Episode 13

GI Bleeds in Rural Canada with Dr. Emily Mitic

Episode Transcript

Dr. Randy Lehman: [00:00:07] Welcome to the Rural American Surgeon. I'm your host, Dr. Randy Lehman. On this show, you'll receive powerful insights and resources for rural surgeons. I'm a general surgeon in northwest Indiana, and this show is tailored around the nuts and bolts of rural general surgery practice. But you'll find topics ranging from practical surgical tips to a host of others, including rural lifestyle, finance, training, practice models, and more. We'll have a segment called Classic Rural Surgery Stories where you'll get a feel for how practice in the country differs from the city. Whether you're a surgeon, other specialist, or primary care, or simply someone interested in healthcare for rural America, I'm glad you're here. Now let's get into the show.

Dr. Randy Lehman: [00:00:46] Welcome, listener, to the Rural American Surgeon. My guest today is Emily Mitic. She's a surgeon from America's Hat, Canada. Thanks for coming down and joining us on the show today. And she's a rural surgeon that I met while I was on a trip to Hawaii doing some educational things. And we, you and your husband and my wife and I bonded in the hot tub.

Dr. Emily Mitic: [00:01:12] We met in the hot tub. Yeah. Thanks for having me.

Dr. Randy Lehman: [00:01:18] Yeah. And so here we are, and you're going to tell us a little bit about Canada versus the U.S., and we're going to touch on some classic rural surgery stories, just like we always do. And we'll do some, some how I do it with GI bleed. But before we get into that, tell me about what your practice is like in rural Canada, how you got there and what brought you to that, that course of a career.

Dr. Emily Mitic: [00:01:43] All right. So I'm from Canada. I grew up here. I trained here, I work here. I matched to general surgery at the Northern Ontario School of Medicine, which is not in a major urban center like most of the other universities in Canada. It's based in two smaller communities in Northern Ontario, Pan Northern Program, where you actually train at sites throughout northern Ontario, many of which are quite small, some of which are a little bigger because you got to get, you know, your particular experiences, your HPB colorectal and stuff.

And then I actually got a job after that at one of the sites I had trained at in Timmins, Ontario, which is pretty remote, although not terribly small. There's 45,000 people there, but really far from anything else. So you have to handle whatever comes. But my family is actually in southern Alberta. I grew up in a small town called Okotoks, which is fairly near Calgary. So I eventually decided to come back to Alberta and I locummed around for a year and got a job in Red Deer, which is halfway between Edmonton and Calgary and is a small city that serves a big population.

Dr. Randy Lehman: [00:02:51] That's a beautiful name, Red Deer. So what do you think the pop total catchment size is for that area?

Dr. Emily Mitic: [00:02:57] There's 90,000 people in Red Deer, but I think our catchment's about 425,000.

Dr. Randy Lehman: [00:03:02] Wow. So the hospital that you're working at, what's it like?

Dr. Emily Mitic: [00:03:08] So it is a... I'd call it a regional hospital. We have seven working ORs, we have surgical services, general urology, plastics, obstetrics, ortho, we have a cancer center and we actually have gastroenterologists. So since I recently got this job, I actually have not really been doing GI bleed call. But I think I remember enough about it from Timmins because that was my call Karma. I had two or three of those every shift.

Dr. Randy Lehman: [00:03:42] And tell me about Timmins. So you... This is Red Deer, but... And now I understand the resources you have available. What sort of resources for the audience did you have in Timmins?

Dr. Emily Mitic: [00:03:52] So in Timmins we had general surgery, urology, obstetrics and ortho. And we had one gastroenterologist who was actually like pushed in his 80s so he was not on the call schedule for like a decade prior to me working there. So we were coverage for everything GI. I was the de facto junior gastroenterologist of Timmins. We saw people with IBD, we saw people with, you know, food boluses, GI bleeds, foreign bodies, you name it. GI emergency, that's us.

Dr. Randy Lehman: [00:04:23] If, if you weren't there, how far would people have had to travel?

Dr. Emily Mitic: [00:04:27] It would be about a three and a half hour drive or one hour helicopter ride. But it's remote northern Ontario so weather is a definite factor. There's no guarantee you're getting out.

Dr. Randy Lehman: [00:04:40] The people that live there, what do they do?

Dr. Emily Mitic: [00:04:43] Gold mining.

Dr. Randy Lehman: [00:04:44] Really? All around Timmins? Basically, yeah.

Dr. Emily Mitic: [00:04:48] Timmins is based on several large gold mines and then there's like a very small sort of like private college and public service sector.

Dr. Randy Lehman: [00:04:58] Okay, well that's remote. And now you have like the tale of two cities here. Basically you have a catchment area that's pretty large and essentially a tertiary care center with where you're at at Red Deer. What I didn't hear is do you have any surgical subspecialties that come out of general surgery?

Dr. Emily Mitic: [00:05:19] We have one colorectal surgeon.

Dr. Randy Lehman: [00:05:22] No surgical oncology. The general surgeons do breast?

Dr. Emily Mitic: [00:05:27] Yep, we do. Well, some of us do.

Dr. Randy Lehman: [00:05:29] And colorectal? Probably some of it too, I assume.

Dr. Emily Mitic: [00:05:32] Yeah, we all do some colorectal. Yeah, I don't do rectal.

Dr. Randy Lehman: [00:05:36] Yeah. How about they don't do any pancreas or maybe a distal panc or a trauma thing.

Dr. Emily Mitic: [00:05:43] There used to be someone who did like a HPB fellowship there, but he actually stopped doing it for a while before he moved away because it's very difficult to be the only hepatobiliary person in town doing Whipples. And he's actually left for a smaller and more rural practice this year.

Dr. Randy Lehman: [00:06:00] Or he's also not going to do Whipples.

Dr. Emily Mitic: [00:06:02] Or he's definitely not going to do Whipples.

Dr. Randy Lehman: [00:06:04] Yeah. Okay. Well, that gives us some color to where you're at. And that leads us into the next segment of the show. So why is rural surgery specialty? You talked about your family a little bit. Are there other reasons?

Dr. Emily Mitic: [00:06:16] Yeah, rural surgery is special to me because, you know, 30 to 50% of the population of Canada doesn't live in or near a major center with access to a tertiary care center.

... And I think that it's really important for everybody in our country to have equal access to high quality medical care.

Dr. Randy Lehman: [00:06:35] Yeah. So it's about the patients. Love it. That's beautiful. America. Or you know, Canada's so big. United States is big, you know, too. But Canada, there's just like so much goes on and on forever. But that's great. In Alberta, funny story, I had a major import from Alberta this year.

Dr. Emily Mitic: [00:06:57] Was it a cow?

Dr. Randy Lehman: [00:07:00] Close. It was a cattle chute. So there's a, there's a dealer, Huber Ag Equipment, I believe. Link in the show notes, tell the team if anybody's breeding Highland cattle. So they're importing a specialized type of chute that's for longhorned cattle. It's actually made in Scotland for Scottish Highlanders, which is what I have. And so you can bring them in and it, instead of doing a head catch chute side to side, it does a like a roll down thing that sweeps over the horns and then immobilizes them so you can give them their shots or whatever.

Dr. Emily Mitic: [00:07:35] So the Alberta, you've got cows here, no doubt.

Dr. Randy Lehman: [00:07:40] Yeah, that's right. So let's roll into the how I do it. So today we're going to talk about GI bleed. So I was told most common cause of a lower GI bleed is an upper GI bleed. Is that still true?

Dr. Emily Mitic: [00:07:52] Yeah, I think so.

Dr. Randy Lehman: [00:07:54] So the patient comes in, say they had food that day, whatever, and they're having melena. So what? And there's no right. I don't mean there's probably some wrong answers, I guess, but there's really no right or wrong answers. There's a lot of ways to do it. So I just want to hear, you know, how do you do it? And I can chime in, but some of the things that I've picked up because it's not all in the textbook and it's definitely not on the outdated board review courses that we did. And some people didn't go on the GI bleed service in residency or whatever, but then they find themselves doing a lot of scopes in rural practice. And you sort of have to have mentors to help you along, but that person comes in with melena, no vomiting. What's your approach?

Dr. Emily Mitic: [00:08:42] So my approach to a GI bleed is I always break it down into sort of three stages of the patient's care. There is the immediate resuscitation and diagnosis, there is the hemostatic maneuver, and then there is things you have to think about and do after hemostasis is achieved. So you have to remember your patient comes in, they have melena or hematemesis or what have you symptoms of a GI bleed. And you have a patient who's bleeding.

So you just roll exactly into how you would treat any other bleeding patient. Are they stable or unstable? You resuscitate them, you get two large bore IVs, you get a Foley catheter, you do some goal directed resuscitation, you type and cross them, you give them blood if they need it, et cetera. I would say that early access to endoscopy is critical, especially when you're somewhere a little bit more remote and you need to have your ducks in a row if a transfer is going to be part of the treatment plan, which it might be.

Even where I work now, we don't have interventional radiology, so it's scope surgery or nothing. Unless you can stabilize them for a trip. I think it's always a good idea to try to at least somewhat stabilize them before you go to the endoscopy suite because you're going to have less resources for resuscitation there. Some places where you work you might do this in the OR. You may or may not be lucky enough to have your anesthesia colleagues with you to help you with that. I would try to have them if you can. I would try to have them intubated if you can, if they're unstable.

So there's the whole, you know, pre-bleed resuscitation to be done. There's jokes amongst most gastroenterologists that if a patient's unstable, they're too unstable for a scope. And if they're stable, they can wait till the morning. I discourage that approach for your rural surgeons because, you know, you never know how they're going to improve or deteriorate and what you're going to have to do with them up to and including transfer. So if you have to get up at 2 in the morning and do a scope, go ahead. I think also most rural surgeons have something else they have to do the next day instead of scheduling a random X-ray scope that might take five minutes or an hour and a half. So I would just get up and do them.

And then there's the scope itself. So you have to be doing sort of an ongoing hemostasis and a resuscitation approach. And if you can get your anesthesia colleagues involved for the scope itself, it's really helpful to both take advantage of their expertise and to cognitively unload you while you do what can be a complicated procedure. So when I scope, I think you got to be really aware of what your resources are in your community. What kind of scopes do you have? Do you have therapeutic channel scopes? Do you have one scope that suctions better than your other ones? Do you have clips? Do you have, you know, thermal devices? Do you have epinephrine mixed up? Can you make some? Can you, you know, make up a little baggie of 100 mils of saline with an amp of epi in it and drop 10 mils at a time? Or do you have some commercial preparation for injection?

If they have hematemesis or you think that they have a really full stomach for some reason, or if they're unstable at all, I really try to get anesthesia to intubate them because they usually have eaten. They can have a stomach full of blood clots and especially variceal bleeds, can vomit a lot and then aspirate while you scope. Then you scope. You all know how to do a gastroscopy, I assume. So you have a look if the patient's stomach is full of clots or if you have time before the scope to give them some erythromycin to get their stomach empty. It really helps you try to suction out as much as you can and have a look around.

And then what you do from there really depends on the etiology. I think peptic ulcer disease is going to be your most common thing that you find. And I think you all know your Forrest classification where you're, you know, got a spurting vessel or an oozing vessel or, you know, visible vessel, etc. And I think that it's important to have more than one hemostatic maneuver available to you. And the guidelines recommend a dual hemostatic maneuver. I was injecting Gelfoam [Uncertain] myself because it was available and I was comfortable with it, but we also were lucky to have APC. So if you have, you know, sort of a GAVE with sort of just diffuse oozing of a large portion of the stomach, you can, you know, apply something thermal. Now, probably the favorite segment of the show, classic rural surgery. That time that was just so classic.

It just depends on what you have available and what you're comfortable with. But always try to do two things. I think injecting first is really useful for a lot of GI bleeds, especially ulcers, because it kind of slows it down to a dull roar enough that you can target your clipping or burning in a more precise fashion. And then, you know, once you start loading clips onto it, it becomes more and more difficult to see and you can't take them off.

So I think injecting four quadrants around where you see you're bleeding like half to one mil at a time in the submucosal plane really slows it down enough to get a really good visualization of where you're going to do a more precise maneuver. Talking separately about variceal bleeds for a second, because I did deal with those quite commonly in my practice in Timmins. Your resuscitation is a little different. You have to remember to give them octreotide.

I think that if you have any suspicion that the patient has liver disease, then giving them octreotide as part of their initial replacement resuscitation is a good idea. You can always stop it later. And banding of varices is only really something you should be endeavoring to do if you have the equipment and experience to do it. You have to do a couple with somebody who has expertise in it to get trained up. You don't have to do a thousand of them, but you have to do a couple in your training or after training with a mentor to really understand the device.

It's a bit finicky and how to load it and how to do this. And then just the banding itself has certain tips and tricks. And then if you think the patient has variceal bleeding, I think it's just important to remember, like where your Blakemore tube is, that it's not expired and how to use it. Every couple of years I have to go review how to use the Blakemore because fortunately, I've never actually had to deploy it.

Check the expiry date on something once in a while. Keep it. I think they keep it in the fridge in the ICU where I work because it does have to be refrigerated for some reason. Yeah. And gastric varices are really sort of troubling for the rural surgeon because the treatment is to inject that glue into them. And I've never done it. I guess I'd be prepared to do it if I really had to and nobody else was around. But, I mean, you can sort of fail at it in terms of achieving hemostasis if you don't know what you're doing. And you can also destroy your scope. I mean, I guess if I was going to choose between saving a patient and destroying a scope, I'd go ahead and destroy a scope, but I'd optimally prefer not to do that.

Dr. Randy Lehman: [00:15:30] Sure. Let me ask you a question. Just make it personal for me in my practice. So I'm in a critical access hospital. Like, you know, we normally have three patients admitted to the hospital at a time. We have 4,000 ER visits a year. I have not banded esophageal varices ever. But the patient comes in and they're just having, like, they're unstable and they're having just lots of hematemesis. So I agree. Like, I. . . I don't think I should band those varices, but at the same time, there they are. So. . . And. . . And you give. . . So you'd give them medical management, like octreotide and then. . . And then try to find a helicopter or. . . And they could be too unstable to. . . To get them in there.

Dr. Emily Mitic: [00:16:20] Yeah. I think they're often resuscitate. And if they're not, they may be. . . I mean, I think as a rural surgeon, you have to sometimes tell yourself that if you can't resuscitate someone long enough to get a colleague on the phone and talk to them, then you maybe were never going to be successful with the operative maneuver. You can put in a Blakemore if you suspect that it's an esophageal variceal bleeder. If you scope them and you see that and you're not comfortable, you can intubate them and deploy your Blakemore.

Dr. Randy Lehman: [00:16:46] Yeah. So they didn't have one when I got there. I asked them to order one. I'm not sure where it is in the hospital, you know, so I may ask for it and it's outdated or we don't find it. I don't know. You think that every rural hospital should have one and keep it up to keep it in date?

Dr. Emily Mitic: [00:17:04] I think every endoscopist should. So, I mean, not all of our rural hospitals in Canada have access to endoscopy or surgeons. I don't think it's the kind of thing you, you know, shouldn't necessarily be deploying if you're not an endoscopist. But if you have endoscopy services, it's. . . they're not like you have to remember, you know the steps, but I don't think they're hard to use.

Dr. Randy Lehman: [00:17:27] Yeah. Okay, well, that's great. Things we hope we never have to do.

Dr. Emily Mitic: [00:17:34] No doubt.

Dr. Randy Lehman: [00:17:35] Yeah. All right. So did you have more for your. . . This is like a beautiful dissertation on GI bleed, so thank you so much. This is fantastic. I do have a few questions, but you, you can carry on if you've got more.

Dr. Emily Mitic: [00:17:47] Sure. Just I guess we didn't really touch on lower GI bleeds, which we can in a sec. But for the rest of your upper GI bleed, when you've, you know, achieved hemostasis, there's things to consider. You have to consider whether you're planning to rescope or just prepared to rescope. So I don't feed these people immediately, even if it was a clean based ulcer, but if it was like a Forrest one or two, I plan a repeat scope in 24 to 48 hours. I keep them NPO and you know, ongoing resuscitation.

I think that you have to think about the cause. So, you know, are you on NSAIDs? Do you use cocaine? Do you have H. pylori? I think you need to either efficiently test and treat H. pylori or if you're in a place where you cannot efficiently test for H. pylori like where I used to work, we could only do it by biopsy and I'm not biopsying this bleeding patient, so I would just treat them for H. pylori and then you got to work them up for other causes, liver disease, etc. So there's the whole aftercare segment that, you know, I don't think should be downloaded to their family physician. As the endoscopist, I think you're still in charge of making sure that they're diagnosed for their cause of their upper GI bleed and treated accordingly.

Dr. Randy Lehman: [00:19:00] All right, and your three things again. So you said you need to resuscitate them.

Dr. Emily Mitic: [00:19:05] Resuscitation, your hemostatic measures, interventions, and then, you know, you're after. . . After stuff.

Dr. Randy Lehman: [00:19:12] Okay, so tell me about the lower part of it because, you know, they haven't prepped. So originally you're upper and you find a source, then you don't worry about the lower and that becomes problem number three.

Dr. Emily Mitic: [00:19:26] Yeah. So lower GI bleeds, fortunately, are much less likely to become unstable than upper GI bleeds and much less likely to require an endoscopic intervention. They often stop on their own. So the first thing I do, keep resuscitating them. And I'm much more patient with that resuscitation than I would be for a suspected upper.

I think part of diagnosing a lower GI bleed is excluding the upper GI bleed, then starting the next morning, usually because they always... They never seem to come in before dark. If they have adequately stabilized, I'll prep them and scope them as soon as I can. After that, they almost always stop. If they haven't, your options are an unprep scope, which is, in my experience, generally not particularly effective unless they have something like hemorrhoids, which is like a surprising amount of these lower GI bleeds or hemorrhoids, especially if they're bright red. You do a CT angiogram to try to identify the source. And if I'm doing that and I have an unprepped person that I can't immediately scope or have I attempted to scope, I'm usually on the phone to a center with interventional radiology, which is not even, even in my larger center now. I don't have access to vascular IR.

Dr. Randy Lehman: [00:20:42] Yeah, there's limitations. Okay, well, that's beautiful. So let me tell you or ask you a couple questions. So first off, somebody that's not vomiting. So I said that at the beginning. So does an NG tube have any role in your management of a GI bleed?

Dr. Emily Mitic: [00:21:04] I think if you can't for some reason scope the patient, I think it's useful for diagnostic purposes. Like if you're a rural emergency physician in a non-endoscopy center and you're trying to figure out what's going on, putting it in is reasonable. I don't find it's particularly helpful for like, stomach emptying. If they were vomiting, I'd put it in to try to prevent them from aspirating.

Dr. Randy Lehman: [00:21:27] As a diagnostic tool, you know, when I learned from textbook or something is, you know, if you put it down and it's clear, tells you nothing. If it's green, it means you don't have an upper GI bleed. If it's red, then you diagnose your upper GI bleed in a person that's not vomiting. But how helpful is that? When in my location right around the corner is endoscopy, and I have a 24/7 call team. So it doesn't really make any sense. Why don't I just do an upper scope? I mean, is that... Agree with that if I've got that capability?

Dr. Emily Mitic: [00:22:04] I think if it's red, it helps you. If it's clear or green, I don't think it helps you at all, because it depends on how competent your pylorus is. You're pumping... Duodenal ulcer won't necessarily make you vomit or have red NG output. I never did it. We also had, like, we were the GI bleed team my entire residency as well. I don't remember us. And then you just have it in the way when you scope or you got to pull it out, or it's just rubbing on your ulcer that had clotted off and rubbing the clot off your ulcers. I agree. If you have access to immediate endoscopy, I don't find it's highly utilitarian.

Dr. Randy Lehman: [00:22:42] And if you think it's an upper GI bleed, I mean, definitely intubate the patient with a cuffed ET tube. I mean, to protect that airway. Now, let's talk about a different scenario, which is most common that I usually have, which is that stable patient. It's a GI bleed that wasn't... Okay.

Dr. Emily Mitic: [00:23:00] Yeah.

Dr. Randy Lehman: [00:23:00] So... So a stable patient. Melena. No vomiting, no upper symptoms do. And they were stable from the time they walked in the door. So a lot of options. Again, I don't know what that I could say they're right or wrong, but some of them are so stable, you could... You could scope them outpatient. A lot of them where I'm at, we end up admitting. And I don't do the EGD right away. I do it... I prep them, and I do both of them the next day. But, you know, you could do the EGD now, prep them and scope in the morning, something like that. I'd like your opinion on pros and cons of each approach. And then if I did go with the... The next day, then I don't intubate them because they haven't been vomiting or did... You know, I'm not really concerned, so... And I'd like your opinion on that, too.

Dr. Emily Mitic: [00:23:57] So this was actually a really common consult that I got when I was in Timmins. A lot of these people would get admitted to hospitalist and either be admitted with, you know, they're stable and they've had a couple or one episode of melena, or they're admitted for some other reason, usually cardiac, and then they've gotten some Plavix and then they've had some melena.

I agree. If they're entirely stable, I don't necessarily prep them and do a double right away because I think a lot of these people have other comorbidities where the prep is not necessarily going to be something super well tolerated for them, especially when they're admitted with like a fresh NSTEMI or whatever. But I fast them overnight. I don't rush to scope them within the hour like I would an unstable patient. I, you know, we keep an eye on them overnight, we get we fast, then we give them some Erythromycin and just make sure we have a really good empty stomach.

And then I only usually prep a stable patient if the upper scope has been negative or they have some other compelling indication for a colonoscopy, or if I really highly suspect it's a lower GI bleed, like it's bright red or it's maroon or they have a personal history of colon cancer or some other compelling indication for a lower scope. I don't find most patients mind skipping the prep and then having the upper and then coming back prepped for the second one. They appreciate that from a patient experience standpoint as well. Avoiding the colon if they can.

Dr. Randy Lehman: [00:25:15] When you do the colon, then that's an outpatient procedure later.

Dr. Emily Mitic: [00:25:18] Not usually. I would usually usually, like I said, these people were almost always admitted for some other reason. So they were just around to prep. If they were super stable and they had no other reason to be in hospital and I could arrange an urgent outpatient colonoscopy, then I would theoretically do that and would have in Timmins because I had a lot more control over the endoscopy schedule. And you know, I could say like, yes, I can definitely scope you on Thursday and nobody can tell me now where I work.

Now, I can't guarantee that I'm going to scope you for like six or eight weeks. So if you are an inpatient for that, I would get it done before you left.

Dr. Randy Lehman: [00:25:53] Yeah, those are great differences. I'm pretty much like you. If, if I say that we can do this procedure on if my schedule allows, then it can be done. So that is one big benefit of working in a very small place.

Dr. Emily Mitic: [00:26:07] I used to do a lot of like semi-urgent gastro on my lunch during a clinic day. When I work, I do the same thing. Show up, I'll see you at 12:15.

Dr. Randy Lehman: [00:26:18] Yep.

Dr. Emily Mitic: [00:26:19] I didn't eat a lot of lunch.

Dr. Randy Lehman: [00:26:21] Yeah. All right, well, this is fantastic. What else are we missing?

Dr. Emily Mitic: [00:26:27] Oh, what else are we missing? I think that we're missing, you know what if your hemostasis fails. Let's go back to upper GI bleed. Let's say it's an ulcer. If you fail at hemostasis or you have rebleeding, I think that your first step for a rebleed is always just to absolutely start again. Resuscitate, scope again. Often takes two cracks to get these things to stop bleeding, especially if they're a Forrest one or two.

But if you're highly suspicious of a rebleed or you actively have a rebleed, you have to be thinking of your bailout options. And I think that for most rural surgeons, unfortunately, unless you have really efficient transfer somewhere or the patient is stabilized, you gotta be prepared to operate for this. Which is something I have fortunately had to do infrequently because I usually manage to get control endoscopically. There was one patient that I managed to stabilize and transfer for IR when I was in Timmons because he was so surgically comorbid, I did not think he would survive a laparotomy.

Dr. Randy Lehman: [00:27:27] Yeah. So I had one in residency and I'm so glad I got to do that case with Dr. Skimp, just like, you know, from another era. And we had double failed rebleed, duodenal ulcer bleeding. Duodenal ulcer. So, and it was just classic. So we went in and we did an open oversewing of the ulcer. So open. And this is, tell, tell me if this is how you do it. So vertical midline laparotomy. Open the duodenum longitudinally and identify the bleeding ulcer. Place a three-point stitch so you're, you're above and below the GDA. And then one stitch to the left side to get that transverse pancreatic branch. And you're not going too deep because your bile duct's right behind you and you just throw in a little silk on top of it, get it to stop, and then closing the duodenum transversely. If you can get a two-layer closure, probably possibly you can. I think we did. And then, you know, close up shop. So is that what you would do?

Dr. Emily Mitic: [00:28:41] That is what I would do if I had to. No doubt.

Dr. Randy Lehman: [00:28:44] You haven't had to do it.

Dr. Emily Mitic: [00:28:45] I have not had to do it. I think that that's great if it's a duodenal ulcer bleed, and I think it usually is in those scenarios, a GDA bleed, if you found that your bleeding was somewhere else in the stomach on your scope, I mean, being prepared to go into the stomach, but I mean, you can fill the stomach and put it back together and it'll probably be okay.

Dr. Randy Lehman: [00:29:05] So if you had to do that, where would you open the stomach? How would you do that?

Dr. Emily Mitic: [00:29:08] It depends on where I found the bleeding at the time of endoscopy. Like, I would just. It's hard to say because you would.

Dr. Randy Lehman: [00:29:17] Try to target over where it's at. I would try to target. Hard to know if what's the anterior and posterior stomach, even when you're scoping sometimes.

Dr. Emily Mitic: [00:29:24] But yeah, I think I would just open some nice easy place to repair on the anterior stomach and not be too worried about how big I made it and get in there and look around, I guess. But you're right. These uncontrollable upper GI bleeds are almost always either variceal, for which the surgical option is like some HPB textbook bypass that I'm not doing, or like, you know, a Blakemore or TIPS. So, I mean, I don't think I'd ever attempt to operate for that. I don't think that would be appropriate. And then almost always your other uncontrollable ones are your GDA bleeds. The one that I had to send to the city was a GDA bleed. They did manage to embolize it, but this guy, he couldn't have tolerated a laparotomy or I would have tried, but I actually had opened three times because he was stable and not control.

Dr. Randy Lehman: [00:30:17] Well, this is great. I think we should wrap it up because there's a lot of things we could talk about hemobilia, we could talk about cancer, we could take it a lot of different directions. But this gives us a pretty good idea is exactly what I was wanting to talk about. The person that comes through the ER, we got the acute GI bleed and how we're going to handle it. I think we can get all these patients to our definitive procedure, like you said, and stay stabilized. So thank you for taking all that time.

Dr. Emily Mitic: [00:30:40] You're welcome.

Dr. Randy Lehman: [00:30:42] Let's move on to the next segment of the show called the Financial Corner. Now, I had a specific question I wanted to ask you. So in the United States, we have such a fragmented healthcare payer system, and everybody down here just thinks in Canada it's socialized medicine and it's a single payer and it's simple. So is it like that?

Dr. Emily Mitic: [00:31:06] It's more like that than not like that. Everybody has healthcare, everybody's got a health card. You don't show up to the hospital with your credit card or worried about whether you're going to pay for it or not. You probably should bring that card with you or they will bill you, as happened to me once when I was first a resident because I'd moved between provinces.

So each province is actually individually responsible for healthcare. And when you're out of province, unless you're from Quebec, there is a mutual agreement between the provinces to cover each other. But a patient from Quebec in another province, it gets a bit tricky. They typed my health card number in wrong the first time I went to emerge when I had moved to Ontario, so they thought it was invalid and they came after me with a bill just as quick as any American hospital until I just corrected the number. From the physician's perspective, I think it is a lot simpler because you have a single pair. So you just still have to know codes, you have to know your billing, you have to know the tips and tricks of your specialty and how to bill.

And billing is different in every province, which is a little bit annoying if you're a locum or if you've moved. But you don't have to worry about billing different payers. For the most part, you do get the occasional uninsured patient.

Dr. Randy Lehman: [00:32:19] Do you use AMA code or the same codes that we do, like 4, 5, 3, 7, 8 for a colonoscopy or no?

Dr. Emily Mitic: [00:32:26] Each province actually has their own complete coding system. The diagnostic codes are pretty standard across. Like if you look at like ICD9 codes, you have to provide a diagnostic code for each billing. And I think they're, as far as I have ever looked, similar or the same. But no. If I go do some work in British Columbia, they have a completely different fee schedule. They have their own system for coding the fees and they all pay different.

Dr. Randy Lehman: [00:32:52] That's so painful. Is there anything that I just wouldn't believe about your system from a setup organization, financial, how it's all done, like what? The other thing we imagine is you have cancer, you're going to wait six months to have an operation.

Dr. Emily Mitic: [00:33:08] Depends. Six months would be on the outside, but it depends where you live and what your access is. And I think a few provinces, including Alberta, where I currently practice, are really facing like medical oncology shortage. It can be really hard for us to get our patients to medical oncology in a timely fashion. And I am absolutely crushed under breast cancer consults. And it is like a daily struggle to find operating time to operate on my breast cancers in a timely fashion. But we're like just managing at the moment.

Dr. Randy Lehman: [00:33:41] So how long are the waits for breast cancer?

Dr. Emily Mitic: [00:33:44] Four to eight weeks.

Dr. Randy Lehman: [00:33:46] Wow. Okay.

Dr. Emily Mitic: [00:33:49] Do you do breast cancer, Randy?

Dr. Randy Lehman: [00:33:50] Yeah, I do breast cancer.

Dr. Emily Mitic: [00:33:51] And how soon after a diagnosis can you operate?

Dr. Randy Lehman: [00:33:54] Well, I have my medical oncologist that I use gets them in in three days every time. New cancer, whether that's colon or breast, those are the most common. Then I do a ton of skin cancer, of course. Yeah, I've been diagnosing. I diagnosed several esophageal cancers in the last two months. Like four. I think three or four. I can get those in pretty quick. Rectal. I usually send rectal out and then the colons, of course, I do myself.

But for me getting doing surgery, you know, I just clear my schedule. And so usually I get them in within probably two weeks, but sometimes same week. It just depends on exactly what we're talking about. Because for breast cancer, you need to sit down ahead of time. For colon cancer, not necessarily. We need to get your specimen out so that we have the information for the medical oncologist. So then it's just a surgical availability thing as long. And I do my own staging workup. Like if I'm doing a colonoscopy and whether I knew or didn't know there was a mass and I find a mass, I just order their staging workup that same day, I do too.

Dr. Emily Mitic: [00:35:04] And they get their staging workup pretty quick. When I was in Timmins, it was actually a better situation because I had just a lower referral volume and I could bump benign things. Breast or colon cancer diagnosed in Timmins, I'd usually operate on you in two weeks. I'd actually, for breast cancers, have a heads up that biopsies were done from our traveling radiologist who'd come up, and I'd just save scheduled time. And it was pretty easy, you know, to call someone up and say, hey, you want gallbladder out in five days if you didn't fill it?

And Red Deer, I mean, I have a breast cancer practice here that's pretty busy for the summer. I did one non-breast cancer operation the entire summer, not on call. For my elective practice, it was wall-to-wall breast cancer every single or day, two to three days a week for two and a half months. I did one Crohn's operation.

Dr. Randy Lehman: [00:35:52] Wow. How's pathology?

Dr. Emily Mitic: [00:35:55] Decent. Decent. Two weeks.

Dr. Randy Lehman: [00:35:57] Mine's two. Two weeks. So I have one week. That's my long one. And I complain about that one. But I put a rush on their path, you know, but one of the places I'll get it back in 48 hours. And so that's the other thing. You know, it's frustrating when you know it's going to be cancer. You prepped them and everything, but you, you gotta let them eat, you know, and you can't just like do it the next day or anything like that. You just gotta wait, name it, stage it, treat it, you know, the typical cancer thing. But I would say I've diagnosed cancer and had them in the OR for colon cancer within a week, you know, sometimes.

Dr. Emily Mitic: [00:36:31] So that would be pretty unreal in Canada.

Dr. Randy Lehman: [00:36:34] Yeah, well, it's those things and that's a small town. I would say that would be unreal at Mayo Clinic too, you know, which, where I trained is very fantastic place. But you're small and you're nimble, you know?

Dr. Emily Mitic: [00:36:47] Yeah. So.

Dr. Randy Lehman: [00:36:48] And it's one of those, what is it? Do you want to go fast, go alone, you want to go far, go with the team? It's kind of like you're not alone. I mean you got your little team, but your little team can really go fast when they want to.

Dr. Emily Mitic: [00:37:02] No doubt.

Dr. Randy Lehman: [00:37:03] Versus the big Mecca ivory tower thing.

Dr. Emily Mitic: [00:37:06] So do you think it makes a difference to your outcomes to get your path back in two days versus two weeks?

Dr. Randy Lehman: [00:37:10] No, I just think the patient.

Dr. Emily Mitic: [00:37:12] Yeah, that's what the Canadian government would argue for us.

Dr. Randy Lehman: [00:37:15] I would say that's true, the two day thing. But I have a close friend who's 34 with breast cancer, just got diagnosed and it's that waiting around, it definitely.

Dr. Emily Mitic: [00:37:28] Makes a psychological difference.

Dr. Randy Lehman: [00:37:30] Yeah, I mean a lot of our.

Dr. Emily Mitic: [00:37:32] Patients aren't prepared to have surgery within a week. They're not prepared to.

Dr. Randy Lehman: [00:37:36] Depends on your person.

Dr. Emily Mitic: [00:37:37] Yeah, they're not prepared to leave their job, they're not prepared to have their family cared for. And a lot of our population doesn't live here. They have to get here, they have to plan to stay. They need to get a ride.

Dr. Randy Lehman: [00:37:50] It's a good other side to the, to that story. So. All right, very interesting financial corner.

Dr. Emily Mitic: [00:38:03] So I think classic rural surgery is just applying your skills to a completely oddball situation that you did not train for in residency. I had a Friday afternoon, I just finished up a, you know, pretty chill, benign OR. I was going to go away for the weekend and I got paged from Emerge. I'm leaving the OR saying, "Hey, are you on call? Can you help us with something?" And the emergent doc who called me is usually like a pretty steady girl. She's not excitable. She doesn't panic. And she just had this, like, note of panic in her voice.

And I said, "Oh, actually, Julia's on call. Try her, but if you don't get her in five minutes, let me know," because she just didn't sound herself. And so I, you know, I go to my locker, I get changed, I put my coat on, and then I hear, like, a code called to Emerge. And I was like, "Well, I'm probably gonna take that door out of the hospital and see what's going on." Turned out my colleague was operating on an emergency case, so she hadn't answered her page yet.

So I walked through, and I was like, "What's going on?" And, like, "He's bleeding. He's bleeding from his mouth. He's bleeding from his mouth."

Dr. Randy Lehman: [00:39:04] Help.

Dr. Emily Mitic: [00:39:05] So I'm like, "This can't be that big of a deal. Like, let's calm down." And, like, here I'm in my civvies here. Like, I'm in my clothes from my house. I'm not gowned, I'm not in PPE, whatever. And I go into this trauma bay in our little Emergency Department in Timmins, and there's blood on the walls. There's blood on the ceiling. There's blood on the floor. Like, there's just blood everywhere.

I'm like, "Somebody tell me what's going on here?" Like, "The guy went for buccal mucosa cancer surgery four hours away yesterday, and he says the flap fell off." I'm like, "Well, that's actually like, a great amount of history. Like, we know what's going on. Thank goodness."

So I go in there, and unbeknownst to my colleagues in Timmins at the time, I actually used to be a dental assistant. So I said, "Move the bed away from the wall. Bring me a little stool." And I took the slider from his bed, and I hauled the guy's head into my lap. So he's tipped back. He's looking at me, and I said, "What side was it?" And he goes like this. I said, "Open your mouth." And it goes, blood volcano.

And I'm like, "Okay." So I take a wad of gauze, I fish hook him in his cheek, and the bleeding stops. And I said, "Guess what, my friend? We're gonna be hanging out like this for a while. My name's Emily." He said, "Lynn." "We're buddies now, because I'm not taking my hand off until you've got a tube in your throat." And he's like, "Aha. Okay."

And so we're, you know, we get him calm. The Emerge doc, who's great, keeps resuscitating him. They get gathered [bladdered - Uncertain]. You got to get anesthesia. We're not dealing with this anywhere but the OR. So we wheel him up with me, like, literally crouching on his bed with my hand in his mouth. We get him upstairs, we get him intubated. Of course, by the time I take my hand off, pressure was sufficient. But I was just gonna throw some, like, figure of 8 micros in there.

They had been trying to call the very good ENT oncologist who had done his surgery in the city, and he was basically giving them all sorts of, like, wacky ivory tower advice, like some sort of special tonsillar hemorrhage clamp, and "You got to use that" and blah, blah, blah. So I called the guy after. He's like, "Hey, did you find the tonsillar hemorrhage clamp?" And I was like, "Gordon, I know this guy. The proper advice for a rural Emerge doc is not 'locate obscure piece of equipment which you probably don't have and definitely don't know how to use flawlessly.' Execute this device? Bada bing? Like, you're gonna have to think of something else to tell these people." Like, "I don't know what. Anyway, take your patient back. He's in a helicopter. See you never." Anyway, so the classic rural surgery part about this is, it was my GP's uncle.

Dr. Randy Lehman: [00:41:36] Wow.

Dr. Emily Mitic: [00:41:37] I got a card. I got a nice little card.

Dr. Randy Lehman: [00:41:40] It's all the pieces right there. Personal guy, that, you know, thing you've never... You've never found yourself in before, but you're relying on your having a colleague.

Dr. Emily Mitic: [00:41:49] Having a colleague pick my kid up from school while I had my hand in this guy's mouth, and they're like, "Oh, yeah, no problem." My kid just, like, knows them and will go with them. Like, that's rural surgery. Yeah. Manual pressure fixes everything.

Dr. Randy Lehman: [00:42:01] It's like, we need to tell everybody, even other healthcare workers. But that's all right. I get it. It's a panic situation. So... What a beautiful story. Last segment of the show, resources for the busy rural surgeon. You know, I know that you do courses because we met at a course. What do you recommend? Something that... How do you stay so up to date?

Dr. Emily Mitic: [00:42:24] So it's going to be kind of a boring answer because I think I use just very, you know, all the same resources we studied for our boards for. But I have to say that I find myself going to the American Society of Colon and Rectal Surgeons guidelines at least once a week to look something up.

Dr. Randy Lehman: [00:42:40] For endoscopy stuff.

Dr. Emily Mitic: [00:42:42] Yeah, for endoscopy, for diverticulitis, for perianal disease, for... I mean, they're just really good guidelines. They only take a minute to read. They're up to date. You can trust them. I really like the ASCRS guidelines.

Dr. Randy Lehman: [00:42:54] You go to their website to access them?

Dr. Emily Mitic: [00:42:56] Yeah. And they're free. You don't even have to sign in or anything.

Dr. Randy Lehman: [00:42:58] Yep, yep. Yeah. That's beautiful. All right, well, Emily, thank you so much for taking this time. You are welcome back. You have to come back sometime because... Because you have great stories and this is like a straight up clinic coming from Alberta, so it's beautiful. Is there anything else that the audience maybe could do for you? Things that we could do to connect or anything else you'd like to share?

Dr. Emily Mitic: [00:43:22] No, not really. I'm not like super active on social media or anything, so you don't need to, you know, if you're gonna like and share, do it for Randy's sake, not mine. But thanks for having me, man. Great podcast. Glad to introduce... Hi, glad to join you.

Dr. Randy Lehman: [00:43:35] It's my pleasure. So thank you, listener, for joining in on this episode of the Rural American Surgeon. We'll catch you on the next show.