Episode 31

The Privilege of Practicing Back at Home with Dr. Gary Timmerman

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 another episode of The Rural American Surgeon podcast. My guest today is Dr. Gary Timmerman from Sioux Falls, South Dakota. Thank you so much, Dr. Timmerman, for joining me.

Dr. Gary Timmerman [00:00:58]: Honored to be here today. Thank you.

Dr. Randy Lehman [00:01:01]: Yes, and we are both members of the North American Rural Surgical Society. We've come into contact with each other there. We have a lot of other shared friends and connections. And you are one of the godfathers, I would say. And I'm very honored to have you on the show from the Northern Plains area. You've done it, and now you're training it. So, please tell us a little bit about your background, your past practices, and what you're doing now.

Dr. Gary Timmerman [00:01:28]: Thank you, and again, thank you for the honor and privilege to be with you and your listeners today. I hope your listeners gain some insight, some wisdom, and perhaps learn things not to do as they go through their entire career. I'm, in fact, born and raised from a small community, but in South Dakota, everything is pretty much a small community. We like to consider ourselves a city. When I grew up, it was Watertown, South Dakota. It was a community of about 20,000 people.

Dr. Gary Timmerman [00:01:59]: But in the state of South Dakota, that was the fourth largest "city" in the state. So, relatively speaking, if you will, in the state, they saw me as a city kid rather than a rural kid in a community of 20,000. I was introduced to surgery in that community probably when I was a junior in high school, as my older brother, who is also a surgeon, a colorectal surgeon, his father-in-law was a general surgeon. I had shown some interest in surgery.

Dr. Gary Timmerman [00:02:30]: So when I was a junior in high school, he wondered if I wanted to be a scrub tech and assist him in surgery. It turned out there were four particular surgeons, two at each clinic, and there were two clinics in Watertown, even two hospitals at that time. I would go between the two hospitals with the four surgeons and actually worked my summer job as a scrub tech and did that between my junior and senior year of high school and my senior and first year of college, and then two more years.

Dr. Gary Timmerman [00:03:00]: Honestly, I can tell you that I was blessed to take my first appendix out when I was 17 years old, basically just taking the knife and cutting the appendix off after everything had been done, but still claiming to fame that I had an early start in surgery. From there, I went to South Dakota State, which was our state's largest university, and was blessed to get into medical school after three years of college instead of four. The only place that would take you without a college degree, if you will, at that time was our own university.

Dr. Gary Timmerman [00:03:31]: So I went to the University of South Dakota, went there for two years, and it was a two-year school that had just recently become a four-year school. But 15 of us were still rather obligated to transfer. If you didn't want to do primary care, for the most part, most of us that left, there were 15 of us that left, went off into surgical fields of some sort. Because our medical school was 100 years old, they had great relationships with medical schools throughout the United States.

Dr. Gary Timmerman [00:04:01]: I was blessed to go to Washington University in St. Louis and finished my medical school training at WashU and graduated from WashU. From there, I was off to Chicago. Quite honestly, everyone knew when I came to Chicago that my goal was still to go back to my hometown. Even though I was in a really very large city where I think everyone, there were eight of us, everyone but myself went into a specialty. I was the only one that was determined to go back and do general surgery.

Dr. Gary Timmerman [00:04:32]: One of my partners stayed at Rush and did, in fact, do general surgery. But certainly in an urban community, I went back to Watertown. So, back in '89, I made my way back to Watertown, South Dakota, joined the clinic that had employed me when I was in high school. All four of those individuals were still there. They were my senior partners and had three others as those four were retiring. Basically, there were four of us again within two years and two of us for each clinic.

Dr. Gary Timmerman [00:05:03]: For 10 years, I practiced in Watertown. Yep, every other night for 10 years, which wasn't all that different from surgical residency in Chicago at the time, and had a wide variety of general surgery. I did vascular, did aorta bifems, fem pops, in situ fem pops. We just had a new urologist but needed some help with nephrectomy, so I did kidneys; I did probably 300 C-sections along with one OB-GYN.

Dr. Gary Timmerman [00:05:34]: I did Ortho. We had one ortho who needed help or would be gone and someone would have to cover them on the weekends. So I did orthopedics back then; thankfully, most of it was casting, but did pin some hips, did do some K rods, K wires. I actually got in, did a lot of the chest, did lungs. But again, different time. We were trained to do all of those things in general surgery. There were no subspecialties other than maybe plastic surgery, colorectal, and ped surgery, and cardiothoracic vascular, those three together.

Dr. Gary Timmerman [00:06:35]: The one thing I found, though, when I was out there was that I often felt alone. Even though I had partners because of the large scale of the operations that intrigued me, I really wanted to know how to do things and not just one way. And that's something we can talk about a little bit later. But really did visit about the idea that if you're going to be there, surely you can do a lot, but you better be safe at the things that you're doing and you better have options because you may not have a surgeon right down the hallway to call in to help you when you might be it for the whole weekend.

Dr. Gary Timmerman [00:07:06]: So that was pretty much how I got back to Watertown and practiced there for 10 years. After about 10 years, I had a large trauma background at Cook County, and they needed someone to help run trauma down in Sioux Falls, our largest city. The largest city at the time was about 160,000. When I came to Sioux Falls 10 years later, I became the director of our level 2 trauma center and did that for about 12 years.

Dr. Gary Timmerman [00:07:36]: Then after that, I kind of fell in love with the thing that I really always liked to do, which was surgical oncology, and was very much a pancreatic and esophageal cancer surgeon toward the end of my career here. So it's a long path, but all the time in South Dakota.

Dr. Randy Lehman [00:07:57]: Yeah, that's beautiful. And I'm not sure how much you know about me, but right now I'm sitting in the building where I went for my 8-day well-child visit. I found my paper chart in the basement. This is also the building that's across the street from the hospital I was born at. And I bought it. I moved back to my hometown, started an independent practice. And I've said a lot of this before on the podcast, so. Speaker A: But it's the draw to come back to your hometown; it's more specific than just going out and being a rural surgeon because it's that depth of commitment to your home community and what you mean to them when you can come in and do cases locally. It's, yeah, that one-on-one connection with the patient, but it's far-reaching with jobs created in your county, the pride that the town can have by keeping a hospital open, you know, the role model that you serve potentially to students—you know, she can be involved in the community. There's a lot more to it. And so I understand just intuitively that desire to go back to this, the small town. And because the reason where I'm going with this is the next question for the show is why is rural surgery special to you? Some of it goes without saying, but do you have a better answer than what I just put out there?

Dr. Gary Timmerman [00:09:19]: Oh, no. And I'm smiling because you're in your own clinic. I was too. And you know, when I came back, the coolest part of my clinic was when you walked into the lobby. They had a giant koi pond that the kids would always fall into while waiting to see their family medicine doctor. And that was still there when I got back. Then I found my medical records, and same thing: paper charts back then. And you know, I was a sickly kid. I guess it was like that thick. But it was. It's the enjoyment of the people that you're there. Why do I love it? Well, number one, I said the people, to the community. I never felt like I was in a small town. When I was in the small town, I never felt disadvantaged. I worried that others might think I was not providing great service. That kept me on the cutting edge, that kept me forced to read, that kept me up to date. But I never felt like they believed they were getting lesser care. And if they were, that felt that was my fault for not finding out how to do things better for them. I believe, Randy, you would agree that small-town America is probably the best-kept secret. And I don't mind that we're considered a flyover state. In my opinion, just keep on flying. There's something very special in a community like that. There's perseverance. I tell my medical students the greatest honor about coming back to your hometown or your home state is that the blessing and honor you have to take care of people that raised you. I got to take care of my high school teachers. I got to take care of my parents' best friends. I got to take care of my high school parents' high school best friends' parents. Then I even got to take care of many of my high school classmates, especially when it came time for age 30 and 35 to have their vasectomy. And I tell you what, something I did. People might today say I was nuts, but I thought, if you have the courage to come see me, you will not get a bill from me. So I never billed my high school classmates. And then the word got out on that, and I was doing vasectomies on all my high school classmates. But at the same time, I saw it as such an honor and such an incredible privilege you have to take care of people who kind of knew me when maybe I wasn't so great or maybe knew me when maybe they had doubts about me. But obviously, I felt compelled that maybe they must have thought better of me with my practice as well.

Dr. Randy Lehman [00:11:57]: So, when you were in high school, did they have a voting for the seniors for most likely to be late to graduation or most likely to this or that?

Dr. Gary Timmerman [00:12:08]: Actually, they didn't. But you know, this will make. My wife is from a very small town in South Dakota, and in her yearbook, it said most likely to marry a doctor and move to the city. And so, but she moved from a really small city to a little bit bigger city. But she did live in Chicago and St. Louis with me as well. So, I told her I was set.

Dr. Randy Lehman [00:12:30]: Up, but self-fulfilling prophecies. Yeah, I love it. Very good. All right. The next episode of our show is how I do it. And so we go into extreme detail about how you do a particular operation. What are we going to do?

Dr. Gary Timmerman [00:12:46]: Well, you know, how would I say this? For my practice in Watertown, it is very much like it is believed to be. Most of it's endoscopy. A great deal of it is fundamental surgery, like hernia repairs. A great deal of it is gallbladders. And then maybe a little bit more commonly was colon surgery and small bowel obstruction. So a lot of the fundamental things, I was very okay with that. But again, I was trained very much also in a very big city. And my favorite operation that I felt very good at when I left was esophagectomy. And then people are going to go, okay, what's he talking about, esophagectomy? And you may have heard me say about the idea of if you're going to do something, you better do it well, and you better be able to defend it and you better be able to know that you offered the patient everything there was for it. That actually is one of the biggest reasons I got heavily involved with the College of Surgeons. Every clinical congress I went to, I absorbed every seminar on esophagectomy and esophageal management. I bought every journal and every text that I could that talked about esophageal surgery. Remember, I said I was always doing lungs, I was doing vascular, and I really felt that if I had the right support with it, and I did have an intensive care. By the way, I was the intensivist, and I had another contemporarily trained partner who also felt comfortable in the ICU, that given the opportunity, we might consider doing something like that. Yeah, it took me about four years to get the courage to do that, but not only did I do it, but I did on average probably anywhere from 7 to 12 a year. Now, a lot of places would say that was way too few. Yet you also need to know that every one of those patients I actually included in papers that I wrote, articles I wrote, presentations I made to our South Dakota, ND chapter of the College of Surgeons, and even to the point where I presented it elsewhere outside of South Dakota so that I could at least demonstrate to the individuals that were doing a lot of them that I was being conscientious. I also made allies with many at the Mayo Clinic and University of Minnesota that I would be able to contact them. They felt comfortable with what I was doing out there. I never felt that I was doing something I shouldn't be doing. And so, yeah, that I'm not encouraging your listeners to take on something like a Whipple. Although ultimately, that was my career at the end. But at the same time, I had to be able to say, I'm not going to start doing Whipples again at age 45. I had to know how to keep that up. And I always knew one day I'd probably be moving to a larger community. I did not suffer horrible complications, but believe me, I spent a lot of nights with folks to make sure they didn't suffer complications. Yeah. Can you do it? Yeah. But it comes with a huge responsibility if you're going to take on big stuff.

Dr. Randy Lehman [00:16:12]: Yeah. So that's what I was hoping that you would say. And for the listener, basically, we were thinking, hey, we're going to talk about one quote that you have was that I've already heard, “You have to have options when you don't have options.” Am I saying that correctly?

Dr. Gary Timmerman [00:16:28]: Yeah.

Dr. Randy Lehman [00:16:28]: So we were going to talk about inguinal hernia because there are several ways to do it, like tissue repair and stuff like that. But then you kind of mentioned to me just before we started the show, you know, you had to practice with the esophagectomy. I'm like, I may not have. Most of my guests aren't going to be able to talk to me up and down about options for esophagectomy. Speaker A: Me, I'd love to talk about it. I'll tell you my background. I'm five years out of training. I can see how a person that's four or five years out of training now is different than a person that's one year out of training. I can see why you waited four years to do your first one. But I'll also say I trained at Mayo, and the thoracic surgeons did obviously the lung surgery, the esophagus surgery, and the hiatal surgery at Mayo. And so I was, I had two great rotations on thoracic surgery, and I had a really great fellow and then some other good surgical mentors. We divided because he didn't really need any more hiatal work. I knew I wanted to have that as part of my practice, but I knew I wasn't going to do esophagectomy, and I'm not going to do lobectomies either. So, like, I would do some of the minor chest cases and the hiatal work, and then he would go do the Ivor Lewis and, you know, the lobectomies. It worked out really well, the division of labor. And so that's my perspective. I know I'm never gonna do esophagectomy because I took these tests when I was a medical student, and it said you like to do 30 to 90-minute operations that do well. You go home and you can go to sleep, and you like to do a lot of them. And I don't think I would sleep well enough. I don't know. We'll see. It's a long career, but I would love to pick your brain about the many options. And esophagectomy specifically is an operation where there are drastically different approaches. Speaker B: Right. Speaker A: So. So I'm going to let you just take that where you want, and then I'll fill in with some questions. Speaker B: I was blessed in that I trained at Rush, and we had several surgeons that did esophagectomy. One in particular, he's one of my giants of surgery, Alex Doulas. He trained, he did them with O'Ranger, if you remember, the blunt esophagectomy was a transhiatal and he was phenomenal at it. He showed me and then taught me how to do blunt esophageal and. And then I had another surgeon down in the southern part of a community hospital that did Ivor Lewis's and retrosternal esophagectomies. As far as replacements, we would do the stomach pull-through retrosternal. So, I had a really large exposure and fund of knowledge for that and also knew about the complications, knew about what it took. But still, my own paranoia kept me always at the cutting edge of what was going on. So you're right. Transhiatal blunt esophagectomy, it was back in the 80s when esophageal cancer had a cure rate of less than probably 15%, maybe 12%. And so actually, blunt esophagectomy was moderately the least invasive operation because you didn't have to open two cavities; you could get it done in the neck. If you get a leak in the neck, it's much better tolerated than a leak in the chest. And it kind of just got through the bypass, got through the obstruction. Most of these folks still succumbed to their metastatic cancer. A lot of them were obstructed when they presented. And then over time, we finally got some decent chemotherapy and neoadjuvant, something new. I helped bring that back to our community. We didn't even have radiation therapy yet in Watertown at the time. My patients were going to Sioux Falls to get their neoadjuvant or Aberdeen, which is about both ways about two-hour drive to get five days a week of radiation and then come back for me to do their definitive operation. When I decided to do esophagectomies four, five years later, I remember visiting with Dr. Doulas and said, your safest bet is to do everything in front of you. Do them open. You don't want a complication, you can't afford a complication. Do an Ivor Lewis. So an Ivor Lewis, of course, is a thoracoabdominal. There's three phases as well, but you still use the stomach as the conduit, and you do the anastomosis in the neck, and everything is with direct vision. Those went very well. And to be honest, I probably only had done a couple of blunts, and I just liked the safety of open in my circumstance. Again, having comfortable ability with my pneumonectomies and my lobectomies, I felt comfortable doing the chest and closing. It was a long operation, you're right, it's not a 30-minute operation. But at the end of the day, complication rates. Our biggest complication was atrial arrhythmias, SVT. I studied all of this. I had a leak rate of less than 2% and thankfully none in the chest. Most of those were in the neck when I was still doing some blunts. And then actually in 19, well, I guess it was 1999, maybe 2000, I went to a clinical congress and there was a surgeon there sitting at a machine and the patient was like in France, and he was doing a golf, and it was called the robot. And back then it was called Zeus. I got back, and I by this time moved to Sioux Falls. I said, you know, we should get us one of these things. This thing looks phenomenal. And we actually did, and we got the first da Vinci in the entire upper Midwest. Then I went off. You had to go to do training again. It wasn't hard for me. It was in my nature. I went to San Jose where the company was and learned how to use the da Vinci to its maximum with full intent to do transhiatal esophagectomy with it. And that, of course, you can do most anything, you know, with it. But I did the first 25 esophagectomies with the robot in South Dakota and then published that and presented that at numerous medical conferences across the United States. By this time, I was more involved in the college. And again, because I had the ability to demonstrate my outcomes and people could question me about it. I don't think anybody threw anything at me. I don't think they probably do, but not openly. They didn't write articles about how horrible I was for doing it. They knew the due diligence that I was doing. And so talk about three ways to do it. Yeah, you can use the stomach, I've used the colon, I've used. I've put them in situ where the esophagus normally resides. I've done retrosternal. I brought it to the neck, I brought it in the chest, I've done three-phase, all of those things, Randy. Every time I do an esophagectomy, and that might be even at the end of my career, for 15 to 20 a year, I would read for darn near six hours, five hours, making sure I knew every way to do it in the event that maybe the stomach conduit didn't look viable, maybe I needed something else. And I couldn't use the stomach and the colon better be prepped. Maybe the colon didn't look well, and I had to use the small bowel. So every one of those operations, I had an alternative. That's what I just drill into my medical students going into surgery. When you think of something, think of three ways to do it. When you think of a diagnosis, give me three diagnoses so that you know how to hone in on something. That's probably been my best life lesson that I learned practicing, where people were always going to be looking at me saying, are you sure you should be doing that? Can you be doing that? And then having the wherewithal to show that, yes, you can do it, but you better prove to know how to do it. Speaker A: Yeah, I feel a lot of that same pressure. I very much understand it. For the how I do it, I often like to approach it as if, say, you're talking to an intern that never did an esophagectomy before or even if you're writing an op note. Could you, one really quick question, did you prep everybody for all? Speaker B: Yeah. My first 10, 15 years, I sure did. Speaker A: Okay.

Dr. Gary Timmerman [00:24:31]: But, you know, as technology got better and we could study the stomach better and we knew what the vasculature with CAT scans and CTs with IV contrast and I could actually see the vessels, not as much, but I typically would give them. So it is not uncommon to give GoLYTELY. And I never felt bad about that.

Dr. Randy Lehman [00:24:53]: Yeah.

Dr. Gary Timmerman [00:24:53]: And especially after neoadjuvant, where so many of the folks, when they first came in, they were so debilitated and they had to go straight to surgery just like Whipples. As we got better and they got neoadjuvant, you could actually beef these people up. And I had them all on impact. I had them on high-protein diets, getting them ready for it so they could withstand a bowel prep because a lot of times they had one leg sadly in the grave. And as we were able to do things neoadjuvant, I could beef these folks up, get their back in positive nitrogen balance, get their protein levels back up. Bowel preps are really hard on people that are dehydrated and sick because they're obstructed. And we didn't have neoadjuvant yet. So, yeah, I was really nervous. Usually they don't use it anymore. Fleets Phospho-soda. That really worked well; it was a great bowel prep, but it just zapped the heck out of them. Now with GoLYTELY is a lot better than what it was. But, I mean, my first 10 years, I sure did. And then as I got confidence with what I was doing, not as commonly.

Dr. Randy Lehman [00:25:57]: Yeah. So why don't we pick the trans hiatal approach? And can you just talk to me from positioning, prepping, incision? Exactly. In detail, how you do each step of the operation all the way through closure.

Dr. Gary Timmerman [00:26:15]: Well, okay, so I'll be honest. I'm going to tell you how we did it because it's basically the same setup with the robot when I would do it, because I would do trans hiatal and then still bring it up into the neck. And then now a lot of folks do the Robot and then put the Robot in the chest to do it. An interthoracic operation, like a minimally invasive Ivor Lewis, I would do it like a blunt. So, of course, I lay the patient supine arms. Anesthesia usually leaves their arms out so they can put all kinds of access. They typically have a central line, but I prefer a subclavian because I want the neck open. So, and then I would use the left neck. So we would prep the left neck, and then I, knowing that I was going to do a blunt, I would shave the chest but wouldn't prep the chest, and then have them supine, much like doing a Nissen where the abdomen is exposed. Full source. If I was doing this open, I'd make my upper midline incision, explore the whole abdomen first, looking for mets, and then having found none, then I would mobilize the whole stomach, taking down usually the short gastrics first around the spleen, leaving the right gastroepiploic.

Dr. Randy Lehman [00:27:34]: So.

Dr. Gary Timmerman [00:27:34]: So I have a decent blood supply to my proposed pouch. Then I go and encircle the esophagus. Typically, if there's a cancer there, you can usually feel it. I would take a rim of hiatus with it if I could, to make sure I got any kind of invasion away from that. Even after they had neoadjuvant, I would still do that just for margins. Take that and then.

Dr. Randy Lehman [00:27:58]: So that's the rim of the diaphragm.

Dr. Gary Timmerman [00:28:00]: Rim of the hiatus. Yep.

Dr. Randy Lehman [00:28:02]: Just right around. Just the muscle, right around it. Got it.

Dr. Gary Timmerman [00:28:05]: And then go along. And I would skeletonize the left gastric down, all the way down to its root, and then take the left gastric with the specimen. And after I've got the whole proximal forestomach mobilized, then I would take staplers, and I would begin about the second vessel to the antrum, I would call it, you know, where your nerves of Latarjet come down onto the stomach, and then that leaves you your antral branches. I usually would leave the first couple there and then staple into the lesser curve and then make my pouch alongside so that. Oh, I don't know, it's more of a visual thing. I would give at least 2, sometimes 3 cm along the greater curvature, which is going to be my interposition pouch, and staple that up. It would take several staple loads. I'm an old-fashioned guy. I would always oversew my staple line. I just didn't like leaks, and I didn't like the risk of leak. And you did.

Dr. Randy Lehman [00:29:10]: You're using an open stapler to do this?

Dr. Gary Timmerman [00:29:12]: Yeah. I don't know. 60 the. Well, the.

Dr. Randy Lehman [00:29:18]: What staple height, thicker staples?

Dr. Gary Timmerman [00:29:20]: The greens. The greens.

Dr. Randy Lehman [00:29:21]: And then you oversewed it with silks or what'd you use to oversew interrupted?

Dr. Gary Timmerman [00:29:25]: 3-0 Silks, pop-offs, and then just go along up and so everything looks invaginated. So it's. And it also is smoother. It slides easier.

Dr. Randy Lehman [00:29:34]: Yeah.

Dr. Gary Timmerman [00:29:34]: And then now, like I said, if I'm going to pull this out through the neck, I would not complete it. I would take the staple line close to the angle of His, but away from the angle of His toward the greater curvature, out toward the greater curvature and not complete it. Then put a silk suture on the anterior surface of that stomach pouch, so I know what's anterior and what's posterior as I'm pulling that through. And then if I'm going to do the blunt at that point, then I would take my hand inside, and the term is Roto Rooter. And I would just literally— that's why I never thought it was a good cancer operation because you're not really knowing what nodes you're going to take. But if I were to do it with the Robot, I would have docked the Robot at that point and then visually take the lymph nodes as I'm going to all the way up. And I would typically, with the first generation and second generation Da Vinci's, I could get to the level of the azygos vein and make sure all the lymphatics were with that circumferentially. And then from that point, now I've got that all mobilized, and the stomach is still attached to that angle of His so that it can still be a conduit to be pulled up as one unit. Then I'd make my incision in the neck, go up to the neck, make my incision there, go down to the.

Dr. Randy Lehman [00:30:49]: Anterior border, sternocleidomastoid, or how are you doing that?

Dr. Gary Timmerman [00:30:51]: Incision, anterior border, and pull it back, reflect it, take the thyroid, and move it medially, and then bluntly take my finger and find the esophagus, encircle the esophagus at that level, lift that up. The recurrent laryngeal nerve typically is well anterior to that, but I always make sure it is, and then proceed to bluntly dissect it like a blunt esophagectomy down into the chest with my fingers, all the way down as low as I can.

Dr. Gary Timmerman [00:31:22]: This was always the tricky part. If I did it with my hand, I could go all the way into the neck and free it. But if you do it the Robot, the technology back then, when I was doing a lot of robotics with it, was that I could only get to about the azygos. So bluntly with my hand, I would go from the neck down into the mediastinum and then free it off the back of the trachea and all the way down to the connection, if you will, where it's been freed up by the Robot.

Dr. Gary Timmerman [00:31:53]: At that point, you should be able to take the esophagus and the stomach and swing it back and forth in the chest cavity. Once you're able to do that, I always, again, paranoia, making sure there's no big bleeder. I always knew in the back of my mind that most bleeding in that area stops. And I always kind of laugh. There are some big structures that wouldn't stop. But, you know, blunt esophagectomy was never done with hemostasis. It was just done with your hand, and then it would stop on its own.

Dr. Gary Timmerman [00:32:23]: It effectively was a blunt esophagectomy but done visually with the robot, where the nodes are important, which is usually the lower third of the esophagus, to make sure you got all of those nodes. Then, bring the whole specimen out through the neck. Remember, I have my anterior stitch to the anterior wall of the stomach. I can see that coming out as I'm delivering the whole specimen in the neck and then complete the staple line there where I had brought it up. Then, bring the two ends, the esophagus and the stomach, so

Dr. Gary Timmerman [00:32:55]: that if they were like this on end, I actually brought the back end like here, put my anchor stitch, opened both holes, stapled it, and triangulated the anastomosis. I would put another. Just a. This one wouldn't have to be... This could be a blue load stapler firing down and then closing in a triangulated fashion, because then I pull it transversely and closed it so that, I typically would do, even by hand, a two-layer closure of the anterior one. Then

Dr. Gary Timmerman [00:33:26]: literally drop the whole thing back into the neck, put a single drain, a little Blake drain into the neck, and bring it out through a separate stab wound. I would also then tack the posterior wall of that stomach to the anterior fascia over the vertebral column, that is there to keep the pressure off of that anastomosis, so it was an anastomotic repair done with no pressure. All of the stitches were placed posteriorly to keep that pouch from slipping down, and

Dr. Gary Timmerman [00:33:57]: then close the belly. Now when you do it with the robot again, I even would. So I was faster laparoscopic with a lot of stuff than I was with the robot. A lot of that I would do just plain laparoscopically, mobilize the whole stomach, put the staple loads in and everything all through the laparoscope, and then dock the robot to do just the chest part of it so I could see the nodes, so you...

Dr. Randy Lehman [00:34:23]: could get up there. I need a little more clarification on the anastomosis in the neck. Okay, so take your two limbs.

Dr. Gary Timmerman [00:34:29]: Staple, staple. Pull them up like this so they're not together. I mean, it's like a side to side.

Dr. Randy Lehman [00:34:37]: Yes.

Dr. Gary Timmerman [00:34:37]: I'm going to make it a functional end to end. Then I'll put my stitch where my palms are here for an anchor stitch. Then I open the two staple lines that are at my fingertips.

Dr. Randy Lehman [00:34:49]: Yeah.

Dr. Gary Timmerman [00:34:49]: So I'm looking in, I'm dropping my stapler down through each hole—one, the esophagus, the other, the stomach. Fire my stapler, that brings those two together. Then pull transversely like pyloroplasty and close the anterior aspect of the esophagus to the anterior aspect of the stomach.

Dr. Randy Lehman [00:35:09]: And I think the people who are listening on Spotify and Apple might need to go to YouTube for this one because that was helpful. I guess what I was thinking is what keeps that crotch from splitting open, but I'm not thinking about my staples correctly. It's cutting all the way down. So just remember I put...

Dr. Gary Timmerman [00:35:26]: And then old school, put a stitch down there.

Dr. Randy Lehman [00:35:29]: Yes.

Dr. Gary Timmerman [00:35:29]: So again, that anchors that angle of the stitch, so it isn't an easy pull apart.

Dr. Randy Lehman [00:35:34]: Yeah. Okay, got it. Very good. And then you closed up. Obviously, we can skip that part. But I did want to talk about, you know, what's different with the other techniques of esophagectomy that you had in your back pocket? So, one I want to talk about. When would you not use a gastric conduit? And how did you do the colonic conduit? And then maybe touch on Ivor Lewis.

Dr. Gary Timmerman [00:36:03]: Well, we could go into that. Extreme technical challenges there. But let's say a patient's had a gastric bypass and gets esophageal cancer. The stomach may not be an option at that point, and so that would be one that I would consider all options, including. But most commonly is colon. So I might consider the left colon and bring it up on the middle colic vessel. Some use the right colon. I usually use the left because it was a little bit smaller, a little bit more functionally able to be done. Then I brought the distal colonic up, so it actually was anti-peristaltic. And then would dock it to the stomach. What was left in the abdomen. A lot of gastric bypasses, of course, have the remnant stomach that you could still use as a landing point. I saw it, but I never had to do it, where a kid once swallowed lye and had no esophagus, and most of the stomach was destroyed by the lye as well. That was when we actually did it retrosternally because that whole bed was destroyed from the alkali. We did a retrosternal colonic anastomosis and brought it up into the neck retrosternally. We take out the sternal head to make, you know, the manubrial head here to make more room for that to come up to the neck. It's a bigger operation, but certainly, again, remember I said options. You have to have options to think outside the box to get things together. Another time, I don't know, the stomach just didn't look viable to go high enough to me. After we did it, maybe I did something to the left gastroepiploic, maybe something got damaged, who knows. But I just didn't like it, the whole stomach, so I ended up using a small bowel interposition. Not a free flap one, but brought small bowel with a Roux-en-Y and was able to bring it to the mid-esophagus to complete that anastomosis. So, yeah, esophageal surgery—some folks think, oh, that's easy. It's just one anastomosis. Oh my goodness. You got to think of all the variables and all the reasons you're doing it and all the anatomy that might be different. To me, that was an incredible challenge for me technically, to think of those things. And again, being able to report on those was very exciting.

Dr. Randy Lehman [00:38:45]: If you brought up a colonic conduit, I can imagine your anastomosis in the neck being very similar.

Dr. Gary Timmerman [00:38:52]: Very similar.

Dr. Randy Lehman [00:38:53]: But how did you connect it in then to the stomach and you put it like in the antrum? Right. You have to.

Dr. Gary Timmerman [00:38:58]: So you end it toward the antrum or the body, what might be left? But typically, like I said, if they took out and they made a 30 cc pouch and you've got the rest of that, some might say, well, can't you just use the rest of that stomach? It depends on what they were doing when they were doing the gastric bypass. What if they did a sleeve and took all the gastroepiploic with it, and now you're based on the left gastric artery for the same sleeve. You can't use the stomach at all for a conduit because you have to take the left gastric. That's required as part of esophageal surgery. But you can use the antrum as a landing dock for the other end of the colon. That is correct.

Dr. Randy Lehman [00:39:35]: So then when you did the anastomosis, was that a linear stapler that you used or usually hand-sewn, just hand-sewn, two-layer. Hand-sewn. Okay. Gotcha. Actually, you know, why don't we stay with that. Tell me exactly how you did the. The hand-sewn anastomosis, if you don't mind.

Dr. Gary Timmerman [00:39:53]: Oh, yeah, sure. So I'm a PDS fan, so I would do the inner layer just running and start at one end and then bring it around to. So I would do both sides of it inside. If it was end to end anterior, do it that way, running it with the four PDS and then seromuscular with silks.

Dr. Randy Lehman [00:40:16]: So when you divided the proximal colon, say you're using a left colon conduit, you divided it with a stapler?

Dr. Gary Timmerman [00:40:23]: Yep.

Dr. Randy Lehman [00:40:25]: Did you cut the staple line off and then sew it? Sew the end on?

Dr. Gary Timmerman [00:40:30]: Yeah.

Dr. Randy Lehman [00:40:30]: Okay. And so did you sew a back layer of silks before you put the PDS?

Dr. Gary Timmerman [00:40:35]: Oh, yeah.

Dr. Randy Lehman [00:40:36]: I mean, this started doing the PDS.

Dr. Gary Timmerman [00:40:38]: It's the easiest thing to do.

Dr. Randy Lehman [00:40:39]: So you just made a hole, sewed a back layer of silks, and then you ran the PDS around the inside at four OPDs. And then you sewed your anterior layer, correct? Yeah. And so it just kind of like comes down and plops right into the answer. Yeah. Okay. A couple of other things that I thought would be relevant for a rural surgeon maybe who's not doing esophagectomy. So they are doing the scopes, and they are diagnosing esophageal cancer. So things to do, tips and tricks on the EGD portion, maybe when the diagnosis is made. Do you have any of those?

Dr. Gary Timmerman [00:41:16]: If it looks at all funny, biopsy it. I've seen, you know, things that caught my eye, and I said, geez, that probably is nothing. Let me biopsy. Then it's severe dysplasia, you know, esophageal cancer. If you catch it, it's curable if you catch it early. And, you know, my biggest fear always was, well, what if I come back in five years and now there's a cancer there? And I knew there was something goofy. So anything that looked irregular, I would biopsy. Barrett's. Yeah, I surveyed. I did surveillance on those, depending on the amount of Barrett's, but certainly every one to three years, I would scope those folks. Remember again, a lot of these farmers live far away. Getting them back yearly can be tough. But then I would, you know, tell them, you've still got a risk of cancer. We need to follow this. And then making sure the Barrett's doesn't progress. The beauty of cameras today is that they're extremely great resolution versus 25 years ago where it was more hazy. And you can actually see the progression of things as well with the cameras as you do with your own eye and compare past photos that we weren't, you know, able to do as well back in 40 years ago when we were doing this. I would say the other thing is, you know, there's the protocols for doing quadrant biopsies. Every sonomage, do it, follow the protocols. There's a reason for those protocols. And again, you'll pick up things that you're not likely to think are anything. And then all of a sudden they'll say, you know, there's a little bit of dysplasia here. And you're like, whoa, I didn't expect that at all. And that's going to change your follow-up for that person as well. The biggest thing I would tell you about esophageal cancer, it's like pancreatic cancer in the 1980s. Very few people weren't really doing Whipple's as often anymore. And most of those folks came in, they were debilitated, jaundiced, ill. Their surgical outcomes were tough. Most of them were bypasses. Same with esophageal. That's why the blunt became so popular. It was basically just a bypass operation. All of a sudden, we have neoadjuvant chemotherapy, and we have 40% survivals of these folks. I know that's not 90, but when I started, it was 12, 15%. And I have literally every month, an esophageal patient that'll come up. And that's the neat thing about being in rural communities. They're still around, and they'll come up and say, hey, how you doing? I actually did one of my high school classmate's esophagectomies. And she comes and she sends me a happy Father's Day thing. She'll send me. And she's a high school classmate.

Dr. Randy Lehman [00:43:59]: Yeah.

Dr. Gary Timmerman [00:43:59]: And I'm saying, and she's alive now.

Dr. Randy Lehman [00:44:00]: Eight years. What's your graduating class size in high school?

Dr. Gary Timmerman [00:44:04]: Oh, we had a big one for Watertown. Remember, it was a city, so it was about 300, 310 kids.

Dr. Randy Lehman [00:44:11]: Okay.

Dr. Gary Timmerman [00:44:11]: Whereas my wife's was 12.

Dr. Randy Lehman [00:44:15]: Yeah. Somewhere in between is a vast majority of my audience.

Dr. Gary Timmerman [00:44:19]: That's why I say there is no forgiveness for being sloppy or saying, no one will care when you're in rural. I believe every rural surgeon has to have the same standards and opinions of things as getting to the bottom of it. As someone at Mayo or someone in Chicago or someone at Sloan Kettering, I just think we cannot say, well, that's okay. We're just out here in rural. I think, if anything, we own more, because I just really do believe we're blessed to be there with them, and we should be providing them the most outstanding care that we can give them. Yep.

Dr. Randy Lehman [00:44:57]: I totally agree. Another question, though, is feeding access for love.

Dr. Gary Timmerman [00:45:02]: I love J tubes. Absolutely. And a lot of folks don't do that anymore. I guess they have a lot of confidence. I always did it, and oftentimes that was their biggest complaint, was the feeding tube. And always happy when it came out. But no.

Dr. Randy Lehman [00:45:16]: Were you saying at the time of the esophagectomy doing a feeding tube? No.

Dr. Gary Timmerman [00:45:20]: Now with neoadjuvant, I oftentimes would put it in. But now also with radiation, the tumor shrinks, and they can eat usually within a week. So a lot of times I might just put a dot, puff down them for about a week until they were swallowing again, take it out and let them eat.

Dr. Randy Lehman [00:45:35]: Okay.

Dr. Gary Timmerman [00:45:36]: Yep.

Dr. Randy Lehman [00:45:37]: So. So let's say we didn't do that. And we were asked by oncology because they're going to go for neoadjuvant to put a J tube in.

Dr. Gary Timmerman [00:45:49]: That's a weekly occurrence for me. We have tumor conference every week. And they always ask, you know, what do you think? Should we put a feeding tube in? And I said, let me look at them. Let me see what they look like and then find out. Judge how hard they're swallowing. And if they can't even hardly keep liquids down, even if it's only a week, I usually said, let's just put it in a feeding tube. A lot of folks said, don't put it in the stomach. Always use the jejunum. I just did. But I know there are surgeons out there that did do G tubes, and it really didn't affect my operation as much as I thought it would.

Dr. Randy Lehman [00:46:21]: Okay.

Dr. Gary Timmerman [00:46:22]: And so it's not absolutely taboo, but.

Dr. Randy Lehman [00:46:25]: Generally you want a J tube.

Dr. Gary Timmerman [00:46:27]: I mean, I sure did. Yep.

Dr. Randy Lehman [00:46:29]: And so how do you do your J tubes? Do you do them laparoscopically or open?

Dr. Gary Timmerman [00:46:33]: No, I whistled, and I would do them laparoscopic when that became popular, but the only things I would open, put a red rubber tube in. But now they don't anymore. Now they have these nice, even the needle jejunostomy tubes that you can put in. Much like a Witzel. Yep.

Dr. Randy Lehman [00:46:47]: Yeah. So at the end of your career, how exactly were you placing the J tube?

Dr. Gary Timmerman [00:46:53]: Yeah, laparoscopic.

Dr. Randy Lehman [00:46:55]: Okay. And so where do you put your ports?

Dr. Gary Timmerman [00:46:59]: Oh, good lord, it's been five, six years since I did it.

Dr. Randy Lehman [00:47:04]: Okay, don't let me put you on the spot.

Dr. Gary Timmerman [00:47:06]: No, no, I would have put them in my periumbilical and then probably two in the—one in the upper abdomen on the right side and one in the lower abdomen on the right side. So triangulating it from the left side to look to the right.

Dr. Randy Lehman [00:47:21]: Yeah.

Dr. Gary Timmerman [00:47:21]: The feeding tubes would go—I'm sorry, start on the right to look to the left because I put my feeding tube on the left.

Dr. Randy Lehman [00:47:27]: Right, you're going to put it in the left upper quadrant. And so let me talk through it just for a second. Speaker A: And then you correct me where I'm wrong or where you would do something different. So, say you put those ports exactly like you said, and then you elevate the momentum, push it up over the stomach, identify the ligament of Treitz. You chase down how many centimeters from the ligament of Treitz? 20 cm or so from the ligament of Treitz.

Dr. Gary Timmerman [00:47:52]: Easily reaches the anterior abdominal wall.

Dr. Randy Lehman [00:47:54]: Sure.

Dr. Gary Timmerman [00:47:54]: Then I hold it with graspers. I think I may even put three ends because I may hold, you know, grasper, grasper, and then do something percutaneously. Depending on, because they have the needle that can go percutaneously. And then you can actually thread it into the jejunum. You can actually watch it coil inside the jejunum as it goes down. And then, you know, with some of the kits, you can actually just tack that point to the anterior abdominal wall. I always worry about a leak there as it would cause a lot of inflammation. So, I preferentially would put a stitch to semi-witzel it maybe only a centimeter or two so that the tube is actually not going directly into the mucosa. When you bring that up to the anterior abdominal wall, you're actually bringing serosa to the anterior abdominal wall and not risking mucosa to the anterior abdominal wall. Do you see the difference?

Dr. Randy Lehman [00:48:51]: I do, yeah.

Dr. Gary Timmerman [00:48:51]: And that's why I like the Witzel better than just some. Some people say you can just tack that up like a Stamm G-tube and somehow those seal, but not always, with J-tubes. And I had more problems with the feeding tube because they could get infected while they're getting their chemotherapy. That's why I really like the Witzel, which reduced that likelihood.

Dr. Randy Lehman [00:49:13]: So let me tell you my trick, and you tell me what you think about this. For doing this, I will bring the tube into the abdominal wall, and then I will bring in my stitch. I usually use, like maybe a 2-0 Vicryl. I would make my Witzel tunnel in this way, bring the stitch in, throw on either side of the tube my stitch. Then I would use a laparoscopic suture passer, cut the stitch off, cut the needle off, pull it out, grab the one end and pull it out, grab the other end and pull it out. Tag those outside the skin, and then do a row of those with the laparoscopic suture passer. And one, usually proximal to where the Witzel tunnel starts, to just kind of anchor. Because I had a problem where I was just like stitching it up there laparoscopically. The weight of the bowel is so hard, and I was dropping the pressure. It was very hard. Then I started doing it that way. You can just get all of your stitches thrown with lots of laxity, pull up on all of them at once, and then the weight is.

Dr. Gary Timmerman [00:50:15]: On the stitches through the anterior abdominal wall.

Dr. Randy Lehman [00:50:17]: Yeah. Did you ever do that, or?

Dr. Gary Timmerman [00:50:19]: No? I wish I would have.

Dr. Randy Lehman [00:50:21]: I think I made that up, actually.

Dr. Gary Timmerman [00:50:22]: I think that's really smart. I wish I would have. That actually sounds a lot smarter than the way I was struggling with it.

Dr. Randy Lehman [00:50:28]: And I always used a balloon one now that's like the balloon is far away from the tip, and I get that balloon fed down before I pull up, and then it'll kind of do it all at once. The last few that I've done have been pretty slick. Now, I did talk to, last time I did it with a thoracic surgeon. Cancer thoracic surgeon, cancer surgeon. And he said to me that he thinks an open J-tube is better than a PEG, still.

Dr. Gary Timmerman [00:50:57]: No. No. You know, so for, yes, I'm going to say that when done correctly, absolutely. But the beauty of a PEG is that you just take it out, and it's done. Well, you can do the same with the feeding tube, I guess, but I don't know. What do you think about the risk of small bowel or internal hernias down the road with that?

Dr. Randy Lehman [00:51:22]: With your laparoscopic J-tube, you mean? Yeah, I mean, my practice isn't going to be the one that's going to speak about the risk, so maybe you're the one that sees more volume. You'd have to have a catastrophic event, but it could be catastrophic.

Dr. Gary Timmerman [00:51:40]: I have seen bowel obstructions, internal hernias around my J-tubes. Yep.

Dr. Randy Lehman [00:51:45]: And you're not going to be taking that down, obviously.

Dr. Gary Timmerman [00:51:48]: No. Usually. Ever. Ever.

Dr. Randy Lehman [00:51:52]: Okay, well, I would say the jury's out on a lot of this stuff. There's like, a lot of things in surgery. There's not necessarily right or wrong, so you have several opinions.

Dr. Gary Timmerman [00:52:01]: I do really like the way you attacked it, so.

Dr. Randy Lehman [00:52:04]: All right. Well, thank you. Another thing you said to me about doing surgery open, you know, I do carpal tunnels. That's a good example of, like, the difference between me and you. Okay, I'm taking it easy. But I did do some operations with a plastic surgeon who's doing minimally invasive carpal tunnels. Right. Which basically is, like blind, and it's a scissor and push, mostly by feel.

Dr. Gary Timmerman [00:52:30]: And.

Dr. Randy Lehman [00:52:31]: And, you know, he said the same thing to me. That sounds like someone told you, just do them all open because you don't want to have a complication. What I'm doing is kind of gimmicky, and it's, at the end of the day, you know, once you start doing a good number of carpal tunnelings, in practice, you start to appreciate. You change these people's lives, and they just love you so much. Hiding a 2-inch or inch-and-a-half incision in one of the skin creases in their palm is not really a big part of the operation. The main thing is to get a good proximal release, do it under direct visualization. So that's something that I could sort of relate again.

Dr. Gary Timmerman [00:53:10]: Yeah, the whole key is functional. I agree.

Dr. Randy Lehman [00:53:14]: So thank you so much. This has been extremely helpful how I do it. I'd like to move on to the next segment of the show called the Financial Corner. Do you have a money tip that you could share with our listener?

Dr. Gary Timmerman [00:53:24]: Invest young. Yeah, by whatever reason, I actually bought life insurance when I was young, when I was a resident. Smartest thing I ever did. Because, you know, when you're old and you go to buy a life insurance premium or something like that, good luck with that, you know. But when you're young, you have nothing wrong, and the rates are cheap and you can. And then it grows. For whatever reason, if I put my money away, I invested in my 401ks, you know, that were. Now there are 457s. I did life insurance, all of those things. I started in my 30s when I was trying to raise three kids. You know, part of me said, "Jeepers, I'm giving this amount of money, and I could be using this to go on that trip or that." And I just, that money was taboo. I'm 66 years old now, and I'm looking back saying probably of all the things I ever did, the smartest thing I did was start early when everything said, "Hey, buy that car or buy that huge house or buy that, because, by God, I'm a doctor and I deserve it." I bought conservatively when we started, and now I have very nice things. But I don't know. I don't. I think that was the smartest thing I ever did, just not. I know folks that dip into their 401ks to pay for this or that. I'd rather suffer for two months and not get something I want than to dip into something that 20 years later I'm going to regret. And I'm now actually coming to that end where I'm looking to see what I have, and my eyes are kind of shocked. I mean, I'm very happy that we did it that way. I don't think that anybody taught me that other than just values of don't spend everything you make, save it. And I've been blessed to have good fortune with that. So I think just start young.

Dr. Randy Lehman [00:55:34]: Yeah. Thank you. I've got another question that's not on our agenda real quick. I see that picture behind you. I was wondering if you could comment on the role that your faith has played in your practice.

Dr. Gary Timmerman [00:55:45]: So one of your questions, and I'm going to answer it prematurely, which was in one word, how do you help people? And I pray a lot. And then, I don't know, maybe for the things I was doing, I was so stressed. And I learned something. I'm really good with these, and I'm really good with this. But maybe at times I wasn't good enough with this—my heart. Then patience taught me that it's okay to be nervous. And patients teach me more about dying and living than I thought I knew. And I kind of got it. I realized, you know, I'm not doing this alone. And a patient gave me that. I give God the glory for the outcome. I kind of like football players; I always smile when they say, I'm really glad that, you know, I want to thank my Lord and Savior, Jesus Christ, for having me win this game and that sort of thing. And I thought, well, that's maybe not just the game. Maybe that's called life, and maybe I should be doing that about life. And so, yeah, I learned long ago that I'm really good with my hands. I've thought about a lot. I think I've shared with imparted on you the things that made me a good surgeon. But the other part that made me a good surgeon was recognizing that not all the time was it me. And I had patients pull through that I never thought should have, and they did, and they wanted to give me credit. And maybe when I was younger, I wanted to take it. And now I just say, you know what? There's a doctor better than me. And that's that picture where the surgeon's there, and Christ has his hand on his shoulder, holding his scalpel. Yeah, so it's a big part of my career. I came in every morning at 5:30, 6:00 an hour before surgery and read devotions for 30 minutes to start my day. And I did that for 35 years. And that put my mind in the right place. It put my expectations in the right place. And it was amazing how it calmed my heart so that I could go do what I did. But then in return of that, I give back then and say, yeah, we were able to do that. But I had a lot of help. And I know it's not just me.

Dr. Randy Lehman [00:58:11]: Yeah, I think we could talk all day about it. But I just wanted to ask. And I appreciate you being vulnerable and sharing that with us.

Dr. Gary Timmerman [00:58:18]: Yeah.

Dr. Randy Lehman [00:58:19]: Thank you. So is there a classic rural surgery that you would like to share? These are stories that your urban counterpart just wouldn't believe. You've already shared a bunch of them. Operating on friends and family members, things.

Dr. Gary Timmerman [00:58:33]: That came to mind. So in South Dakota, much like other parts, we have different cultures within South Dakota. And one of the cultures is colony folks. They're called Hutterites. They're much like the Amish. The Amish get more press, but there's way more Hutterites than there are Amish in South Dakota. And I love that group of people. They're very Christian-based, founded people, but they live as a community. And I can remember when I was in Watertown, one particular day I saw, you know, remember when I was in Watertown, I thought it was a city, but we had no ER doc. So I took general ER call, and I took general call for walk-ins in the clinic. And one day I came into my office, opened the door, and there was a mom there with her six kids. And she, I said, well, okay, what are you here for? And she said, well, I have a bad knee. And I said, well, okay, let's take a look at that knee. With her kids running all over the place, six of them in the room, and it's a small room like this room, and they're kind of up and down, and they're talking German. When they're young, they speak mostly German. She didn't know that I knew German. So when they were speaking, I was listening. And then she would say something to him, and I was understanding. And then I said, okay, I think your knees are sprained. We can do this. And then she'd say, well, what would you say if I told you I have a child that has a rash? I'd say, well, let's take a look at it. And then the kid's there and pulls up the shirt, and he has a rash. And then she said, what would you say if I told you one of my kids has a sore ear? And I said, well, okay. Then I looked, and I said, that could be just such a and such a thing, maybe an otitis. And then she said, do you have any samples? And I, yes, I've got samples. And then the next one was, what would you say if I told you my son here hurt his finger? Would you look? And by the time the visit was done, I'd seen all six kids and the mom, but I only, when she left, billed just the mom.

Dr. Randy Lehman [01:00:33]: Sure.

Dr. Gary Timmerman [01:00:33]: And then she left. But this was great, because a week goes by later, and I come out to the front desk, and there's two loaves of bread and two chickens that she had gone and brought to me because I cared for all six kids without making separate appointments for all of them. That's a classic rural. Okay. And the other is that I practice now in Sioux Falls, and it's 40 miles from where my mother grew up. And so as a tribute to my mom, I did outreach. And I still love outreach because it's like going to Watertown, and I went to Freeman and did scopes there and saw general surgery stuff there. Didn't do any major stuff. They have a critical access hospital there. But I went there and did this. But I swear to God, Randy, every one of those people were related to my mother. And so when you get there, it's like, I found out I had more cousins than I ever knew in my whole life. And they all knew my mother. And I feel so much a part of that community simply because of my mom being born and raised there. And there's that connection. It's three degrees of separation, while in that case, it's maybe two. Those are two examples. Yep.

Dr. Randy Lehman [01:01:41]: And that's beautiful. I have one to share on my own. I've now taken care of my, well, first off, last week, I had somebody bring in a picture of my mom. So my mom died 13 years ago in a car accident. And a picture of my mom and my adopted little sister from her, my little sister's special ed teacher. And I've also taken care of my mom's bus driver, her babysitter, and a lot of these people that I didn't know.

Dr. Gary Timmerman [01:02:10]: Yeah.

Dr. Randy Lehman [01:02:10]: They weren't like, I know a lot of my first-generation relatives and some of the second generation. But these people, I wouldn't have otherwise made the connection except for I'm in a couple of places, and one of them is the county that my mom grew up in. So I very much relate with you on that one as well.

Dr. Gary Timmerman [01:02:29]: Yeah, yeah, yeah.

Dr. Randy Lehman [01:02:31]: Wonderful. So, and the last segment of our show is resources for the busy rural surgeon. So do you have any resource that you think every rural surgeon should know about?

Dr. Gary Timmerman [01:02:40]: Yeah, the American College of Surgeons. Absolutely. I think that from there, you can go in. You find out about all the other societies, like our Northern North American Rural Surgeons Society. I learned that through the American College of Surgeons. They have the resources of rural surgery. And I'm actually very much involved with the College of Surgeons now, and I will share that. We have the Division of Rural Surgery. We have an advisory council for rural surgery.

Dr. Randy Lehman [01:04:34]: I smile because you're humble. First off, your introduction of yourself was, "I'm from a town of 20,000 in South Dakota, and I did general surgery training and went back to Watertown." Right? Other people might introduce you in a different way, and that was a beautiful introduction, but I would like you to tell us a little more. You say you're involved in the American College of Surgeons, but tell us about your role and, just in brief, basically what you've been able to do there.

Dr. Gary Timmerman [01:05:02]: Well, so, yep, I got involved with our state chapter. I then went to a young surgeons meeting that was for young surgeons back in the '80s and somehow got invited to be on the council for the Young Surgeons as a rural person because everyone there was from urban areas, and so I was a novelty. And, you know what God gives you? He gives you opportunity. That was an opportunity. I recognized that there wasn't enough voice for rural surgery in the college when I was there. It was kind of like, "Well, let's see what Gary says. Is this going to help the rural surgeons? Will this help the young rural surgeons? Well, let's see what Gary says." I was kind of like that representative. I took that and ran with it and said, "I am in South Dakota." Most didn’t even know where that was. The idea that we could do great surgery and big surgery in small communities, by many members of the College of Surgeons, maybe was like, "Well, yeah, okay, fine, you could." But I didn't say or allow them to say it's acceptable to maybe have less acceptable care. I totally expected and showed that we could do just as good a care there as they are in the cities, and I think that's been proven over the last three decades. My long story is from young surgeons, somehow I then became the governor for our state. Then, when I was the governor, I kind of climbed the ladder there and became ultimately the Chair of the Board of Governors for the College of Surgeons. Then, I think, again, they felt bad they didn’t have a rural surgeon in the regents' room, so I'm a regent for the American College of Surgeons. I'm in my 8th out of 9-year term, kind of finishing up on that. With that come countless committees and countless opportunities. I helped create the Advisory Council for Rural Surgery. That, again, is my obligation back to my rural surgeons of America, saying, "We can do this just as good as anyone else. It's how determined you are to do it. Don't take shortcuts." I think we should be proud of what we provide patients in rural America.

Dr. Randy Lehman [01:07:19]: Well, I appreciate you. I think you're a great representative for us in the college. So thank you for everything that you're doing there. It really means a lot. Did you have anything else that you would want to share with my audience at all? For example, anything about the residency program? Anything you think people need to know?

Dr. Gary Timmerman [01:07:34]: I'd be remiss if I didn't tell you I work at one of the greatest healthcare systems, it's Sanford in Sioux Falls. To that end, when we started our general surgery residency program, there were no CMS slots left. The last time we had a residency here in South Dakota was when a surgeon by the name of Chet McVeigh from the McVeigh Hernia Repair was in Yankton. I actually learned inguinal anatomy from him personally. He had the program until '86, and it fell off because they believed in '86 that there were going to be too many general surgeons, so they started shutting down programs, and this one got shut down. I went to my hospital and said, "I think we should do general surgery here." We were doing upwards of 24,000 cases a year, and I thought it was a waste that we weren't training residents with that volume here. My administrators agreed, and they funded my program. So my program is 100% funded by Sanford. Well, then Mr. Sanford himself, about 10 years after that, saw the success we were having with our general surgery and they also helped start a pediatric one. He came up with a large amount of money again and started our Sanford Medical Education division, of which now I work with Fargo, Bismarck, recently Marshfield, and Sioux Falls. We have created 10 new, totally sponsored residency programs with the intent to provide services that we cannot seem to recruit to South Dakota, North Dakota, Minnesota, Iowa, or Wisconsin. We just now got approved for an ER residency. We have a GI fellowship starting this year. We've started neurology residencies, medical oncology, surgical critical care. A long list, about 10 different programs at the gift of our namesake, Sanford, with the intent to keep our doctors local. That is the commitment of what all of us are trying to do, which is provide healthcare to people where they need it, when they need it, and by whoever specialty might be available to them in their local area communities. That's something my healthcare system is committed to.

Dr. Randy Lehman [01:10:02]: Dr. Yeah. So check out Sanford Health, basically. All right, well, thank you. This has been very inspirational, and it makes me think about the pathways that my career can take. I'm sure that any young surgeon or surgical trainee listening will get that breath of inspiration from you. I really appreciate you taking the time to be on the show today.

Dr. Gary Timmerman [01:10:23]: I'm honored to be here. I'm sorry I probably bored your listeners, but delighted to have been here. Thank you so much.

Dr. Randy Lehman [01:10:28]: Yes. And thank you to the listener for being here as well. We appreciate you and we love to hear feedback from you. I've gotten some recent fan mail and I really appreciate it. Thanks. Shout out to Benji. Thanks for sending me an email. It's our pleasure and honor. We're here to try to be essentially a surgeons lounge for the rural surgeon. It's a place where you can go and hear stories that, you know, you don't have people all around you. So if you enjoy it, please don't forget to like, subscribe, like us on Facebook. Share this on your personal Facebook. Share it with your friends because that's the thing that you can do to help us. Thank you so much, and we will see you next time on the next episode of The Rural American Surgeon.