Episode 36

Saving a Dying Hospital with Dr. Manu Kaushik

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'm your host, Dr. Randy Lehman. I'm joined today by Dr. Manu Kaushik. We met at the Rural Surgery Conference in Denver, and he was practicing in a critical access hospital in Greenville, Alabama. I said, you got to come and share this story. He had some very fascinating tips and things that he was working on down there. So, Dr. Kaushik, thank you so much for coming on and sharing your story with our listener.

Dr. Manu Kaushik [00:01:13]: Hey, thank you, Dr. Lehman. I really appreciate this opportunity and congratulations on your podcast and the great work you've been doing. I know when the first time we met, you were about to start the podcast and you had such great ideas. I'm glad that it's all set in motion. And some of your episodes, they're just fantastic. I mean, listening to Tyler Hughes and all these people, the giants of rural surgery, who made an impact. So congratulations.

Dr. Randy Lehman [00:01:36]: Yeah, thank you. Yeah, I was this close to starting a podcast for about a decade, so I'm not sure when that was.

Dr. Manu Kaushik [00:01:41]: I think when we talked, you were almost there, so I'm glad you made it.

Dr. Randy Lehman [00:01:44]: So that's finally got it off the ground. So thank you. Why don't you tell us a little bit about your background, what kind of even what brought you to medicine, your training, and the practice that you've had so far.

Dr. Manu Kaushik [00:01:54]: Yeah. So, you know, I was born and brought up in New Delhi, India, and I come from a dual physician household. My dad, he was a practicing general surgeon who did some surgical oncology in a government hospital. Back home, they have this private sector and the government sector, and the government sector basically serves the underprivileged and people who cannot afford insurance and basic care. So. And my mother, she was a gynecologist in the same setting. It was pretty inspiring to see them help these people, and I think the interest in medicine cultivated from them. At a very early age, I was exposed to the hospital, the operating room, and I really enjoyed seeing my parents serve people. That was a big factor in me choosing medicine. In terms of my move to the United States, that happened after medical school. I finished my initial training back home. Back home, I always was interested in the rural aspect of medicine because we have a large population outside the big cities. In the big cities, you have all the fancy robots, the facilities, big hospitals, but there's a good population who don't have even good access to basic primary care. I was inclined to work in that aspect. But I was really attracted to the structured surgical training in the United States, which I think, in my opinion, we lack back home. That was the main driving factor for me coming here also. My wife was also making the transition. She's a hematologist now, practicing leukemia. That's why I came to the States. Being a foreign graduate, the initial road was a bit rocky, trying to get in the system, trying to understand the system. I did a few months of research at the University of Connecticut in Farmington and eventually worked my way into a preliminary surgical spot in a Michigan state program and then eventually became a categorical resident. I finished my residency in 2021. Then I took up my first job at the University of Alabama. This was an interesting move because I met Greg Kennedy, who was a division chief that time down here in GI surgery, and he said, because my wife had taken up a job at UAB already and I expressed my interest in community rural surgery. He said, you know what? We are partnering with the rural community hospitals to improve care in the periphery. And here's this opportunity. Do you want to dive in? This is something I really connected with and went ahead with it. There I was in a critical access hospital with 50 functioning beds for a population of 18,000. I spent the first three years over there, and now I made kind of a pseudo transition based on the needs of a department. I was away from my wife for a while as well, working in that hospital because she was staying in Birmingham and I was staying down there mostly. So because of those reasons, I did make a transition to the main campus. But I still go and operate, to clinic and work at the community hospital.

Dr. Randy Lehman [00:04:46]: Sure. That was in Greenville, Alabama. That's about two hours south of Birmingham. And now you're up in Birmingham, like you said, working more at the university setting. I had a question. Were you here on a J1 visa, and did that force you to be in a rural place for three years? Or how does that work?

Dr. Manu Kaushik [00:05:04]: So, yeah, I was on a J1 visa, and there is a commitment where you have to be in an underserved community for three years before you can work anywhere you want. For me, the stars kind of aligned getting to that place, because that was something I was always interested in. There were job opportunities in cities as well, which were considered underserved but were not really underserved. But this opportunity brought me close to family. Me and my wife were away for eight years during the training process, so we had to be in the same household, at least in the same state. I was able to expose myself to rural surgery like I always wanted to be. So, yeah, it was the J1 process. My interest, everything kind of aligned, and I landed up there.

Dr. Randy Lehman [00:05:47]: Yeah. And so were you there for three years then?

Dr. Manu Kaushik [00:05:50]: Correct.

Dr. Randy Lehman [00:05:51]: But you're still there. And how often are you going?

Dr. Manu Kaushik [00:05:54]: So, you know, I was asked, do I really want to continue doing that? After, I mean, you've been in the community, you know how it is. You get so connected, it's hard to let go. So many people you work with, and you become a part of the community. For me, the community accepted me with open arms, and I got a lot of love from all the people there. So for me, saying I don't want to do that anymore was not the right thing to do in my head. I still go once a week over there.

Dr. Randy Lehman [00:06:19]: Once a week. Okay.

Dr. Manu Kaushik [00:06:20]: I still go once a week over there. And I'll try to go more, depending. I'm still working on arranging my schedule and everything. But I do want to continue playing an active role over there.

Dr. Randy Lehman [00:06:31]: Yeah. Okay. So when you were practicing, like, I guess when you were there full-time versus now, is there a change in the type of cases that you're able to do down there?

Dr. Manu Kaushik [00:06:43]: That is true. There was always a challenge doing cases down there. Just to give you a background, this hospital had a general surgeon for almost 40 years. His name is Dr. Norman McGowan. He was trained at UAB. He was from the community, so he went back to the community to serve his own people and did a fantastic job for 35, 40 years. And then he retired. Then Covid hit, and the community, basically the OR had shut down. And, you know, like, you know, the OR is a big driving force for a hospital, and a lot of people were losing employment, and it was hard for the city to, you know, transfer these patients out. So the hospital was really suffering, and a nearby hospital already shut down because of the same reason. At that point, they partnered with the university to try and supply PRN surgeons to go down there, do some clinics, and some elective cases to keep the place open. When I went down there, the task I got was to restart the inpatient services. So initially, when I started down there, you know, obviously the equipment was not working or really old, there was no staff, so I had to rebuild from scratch. We started with some simple cases there, but we were eventually doing colon resections and more high equity cases. Now, since I'm here, I'm doing more of an elective practice down there. In case I'm there and an emergency comes in, I take care of it. Otherwise, we have been transferring patients to the main hospital to take care of them if something comes in and there's no surgeon in house.

Dr. Randy Lehman [00:08:12]: Yeah, okay, that makes a lot of sense. You kind of already answered the question, why is rural surgery special to you? But is there anything else you'd like to add to that in any way? I mean, becoming part of the community, in the fabric, you know, for sure.

Dr. Manu Kaushik [00:08:25]: I personally feel rural surgery is one of the most... The past three years have been the most humbling experience of my life. I mean, it has been a life-changing endeavor because I think, you know, there was a podcast by Dr. Dorothy Hughes that I listened to, and the one thing she said was very interesting when she talked about the circles. You know, when you're in a big city, you have 100 circles you're working in. There's a circle in the hospital, circle in your community, circle in this neighborhood, that neighborhood where patients come from. In the community, it's one circle. I really like what she said, and that was very special to me. I think you are part of a process and you're part of this big family. And I think that I really like. It puts a lot of pressure on you because everybody knows everybody. You know, you know that better than me. But for me, rural surgery is special because I think you're not just dealing with a patient, you're dealing with so many people around them, and they're connected. The good thing I liked about the rural surgery concept was that you get to see the patient after you help them, and you repeatedly see them, which is interesting. You see how well they do after your surgery. Over here, you do a surgery, you get one outpatient visit, follow up, and then you're done. You don't see that patient, hopefully never again. So I think the dynamic nature of patient care and being in the community was very special to me. I felt like I was making a difference and actually learning more from the community than I helped the community, to be honest.

Dr. Randy Lehman [00:09:57]: Yeah. Each year that I go to, like the parade or the county fair or something like that, it's like there's an eerily increasing percentage of these patients that I've operated on or these people that are at the crowd, you know, that I've operated on. And it gets a little bit really close to home really quickly.

Dr. Manu Kaushik [00:10:16]: I've had patients show me their incisions at the grocery store, lift up their shirts, "Oh, you did this big surgery on me two years ago." I'm like, "Oh, okay, I'm glad you're doing well." But it's humbling. It was very, I think, very gratifying.

Dr. Randy Lehman [00:10:30]: Yeah, very good. So we're going to talk in extreme detail about one particular operation, the "how I do it" segment of our show, which is up next. So we're going to be talking about open ventral hernias, various different sizes, and situations. So I guess we can start with some different patients that present to you. Maybe first thing we could say is, are... let's talk about contraindications to ventral hernia repair. Are there people that you're turning away and for what reason?

Dr. Manu Kaushik [00:11:00]: Yeah, I mean, great. I mean, that's such a complex question because, you know, when training at a bigger center, you know, having all the prehabilitation for patients, having the robot to do things, I think the game was completely different moving to the rural community when starting from scratch. I started with open, you know, open ventral and inguinal hernias because I was comfortable doing them because my training had a lot of older attendings who taught us those. So I did gravitate to doing some stuff laparoscopically there as well. But open ventral hernia still is where my comfort zone was. In terms of my patient selection, you know, when I started, I was very selective. BMI 35, you should not be a smoker, stop smoking for six to eight weeks. You know, all those big points we hear at SAGES. But then I realized, you know, asking someone with a BMI of 40 to lose weight in the community is just not happening. I think I would say if I asked 10 patients to lose weight, maybe one patient lost 10 pounds, and that still didn't meet those criteria of the BMIs in 35. And initially, I was saying no to patients who were actively smoking. But then I realized, you know, if I don't operate on these people, I won't be operating on one out of three patients coming to me. That was pretty much what was happening. What changed things for me was one patient. I still remember him very well. He was a 45-year-old gentleman who had a 3-centimeter umbilical hernia. And I said, "You know what, you're smoking actively; we will reevaluate you in two months, see how you're doing." He came back strangulated two weeks later. Then I had to operate on him. And I realized, you know, in the rural community, it's very hard to turn these patients away because when they come in strangulated, I mean, the situation is even worse for these guys, and the resources I had sometimes become too challenging to take care of them. So, slowly I started taking on smokers. I started taking on some obese patients. I increased my cutoff from 35 to 40 BMI, and I was actually operating on active smokers. And I saw some data which came out of Columbia that Yuri Nowitzki published some data that smoking honestly does not affect the outcomes for hernias between 3 and 5 centimeters. So I stopped turning away patients unless their BMI was over 40, which I think they would benefit from bariatric operation. Even some patients with BMI more than 35 with comorbidities, I would push them more towards getting a bariatric operation. I did have some success doing that because since I had the connection with the university, I was able to get them in the weight loss clinics really fast, and some of them got a sleeve, and then we did elective repair in the future. And yeah, so that's, that was my practice pretty much.

Dr. Randy Lehman [00:13:38]: Yeah. And I would say your practice that you started out with, that's like my practice still. Yeah, I just kind of, you know, and I actually have had pretty good... I usually put people on three-month follow-ups and try to get them to lose weight and stuff. And I don't know if I say pretty good success. That's not what I was going to say. I've had people understand, okay, until recently. And I've had a couple of patients recently that, like, one lady left in tears from the office and just said, "So you're saying I'm too fat to have my hernia fixed?" I'm like, I mean, those are your words. But basically, yes, you know, but I'm trying to put you in contact with somebody to help you with really the bigger problem than your hernia, which is the fact that you've got a, whatever, BMI 45 or something, you know, and, and there are options for that. Speaker A: But, you know, they're having pain from this hernia, and it's hard. I think she's not necessarily crying at me because I'm mean; she's crying at the regret for sure, you know, all the donuts or whatever. Now she's got this problem that's impossible, and it's self-inflicted. That's a really painful problem to accept for people. So, we have weight loss clinics around here. That's my go-to as well, that I try to send them to.

Dr. Manu Kaushik [00:14:57]: I think like, you once mentioned in one of your podcasts. I do listen to your podcast.

Dr. Randy Lehman [00:15:02]: Yeah, thanks. I can see that.

Dr. Manu Kaushik [00:15:03]: I think you're doing a great job. One thing you also said in one of your podcasts is just the way you narrate the situation to the patient, which is so important. You know, like obviously you're not calling them saying they're fat. We are trying to do what's best for them. Most patients understand. I have rarely had trouble where someone said, "Oh, you just don't want to do surgery on me," because, you know, I love doing surgery.

Dr. Randy Lehman [00:15:27]: That's literally my entire thing. It's like my favorite thing to do.

Dr. Manu Kaushik [00:15:30]: But the problem I have encountered is, you know, in some patients, when there's a nail, somewhere there's a hammer. Yeah. Somewhere, they will find a surgeon who will say, "Yeah, I'm going to operate on you." Then you become the bad guy who didn't offer surgery, and then you're dealing with a post-op complication from somebody else.

Dr. Randy Lehman [00:15:46]: That's right.

Dr. Manu Kaushik [00:15:48]: Yeah.

Dr. Randy Lehman [00:15:49]: Did you use any type of risk calculators, like, for example, the Cedars app or anything like that to sit down and show the patient, "Here's what would happen if you lost weight or you stopped smoking"?

Dr. Manu Kaushik [00:16:01]: I did exactly that starting in my second year. In my first year, I was not doing that. Then, I think at ACS, I met some hernia surgeons who educated me on that, and I started using that, like Cedars.

Dr. Randy Lehman [00:16:13]: That's the thing you use. Did you use it on your phone or a computer?

Dr. Manu Kaushik [00:16:17]: I carry an iPad in the office, so I use that. I show it on the picture to the patients.

Dr. Randy Lehman [00:16:20]: And then there's, of course, there's NISQIP too.

Dr. Manu Kaushik [00:16:25]: I try to be as data-oriented as I can be for the patients. I think sometimes when they see the numbers, they understand that we are talking facts and not just refusing an operation for somebody.

Dr. Randy Lehman [00:16:35]: Yeah. Okay, so let's talk about size. So, in your mind, is there a size after which you think about it differently?

Dr. Manu Kaushik [00:16:47]: So, my traditional practice has been anything less than 2 cm. I still go for a primary repair. Be it epigastric hernia, an average abdomen, or incisional hernia or an umbilical hernia, I go for a primary open repair for those. Unless it's somebody who's a weightlifter, goes to the gym a lot, or somebody who's obese, I do prefer putting a mesh in those people. If it's less than 2 cm, I still go for the ventral S.T. That was the only thing available to me, that and the ventralites. So, I would use that with the typical four-point fixation. Get it down, close the fascia on top. If I'm doing a primary repair, my preference was I used to do figure of eights and close the fascia. I have done that both with the permanent and absorbable sutures. So far, I haven't seen a difference. But my preference now is using PDS. But I've used braided nylon in the past. I've not seen much difference in obese patients. I did incline to using surgery-lawn or braided nylon just because maybe I was nervous in my first year using an absorbable procedure.

Dr. Randy Lehman [00:17:53]: Yeah.

Dr. Manu Kaushik [00:17:55]: In terms of now, I am not doing figure of eights anymore. I do it like it's a modified Smead-Jones stitch, which I learned when I was a medical student from one old professor. What he used to do was take a suture on the defect, go far, near, near, far. With the same suture, he would go level down.

Dr. Randy Lehman [00:18:15]: So let me, far, near, near, far.

Dr. Manu Kaushik [00:18:19]: Okay, I'm just drawing it real quick. There you go. So yeah, he would go far, near, near, far, not cut the suture, take the same suture, continue level down. And now backhanded, go far, near, near, far. So, it looks something like this. Sorry. So he would go far to near, near to far on the defect and then, sorry, from this side, come here, and then continue the same stitch in a running fashion. Go far to near, near to far. So both the sutures are on one side. His understanding was when you tie it down, the tension from the midline somehow is transmitted to this pulley you created over here. I found that to be very interesting, and I did try it on different things, and I actually noticed the tension does go down to this pulley. I've done this for a few patients so far, and I've not had a recurrence two years going, but I'm following up these patients closely to see if this stitch works.

Dr. Randy Lehman [00:19:26]: So this is a primary repair?

Dr. Manu Kaushik [00:19:28]: This is a primary repair.

Dr. Randy Lehman [00:19:29]: You're using PDS for this?

Dr. Manu Kaushik [00:19:32]: For this one, I was using a braided nylon.

Dr. Randy Lehman [00:19:35]: Braided nylon, yeah. So, and what weight? Like, is it a 2-0 or 0 or what?

Dr. Manu Kaushik [00:19:40]: Oh, I was using 0 for these ones, but this was like an obese patient.

Dr. Randy Lehman [00:19:44]: It looks like you're closing it vertically.

Dr. Manu Kaushik [00:19:47]: I am closing them transversely, actually.

Dr. Randy Lehman [00:19:49]: Transverse. So that's, like, from superior, like far, and then near. Near to far. Superior to inferior, correct?

Dr. Manu Kaushik [00:19:59]: Yeah. Cranial to caudal.

Dr. Randy Lehman [00:20:00]: Yeah, yeah, got it. Okay, so if you're listening to this on Apple or Spotify, you might need to go check it out on YouTube if you want to see the picture that did come through on my screen. So, I could see it fine. You could pause it. I have seen that. I have seen that stitch as, like, a retention stitch used in residency. You called it a... what'd you call it? A Smead-Jones.

Dr. Manu Kaushik [00:20:22]: Oh. So, I saw this as a retention suture too, just like you did. So S M E A D, Smead-Jones. And I think the far-near, near-far is an adaptation of that, and this is a further modification. I do not know the historical basis of this stitch, but I saw it as a medical student, and I saw it do pretty well for patients. This was done in a setting where they could not put a mesh or for obese patients. Interestingly, I have seen this stitch being used for defects as big as 4 or 5 cm and have reasonable outcomes. Yeah, I haven't stitched on that big a defect yet, but if I have a good outcome with the primary repairs with the smaller hernias, maybe I will venture out and try them on some patients.

Dr. Randy Lehman [00:21:10]: Yeah. Do you do this, like, when you close that stitch? I can imagine if you really crank on it, it would just wad everything up and cause ischemia. Do you just still approximate? Don't strangulate? Is that...exactly.

Dr. Manu Kaushik [00:21:21]: Yeah, just approximate. Don't strangulate. Yeah.

Dr. Randy Lehman [00:21:23]: Okay. I remember being an intern at Mayo, and, you know, I was trying to do the right thing, get up at 4 o'clock in the morning before case, have the case log in front of me. I have Zollinger's. Right. So that's an old textbook. And I open it, I'm reading, I find the Mayo vest-over-pants repair. Speaker A: You know, we go to pre-op morning rounds, and I'm like, so here, this is the patient, you know, and it's basically a small, you know, hernia that we had in chief conference. And I said, so I think that the best thing to do would be a Mayo vest over pants repair. And I just, of course, got laughed out of town. They're like, we haven't done a Mayo vest over pants repair here since Charles Mayo was here or something. You know, I remember that I actually. Yeah, go ahead.

Dr. Manu Kaushik [00:22:05]: One of my mentors, he used to do them a lot, I think, but he had some initial recurrences, and he stopped. So, I mean, he's retired now, very good, technically good general surgeon. But he said he did them for the first 10 years of his career, but after a lot of recurrences, he stopped. So.

Dr. Randy Lehman [00:22:21]: Yeah. So I. And then do you clean up the edge a little bit?

Dr. Manu Kaushik [00:22:25]: Yes, I do. Yeah, clean up the edge, expose the healthy fascia. Because I believe in putting a mesh, not putting a mesh till I like my stitches to go through healthy fascia, not going through fat and, you know, tissue on the fascia.

Dr. Randy Lehman [00:22:39]: So are you doing that Smeed Jones closure on something less than 2 centimeters as well?

Dr. Manu Kaushik [00:22:45]: If I can get one stitch. If it's too small, like a 5-millimeter defect, I'm just doing a figure of eight for those.

Dr. Randy Lehman [00:22:51]: Yeah. And then same thing when you tie your figure of eight down. You know, it's a hemostatic stitch. So if you pull it hard, then you're going to cause ischemia. So you're just making the edges kiss?

Dr. Manu Kaushik [00:23:03]: Yes, just touching. I've seen some of the MIS guys these days; they're actually inverting the edges. They're not suturing edge to edge anymore, some of them. So that's interesting. Yeah. But yeah, ultimately, don't strangle it has been what I've been practicing.

Dr. Randy Lehman [00:23:17]: Yeah. Usually on those, I do figure weights for, like my, some port sites and whatnot. But then I'll just like, do simple interrupted sometimes on those small hernias. But anyway, basically, however, you close those doesn't really matter, you know, that's what I feel.

Dr. Manu Kaushik [00:23:31]: Yeah.

Dr. Randy Lehman [00:23:32]: Yeah. And then the, the ventral X going in there. You parachute that in with four stitches.

Dr. Manu Kaushik [00:23:40]: Yes.

Dr. Randy Lehman [00:23:41]: Like 12, 3, 6, and 9 o'clock. Sort of three deal or.

Dr. Manu Kaushik [00:23:45]: Yes.

Dr. Randy Lehman [00:23:46]: Do you ever have any pain at those three and nine o'clock stitches? Because it may go through the muscle.

Dr. Manu Kaushik [00:23:52]: Yeah. So interesting you ask. Yeah, initially, I had some patients with that, and surprisingly in the past one year I haven't heard that complaint much. I did. I would confess that for the first two or three post-operative weeks, there was an element of significant pain at those sites.

Dr. Randy Lehman [00:24:11]: Okay. So yeah, I kind of changed from. I was using the Ethibond, and then I stopped using the Ethibond at the 3 and 9, and I just use them at the midline, and then I put a Vicryl on the side. So.

Dr. Manu Kaushik [00:24:23]: Yeah, that's, yeah, that's, that's, actually sounds smart. Yeah.

Dr. Randy Lehman [00:24:26]: Just, I mean, I made that up. I don't know if it's just because. Because then if they have the pain, and you know, maybe it'll be shorter-lived.

Dr. Manu Kaushik [00:24:34]: Yeah, for sure.

Dr. Randy Lehman [00:24:37]: Okay, so then if you have somebody that's bigger than 2 cm, what's the next sort of breakpoint in your mind where I'm going to do something different?

Dr. Manu Kaushik [00:24:48]: So I think for me, it's two to five is the next breakpoint for me, and I've approached it a few different ways. So I started doing initially when I came out to practice after residency, I started doing some laparoscopic IPOMs for those guys, and I even tried the IPOM plus if it was like 3 cm to approximate the defect laparoscopically and then put a mesh. And I did try the micro tacks initially for those. But then because of supply issues and, you know, the hospital was not doing too well initially, I had to abandon that, and I started doing them open. For those defects, I actually did some onlays, which I had some good success with. So I was closing the defect and putting a big piece of Marlex on top, fixating it, at least having a 5-centimeter coverage and leaving a subcutaneous drain on top of it for three to five days. Initially, when I did that, I had a few seromas, but then I put the drain in for three to five days religiously. For some cases, I stopped having the seromas. So that was my practice. I did for a good two years for those defects. I did a lot of onlays, and initially, I was a bit skeptical about onlays because of the historic risk of infection and stuff. My ideal preference would obviously be a sublay for those if I can, you know, get a mesh in, close the peritoneum, but the supply issues were such I was not getting the meshes I needed. So I was forced to do an onlay on some of the cases. And since the results were good, I did that for a few more patients. And it's been, it's been, it's been quite successful for me. So for them, if I if I can do a sublay, that's my preference, but if not, I do an onlay.

Dr. Randy Lehman [00:26:36]: So when you're doing the onlay. So say it's a 5-centimeter defect.

Dr. Manu Kaushik [00:26:39]: Yeah.

Dr. Randy Lehman [00:26:40]: You're closing the defect still transversely, or it just depends on how it comes together?

Dr. Manu Kaushik [00:26:45]: It depends on how it comes together, yeah.

Dr. Randy Lehman [00:26:47]: And then you're clearing the fascia off.

Dr. Manu Kaushik [00:26:48]: Yeah, yeah, I clean the anterior fascia off. I mean, I've done some anterior component separations for even bigger ones, which are 5 to 10. I did them in my second year, I think. But most of the time, I clean the fascia off, and I'm able to get a big piece of mesh on top with at least a 5-centimeter coverage all around.

Dr. Randy Lehman [00:27:07]: Okay.

Dr. Manu Kaushik [00:27:07]: And since you do that, and since in Alabama, patients are bigger, the risk of seromas really went up. So the drain.

Dr. Randy Lehman [00:27:14]: Yeah, yeah. And so the drain, you're using what, 19 French JP or what?

Dr. Manu Kaushik [00:27:19]: That's all they have here.

Dr. Randy Lehman [00:27:20]: So just bring it out to the side, your skin's closed up over top. Do you close the sub-Q as well with some Vicryl?

Dr. Manu Kaushik [00:27:27]: I do close the sub-Q with some Vicryl. In residency, most of the attendings did that, and that was just, I got used to that practice. And I know there's some conflicting data about that. Some people say that it causes, you know, ischemia to that area, to the fat, can lead to more seromas. I've heard that at a few conferences, but my preference is to close the sub-Q with some Vicryl, get the dermis together, and close the skin.

Dr. Randy Lehman [00:27:49]: Yeah, that's what I do. I mean, I remember coming through medical school, and I was in OB-GYN rotation when they had that. Who do you close the sub-Q? They ran a big study on that, and it was who do you close the sub-Q on with a C-section? And they said 2 centimeters. And I'm like, yeah, like that makes sense. You know, you got a big, big space. Put it together. You know, if you're skinny and it's just skin and fascia right there, then you wouldn't need.

Dr. Manu Kaushik [00:28:14]: And I personally felt if you close that space and then you have that drain in there, that area gets nicely decompressed. And I think the risk of seroma goes down. That's my thought.

Dr. Randy Lehman [00:28:23]: Yeah. 100. Now the IPOM. I want to go back to the IPOM that you were. You said you were doing that at the beginning.

Dr. Manu Kaushik [00:28:29]: Yeah.

Dr. Randy Lehman [00:28:29]: And then you transitioned to this other. But the IPOM. Speaker A: And then the I-POM plus. So, when you're saying I-POM plus, you mean closing the defect.

Dr. Manu Kaushik [00:28:38]: Yes.

Dr. Randy Lehman [00:28:39]: And putting a...

Dr. Manu Kaushik [00:28:40]: Yes. So, you know, for something like a 3-centimeter hernia, I was closing the defect laparoscopically. I tried, I did try that, you know, the Carter-Thompson thing some people do. From the outset, I didn't like that a lot. I think the patients had more pain doing that, so I was not a big fan of that. So I just started laparoscopically suturing it.

Dr. Randy Lehman [00:29:02]: Okay. And did you excise the sac or sacrifice it?

Dr. Manu Kaushik [00:29:08]: You know, in some cases, I did incorporate the sac in the closure. In my practice, I initially did excise the sac for a few cases, but I had a seroma because of that, so I just started incorporating that in the closure.

Dr. Randy Lehman [00:29:24]: Okay, I see. So, you're like tacking it down in, grabbing a bite up top. Okay, to try and obliterate, because it would be a high risk for seroma if you just left the sac up there, and there's a lining. You know, of course, you're going to have a seroma. Okay, so that's actually... And it's not a... It's my show, I guess, but it's not a... How does Randy Lehman do things? I'm asking you, you know, but it's hard for me not to share. I do a lot of that I-POM plus technique, and I do use the suture passer to close the defect. And I always excise the sac because I think that it'll scar down better without seroma when the peritoneum is out of there. But yeah.

Dr. Manu Kaushik [00:30:06]: Yeah, for sure.

Dr. Randy Lehman [00:30:07]: All fair. And then you... You were using a Ventralex, I mean, Ventralight ST mesh on there.

Dr. Manu Kaushik [00:30:12]: Yes.

Dr. Randy Lehman [00:30:13]: And how much overlap are you trying to get?

Dr. Manu Kaushik [00:30:15]: I was trying to get at least 3 to 5 centimeters in these cases.

Dr. Randy Lehman [00:30:19]: So...

Dr. Manu Kaushik [00:30:19]: Yeah, the problem for me was the suppliers I had were very limited, you know? So, it's a day you want to do the case, you're told in the morning you don't have the mesh you need.

Dr. Randy Lehman [00:30:28]: So, I have been there.

Dr. Manu Kaushik [00:30:30]: Yeah, you know how it is.

Dr. Randy Lehman [00:30:32]: Yes. So, all right. And then how do you secure that mesh?

Dr. Manu Kaushik [00:30:36]: So, I use the Vicryl tacks, that's what I was using.

Dr. Randy Lehman [00:30:39]: Okay. I'm not sure if I'm familiar with the Vicryl tacks, but I mean, I use the SecureStrap, which is a PDS tack, kind of like that. It's basically an absorbable tack.

Dr. Manu Kaushik [00:30:49]: Yeah, absorbable tack, yeah.

Dr. Randy Lehman [00:30:51]: Yeah, okay, fair enough. I know some people use circumferential stitches, you know, bring them up. That's an old factor, kind of like a way to do it. Also, the metal tacks, which I don't know, those I would say are out of favor.

Dr. Manu Kaushik [00:31:04]: But because, see, for me now, I'm transitioning to the robot too, you know, being at the university hospital. So doing them... I mean, now I'm slowly trying to do these I-POMs robotically. And I think my preference now will be just suturing it circumferentially with a V-Loc.

Dr. Randy Lehman [00:31:18]: Yeah. And in that situation, you're pulling the peritoneum down.

Dr. Manu Kaushik [00:31:22]: Yeah.

Dr. Randy Lehman [00:31:23]: We might as well talk about it now, since we were going into it. So, first question though, go back. Your port placement for that I-POM.

Dr. Manu Kaushik [00:31:32]: So, I basically used to enter with the Veress needle. I'm personally a big fan of cutdowns, to be honest with you. The problem was initially when I started, they could just not get me a trocar, I do not know why. So, I would do... I have done gasless optavia entry. I've done Veress needle. Whatever is available, just use it. So, I would basically, if you had a midline hernia, I would just try to go on the contralateral side. Three incisions in a row, that was my go-to. Yeah, I think I was able to triangulate well with that in terms of...

Dr. Randy Lehman [00:32:04]: Sutures or defect closure and all of those. Then are you did the Veress and then you... Optical entries with your first one, right?

Dr. Manu Kaushik [00:32:12]: Probably optical entry. So basically...

Dr. Randy Lehman [00:32:14]: So, were they 5?

Dr. Manu Kaushik [00:32:16]: Two fives and a 12, I would say.

Dr. Randy Lehman [00:32:18]: And it's a radially dilating 12, and that's where you brought your mesh through, correct? Yeah, so that's the other thing that becomes an issue is getting the mesh in. And obviously, the Ventralight bigger ones come with a stylet thing that you can twist it up and get it through. But the... What do you... Before we go into the robot thing, what do you think about the coding changes? I think they came in 2023. Yeah, so there used to be a laparoscopic code and an open code for anterior abdominal wall hernia, which would include... And then there was incisional hernia and umbilical hernia and epigastric hernia and Spigelian hernia. And now all those are lumped together. Yeah, they're coded by size. But the codes that go from 3 to 10. So, 0 to 3, 3 to 10, and greater than 10. The only difference would be incarcerated or reducible. And I think recurrent versus, you know, like the first-time repair is also a separate code. Like, if it's been repaired before.

Dr. Manu Kaushik [00:33:24]: Yeah. I personally like it. I don't know what your thoughts are. What do you think?

Dr. Randy Lehman [00:33:29]: I like it. I like it too. And here's the reason: to have it be a different value for laparoscopic versus open. What you need... You need to fix the hernia.

Dr. Manu Kaushik [00:33:43]: Yeah.

Dr. Randy Lehman [00:33:43]: Okay, that's what you need to do again. Fix it in a way that it doesn't come back. And the best technique. And there should be no decision-making that comes into play as to whether you do it open or laparoscopically. Because there's a lot of things that if somebody's had, like, a lot of previous abdominal incisions and you don't want to go in there, and it's fraught with danger. But if somebody's incentivized to do laparoscopic because that's always the way they do it. Maybe, maybe they don't even know that, you know, but they've just always done it that way because... Because the coding should be taken out of it. The other thing that I do sometimes is if it's... If it's an incarcerated hernia and you go in there laparoscopically, you can get such nice overlap with a bigger piece of mesh. Laparoscopically. But it's sort of dangerous to some if there's bowel stuck out there to be tugging on the bowel from the inside.

Dr. Manu Kaushik [00:34:30]: Yeah.

Dr. Randy Lehman [00:34:31]: And you could just make an incision over the top, get it reduced open, close the defect, open, close the subcut, go back laparoscopically, throw your mesh up. You also have a bigger hole there. You can drop your mesh in before you come up. And I do that all the time. I don't know if that many other people are doing it too, actually.

Dr. Manu Kaushik [00:34:47]: And I think it's a great hybrid approach to the problem. And you're basically getting the best of both worlds, you know, open and laparoscopic.

Dr. Randy Lehman [00:34:55]: And then there's no question on coding, you know, you just fix the hernia the way that you...

Dr. Manu Kaushik [00:34:59]: That's a period. There should be no... I mean, you're right. There can be a bias towards one technique and can be used in the wrong situation, harming the patient.

Dr. Randy Lehman [00:35:07]: Yeah. Okay, sweet. So let's talk about... Now, you're using the robot for most of them or what?

Dr. Manu Kaushik [00:35:13]: So, I am right now focusing a lot on robotic inguinals. Because, you know, my residency didn't have a lot of robotic training, which is surprising. We had a lot of young MIS guys, and the older guys were doing them all open. So I started with some cholecystectomies and moved on to the inguinals. My next step is ventral hernias. Right now I'm watching a lot of MIS partners to see the way they do it. But my preference for when I start doing them will be a robotic TAP. To be honest with you, that's what I'm thinking, because I think the robot gives you the ability to do this operation ergonomically—much easier compared to doing the TAP laparoscopically. And if the TAP fails, you can always do an IPOM. You know, if you're not able to create a flap on a patient, if the tissue is not healthy, you can just do an IPOM, so.

Dr. Randy Lehman [00:35:55]: Right. And the funny part about it is that the cholecystectomies and the inguinals are great to train on. I do think ergonomically, maybe you can—maybe you don't have as many rips in the fascia. And it's easier ergonomically for the inguinals, but for the cholecystectomies, like, meaningless. But for the ventral hernia, it actually changes the operation.

Dr. Manu Kaushik [00:36:16]: It changes the operation. Yeah, it does. I think for the inguinals, you know, I'm a big proponent, and I do support open inguinal hernia repairs a lot because it's one of my favorite operations, I won't lie to you. And coming back to the university setting and seeing how residents do maybe three or four in the whole residency, and then when they get a strangulated hernia, they're struggling because no one knows the anatomy. What's the conjoint tendon? This and that. I still value that operation a lot. You do? I think the one big advantage is covering the whole myopectineal orifice from the inside in a TAP. That's the beauty of that operation, which I appreciate. But, you know, every now and then, you have patients. I mean, when you're starting out on the robot, you don't want to take on a radical prostatectomy patient who's had radiation, who needs an inguinal hernia repair. So most patients are still doing them open. Going through my learning curve on the robot in terms of cholecystectomies, you know, I'll be very honest with you. I didn't see much difference between doing it laparoscopically and robotically. I mean, to be honest with you, hundreds of these laparoscopically in the rural community. I mean, I did not have ICG there. I have ICG now. That's one added advantage. Maybe, but I just think it takes longer.

Dr. Randy Lehman [00:37:30]: Yeah, but you can have ICG laparoscopically, too.

Dr. Manu Kaushik [00:37:33]: So you just need the better tower and the, you know, camera. You can have it.

Dr. Randy Lehman [00:37:37]: Yeah. I have two questions for you. Yeah, off topic. That's number one. I have a patient that I did a lap. Well, let me tell you a story first. A terrible story. So, I have one of my worst complications. I had a patient that had a previous—what was it? It was like, I think a Nissen or something in the past. And then they had a—yeah, that's what it was. It was an anti-reflux procedure. And then there was some sort of missed duodenal injury somehow. And they had come back, and they'd repaired it in ICU. Long time. This was all like, decades before. But anyway, multiple catastrophic surgeries. Okay. And I don't know if you've seen the new, like, guidelines. They say, you know the best when you do laparoscopic inguinal versus open. We're jumping topics here to inguinal, but, you know, bilateral, obviously recurrence after an open. But now females recommend it because you're covering a femoral defect. I think that's the reasoning. But so that had just kind of come out. It was a couple of years ago. And I'm being real smart and cutting edge and everything. So I got this lady. It's like this little, perfect little marble. Looks like a shooter marble—you know, hernia and reducible and everything. And I'm like, well, best thing for you, according to the data, is laparoscopic repair. That was stupid because I went in there, and it was terrible. And she ended up having a missed bowel injury from me. Yeah. And then she came back, and it's a septic. And then she—we ended up—I couldn't do her redo operation because then she's, like, meeting the limits of my institution. And there's no ICU, really, that we could do. So I have to send her to somebody else to manage my complication, which feels terrible. They took out my mesh, and then, you know, left her. I think they left her open for a day or something and then came back. And that sucks. Sorry. Of course, it's like my neighbor and everything. So it's just terrible. And rules, it's like, what is it? Learn the rules, follow the rules, break the rules kind of thing. Rules are—. That's why they're guidelines. Not really rules. Yeah, you know, 100%.

Dr. Manu Kaushik [00:39:48]: I think guidelines are—guidelines are strong suggestions with evidence. And you just have to, you know, pick and choose when it comes to the patient, what works for that particular patient. And I think especially being in the community, when you don't have a lot of specialist services around you, and the hospital has limit—I mean, you can technically do a lot of things, you know, but the hospital limits. You have to be so careful in your approaches. And that was also one of the humbling things. I mean, coming to complications, I mean, we've all had them, you know. And I have had situations in the rural community where I had a complication, I had to temporize it, transfer the patient—it just, it just, it's just a lot. Yeah.

Dr. Randy Lehman [00:40:28]: All I would have had to do, honestly—I mean, I wouldn't do this, but I could have localized her in the clinic, went down, and thrown two stitches of Vicryl into that hernia, and she would have been fixed, you know. And I made in this big ordeal, thought I'm doing cutting edge. It's like, no, you fix the hernia, right? That's what you're literally there to do. So then I got another patient that is a current problem of mine, and I did a laparoscopic repair, a TAP on her, and she is having pain down her leg, like shooting neuropathic pain down her leg. And I'm wondering if I put the mesh down too—like, you know, I'm always trying to chase down that groove down to. Did I put it too low? Yeah, did I put it too low? Or what would you do, like, workup-wise? I started on gabapentin; that seems to be helping.

Dr. Manu Kaushik [00:41:14]: But I don't think it's somewhere the lateral cutaneous nerve like a meralgia paresthetica kind of thing. Because it's a lateral.

Dr. Randy Lehman [00:41:20]: I don't know. I don't think so. Because it's more down the groin, like shooting down the inside of the thigh rather than the lateral thigh.

Dr. Manu Kaushik [00:41:30]: Because laparoscopically it's more common to affect the genitofemoral nerve and the lateral cutaneous nerve compared to the ilioinguinal.

Dr. Randy Lehman [00:41:39]: I don't think it's the tack. I think it's the actual mesh, and I think it might be too close to the femoral nerve, possibly.

Dr. Manu Kaushik [00:41:46]: Yeah.

Dr. Randy Lehman [00:41:47]: But I don't know if it'll get better, or, you know, like, I could just imagine that situation. That mesh might eventually need to come out if it doesn't get better. I'm not sure.

Dr. Manu Kaushik [00:41:55]: I mean, you started on gabapentin. Wait and watch. I mean, I don't know about those. I mean, some people do the neurectomies and have some benefit from that.

Dr. Randy Lehman [00:42:06]: We'll see how that one goes. Maybe I'll give you an update.

Dr. Manu Kaushik [00:42:09]: I hope it gets better. Yeah.

Dr. Randy Lehman [00:42:11]: And then the last question I had for you on this inguinal topic before we get back to the ventrals is you mentioned the conjoint tendon. So you're suturing the superior aspect of your keyhole mesh to the conjoint tendon.

Dr. Manu Kaushik [00:42:24]: You mean an open repair?

Dr. Randy Lehman [00:42:25]: Yes.

Dr. Manu Kaushik [00:42:27]: So, yeah, laterally. Initially, I used to do interrupted on the inguinal ligament. Now I'm running that suture, and immediately I do longitudinal. I do throws on the interrupted throws on the conjoined tendon. Yes. Still the internal ring.

Dr. Randy Lehman [00:42:43]: So do you identify the conjoined tendon by, like, doing anything such as reaching up with an Allis clamp to grab it and pull it down, or are you just, like, pulling up the external oblique and stitching down onto the tissue?

Dr. Manu Kaushik [00:43:00]: The way I do it is when I open the external oblique and put my hemostats on it, I take a small gauze on my finger and dissect down and create that plane below the external oblique. I try to go as medial as I can, close to the rectus, so I have enough space for the mesh to, you know, kind of overlap to avoid the medial recurrence. Then I'm not really pulling it down or anything. I think I get enough dissection that my stitches go right on top of it as I'm securing the mesh. And my mesh is pretty much overlying the conjoined tendon. I try to go for at least a 5-centimeter overlap in that area, so I create a plane nicely below the external oblique.

Dr. Randy Lehman [00:43:42]: So what you're calling the conjoined tendon is basically the tissue that's down after you bluntly dissect up the external oblique, right?

Dr. Manu Kaushik [00:43:50]: Correct.

Dr. Randy Lehman [00:43:51]: It's kind of like the internal oblique. I mean, it's internal being transversalis joining together. So that's what the conjoined tendon is. The reason I'm asking that is I had a surgeon that I trained with who is very good, and one of the guys up there, and he would reach up, kind of like pushing in and under that tissue and grabbing and pulling down what he's calling the conjoined tendon. It's that stuff but sort of underneath. He would pull it down, and the top edge of the keyhole mesh would then be stitched to that because you kind of make it into a ligament, and then when you let go, it sucks the top edge of the mesh almost under the top of the conjoined tendon, if you will. So it's even deeper than the layer that you're talking about putting it in, which is where I usually put it as well.

Dr. Manu Kaushik [00:44:43]: He probably gets even more medial coverage then, I'm guessing.

Dr. Randy Lehman [00:44:48]: Yeah, it's. But. And it's almost like it's. What's the word I'm looking for? I don't know. Layered underneath.

Dr. Manu Kaushik [00:44:56]: I understand what you're saying. Yeah, I don't do it. I just go for the tissue. I get a 5-centimeter coverage. And that's what the textbook describes, too, if I'm correct.

Dr. Randy Lehman [00:45:04]: Yeah, I would agree. And do you interrupt up top on that?

Dr. Manu Kaushik [00:45:08]: I'm sorry?

Dr. Randy Lehman [00:45:09]: Do you do interrupts when you're stitching that top edge?

Dr. Manu Kaushik [00:45:12]: Yeah, I do interrupt it. Yeah. Because I'm always worried about the iliohypogastric over there. So.

Dr. Randy Lehman [00:45:17]: Yeah.

Dr. Manu Kaushik [00:45:17]: And I don't go. The way I do it is like I think Mastery describes in the Lichtenstein repair. If that's the mesh, I don't go mesh to flesh. I go mesh to mesh. I go in this direction along the nerve. I worry that I might trap the nerve if I go in this direction. That's. I just go along it. Yeah.

Dr. Randy Lehman [00:45:36]: And is that a permanent stitch or absorbable stitch?

Dr. Manu Kaushik [00:45:39]: So I do a Prolene over there.

Dr. Randy Lehman [00:45:42]: Yeah, yeah, yeah. For all your stitches are Prolene to stitch the mesh in.

Dr. Manu Kaushik [00:45:45]: Yeah, I do Prolene. Yeah, I know the textbook says Vycryl on the wing with the ligament. I just. I just Prolene it.

Dr. Randy Lehman [00:45:51]: Yeah, I actually did Prolene everywhere, but I moved to just that. Those top tacking stitches, those are the ones I. I changed to Vycryl, actually.

Dr. Manu Kaushik [00:46:00]: I think. I think there's enough literature and surgeons out there who will say whatever you use, as long as your dissection doesn't matter. Yeah. Because the mesh should get incorporated sometimes.

Dr. Randy Lehman [00:46:08]: What about if you got a blown out? I. I know we're really digressing here, but again, it's my show.

Dr. Manu Kaushik [00:46:17]: I mean, these are great discussions. You don't get to have them every day.

Dr. Randy Lehman [00:46:20]: Yeah. So if you've got a blown out floor, how do you, do you do a formal repair of the floor before putting that mesh? Or do you just kind of put a few stitches or do you just push it in until the mesh covers it?

Dr. Manu Kaushik [00:46:32]: Also, I try to approximate and I, I try not to leave the floor open and just rely on the mesh. I try to, if it's a small hole, I try to approximate whatever I can with like some figure of eight, even interrupted with a permanent suture. I have done like a, I don't know if it's an actual Bassini, but a bit of a modified where I bring the conjoined down to the inguinal ligament to close that hole. Yeah, that's what I do usually. And then put the mesh on top.

Dr. Randy Lehman [00:46:58]: That's actually like the standard repair that one of my mentors, Eugene Shively, learned from Louisville and he does that below all of his Lichtenstein patches. And he says, I never had a recurrence that came back to me. Right. And this is a guy with a 40 plus year career and he's saying that tongue in cheek. But I, I do think it worked for him for a very long time.

Dr. Manu Kaushik [00:47:19]: My, my, my program director used to always say, again, experienced surgeon. He's retired now. He's the same. See that? You know the concept of inguinal hernia is you have to strengthen the posterior wall.

Dr. Randy Lehman [00:47:29]: Yeah.

Dr. Manu Kaushik [00:47:29]: So I think that explains that. Maybe that's why he does it.

Dr. Randy Lehman [00:47:32]: So yeah, of course, if it, if it's an older guy and it's not a blown out floor and it's truly just an indirect, you might, you might just, by excising and reducing and throwing a stitch, you might have just fixed it just like we do with kids, you know, so then, then you probably don't have to do that belt and suspenders thing. But the blown out floors, it's worked well for me too. I think they have a little more pain when I do that. So I don't, I use it selectively. But me too, because I think short-lived.

Dr. Manu Kaushik [00:47:57]: One thing I have done, I don't know if it's a good idea or a bad idea. Once I had some tension when I did that. I did release the, I did do some relaxing incisions on the conjoined tendon side, and that took tension away. I think that did lead to less pain than what I anticipated for the patient because I've had one patient, I actually had a recurrence. This was two years ago where I think what I did was it was too tight, the repair, and it just blew up. And the mesh had not incorporated, and obviously the guy went to work at the farm two days later and probably blew a stitch.

Dr. Randy Lehman [00:48:29]: Yeah. What are you going to do? I mean. Okay, so let's go back to ventral hernia. I don't want to take too much of your time. This could go on forever. But actually, before we talk about the robot, when you were in Greenville, Alabama, and you have a hernia that's over 5 centimeters.

Dr. Manu Kaushik [00:48:48]: Got it.

Dr. Randy Lehman [00:48:49]: Is there another threshold beyond that, or is it kind of. Okay, over 5 centimeters. Now you're in this category.

Dr. Manu Kaushik [00:48:57]: Have I done it only for those patients? Some of them, yes, I have done that. I won't lie to you. But I have also done anterior component separation, but it was like a 7-8 centimeter defect. When it came down to the bigger ones, I did. Since I had the connection with the university, I did pass them along to my MIS partners because they were big on doing those robotars and doing the, you know, recto rectus mesh.

Dr. Randy Lehman [00:49:24]: Is that the most common thing you saw happening when you sent like the 10 to 12 centimeter hernias? It's a robotic bilateral TAR with a retrorectus.

Dr. Manu Kaushik [00:49:33]: Yes, I saw that happen to most of them.

Dr. Randy Lehman [00:49:35]: And the mesh they put, is it a pure Prolene mesh, or are they still putting a Prolene with something else? No, the Prolene, yes, because it's not exposed and you got the posterior sheath. But what if you can't get the posterior sheath closed in the middle? Well, you should be able to, I guess.

Dr. Manu Kaushik [00:49:52]: I think you should be able to, but I have had none of my patients had an issue. I mean, they did a great job on all those cases where they had to then go to a bit of a hybrid approach, open, do a little bit of anterior release as well, and put an onlay mesh on top. I've seen that, too.

Dr. Randy Lehman [00:50:09]: Okay.

Dr. Manu Kaushik [00:50:09]: Yeah.

Dr. Randy Lehman [00:50:10]: Very good. So, and when you did open component separation, then that's a separate lateral vertical incision.

Dr. Manu Kaushik [00:50:19]: Yeah. So basically, you know, same thing. You go from midline to lateral, go right over the rectus sheath, keep dissecting the subcutaneous plane, and sometimes just taking down the subcutaneous plane gives you five centimeters, you know, that's the subcutaneous flaps, and you're able to close the defect. I was lucky once where I think for a 6 centimeter defect, if I remember correctly, I was able to get enough mileage on the flap just by taking down the subcutaneous tissue and then I put a big onlay mesh on top. But ideally, I go over it, I mean, I feel with the semilunaris. You know, linear semilunaris is approximately 2 centimeters from the edge of the rectus, make that longitudinal incision. If it's a big hernia, you can go all the way from the costal margin down to the inguinal ligament and then get in that plane between the internal and external oblique, which nicely opens up. And I think I never had to be very aggressive with it. I've never had those cases, but the few I did, I just released a little bit of the external oblique and I was able to get a good 6 or 7 centimeters in the middle.

Dr. Randy Lehman [00:51:19]: Yeah. So you're doing this all through the same midline skin incision.

Dr. Manu Kaushik [00:51:24]: Correct.

Dr. Randy Lehman [00:51:24]: Which makes a big flap. Yeah. The other thing that I saw in residency, then that's great. That's the way to do it. But the other thing I saw in residency is going laterally, a little transverse incision, like maybe two inches or something. And then if you have those long lighted retractors...

Dr. Manu Kaushik [00:51:44]: Yeah.

Dr. Randy Lehman [00:51:45]: To come in and you're basically measuring like maybe you have a CT scan or something, and you know how far the semilunar line is from the midline pre-op. Then you go out lateral to that a couple of centimeters, right in the place where you're doing your release, and then go down and then just open it and then use those retractors and a long cautery to like release it. That avoids all of that big huge flap. But then you're saying you might get some benefit from releasing that flap too, you know.

Dr. Manu Kaushik [00:52:12]: Yeah, that's the thing, you know, and sometimes you don't have to go and release the muscle.

Dr. Randy Lehman [00:52:15]: So.

Dr. Manu Kaushik [00:52:16]: But I think it's case by case. I mean, some people I know are still religiously doing the Rives-Stoppa and those open repairs and have good outcomes. I mean, but I think like you said, the robot changes the operation. I mean, obviously I don't know if I'm going to do those complex repairs, but just watching them, it's pretty impressive how much they can do now.

Dr. Randy Lehman [00:52:34]: Yeah, yeah. That's the other thing is you... What I didn't realize when I went out to transition from residency to practice is that you don't have to do. It's that percentage game, right? You can meet like 90% of the demand, 90% of the hernias. And in turning away the 10% or, I mean, referring them to like somebody who's like a self-appointed hernia or whatever, fine, let them do that. It actually makes your life a lot better. Your community still got the 90% of the benefit, and you probably weren't even the guy. Like I'm not even the guy. The right guy to fix that really huge recurrent guy thing. And they're probably getting a better operation. Whereas if I'm fixing the 3 centimeter to 5 centimeter hernias, they're not getting a better operation by traveling, they're getting the exact same operation.

Dr. Manu Kaushik [00:53:25]: That is true. And that's what I tell the patients. I always told them that my job is to give you the best care possible or get you to the best care possible if I have the ability to do that. And patients, I think I never had an issue with understanding. There have been patients who said I cannot travel no matter what and then they just disappeared and they were followed up. That's happened. So yeah, it happens in the ER and I always worry about that.

Dr. Randy Lehman [00:53:49]: So yeah. Did you have anything else that you wanted to share about the robot before we move on from this segment?

Dr. Manu Kaushik [00:53:56]: I think one thing I do want to bring up is, I mean, you know, this hot topic of the robot in the rural community. I was just wondering what are your thoughts about that? Because one of our partners, he, I mean, if you want to, I mean, I think you'll enjoy talking to him too. He works in a place called Demopolis. It's also a rural community. His name is Quince Gibson. Very good surgeon. I've operated with him too. And he has a robot down there. And it's interesting, I think it's an interesting perspective when I talk to him to see how much it benefits in terms of you can do more with no assistance, or you know, having the third and fourth arm. But at the same time, the financial aspect of it and being able to sustain that practice, it's... I'm always very curious about that.

Dr. Randy Lehman [00:54:40]: You think he'll come on the show?

Dr. Manu Kaushik [00:54:43]: I can connect you guys.

Dr. Randy Lehman [00:54:45]: Sounds like I'll have to see if he can share how and why it's working. My practice right now is I'm actually in, I'm basically doing a part-time practice in four different places. So that's the problem because if I was doing a... Like last year I did 10,500 RVUs total. But it's all the chip shots at all the places making it easy, not doing the hard stuff. And that model I think is, I'm adding a ton of value. We need more people around where I'm at. And so, you know. But right now there isn't anybody. So I can go do that. But you can't do a robot under that model because I'm not even at one place full-time.

Dr. Manu Kaushik [00:55:29]: Exactly. You cannot generate all the RVUs in one hospital system, which is buying the robot for you. Yeah.

Dr. Randy Lehman [00:55:36]: Hi, Jack.

Dr. Manu Kaushik [00:55:38]: Hey, Jack.

Dr. Randy Lehman [00:55:40]: So Jack's getting hungry. We're gonna have to keep her moving here for the rest of the show. So why don't we move on to the other segments? So we've got the financial corner. Do you have a money tip for our listener?

Dr. Manu Kaushik [00:55:50]: I think when I think the first thing was I think you should be very careful negotiating your first job. That's one thing I really want to bring up because so I was technically an academic employed surgeon, so obviously my salary, everything was academic to the university and yada yada. But I have heard these stories from my friends who signed up in rural hospitals. You know, they got a good salary and they're very happy. And then after one year, it's all about how much you're generating. So I think a lot of them did not negotiate well about the long term kind of terms of the contract when they started. And I think some of them ended up switching their jobs very early. This is when they moved their family, got a house and everything. They settled down. I think that was one thing. I think everyone who's going into a rural practice should be careful because sometimes some rural places offer a lot of money, and I think that can be very attractive to people. But what happens after that? One year of fixed salary, two years of fixed salary? I think they should negotiate that because I've had friends who were not able to generate the volume because the population of the place was so small. All the gallbladders were already out, all the hernias were already fixed. It's like, how do you sustain that practice? What are your thoughts on that?

Dr. Randy Lehman [00:57:05]: I do have some thoughts on that. So first off, in rural America, you should be making more than in the city right now. And so if you're not, you know, if they're trying to put you on, like, for example, I got an offer at one place for 60th percentile production for 50th percentile pay. Okay, I'm not doing that. You need to be getting 90th percentile pay for 50th percentile production.

Dr. Manu Kaushik [00:57:30]: True.

Dr. Randy Lehman [00:57:30]: In rural America right now, if they're going to use percentile things, and the reason for that is because in rural America, first off, they can't recruit. And this is a recruitment strategy, so pay is higher in rural America. I would recommend, and I have on the show, don't do what I did and start an independent practice. Do it either as an employed or contracted model with the Critical Access Hospital right now. Because the pay, the reimbursement is not there when you're trying to chase down insurance and stuff. You can't also do a cash pay model because you're not really meeting the demands of the community because you're trying to take care of essentially poor people in rural America, poor and elderly patients. It's a big burden for them to travel. And so honestly, this, we complain about a lot of the systems, but people are kind of trying to do the right thing, like the Critical Access Dollars. I mean, what that's all about is identifying that these hospitals close. People are going to be hurt, and they're at-risk populations like poor and elderly populations in rural America. So the Critical Access strategy, you just have to partner with that and accept it. Now, if that goes away or changes... But I don't know, people talk about it going away, and actually my one contract, one hospital says if it goes away, the contract's null and void. I just feel like there's so much demand for me and my services. There will be some solution should that happen. So I was comfortable with signing that. Maybe having other options is good. I actually took a little bit of my vacation time and did locums early on. That gave me more of a mental security too. People could consider that, but definitely begin with the end in mind and make sure you're happy with that contract. And if you're a resident coming out, our views mean nothing to you. Talk to people that you're really close with that are surgeons and that you're working with at a residency place. Maybe have them review your contract. You could use companies that exist to do that, or attorneys. But really what I didn't understand when I signed my contract was productivity. I didn't know what 4000 RVUs was or 6000 RVUs. Right now, for reference, I looked at the MGMA stuff. I got my hands on it a couple of years ago, a year or two ago, and it was like 6,500 RVUs is an average productivity for a general surgeon in the United States. I remember being at Mayo, they said this guy, you know, the big HPB surgeon, he's producing 16,000 RVUs a year, right? So, but see, he's running two to three rooms at all times and doing multiple Whipples, like, per day.

Dr. Manu Kaushik [01:00:15]: Right?

Dr. Randy Lehman [01:00:16]: Your equivalent. One surgeon when I was in residency said doing six gallbladders is the same as doing one Whipple. So you can think about that. If it was me doing a Whipple, now take me all day and then multiple parts of all the rest of my days for the rest of the week. Whereas if I did six gallbladders in one day, I could go home and sleep all night and then not get a call, see them all back, or my nurse practitioner sees them all back in six weeks. I've talked about productivity from an RVU perspective. I actually just talked about this on a show that I recorded that's not out yet. But you know, you could ask around about what other people are generating in terms of RVUs per hour in different settings. Because for me, clinic is like three to four RVUs an hour. Surgery could be up to maybe 10 at the top, probably more like eight. And so that's why I didn't really understand why surgeons hated clinic so much, except for the fact that it's boring and we like to operate and it takes a lot of brainpower and it's not working with your hands. But it turns out it actually pays half as much too. So there's that. If it can be hired out, like there's all these little things that you can do to make yourself more efficient. If you don't know those numbers when you're a resident, unless you're digging in...

Dr. Manu Kaushik [01:01:33]: You don't know anything as a resident. That's what I, you know, you don't know how the system works. You just show up, you learn, you go home, you know, take care of patients. But the residency programs don't do a great job preparing the residents when they come out. So I think, I think for all residents, it's very important to, you know, do your own research, talk to people. When you meet people at conferences, for example, you know, the North American Rural Society, I mean, you meet like-minded people who are doing the same work. We've been through the process, who've already been through the struggles. I think it's really important to stay connected and prepare yourself before signing something. And, you know, same thing, talk to your friends, show your contracts to your superiors, companies, just be safe, protect yourself.

Dr. Randy Lehman [01:02:15]: Yeah, and you may not want to show, you may not get a lot of help from a university surgeon either. So if you're going to a community place or a rural place, if you have some mentors that are rural surgeons or community surgeons, show them the contract and ask. I think they will do that. I did not do that as much as I necessarily wanted to, but I mean, things kind of worked out. Track your data and make good decisions.

Dr. Manu Kaushik [01:02:44]: Yeah, make sure, make sure. So, you know, I would say very honestly because since I was going, you know, university employee working in the rural community, my data was not being tracked accurately. And when you get your report, what you've done with your productivity is much lower than what you perform. Because I was – you will be surprised, one financial year that hospital did not bill 71 procedures. Oh, that's a lot. That's a lot. You know, and at the end of the day, it does harm the hospital because obviously the hospital is not making the money. And secondly, if a university is placing a surgeon down there and it shows that they're not being productive enough, they're going to take that person back. You know, that's a service and that harms the whole community. So it's very important to be on top of your data.

Dr. Randy Lehman [01:03:30]: So how do you track it?

Dr. Manu Kaushik [01:03:32]: So everything I see, I document it. Everything I do is on a spreadsheet. Cases I do, how long it took for the case, follow-up stuff, I track all that.

Dr. Randy Lehman [01:03:43]: Yeah, I have a spreadsheet as well and I started doing this early on and it's kind of evolved now. Speaker A: The things that I put on the spreadsheet are the day, the patient, the case, the referring doctor, the CPT code, and the RVUs. I have it broken out to whether it was in the OR, in the hospital, in the clinic, or an office procedure. What I found is that like 65 to 70% of my RVUs were coming from the OR, maybe 25% from the clinic, and almost none from those ER consults, floor consults, or office procedures, which were very low value. I thought they would be higher value. So, I got that piece of information. But that's my practice. It may be different; like, the bigger the hospital, that's going to be different for you. But then I'm able to do tilt tables on Excel and stuff and analyze things. I can see what percentage of my patients are coming from which provider and all that. As far as the time goes, I don't track that, but I've thought about it. Last year, I went back to look at... Speaker B: I just do that for my technical, you know. Speaker A: Pushing yourself, yeah. Speaker B: Like, how am I doing where I can be more efficient as a surgeon? That's just for me. Obviously, none of us look at the clock while operating, like, "Oh, I've got to finish the surgery in 30 minutes." But it's good to see at the end of the year, like, okay, my ventral hernia time is going down and I'm becoming more efficient, being able to do more in this time. Speaker A: So, yeah, that's like last year. Then I was able to compare all my sites and see. Then I did a sort of estimate on how much time I was working at each place, and there's pretty drastic differences between the different sites. I can see where I need to push things one way or another. Speaker B: Especially in a small critical access hospital, I know turnover time, all that, is very difficult. It's different. But my turnover time there is actually better than in the main hospital for so many reasons because... Speaker A: No, I definitely... I mean, Mayo, the turnover time was terrible. Speaker B: Exactly, yeah. Speaker A: Because there's 250 operating rooms, and it just takes longer to get the patient from pre-op to the room. Speaker B: I mean, when you're doing colonoscopies, like you're doing 10 in a day, you can start at 7, get done by noon, and everything's done, you know. Speaker A: Right. Speaker B: Like, great. Speaker A: Right. Speaker B: Anywho. Speaker A: Okay, great. So, let's move on to the next segment of the show: Classic Rural Surgery Stories. Do you have a story your urban counterparts just wouldn't believe? Speaker B: I have a few. Let's see how many I can actually share. So, when I went down to the critical access hospital, I did get a little bit of a cultural shock looking at the hospital and the operating room. The hospital room was just bare bones. There were equipment which were the same forceps being used in 1990. Laparoscopic instruments were from 2001. They're all functional, don't get me wrong, but they were not as good. Things we got trained on were not there. So, that was a big adjustment, especially when you come from residency. You're a chief resident who's got a junior resident, a medical student, an attending looking over your shoulder, you're able to operate, and now you just have a scrub tech, and that's it. You have to figure out your retraction, even for a simple operation. Like, "Oh, I can't use two Richardson's because I only have one person with me," so switching to a Weitlaner and stuff like that. So, that was interesting. The interesting things I saw, number one, doing a lap chole. You're dissecting the critical view, and the system shuts down. The lights are off, the insufflation's off, you're like, "What the hell's going on?" That happened a few times. One of my partners used to go down there. This happened to him during an appendectomy. He was a very prolific surgeon, well-known in the country, and he had to convert to an open appendectomy, which he did, no problem. But it's such a bad feeling when you're doing it for like a 20-year-old. You have everything exposed, you're about to fire the stapler, and boom, everything shuts down. So, that was one. Number two, the story, which I think no one believes me, which I think I told you: Doing a lap chole, and then you see something crawl across the abdomen. That happened, and it was a roach. Speaker A: Oh, man. Oh, no. Speaker B: So thank God I was laparoscopic and I was almost done with the operation. But that's when I went on, you know, a witch hunt. I was like, "Why did this happen? This is impossible. I can never imagine." Because, you know, the OR is like the most sacred place in the hospital, right? And there's a bug. I'm like, "Okay, this is not right." So, I closed the OR. Nobody was happy about it, but, you know, if it was me or my family, you will not do that. Patients are family. You cannot operate. So, I actually went on a witch hunt. I found some open drains here and there. I found some problems with the autoclave. Had to shut that down, retire one autoclave, get the company in, seal some doors with the OR staff, work with them. I had to find, buy bug repellents, those ultrasonic ones, install them in every operating room, get an exterminator, get all the ORs clean. That took like a good three weeks. We were not operating. Since then, we never had a bug problem. But this happened. And, you know, for me, the problem was coming from a bigger hospital with all the resources. I've never heard of this happening. And my OR staff was just laughing. They're like, "Oh, that's funny," you know. So, that was a big culture shock to me. Another thing which happened to me was I was doing a gallbladder once, and the suction tubing fell down from the scrub tech's hand. The scrub tech said, "Oh, that fell down." I said, "Okay, we'll use another one." That was the last tube in the hospital, and I've already insufflated. I started my dissection. So, I had to re-sterilize that tube, which was a very interesting process. I scrubbed out, wore sterile gloves, cleaned it with alcohol, betadine, cleaned it again with alcohol, and then I wrapped Ioban around the tube and used that to finish the operation. So, that was an interesting situation I was in. Then, I think we've discussed this before about me buying instruments. Speaker A: Yeah, that's the main reason I was like, when I heard this story, I said, "You got to come on the show and talk about this." Because, and everything... What you were just talking about is also this ownership of it, that basically you're bringing something in there. It's even just culture and leadership. It seems to you like a simple "you have to do." You were even saying you have to do this. Actually, no, you don't have to do that. Like, some people would come in and not do it, but because of who you are and the type of person that it takes to get through general surgery residency, which is who I think most general surgeons are, they're going to come in and just naturally they're going to say things like that, like, "You just have to do this. It's unacceptable." Speaker B: And the problem is you can raise your hand and say, "Oh, I'm not going to work here anymore," and leave, you know, but... But that doesn't solve the problem.

Dr. Manu Kaushik [01:10:47]: People like us, especially general surgeons, we are problem solvers. You know, we have to find a solution, get the patient through this. So, I think when working in a critical access hospital, what I learned was you have to be like a 3D surgeon. You have to be so multidimensional. Your job is not just to operate. Like you said, you have to be the leader, you have to guide the OR staff. At the end of the day, I'm the one who's signing the anesthesia sheets, too. We don't have MD anesthesia. We have CRNAs who are fantastic, don't get me wrong. But at the end of the day, there's so much more responsibility compared to being in the university setup. You are defended by so many layers; you're protected. There's a manager or someone in charge of everything, you know, in the operating room. But over there, it's just you. I had to do my own inventory, make sure that we have all the meshes, we have all the clips. I would do it myself with the scrub tech, and that just adds on more work to your plate. But if you don't do that, you cannot function sometimes. So, the instrument thing you brought up, yeah, it's a funny story. I typically do a gallbladder with electrocautery. Like most people I know, some people use the ligature, some people use scissors. We didn't have hot scissors, so I used to use a hook cautery, which I'm used to.

Dr. Randy Lehman [01:11:57]: Yeah.

Dr. Manu Kaushik [01:11:58]: One fine morning, at three, gallbladders were booked and some other cases, and I'm told we have no more hook cauteries because they used to have these disposable ones which I never liked because it turns out to be more expensive using those. And they said, we don't have a hook cautery. I said, what do you mean don't have hook cautery? They said, we just don't have it. I said, okay, great. Gave me a heads up. Now there are three patients. I got through the cases with the ligature, which is not my personal preference for doing these operations. But then I went to the management, I said, hey, this is the problem. And then the management tells me, well, we're having a financial issue, we are on backorder this and that. And as a surgeon, you're like, well, I got 10 more patients who need this operation in the next few weeks, what do I do? They said, well, we can cancel the operation, but we do need the revenue. So I actually went to ACS the next week, you know, for my FSCS or something. And then I met some vendors over there and ended up buying my own hook cauteries and brought and used them in the operating room. They still have it.

Dr. Randy Lehman [01:12:58]: Awesome.

Dr. Manu Kaushik [01:12:59]: I used the reusable ones, you know, which I think they should have from the get-go, the universal ones. And then I called that vendor and he supplied me one more by mail. And that's how we continued doing that. I even had to buy my own medicine balls, my own debakey forceps because the ones they had were not sharp. And the hospital terminated the contract with the sharpening company because of financial issues. So I think people don't realize, especially in the urban setting, that a rural surgeon has to go through so much to get through some basic operations sometimes, which you won't even think about being in the city or in a big university hospital. That's what I tell the residents here too. I mean, you know, everyone is so spoiled. Like, you know, you give them a three or silk to do a Lembert suture. They do one, pop the needle off, get a new suture in. I used to do three stitches or four stitches with that because you have to save. And I think it makes you... I personally felt my three years in the rural community made me a better surgeon. Not just technically, but I think emotionally and mentally. I think much more when I'm in the operating room than I used to think as a resident. You know, like, I need to know, like, okay, what instruments do we have? Why am I using this? Why am I using that? I became more economical in my technique and in my usage of instruments.

Dr. Randy Lehman [01:14:17]: So how much did you pay for the hook cautery?

Dr. Manu Kaushik [01:14:19]: $110. I still haven't got them back. I don't expect that. But it was funny. I actually brought it up with the management and said, you know, just saying, I bought them. We are covered. Don't worry about this problem no more. And they were happy with it.

Dr. Randy Lehman [01:14:31]: So, yeah. So was there... I've heard about a honeymoon period where they'll buy you things. My hospitals are... That I'm working in... They do not seem to be in as dire financial straits as what you're describing. None of them.

Dr. Manu Kaushik [01:14:47]: Yeah. So I think Alabama is a special place, too. I think down in the South, we have the famous black belt, like they say, where we have a lot of rural population. And like, the place I was working at, you know, I think 23% of people are below the poverty line in that county. So it's a very poor community. And I actually looked up this data; I was doing some study, and their per capita income is actually $28,000 on average, compared to, I think, $43,000 in the United States. And almost 17% of people don't have a high school diploma. So overall, the community as such is very poor. And the hospital not having a surgeon for many years and with the neighboring hospital shutting down is a big financial crisis. So what we are trying to do at UAB, especially my superiors, they're trying to partner with these hospitals to salvage these hospitals and improve rural surgery care. And I mean, you came through a great program, and that is, I think, in my opinion, that is the permanent solution for this problem. Having more rural training programs. I don't know how that's going to happen. We've been talking about it over here to meet this need because we have multiple hospitals in a similar situation with financial restraints, and they're really struggling. We've had moments where they had to cut out the cable TV from the patient room. They didn't have enough money to take out the trash. Stuff like that, which you never imagine being in a first-world country. It's still happening in the rural community. You know, a lot of data shows that almost 60 million people are in these communities, and we're just running out of general surgeons because no one wants to do general surgery anymore, right?

Dr. Randy Lehman [01:16:31]: Yeah. Well, the other thing that I think is when you come in as a general surgeon, it's kind of like what I was saying about managing up just by being there because you're everybody. This is my belief, okay? Every human being has equal worth because they are a human being, okay? But they're also not the same, right? And so you can manage up just by being different, not being the same, being different from them in terms of your perspective about what you think is acceptable. And just by existing there, it rubs off on the people around you. And that's one thing about keeping your OR, your sterilization. I mean, I know I've been to Haiti and their concept of sterilization is a lot different. And then what you're doing, even just in the town as a whole, that I think can happen. Like, could all incomes raise because Dr. Kaushik's in town and his kids go to town with us and we see a different way and we see how education is valuable, and then maybe we, you know, I don't know.

Dr. Manu Kaushik [01:17:50]: I think, I think you bring up a very important point. I think as general surgeons, we are... We can make a big difference in a community, not just operating and taking care of a pathology. I think like you said, the whole mindset, I mean, the city feels comforted in the fact there is a surgeon to take care of them. I think that's a big trust factor over there. And secondly, like you said, with your individual force and your mindset, you can change the mindset of the whole hospital. I mean, that hospital never thought they would do laparoscopic colectomies. We ended up doing them, you know. And then that changes their mindset. Now the next person who goes there might have an expectation.

Dr. Randy Lehman [01:18:29]: Yeah, yeah.

Dr. Manu Kaushik [01:18:29]: Like, okay, you're already doing lap colectomies. Why can't we do this? Why can't we do that? You know, cholangiogram, for example. I was doing cholangiograms down there. And when I came to the university building, much less cholangiograms being done there, because we've got ERCP right here.

Dr. Randy Lehman [01:18:42]: So.

Dr. Manu Kaushik [01:18:44]: So those things, I think rural surgery, for the technical aspect of surgery, I think it pushes you to get better because you have no choice. You have to do what you have to do with less. But also, I think the difference you can make to the community is just invaluable. I think the ACS website said that a general surgeon in a rural community can generate close to 26 jobs.

Dr. Randy Lehman [01:19:06]: Yeah, that's the number that I've heard as well.

Dr. Manu Kaushik [01:19:10]: So it's incredible. I think we carry so much positive power with us. If we use it the right way, we can make a huge difference in these communities.

Dr. Randy Lehman [01:19:19]: Right. And it's the opposite of the brain drain, 100%, which is where the best and the brightest leave the town because they go work in the city, and then it's like just a self-perpetuating thing.

Dr. Manu Kaushik [01:19:30]: I think that's the immaturity in the mindset. When I was a junior resident, you know, I wanted to be a thoracic surgeon, period. Nothing else would do. I would just be a thoracic surgeon. I wanted to wear my headlight, be in the chest, do the big stuff. But you know, as you mature as a resident, your mindset changes. And I think in the three years I was down there, I matured as a person because I realized it doesn't matter what I want to do. What matters is, I mean, you should be happy. But you have to identify one problem in life and just work towards it. Be it rural surgery, be thoracic surgery, you see a need, and if you fit in the puzzle, that's all that matters. That's how I look at it.

Dr. Randy Lehman [01:20:11]: Yeah.

Dr. Manu Kaushik [01:20:12]: Progress, progress. If you're making a positive impact in something in life, that's big. And as surgeons, we can make so much of a difference. For example, I know it's part of the segment of your show in terms of the losses and how you recover from them and make a positive impact. I have a small story to share. I was in the office and was about to leave back for Birmingham, and then I get a call. There's a gunshot wound in the ER at that hospital. I get a call from the CEO saying, oh, can you just show up to the ER just to show your face, so we said there was a surgeon involved. This kid is almost dying. I said, okay, where was the kid shot? They have no idea. The guy calling me does not know. So I quickly drive, two minutes, I get there, 18-year-old gunshot wound, entry wound with no exit. Right here, the axilla. And they're coding him actively. Terrible situation. I asked when did you start coding and they said two minutes. I mean, the kid needs Edith, you know. And a few months ago, I had trained the ER staff that, you know, if this situation happened. This is our chest tray. I made them buy one rib spreader for the hospital just for a situation like this. And guess what? No one knew where the chest set was. They could not find it. So I had to do an ED thoracotomy with just a scalpel in my hand, which was the most intense experience I went through. Sometimes when you start, you know this might not end well, but also, you cannot let an 18-year-old kid just die in front of you without doing anything. So, I did a left side thoracotomy, got in no clamps, used the nurse's hand to cross clamp the aorta, which was terrible, and then opened the pericardium, got a little bit of blood out, did a clamshell on the other side. Maybe that was stupid of me, but.

Dr. Randy Lehman [01:22:03]: The injury was on the left or the right side.

Dr. Manu Kaushik [01:22:05]: The injury was... Sorry, the injury was on the right side.

Dr. Randy Lehman [01:22:07]: Okay.

Dr. Manu Kaushik [01:22:08]: The injury was on the upper lobe of the right lung, which could have been salvageable at a big center. Now, the problem was it got into the right side. The heart was almost empty because the hospital only had two units of blood.

Dr. Randy Lehman [01:22:18]: Right.

Dr. Manu Kaushik [01:22:19]: And they had not given that blood because the patient was not cross-matched.

Dr. Randy Lehman [01:22:23]: Right.

Dr. Manu Kaushik [01:22:24]: So that's just... yeah, exactly. It was a lost battle to begin with. But, you know, I found the injury. And interestingly, this kid was shot 30 minutes before being brought to the hospital. He was shot, he was talking, he was awake. He was probably just bleeding out from his lung. They were supposed to bring him here with an ambulance and fly him out to the trauma center because they have a helipad. And he coded right on the helipad. So salvageable injury, right. It's just terrible. And the kid died, which was unfortunate. If he was in Birmingham or a big city, if he was in Indianapolis, he would have been okay. A level one trauma center would have saved him.

Dr. Randy Lehman [01:22:59]: But I mean, just a massive transfusion protocol alone would have saved him.

Dr. Manu Kaushik [01:23:03]: Would have given him time, right. The problem is this kid... I lost this kid. And then I have to go talk to the family, obviously, take the ownership. This happened. We tried our best. It made me feel terrible as a surgeon that you know that, but.

Dr. Randy Lehman [01:23:18]: I.

Dr. Manu Kaushik [01:23:18]: Was upset about the outcome, but the outcome was pretty much obvious. The way we were not able to do the right thing for the patient was the most frustrating thing. And that trauma really got to me, that trauma case. And I started trying to train the ER staff, do mock drills, get them prepared for doing a cricothyrotomy, ED thoracotomy, things where we can temporize the patient. So we did a few of those. Actually, I was not aware the ACS does have a rural trauma development course for centers. So I reached out to the ACS, and that's what I would recommend some rural surgeons doing in there by themselves. The closest level one trauma center, if they're working with the ACS, they can actually come down to the center with their ER team and everyone, and they can look at the resources they have and actually train the staff for level one, level two traumas and prepare them how to use the existing resources and package the patient and get them out safely. So we're trying to do that for that community. Our trauma team at UAB has been helpful, and we're going to do that hopefully soon. That's one resource I had no idea about, how we can help ourselves as rural surgeons and improve the environment we are in. The second thing I found useful was teaching Stop the Bleed. I've had a case where someone had a radial artery transection and was laying in the ER and bleeding with no tourniquet. It was terrible. An OR was not available. We had to get the radial artery in the ER, which was fine. He did fine. The guy was okay. Thankfully, he was ulnar dominant. Again, the ER staff did not know to put a tourniquet on the patient, which is so basic. And then we're trying to do Stop the Bleed courses over there, teach the schools. Speaker unspecified: So, long story short, I think what we can bring as surgeons to these communities can be invaluable, even if it saves one life, you know, in the future. Because all these things about school shootings really scare me. And I feel like if all these schools get Stop the Bleed kits and stuff, maybe the kids can help each other if that happens at work. So, yeah, sorry, I went off topic over there.

Dr. Randy Lehman [01:25:18]: No, that's beautiful. And it actually kind of dovetails into the last segment of the show—resources for the busy rural surgeon. So you've just mentioned a couple of things, and then I was wondering. That's different from the ACS Red Book, right?

Dr. Manu Kaushik [01:25:32]: Yeah, it is, I think. So at ACS, for free, you can become a trainer for Stop the Bleed, and then you can actually organize Stop the Bleed courses for your community. It just needs a few resources, which I think the hospitals can help with, and I think that can make a big impact. Training the EMTs is crucial because sometimes even EMTs don't do the right thing in the rural communities, which I have seen a few times. I think training the EMTs, the high schools, the hospital staff, every nurse is important. If you have a post-op patient bleeding, at least they can put pressure on it, you know—until you or I get there. And the Rural Trauma Development course, if you just look it up on the ACS website, it guides you on how to navigate that.

Dr. Randy Lehman [01:26:15]: So yeah, it's crazy how healthcare providers don't always understand concepts like that. We had a patient—this makes me think of a story, a little nasty story. Maybe I should, but whatever, I'll say it. We had a patient, I was in the ICU as an intern, and they had a wound care service sort of developed and turned into, you know, nurse practitioner debridement. That's kind of the way that it ended up. Well, they had this sacral wound thing that was like, you know, I don't know, a 45-minute case, you know, with like over a liter of blood loss, and everything was for the sacral wound debridement. The patient comes up and ends up hypotensive, so they get transferred to the ICU after this case. I'm up there as an intern, just kind of perplexed. But I remember we had to give multiple units of blood, and I was the one presenting on the patient in the morning to the staff. It's like six o'clock in the morning, and I'm talking about, well, at this time, these were the vitals, and then we gave this transfusion and saline, and here's where we ended up. He was just looking at his paper; he looks up at me and goes, "Well boys, looks like you got a little experience resuscitating hemorrhagic shock." And then we moved on. Stop the Bleed, man.

Dr. Manu Kaushik [01:27:36]: Yeah, exactly. But yeah, I mean, I can repeat what you said. You can bring so much as a general surgeon, and just when people see you, I mean, obviously everyone's different, but most people, when they see you showing interest, they get inspired to do something more than they're capable of. I think that really can uplift the whole community, not just the hospital. So yeah.

Dr. Randy Lehman [01:27:59]: Yes, that's very inspiring. I really appreciate your time. Thank you so much for coming onto the show today.

Dr. Manu Kaushik [01:28:05]: Great opportunity. Thank you so much.

Dr. Randy Lehman [01:28:07]: Yep. It's been our honor. And thank you to the listener for joining us on this episode of The Rural American Surgeon. We look forward to seeing you on the next episode. Don't forget to like, subscribe and share this with all the people in your circle who are interested in rural surgery. Thanks for being here. We'll see you on the next show.