take it back. So you're just trying to make a wise decision. Also, the more that you can just involve the patient, if you can take the time to really explain what the risks actually are, the patient will make the right decision for themselves. And that's definitely where we've moved to with, I would say, medicine in general, it's not that paternalistic "I'm going to tell you this is what's got to be done," but rather, "Let me explain to you as best I can." I mean, I can't take the last 20 years of my life and boil it down, but I can do a pretty good job and get you on the right track. It could go this way or this way or this way. I had an 85-year-old patient recently who we decided to do a two peg tube gastropexy technique to manage a large paraesophageal hernia. So it just tilted her heavy bed up, dragged the stomach down with the scope as best as I could, popped two peg tubes in just as an anchor and that's it. No repair of the hernia. She obviously did great with that low-risk procedure, low anesthesia risk procedure, and I didn't know how much it would help her symptoms, but it definitely anchors her stomach down there. And so the risk of torsion is pretty much gone, and actually her symptoms are much better. She made that decision, and we had several conversations about it, and she made the right decision for herself. But I mean, I wasn't opposed to fixing the hernia laparoscopically, and in the right person, if she said no, "I don't want to do that, I really want to drag the whole thing down," if I'd really educated her correctly on the risks, and she made the decision, then we can live with the outcomes and it might have worked fine. But she wanted to go with the lower-risk, lower morbidity, sort of lesser operation, and I really think that was a great decision in that scenario. So best of luck to you. I just want to encourage you, the practice that you have in rural America, you are making a difference. You are changing your communities for the better. You're a role model in your community, you're bringing jobs to your community, you're helping patients directly. But even more than that, the people that see you, that are around you, they're going to feed off of your energy. And that dedication and drive that it takes to get to the point of being a rural surgeon, that independence and strength that it requires to go to a place with fewer resources and be a surgeon in that environment. Keep up the good work. I appreciate you. I appreciate you listening to this podcast. If you're finding any value, the one thing that you could do for me is like us on Facebook, YouTube, on whatever podcast app you're listening. Please give us an honest review and please share maybe on your Facebook, maybe you share through any other ways with people that are interested in rural surgery. Because I'm just a voice crying out into the wilderness here about a topic that I'm passionate about. But I'm having a lot of fun with it. And we just want to reach the right people and the right audience. So thank you again for being with us. And I will meet you guys next time on the next episode of The Rural American Surgeon.