Episode 30
Innovations in Rural Surgery with Dr. Eugene Shively
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. So now that the chloraprep has dried, let's make our incision. Welcome back, listener, to The Rural American Surgeon podcast. I have my first repeat guest, and I'm proud again to be joined with my mentor, Eugene Shively. Thank you, Dr. Shively, for joining us again.
Dr. Eugene Shively [00:01:00]: Oh, it's a pleasure to be here.
Dr. Randy Lehman [00:01:03]: So we can shorten the introduction because you've already been on, but Dr. Shively is a retired general surgeon who practiced his career in Campbellsville, Kentucky, which was his hometown. I rotated down there as a fourth-year medical student. We've been on multiple medical missions together. He was very instrumental. I might have scrubbed more cases in my lifetime with Dr. Shively than any other surgeon mentor, I would say. And he's been very helpful with so many things, not just the technical aspect, but also just the mental aspect of what I've been able to do. And so I appreciate you coming on again to just share that wisdom with our listener as well.
Dr. Eugene Shively [00:01:41]: It's a real pleasure and it's been a pleasure working with you. It's been a real joy.
Dr. Randy Lehman [00:01:47]: Yeah, thank you. And water skiing as well.
Dr. Eugene Shively [00:01:50]: Yes, of course.
Dr. Randy Lehman [00:01:54]: All right, so first off, let's go back to that first question of my podcast, which is: why is rural surgery special to you? And just a few thoughts about that. Please share.
Dr. Eugene Shively [00:02:07]: Well, it was special to me because I went back home and was able to practice. It's more special now in that we've got a real crisis in rural surgery. When I started, the surrounding communities all had surgeons. There was a surgeon in Columbia who did a huge amount of work, one in Greensburg, and then there were three surgeons in Lebanon. All of these towns are less than 20 miles away. And then in Campbellsville, there was one other surgeon, and so now we don't have that. We have two surgeons in Lebanon, but there are none in Greensburg or Columbia. So this is just an example of what a need there is in rural surgery and particularly out west where there's a phenomenal need. We have a lot of rural hospitals that are closing. I'm afraid that's going to get worse because if we cut back Medicaid, then it's going to really hurt the rural hospitals. For example, our hospital here in Campbellsville, 20% of the patients are Medicaid. If we cut that back in half, it's going to hurt financially. It's also going to hurt the universities. But in Kentucky, in addition to.
Dr. Randy Lehman [00:03:40]: Access to care as well.
Dr. Eugene Shively [00:03:41]: All right, we talk a lot about disparity of care, and that is actually true, particularly in cancer treatment. We have patients that used to have to travel an hour and a half one way to get chemo and radiation, particularly radiation. We were able to build a cancer center where they don't have to do that now, and there's less travel. That's been a great asset, but we need to keep that going.
Dr. Randy Lehman [00:04:18]: Yeah, yeah. I mean, you know, I don't really want to make it political on the podcast. This is a surgeon's lounge, basically, for rural surgeons. A young, practicing rural surgeon can find some tips and tricks, and we can all sort of commiserate about things, but also uplift each other and inspire each other and focus on things in a more "what can I do about it?" thing, rather than throwing up your hands. But since you brought it up, maybe we'll dive.
Dr. Randy Lehman [00:04:48]: In this for just a little bit, because I have some opinions, we have some differences of opinions, but I would say the underlying goals and motives are the same. The question is then how. How do you get there? But I guess I would like to say my thoughts about what's the difference between, well, what is a right? I guess. A lot of people say healthcare is a right, education's a right.
Dr. Randy Lehman [00:05:18]: Okay, I disagree. Because a right is things that are defined, for example, in the Bill of Rights. Because a right is not a good or a service that has to be taken from someone else. We can decide as a society or as a country, better word for it. I would say that we're rich enough and we have enough resources that every man, woman.
Dr. Randy Lehman [00:05:49]: And child should have access to some basic type of healthcare. We should provide some type of education. Maybe we even say we should provide universal basic income, right? We could decide that, but really, the words matter. I think it's important to not say that it's a right, because here's what a right is. You have freedom to assemble in groups. You have freedom to say what.
Dr. Randy Lehman [00:06:19]: You want to say, freedom of speech. You have freedom to your religion. You have freedom of the press. You can make a podcast if you want to. But the government is not obligated to provide you with the headset and the mic and the laptop to make your podcast. If it's a good or a service, all of a sudden, it's not a right. You have the right to carry a gun, but the government doesn't have an obligation to give you the actual gun.
Dr. Randy Lehman [00:06:50]: And you also have the right to be free from soldiers being quartered in your home. So these are rights. It's not a good or a service that has to be taken from somebody else. Now then, we can discuss about, well, are we helping or hurting by giving free stuff away? Is the government the right agent to be giving free stuff away? Or does charity do it better? Because often the government's giving away somebody else's money and it's.
Dr. Randy Lehman [00:07:20]: Spending it on somebody else, which there's a four-square diagram that talks about how efficiently money is spent. If it's your own money spent on yourself, it's spent the most efficiently. But if it's somebody else's money spent on somebody else, who cares? And it becomes a very inefficient system. The other thing is in the FFA creed, I believe, it says, "I believe in less need for charity and more of it when needed." So fundamentally, those.
Dr. Randy Lehman [00:07:51]: Are my core beliefs. Now, that being said, we have to have a safety net, and we are rich enough that we should provide some basic healthcare, probably. So that's where we start to talk about where have we been in the past, where we get to now with Medicaid, and now we have to make a decision. So, are we going to stop the madness and pull back on Medicaid, which will initially hurt? And I definitely am sitting there with.
Dr. Randy Lehman [00:08:23]: Patients that have different types of serious conditions, both benign and malignant, that are surgical cures, and watching the burden that that would put on them to have to go to the city. So I understand it. I mean, I'm with you on that, but just tell me, but try to. We'll try to make one more comment on it and then maybe we move on. Your perspective on what you think needs to happen now with Medicaid and what is happening, maybe catch us.
Dr. Randy Lehman [00:08:53]: Up.
Dr. Eugene Shively [00:08:56]: Well, my basic philosophy is that in Western civilization, a profession is different than a business. The professions traditionally have been the ministry, lawyers, and physicians. And that means that they are a group of people, higher education, who can provide services to you that you can provide for yourself. And so I think we've always been obligated to take care of patients regardless of their ability to pay. That's what a profession is. Traditionally, if somebody comes into the emergency room at 2 o'clock in the morning with appendicitis, our job is to go and take care of that patient, take their appendix out, and treat them regardless of their ability to pay. I was fortunate enough to live in times when we weren't so dependent upon government involvement. I went to medical school in the 60s. We had a safety net hospital at Louisville General and also in Lexington. All our hospitals in Kentucky were not for profit, and we've evolved back to that in Louisville. We have three networks that are not for profit and providing service for these patients. The problem now is that we've become dependent upon these services and this money.
Dr. Randy Lehman [00:10:46]: And.
Dr. Eugene Shively [00:10:51]: The cost of medicine is so much that in order to keep our hospitals going, we need this extra money. We've created a kind of a catch 22 in that we can't get away from it now. We can't operate without this extra money. The cost of medicine has just gotten out of control.
Dr. Randy Lehman [00:11:23]: Yeah, I think we could. I think that when you give free stuff away, you're always going to become dependent on it. And I think the only way to solve that dependency is to stop giving the free stuff away. It's going to hurt at first, but eventually market factors will prevail, and you can get back to essentially for profit with charity. I think that's going to be your best and most efficient delivery. The other thing is, you know, I would say, of my practice, probably I'm 90% elective. You have capacity within that 10% to offer some free charity care when really, really, really emergently needed, like life-saving, not life-improving. Most of my surgery is life-improving. It's not a strangulated hernia; it's just a painful hernia. They have bad reflux that they're not going to die from today, but the appendicitis, the strangulated hernias, acute cholecystitis is such a small percentage. It just depends on which practice model you're in. If you're in a university referral center and you're an ACS surgeon, I guess that's a different setup entirely. But you look system-wide, I think the only way to solve it is to stop the madness. But, you know, we kind of have a little difference of opinion. The funny part about it is I know your motives are so pure, and, you know, my motive is probably less pure than yours, but there are still good motives. I'm trying to be motivated by the right reasons, and yet we can still come to different conclusions.
Dr. Eugene Shively [00:12:58]: Well, I think there is waste in the system, and we need to try to fix that. I think there are ways to do it, and we need to start working on that.
Dr. Randy Lehman [00:13:14]: Do you think insurance reform is one of those ways, or what would be the... if you had one thing you could do to decrease the waste in the system, what would it be?
Dr. Eugene Shively [00:13:24]: Well, there are three predominant problems right now. One is for-profit insurance companies are making phenomenal amounts of money. I remember when I grew up, almost all the insurance companies were not for profit. If they made some profit, the money went back to provide decreased premiums or more care. The other problem is pharmaceutical. Don't get me wrong, the pharmaceutical industry has done some unbelievable things, but the amount of money that's involved is just phenomenal. We need to try to fix that. I think the pharmacy benefit managers are making huge amounts of money, and I'm not sure that we even need them. I think that's one of the issues. The other major problem is, there are lots of problems. As you know, I've studied this extensively. In the last three years, we've been doing podcasts on the US healthcare system. We spent over $4 trillion on healthcare, and approximately a third of that is wasted money. For example, when I started in practice, we had an administrator and a director of nursing. Now we have, I don't know how many administrators we have, and why do we really need that? The bottom answer is we need it for all the paperwork. For example, each insurance company is different and requires different forms, and it just takes a huge amount of time. A doctor or a hospital has to hire all these people to do that. So those three things are the main ones. There are other things. Another example is we're the only country in the world that allows doctors, lawyers, hospitals to advertise. New Zealand does allow pharmaceuticals to advertise. No other place in the world does that. There's a huge amount of money that could go back to taking care of patients. I don't mean going back and the doctors make more money, but going back into the actual care of patients.
Dr. Randy Lehman [00:16:08]: Yeah, yeah, those are great points. I appreciate it. I think we probably should move on from this topic. I mean, we could talk for an hour about it, but we have some other plans to talk about today. We want to go into a couple of "how I do it." The first one is where we go into extreme detail about how to do a particular operation. We're going to talk about some of these we've touched on before, but we're going to talk about gallbladder and choledocholithiasis. You were doing laparoscopic common bile duct exploration before it was cool, let's say. So tell us about your experience. Was that in the 1990s?
Dr. Eugene Shively [00:16:44]: Yeah, we started doing that in the 90s. I don't remember exactly which year. We didn't have access to ERCP. We do now have a person who's actually trained as a hepatobiliary surgeon and does that all the time. So we started doing through the cystic duct exploration of the common duct. I routinely did cholangiography for two reasons. One is to try to prevent injury to the common duct. The other one was there is about an 8% incidence of common duct stones.
Dr. Eugene Shively [00:17:16]: So if we found a stone or if we knew about it pre-op, for example, if we knew about it pre-op, then we'd go ahead, do a cholangiogram, confirm the stone, then we would dilate the cystic duct with a balloon, then put a wire down into the common duct. Sometimes we could push the stone through the ampulla. If not, then we'd put a balloon down over the wire, dilate the ampulla, then try to irrigate and push it through.
Dr. Eugene Shively [00:18:17]: If that didn't work, we'd take a choledochoscope. You can also use a ureteroscope and then wash it out, try to push it through. If that doesn't work, you can get biopsy forceps. You can pull the stone back or you can crush the stone. Occasionally, I used a laser to crush large stones. That worked very well. Over 90% of the patients we did were successful in getting the stones out of the common duct and flushing them into the duodenum. Another thing that we did is if there were a problem and we weren't sure we had all the stones out or we couldn't get all the stones out, you could put a stent through the ampulla into the duodenum, and that made it easier for the stones to pass through into the duodenum. If you had to come back and do ERCP, it was easier to do the ERCP through that stent. Later on, if we had a problem or we solved the problem, we could go in and do an EGD and then grab the stent and pull it out. That was very, very successful. It's become kind of the cool thing to do now. And even experts at ERCP agree that this is a good way of doing that. There is a rare complication of ERCP, and I'm sure you've seen severe pancreatitis in the ERCP, and that is really a very serious problem. We were very successful with that. One of my partners did a few explorations of the common duct. The way we used to is we just made an incision and then washed out the common duct and scoped the common ducts and then repaired the defect after you put a T-tube in. So that's another way. And then we did not hesitate in opening that. That's almost a sin these days to open to do a cholecystectomy or expression of the common duct. I think patients do quite well with that procedure, and I don't think there's anything wrong with it. Just the other day, a surgeon told me, he said, well, we could do a subtotal cholecystectomy, and I guess you can do that, but I think there's no reason not to open and take care of it. It's a fairly easy operation. One of the other things I did, if I had a gallbladder that was really that bad, I would try to get one of my partners to help me do that. The other thing that's important is you need to have a surgical tech or nurse who's really good at doing the technical part of exploration of the common duct through the cystic duct. Because if you don't know how to do a technical part, it prolongs the operation. We always use the C-arm, and so we would know exactly what we were doing and be sure we had the stones out. At the end of the procedure, we did a repeat cholangiogram and made sure that there was flow through the common duct into the duodenum. And that worked very nicely for us. We even did a poster on that and presented it at the American College of Surgeons. Now it's becoming more and more common, and I think it's easy to learn. I don't think you have to have extensive training, someone who's done laparoscopic procedures. And I think I've been told I don't have any experience with this, but it's fairly easy to do other ways like with a robot. And it's probably easier to do routine exploration of the common duct with a robot. You all be sure now that you have a fairly large common duct, you don't want to be making an incision into a small common duct. And that can create problems. You know, you can get stenosis. So certain operations, I've like basically 20 questions that I've already written down to ask you about this. So let's stay on this topic for a bit. Certain types of operations, like for example a total joint or for example a thyroid, they can be very regimented. You're going to do this, then this, then this, then this, then this. Operation over even lap coli, I mean, is like that. But sometimes, you know, hernias can be like that or they cannot be like that. Exploration of the common bile duct is not like that. And it's quite variable. And what's funny is I'm a big proponent of laparoscopic transcystic common bile duct exploration, especially in rural places where ERCP is several hours away. I do it similar but also quite differently than what you described and all of those techniques that basically it's sort of a how many tools you have in your tool belt and we have a stone in the duct, we got to get it out. And so it's problem-solving until you get that problem fixed. Whether that's laser balloon, nitinol basket, which is what I use. Pull it out proximally, which I do more commonly than pushing it down. Yeah, we did that a lot. We would basket the stones and get them out. I didn't mention that, but we frequently did that. Yeah. But I can imagine our listener may be wondering a certain number of questions. So first off, what kind of volumes did you have in your practice to support this? Well, we probably would do this once a month. Yeah, so that's pretty common in my practice. I haven't really seen that kind of volume I've been doing, offering it when, you know, I just had one recently that I took who had a known stone pre-op on MRCP. And we plan to do this. It's not like you just have to do it, you know, when like on a whim. And I have only done it still, I think around eight or nine times in five years. So for me, it's like an every, you know, nine-month procedure. So that's the question is staying current and certain things. Like I've never considered placing a stent or actually really heard much about that. But the more pieces of hardware and like the disposables that you have to have, all of a sudden, the more things are going to outdate. It might be expensive for your hospital. And then you may not know how to use the equipment. So what I was wondering next is, did you have reps that would help you with getting this certain type of equipment? Or how would you recommend for somebody today to figure out all of those pieces of equipment? Well, if I knew I was going to do something like that, I was always read about it beforehand, at least the night before, and make sure. And I would talk to the. Or make sure we had all the equipment. One of the advantages I had, we had two or three techs, and particularly one who was really, really good at this. And so if they knew we were going to do it, they had everything available. And that really makes a lot of difference. One of the techs that I used could probably do the operation himself. So that really helps. And having that equipment available. The question came up just the other day is a rules version, what do you do? You have an operation you don't do a lot. And what I did was I read about it, and I frequently had another person help me with the operation. For example, APR. I never did those solo. We'd always do it as a team. So I think that's important. And I think you can do operations safely that you don't do every day like somebody who does just does parathyroids and thyroids. I think you can safely do those operations as long as you've prepared and ready and you have somebody else helping you. All right. Did you ever have pancreatitis with laparoscopic common bile duct exploration? No, I never did. Okay, walk me through the open common bile. So when you're saying open and explore the common bile duct, you can just say those words. But what do you mean by open common bile duct exploration? Well, you've made an incision usually in the right upper quadrant, and you've got to be sure that you've got good exposure. You dissect out the common duct, make a longitudinal incision in the common duct, and then you irrigate out the common duct. And then usually get a choledochoscope and look proximally and distally and make sure that you get to find the stones and then usually basket them. And then after you're sure you've got all the stones out, then put a T-tube in and then drain the right upper quadrant with some type of drain. Okay. And now how big of an incision are you making on the common duct? Oh, probably a centimeter, depending on how big the stones are. You're coming in with your choledochoscope. That's got some continuous flow irrigation so that you can see. Yes. So do you use some sort of clamp or some way to prevent that all from coming out? Your choledochotomy. As you pass your scope, you can. Put a suture in it and just pull the suture up. That's one of the ways of doing that. Okay. You can just pull it up. That way, you can release the suture when the stone comes out. Right.
Dr. Randy Lehman [00:29:04]: If it's bigger than your scope. I got you. I was just wondering how that water was going to flow throughout my whole entire abdomen and everything. So that makes sense. What if you came across an impacted stone that was like a centimeter and a half or 2 cm in the distal common bile duct?
Dr. Eugene Shively [00:29:21]: Well, I usually tried to break it up with epoxy forceps, and that usually worked. And then you'd irrigate it out and then take the basket and get the pieces out.
Dr. Randy Lehman [00:29:34]: Okay, what if it didn't work?
Dr. Eugene Shively [00:29:36]: Well, I occasionally would use a laser and break it up with that.
Dr. Randy Lehman [00:29:42]: Okay, what if you don't have a laser?
Dr. Eugene Shively [00:29:45]: Then the options are you can do a choledocho-duodenostomy. I rarely had to do that. That's probably the best option. If you can't get it out, the other thing you can do, and I rarely did this, you can open the duodenum and do a sphincterotomy and get the stone out that way. But most of the time, I was able to get the stone out to the common duct.
Dr. Randy Lehman [00:30:14]: If you're doing a choledocho-duodenostomy, you're doing that at the superior lateral border of the duodenum.
Dr. Eugene Shively [00:30:20]: That's correct. And I usually make a longitudinal incision and then sew it to a common duct. We're talking about, you know, usually a very large common duct. And that operation actually works very well.
Dr. Randy Lehman [00:30:37]: So how about how big do you make that anastomosis?
Dr. Eugene Shively [00:30:40]: Oh, it's probably a centimeter and a half.
Dr. Randy Lehman [00:30:43]: Okay, so meaning you. You pretty much have to have a duct that's about that size, too. And you're going to have an up-and-down incision, longitudinal incision on the anterior border of your common bile duct. But then you're saying you're going to do a longitudinal incision on the duo as well. So that's kind of going transverse, where your other one's going up and down. And they just match them up.
Dr. Eugene Shively [00:31:04]: Right. And then doing this that way kind of holds it open.
Dr. Randy Lehman [00:31:08]: Yeah, that makes sense. I just had a friend of mine that, I mean, within the last probably two weeks, had that exact problem that I just described to you. And he did a transduodenal sphincteroplasty. And got the stone out that way.
Dr. Eugene Shively [00:31:22]: Yes. That used to be a fairly common operation. Now, you know, you have to. It's kind of difficult to repair that. Gotta be sure that you don't have a leak and be sure to drain that.
Dr. Randy Lehman [00:31:38]: Yep, yep. Okay, well, thanks. Let's move on to this next how I do it segment, which is just gonna be a quick touch on robotic surgery in rural locations. And I was wondering, with your perspective of experienced surgeon watching technology change through the years, what are your thoughts about robotic surgery for the rural surgeon right now?
Dr. Eugene Shively [00:32:03]: Okay. Originally I thought that that was a crazy idea, mainly because of the cost. However, the cost has come down and the number of people doing robotic surgery has dramatically increased. And the people I talk to who are doing it are extremely happy with that, with the robot. And there are some people who are doing it almost exclusively, and there's some people who are even doing it in emergency operations, depending on your staff and their ability to use a robot at night.
Dr. Eugene Shively [00:32:33]: So I began to think that the robot would probably be necessary in most hospitals, and that's actually happening. Some of the robotic robots are available in rural hospitals, and they charge you just for the use. You don't have to pay. And it's my understanding from people I've talked to that that's working out really nicely. We have one in our hospital, and it's being utilized frequently, particularly by the general surgeons. They're doing almost all their elective surgery in the abdomen with a robot.
Dr. Eugene Shively [00:33:35]: They do, I think, almost all their colon resections with the robot, and they do low anterior resections and things like that. Also, we have two urologists, and we're extremely lucky to have two urologists in a small rural hospital. They both train in robotic surgery and use it frequently. And we have one GYN who's using it. We probably need to get another GYN who's had more experience in using the robot. It's my understanding that that is really a good way of doing hysterectomies.
Dr. Eugene Shively [00:34:07]: I have no experience in robotic surgery now. The thing that changed most of my career was laparoscopic surgery. And I remember the details of how that changed. I was at a SAGES meeting and it was actually in Louisville, a national meeting. And there was a Frenchman over in a corner that had a booth on laparoscopic cholecystectomy. And at that time SAGES was essentially an endoscopy club. And I don't think too many people were paying attention to him.
Dr. Eugene Shively [00:34:38]: Then a couple of people started teaching courses in laparoscopic cholecystectomy. Eddie Reddick had a course in Nashville, and I actually signed up for it. I had a spot in June of 1990. They called me and said, you need to come; you can come in January, we have an opening. I was very, very busy and I decided not to do that. That was a big mistake. By June, everybody was doing it. Then I had a new partner who had done it in residency. So we started out doing it together.
Dr. Eugene Shively [00:35:39]: The beginning of laparoscopic surgery was quite difficult. And as you know, there was a higher incidence of injury to the common duct. One of the reasons for that is the equipment wasn't very good and the lighting was terrible. It's dramatically different now.
Dr. Randy Lehman [00:35:57]: Yeah. So volume-wise, I'm in four different hospitals right now. I was wondering if you could tell us about your catchment area for that volume of robotic surgery. Because you, first off, I think you're hitting some pieces of information that I think would be essential to have a successful robotic surgery. So if I'm going to a place like two days a month, all right, and I'm going to do like a half day of surgery and a half day of clinic on each of those two days. And that's my whole practice. The only other guy that's going there is a GI doctor. And that's basically the setup in two of the locations. Then I don't think you can put a robot in. There's no other surgeon that does any surgery at either one of these two locations.
Dr. Randy Lehman [00:37:12]: But it's not to say that that couldn't happen. It's just, you know, you sort of the things that you're hitting on are more than one surgeon, more than one specialty, more than one person that has a full-time practice at that location, and all those things come together, and all of a sudden, sure, you can have a town like Campbellsville, 10,000 people, and you can have a successful robotic program. But what's your real catchment area and volumes needed to sustain that robot?
Dr. Eugene Shively [00:37:13]: Well, I don't know the answer to that. But I can tell you our catchment area is about 100,000. We got 26,000 people in Taylor County. We've also got patients coming in from all the surrounding counties and a few patients coming in from farther areas. We have a lot of patients that come into our cancer center. So I don't think you can support a robot if you're just going there two or three days a month. You've got to have a hospital where you're working there most of the time and you're doing most of your surgery there.
Dr. Randy Lehman [00:37:59]: If you personally had colon cancer, would you demand that the surgery was done by a robotic technique?
Dr. Eugene Shively [00:38:07]: No, I'd let the surgeon decide what he wants to do.
Dr. Randy Lehman [00:38:11]: I have a patient I'd like to talk to you about. Real patient. And there's this quote. Do you know Jimmy John's, the sub shop?
Dr. Eugene Shively [00:38:20]: No.
Dr. Randy Lehman [00:38:21]: All right, there's a subway shop called Jimmy John's. It's delicious. All right.
Dr. Eugene Shively [00:38:24]: Oh, okay.
Dr. Randy Lehman [00:38:25]: They're not paying me for this, but it's very delicious. So they have subway tiles on the wall in the restaurant, and they have all of these little, I love it, like, inspirational plaques everywhere with all these little great quotes.
Dr. Eugene Shively [00:38:41]: And.
Dr. Randy Lehman [00:38:41]: And one time in a Jimmy John's, I saw one of the quotes, and it said something along the lines of, if you take care of people from near, then the ones from far will come. And it's funny because I have sort of, what do you call it, reverse attrition, you know, from the rural community, because I've now started to see people that, like, their family member lives in Lafayette or something, and then they'll come.
Dr. Randy Lehman [00:39:12]: To the small town for care by me because I took care of their family member. And they know that they have good access. They know that I am basically have a good heart, and I'm trying to take care of them. And I'm well trained. And, you know, of course, I speak the English language without much of an accent. You know, there's all these essential things. And so they come and see me. I had a patient recently who had some left lower quadrant pain and is living in.
Dr. Randy Lehman [00:39:43]: Washington, D.C. but it's from one of the small towns that I'm practicing in. She came back, needed a colonoscopy, so they set it up locally, and she came back home. She feels safe, probably. And I did the colonoscopy. Turns out she's got a large polyp. She's got some diverticuli, but also has a large polyp in the sigmoid colon that was kind of like an advanced polyp, but I didn't think it was going to be cancer, but turns out it's a Haggitt 1.
Dr. Randy Lehman [00:40:13]: Adenocarcinoma with clear margins. But there was LVI and there was. And so here I am, boom. I have this pathology result. Now you know, what do I do with it? So first off, I reviewed the NCCN guidelines and they would say that based on that you should do some mismatch repair, gene testing and whatnot. So I called the pathologist. That wasn't done, but then it was added on. That's all negative. And.
Dr. Randy Lehman [00:40:44]: Then according to NCCN guidelines, you can just do a colonoscopy in a year. But if you didn't place a tattoo, you should consider going back and doing it, which I didn't place a tattoo. I don't know. I mean, that polyp didn't look that suspicious to me. I don't know if I honestly would do it if I had it to do over again. Obviously, in retrospect, I wish I would have, but. So here I am dealing with all this, and I'm kind of walking you through my decision-making process. But I did tell the patient, I want to load the boat and send you to oncology. So I.
Dr. Randy Lehman [00:41:16]: Did do that and then I took her back and found the site. This is about two weeks later. I'm pretty confident that I found the site where the biopsy was taken because it looked like a little healing ulcer and it was in the sigmoid colon. I placed a tattoo there and then oncology called me back. I was planning on doing a one-year colonoscopy, but then oncology called me back and they said, hey, with this lymphovascular invasion, we actually would like you to do a sigmoid colectomy. And so that's.
Dr. Randy Lehman [00:41:48]: Why I sent them, you know. And so I'm not necessarily going to argue with that, but I think it is probably not a right or wrong answer. It's a matter of judgment and talking to the patient. This patient happened to be 40 years old and her BMI is almost keeping up with her age and BMI is 38. So I don't have a robot, and I usually do most of my colon surgery, hand assist. And so here's my question, all that. Now you're.
Dr. Randy Lehman [00:42:19]: In a rural place. I'm going to one of the places where I sort of do outreach, I guess. What would you do? And I'll tell you what I did after you tell me your thoughts.
Dr. Eugene Shively [00:42:32]: Well, I think it's okay to do it laparoscopically. Hand assist. I don't see anything wrong with that. And the other thing we need to consider is that anesthesia has gotten so good, particularly with the transperitoneal blocks with marcaine. Some of these patients are not having any pain at all, even with hand assist, and use preemptive local anesthesia and blocks. It's just phenomenal. And I think the surgery should be done the way that the surgeon is most comfortable with it. And so I wouldn't even argue with doing it open. I don't think there's any data that proves there's any difference in any way of doing that.
Dr. Randy Lehman [00:43:27]: Well, what if the. Is there a BMI where you would do something different?
Dr. Eugene Shively [00:43:33]: Well, I think BMI does make a difference. And again, this is not personal experience because I did all that open. I was not an advanced laparoscopic surgeon. One of my partners is, and he's now doing robotic. And I'm sure he would do this patient robotically. But I think if you get morbidly obese, from what I hear from talking to people and reading that, the laparoscopic procedure is much better.
Dr. Randy Lehman [00:44:12]: That's what I think. And actually, even robotic over hand assist and the wrist on the robot. I'll tell you what I did is I sent the patient to a referral center to a colorectal surgeon that trained with me at Mayo Clinic, who did the colorectal fellowship up there afterwards. I use him for a lot of things, and especially colorectal. He understands my training and my limitations and also my desire to keep care local for people. He supports me doing what I can close to home. If I have even questions then about cases that I am keeping close to home, I can ask him because he knows that those higher level, like, for example, I'm not doing APRs. I'm not doing any kind of rectal surgery. You know, basically I have a. A bug out button for patients who are too medically sick for my single CRNA practice in my town. Or they have comorbidities that are, you know, I just don't feel comfortable with or, you know, it’s rectal stuff or, you know, different. Different types of reasons that I could send to him. He does most of his surgery on the robot. Obviously, anytime doing any sort of laparoscopic surgery is at risk that you might want to open for patient safety or whatever, it's all fine. But in this patient, like for wound morbidity alone, I mean, I tell a lot of people, look, that incision is like 9 cm for my hand port, and it's not much bigger than like a 4 to 5 centimeter incision for specimen extraction, which is true, but I think that's more true for a skinnier patient in terms of wound morbidity, because when you got a bigger patient, that wound can kind of grow further for you. And I think that for the bigger patient, the robot shines kind of even more because you can blow up that tiny space and kind of get in there better. And so I chose to send a patient, and it was based on me looking at her, looking at her scans, thinking about the overall situation, and essentially experience. I don't have a hard and fast number. And for hard and fast number for our. For keeping patients, period, is we can't do any anesthesia. But per policy on a patient, on a patient with a BMI over 50, but she's not even close to that. And I still decided, technically, I thought the better operation for her was to send her for the robot. Maybe 35 is sort of a number in my head of, like, where that starts to become a tipping point. But that's just anecdotal, so go ahead.
Dr. Eugene Shively [00:46:43]: Well, I think that from what I understand, and I have no personal experience, for morbidly obese patients, the robot is the best way to go. There's no question about that. I think it's extremely important for the rural surgeon to have a very close contact with people that you trust and can deal with very closely. I had that relationship with the University of Louisville Department of Surgery, and it worked really, really well for me. It's very important to do that, particularly if you're in solo practice. But after you get partners, you can ask them, and they can help. If you have a patient that needs to go somewhere else, it works both ways. You can have them take care of the patient or give you a consult, and then you can follow them up, for example. Now, of course, we can do it with telehealth. Before we had that, sometimes I had patients that had complex operations 90 miles away, and we could have that patient have her surgery, and then I could follow up at home so they didn't have to travel so much. It's really important to have someone you can just pick up the phone and call. I had a very close friend who did vascular surgery, and I didn't do any vascular surgery, so I sent him all my vascular cases. We worked back and forth and he always called me after he did a case and told me what was going on. That is really helpful, and unfortunately, we don't have that close relationship like we used to. I think it's important to try to restore that, particularly for the rural surgeon.
Dr. Randy Lehman [00:48:56]: Yeah, the ways I'm trying to do that are going and talking to the residency programs, being involved in my Indiana chapter of the American College of Surgeons. Those are things, and then just, you know, trying to communicate well on the patients that I am sending so that they sort of understand my practice, give people cell phone numbers, explain really quickly what I'm trying to do. I think it helps that they can sort of have a lens and see where you're practicing. But let's move on to the financial corner. Do you have a money tip for our listener today?
Dr. Eugene Shively [00:49:27]: A money tip? I think it's very, very hard to practice outside of a hospital for a surgeon. I don't know anyone who's doing that. When I grew up, almost everyone was in private practice. Of course, there were groups, and there were some large groups, but when you were starting off, for example, in Louisville, Kentucky, I knew doctors who were on the staff of every hospital, and there were some who were even on the staff of hospitals over in southern Indiana. They spent a huge amount of time on the road and they often established their practice by doing ER following and got their patients that way. Things have totally changed now. Another interesting thing is about nonprofit medicine. Louisville is a classic example of how nonprofit medicine is working. The University of Louisville has done a phenomenal job with that, and Norton's Hospital has set up a small hospital in West Louisville, which is a poverty-stricken area. So, we have a lot of nonprofits that are really doing quite well and providing service for everyone.
Dr. Randy Lehman [00:51:03]: I know that you have a great classic rural surgery story for us today and I want to hear about this Facebook article that you recently saw regarding the 1989 pond fishing gunshot wound to the chest accident.
Dr. Eugene Shively [00:51:17]: Well, this just popped up this weekend. My son-in-law, you know, if you're a friend of someone, it'll pop up on your page. I don't look at Facebook very often, but it just popped up. So I looked at it, and this gentleman, I don't think we should mention names, had posted my op note, my H&P. The H&P went very long because it was an emergency. And the discharge summary was on Facebook back in 1989. He was at a pond fishing on a sunny evening, carrying a gun. He was a teenager, I think about 16 years old, and he dropped the gun, and it went off. He had a gunshot wound to the left chest just below the nipple. He had to walk up to a house, and that house turned out to be my son-in-law's mother’s. She called 911. They brought him to the hospital. The chest X-ray looked like he had an enlarged heart, and the bullet was down in the abdomen. It was actually down underneath the skin, but it had gone through the abdomen. We did a laparotomy. One of my partners at that time was Dr. Annalee Adams. There was a hole in the diaphragm, just a graze wound of the liver, no other injury. We opened the diaphragm and the pericardium. There was blood in the pericardium, so we did a sternotomy, and there was just a graze wound to the left ventricle. We were able to stop that with a bovie, put a drain in the pericardium, fixed the diaphragm, and then closed. The patient did extremely well. This was the anniversary of that event, and he posted it on Facebook. I had forgotten all about that. In my practice, we had several episodes where we did gunshot wounds to the heart and they all did very well.
Dr. Randy Lehman [00:53:54]: And you said that he actually posted his op notes. He must have gotten a hold of his medical record.
Dr. Eugene Shively [00:53:58]: Yeah, it was all my op notes and everything.
Dr. Randy Lehman [00:54:03]: That's incredible. Speaking of that, let's move to the last segment of the show, the resources for the busy rural surgeon. So, what is one great resource that you love that you think every rural surgeon should know about?
Dr. Eugene Shively [00:54:17]: One resource I use is UpToDate, extremely frequently, two or three times a day. Even though I'm not doing any surgery, I still see some patients, and I can't obviously keep up with everything, UpToDate is really good. For years, throughout my practice, starting from my residency, I did the ecologist thing on selective readings. Unfortunately, they're ending that now. Dr. Lewis Flint is the editor of that now. He's been editor for quite a long time, and he introduced me to it when they were doing it in Dallas. It evolved into something that the College did. I assume the reason they're stopping it is because of the amount of work it involves, and other people are using the Internet to get their information. But it's extremely, extremely helpful in getting knowledge. I religiously read almost all of them and got a lot of my CMEs that way. So I think that's very important. Our hospital now has UpToDate on their Internet, and anybody who's on the staff can access it.
Dr. Randy Lehman [00:55:48]: I agree, and the nice part is it counts your time, and you can log your CME from it. That's a pretty good resource. So thank you for sharing that, and I just really appreciate you being my guest yet again today. I'm so glad that we've had all this time to talk about surgery, something that we're both very passionate about, specifically rural surgery in our hometowns. So thank you for joining us.
Dr. Eugene Shively [00:56:10]: It's been a real pleasure.
Dr. Randy Lehman [00:56:12]: And thank you, listener, for joining us for another episode of The Rural American Surgeon. If you've enjoyed this show, please give me a review, an honest review. Please share it with other people in your circle because we just want to reach others in the circle of rural surgery, anyone you think would be interested in this type of content. I really appreciate you being here and listening, and it's just been my pleasure and honor. I'll see you on the next episode of The Rural American Surgeon.
