EPISODE 24

Sentinel Node Biopsy with Dr. Mel Johnson - Part 2

Episode Transcript

Dr. Randy Lehman [0:11 - 1:12]: 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 to The Rural American Surgeon. Our episode last week with Dr. Mel Johnson was just too packed with too many nuggets of information that I had to split it into two episodes so that I could share it all with you. So we're back with her again this week. Now let's get to the show. All right, well, tell me what you want to tell me about sentinel lymph node biopsy. So maybe, like, how you do it and then all the other permutations and, you know, ways to get it up and going.

Dr. Mel Johnson [1:13 - 2:34]: Yep. So, again, the way we do it at Gundersland La Crosse and have for a long time is doing our own Lymphoseek injection, which was new to me. I'd never done my own. But, again, that sort of pulls out the need for that nuclear medicine department there. So we use blue dye. We happen to use isosulfan blue dye, but many places use Lymphazurin. I don't think it matters. And then we use Lymphoseek.

There are, again, ICG as another possible way. If you happen to have ICG capabilities and you don't have a neoprobe, you could look into that. There's also a newer one called Magtrace. I've never used it myself, but Magtrace is selling themselves in that you can inject it. Like, let's say you're doing a mastectomy for DCIS where we would normally do a sentinel node biopsy. You can inject Magtrace at the time that you're doing the case and not do a sentinel node biopsy.

Magtrace hangs around; my breast partner thinks it hangs around for about two weeks. But once you get pathology back, if there's an invasive cancer, you can go back and do a sentinel node biopsy. So that's something newer. Again, we are not doing that. We do blue dye, and we do Lymphoseek, but there are other ways of doing it, and I would say more companies are getting into that space. So you just have to look into what technology you want to purchase for your hospital.

Dr. Randy Lehman [2:34 - 2:53]: So when do you inject? You said you inject the Lymphoseek before they go back. So if they're in the pre-op holding bay, where do you inject them? All right. If they have a palpable mass, are you injecting the Lymphoseek into the mass or in a subareolar location?

Dr. Mel Johnson [2:53 - 3:02]: We do an intradermal injection in the upper outer quadrant, right outside the areola of the breast cancer.

Dr. Randy Lehman [3:03 - 3:04]: Just that one spot.

Dr. Mel Johnson [3:04 - 3:12]: That's it. It's about 0.4 ml. It's injected with a 29-gauge needle and a little diabetic syringe, actually intradermal.

Dr. Randy Lehman [3:12 - 3:18]: So you're raising a wheal when you do that, and you're prepping with some, what, alcohol?

Dr. Mel Johnson [3:18 - 3:19]: Yep.

Dr. Randy Lehman [3:19 - 3:23]: And are you injecting any local beforehand, or you're just injecting that wheal?

Dr. Mel Johnson [3:23 - 3:24]: No, just that.

Dr. Randy Lehman [3:24 - 3:26]: Okay. What size needle do you use?

Dr. Mel Johnson [3:26 - 3:52]: I believe it's our insulin syringe needle. So I think it's like a 30-gauge. Yeah. It comes pre-loaded. Again, our Lymphoseek arrives that morning from UW Madison. Even though we have a nuclear medicine department, they don't deal in Lymphoseek. So anytime they're even injecting, let's say, for a melanoma case, it's the same thing. They're getting it that morning from UW. So, again, if you're a rural hospital in Wisconsin, you could order it as well.

Dr. Randy Lehman [3:52 - 4:05]: I see. A question on the melanoma. When you inject for the melanoma, you know, I noticed that usually the radiologist injects four quadrants around whatever lesion we're trying to do. So that's why I was kind of asking if you did four quadrants for melanoma, but you're still having them do it.

Dr. Mel Johnson [4:05 - 4:34]: In the same way, they do their own injection. I was called one day to inject for a melanoma patient for ENT because evidently, the radiologist covering nuclear medicine wasn't comfortable. So they told me their protocol was to do a two-side injection for this particular melanoma. But, again, don't let me speak for nuclear medicine, because I'm not normally the person injecting for them.

Dr. Randy Lehman [4:34 - 4:40]: Got it. And so then you inject the blue dye after the patient is asleep?

Dr. Mel Johnson [4:40 - 5:20]: Yes, we do a four-quadrant injection around the areola. So that's how I was trained to do it. I use half a ml at 12, 3, 6, and 9. But there are many ways to do it. I have another partner who does his whole injection intradermally at that upper outer quadrant location. So the same location that they get the Lymphoseek. I don't think any of my partners are doing it around the tumor itself or trying to approximate that. Most of us are doing it around the areola. We have one new partner who just got out of breast fellowship. She injects, basically, she fans it out all underneath the areola.

Dr. Randy Lehman [5:21 - 5:32]: Yeah, so how about if you're leaving the nipple, and how about blue dye staining long term and trying to minimize that? Can you talk about that for just a second?

Dr. Mel Johnson [5:32 - 5:43]: Yeah, I've really not seen it be an issue with sticking around. So when I see my patients in follow-up, I can't think of anybody who has a permanent tattoo from the blue dye.

Dr. Randy Lehman [5:44 - 5:45]: And you said you're using isosulfan blue?

Dr. Mel Johnson [5:45 - 5:47]: Isosulfan blue, yeah.

Dr. Randy Lehman [5:48 - 5:57]: Okay, great. So we've talked quite a bit about sentinel node biopsy. Was there something else that you wanted to discuss relative to rural places, or have we covered it all?

Dr. Mel Johnson [5:57 - 6:28]: I was just going to mention a couple of trials that are ongoing, and I can direct people to a recent article that came out. Monica Morrow is one of the national giants in breast surgery and has been for decades now. She had an article in the New England Journal of Medicine called, and this was in December of '24, "Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer: Is It Obsolete?" So just so people know that this is out there, it is not yet considered practice, but

Dr. Mel Johnson [6:28 - 7:00]: there are really two trials going on. One's called Insema, and the other one is called the SOUND trial. They are looking at, so especially the SOUND trial, is looking at T1N0 patients that opted for breast-conserving surgery, and they all had a negative axillary ultrasound and a negative clinical exam of the axilla. So, again, T1N0 breast-conserving surgery only with a negative axillary workup. They were looking at all comers, including all types of receptors, pre and postmenopausal. But interestingly, 95% of the patients enrolled in that SOUND trial were hormone receptor-positive and HER2 negative, and 90% were postmenopausal.

Dr. Mel Johnson [7:00 - 7:31]: So if you want to try to extrapolate these results, I think you really are probably looking at, again, hormone receptor-positive, HER2 negative, and postmenopausal. But they were looking at not doing sentinel lymph node biopsy in those specific patients. So in your T1s, their data showed they were missing about 9 to 11% of people in that group. By not doing a sentinel node biopsy, you're missing, you have to accept that you're going to miss 9 to 11% of people that would have a positive sentinel lymph node if you did it.

The INSEMA trial was including T2s, so for T2s, we're talking about 2 to 5 centimeter tumors. They're missing over 20% of those patients that would have a positive sentinel lymph node.

Dr. Mel Johnson [8:02 - 8:32]: Again, these trials are ongoing, but they are making that tentative recommendation that maybe we don't need to do sentinel node biopsies in T1 patients. I'm old school. I've been doing this a long time. If I'm the patient, you tell me there's a 10% chance I've got a positive node, and you're not going to find that out because, again, if you have a positive node these days, not everybody needs a full axillary node dissection. One or two positive nodes, we're just putting those patients into radiation therapy instead.

Dr. Mel Johnson [8:32 - 9:00]: So I don't. When I read those trial results and see 10%, man, yeah, that might be okay if I'm 85, but if I'm my age, I'd say go ahead and do the sentinel node biopsy because the risks of the sentinel node biopsy are so low. Like risk of lymph node from a sentinel node.

Dr. Randy Lehman [9:00 - 9:01]: Right.

Dr. Mel Johnson [9:01 - 9:10]: I just think people need to be aware that these trials are out there, and there's a national push for getting away from sentinel node biopsy for T1 patients.

Dr. Randy Lehman [9:10 - 9:34]: So you're talking ERPR positive, HER2 negative, mostly postmenopausal patients. This is what we call at Mayo Clinic, fondly, the little old lady breast cancer that laughs in the face of chemotherapy. The surgical treatment is your cornerstone, but they are getting radiation. So is the idea of this that their axilla is being covered with radiation that might be killing some of that?

Dr. Mel Johnson [9:34 - 10:56]: They still are getting their radiation after their lumpectomy, but they're not including the axilla. Not unless. Yes. And they're missing 9 to 11% of people, but they're saying survival is the same, which is okay, but then you're going to get an axillary. I wouldn't even call it recurrence. It's not an axillary recurrence. It's actually a disease that was there that you never found. I'm not telling people to change, but we should all go back and read this again. Monica Morrow is considered sort of a national expert, but there is a push to not do sentinel nodes on T1 patients, which by far, I'd say, that's the vast majority of patients that I have. The little old lady with the hormone-positive breast cancer.

Dr. Mel Johnson [10:56 - 10:57]: How we are handling this I do have, especially the Choosing Wisely is really pushing to talk to women, especially over the age of 70 with these T1 tumors. Talking to them pre-op and saying, here's your risks. Do you want a sentinel node biopsy? So that's taking it beyond just postmenopausal. Postmenopausal people, that's people over age 50. Right. But they're Choosing Wisely is saying you should lay everything out for your patients over age 70 and let them decide if they want a sentinel lymph node biopsy.

Dr. Randy Lehman [10:57 - 11:14]: Yeah, I love it. So it becomes very customized, which is what we're all aware of. And it should be that way. I mean, if you're a doctor, you choose different things for yourself than maybe the standard thing. So maybe that means we should just educate the patients more. It just takes a lot of time. It's hard to do.

Dr. Mel Johnson [11:14 - 11:38]: Right. But if you want, I would say if you want to run a breast program in your rural center, number one, I believe it's very doable. Number two, you've just got to stay up to date on your NCCN guidelines and watching these trials. Again, I would not recommend that anybody right now say, well, I'm going to just follow the sound trial. It's still a trial right now, so you're not going to find that recommendation yet in the NCCN guidelines.

Dr. Randy Lehman [11:38 - 12:39]: Yeah, stick to NCCN. I've got a thing going on right now in my practice that I think it's okay for me to share this because she's sharing it publicly. But my nurse practitioner actually has breast cancer. I think she's 34 and she's going through treatment. I think that is going to lead to us over the next five years really leaning in to breast cancer. She's going to be able to speak to the patients with a lot of authority, having gone through it. Of course, I'm going to bring in the connections and the knowledge we're going to have. I think that's probably a place where we're going to have the commitment that you were describing of just owning it because once you get to that point, you got, okay, Mayo Clinic trained surgeon from here, and his assistant who has been through it. Literally can't get more tailored in the approach than that.

Dr. Randy Lehman [12:39 - 12:41]: Now, the only thing is, can I bring in a plastic surgeon to help me out? Then I think we're all set.

Dr. Mel Johnson [12:41 - 12:45]: I really think you could, especially if you're looking at maybe it's a day, a month, maybe it's two days a month.

Dr. Randy Lehman [12:46 - 12:49]: How do you get that person paid and incentivized?

Dr. Mel Johnson [12:50 - 13:22]: I think you just have to find someone who's passionate about it. They obviously have to get paid for what they do, but you just have to find that. That's where having some of these connections out in your regional centers that have these people and approaching them and saying, hey, this is what I'm thinking about doing. It's more about finding the person. They'll want to get paid for it, but if they truly love providing that service, if they've got some connection to the rural community, those are the people that you go after. That's all you gotta do, is find the right person.

Dr. Randy Lehman [13:22 - 13:41]: Okay. I love it. I didn't go. Usually I go into the technical details, like, to the level of. Say there was a student that couldn't. That wasn't there. There were a few things I didn't. So after you do those two injections, patients asleep, prepped, draped. Do you prep the arm into the field?

Dr. Mel Johnson [13:41 - 13:47]: No, I just prep the arm. You know, I used to. And then I found that I've never, ever wanted to move the arm.

Dr. Randy Lehman [13:48 - 13:52]: So the arm's strapped out to the bed. And then you prep the axilla and the breast.

Dr. Mel Johnson [13:52 - 13:52]: Yeah.

Dr. Randy Lehman [13:53 - 13:56]: And do you go up, like, above the clavicle? What are your landmarks for prepping?

Dr. Mel Johnson [13:57 - 14:40]: You know, if I'm doing mastectomy, like, let's say this is a bilateral mastectomy, Pat, then we're prepping all the way up to the chin, all the way down under the abdomen. I use those beautiful, clear plastic sticky U drapes because, especially for mastectomies, you're going way down. I've found that just the other little blue sticky drapes don't stay put. So if I'm doing bilateral mastectomy, then I'm doing those big clear plastic U drapes to really get a decent sterile field. But if I'm doing just a simple sentinel lymph node biopsy or lumpectomy, so breast conservation, I'm just squaring it off with the sticky blue towels. That's it. But I just include breast and axilla. That's it.

Dr. Randy Lehman [14:41 - 14:56]: So usually what I do for my incision for the sentinel node in the armpit is I mark out the hair-bearing area. Usually, just like the anterior inferior area, I make an incision right at the edge of the hair-bearing area. But I always listen first. Do you have any other tips on how to make your incision, or do you do it just like that?

Dr. Mel Johnson [14:56 - 15:10]: I listen first, obviously, but almost, I'd say greater than 90% of the time, it's in that deep crease that is exactly what you just described. Even if it's off a little bit, I still tend to use that deep crease because cosmetically it looks awesome.

Dr. Randy Lehman [15:10 - 15:13]: Are you making sure now that you always get three nodes?

Dr. Mel Johnson [15:13 - 15:58]: No, you don't have to get three nodes. So even one node is considered acceptable. One caveat to that is if you had a patient get neoadjuvant chemo and then they come back. Even these days, if you have a positive node, it can't be clinically positive nodes like matted lymph nodes; that would be excluded from this. Let's say you find on your pre-op ultrasound that the patient has a suspicious node, and it's biopsy-proven positive. That patient can undergo neoadjuvant chemo and then come to you, and you can do a sentinel lymph node biopsy. Those patients must have that previously biopsy-proven node removed, and you've got to have a way of localizing that. It could be with a wire, a seed, or several other methods.

Dr. Randy Lehman [15:59 - 16:01]: And it had to be clipped at the time of the biopsy, right?

Dr. Mel Johnson [16:01 - 16:40]: It's got to be clipped at the time of the biopsy, and you have to remove that at the time of your surgery, plus a minimum. So you have to use localization of that node. You have to use two different tracers, whatever those might be, and you have to get a minimum of three nodes. If you fulfill all of those things and all of those nodes are negative, then you're done, and that patient can just have a sentinel lymph node biopsy. In that patient population, you've got to make sure you get three. In all of our other sentinel node patients, if you have one sentinel node, the requirements with the CoC guidelines are any hot node needs to go, any blue node needs to go, and any abnormal node, which might be one lymph node, and that's okay.

Dr. Randy Lehman [16:41 - 16:46]: The problem is then you maybe can't apply Z11 to that patient. That's why I asked.

Dr. Mel Johnson [16:46 - 17:04]: We still do. Yep. If you have one node and follow all of those guidelines, we have to document it. We have a little templated dot phrase for the CoC guidelines. If there's one and it's positive, that patient gets referred for radiation therapy to the axilla.

Dr. Randy Lehman [17:06 - 17:19]: So if it's one and it's negative, I'm pretty comfortable with that. But if it's one and it's micro metastatic disease, then it's just radiation. But if it's one and it's macrometastatic disease or extranodal invasion or one of the criteria, then those people get axillary dissection.

Dr. Mel Johnson [17:19 - 17:35]: You can have a macromet, but I would say not extranodal extension. Extranodal extension, I would at least do additional imaging before making that decision. But let's say it's a macromet; now, even if you have one or two positive, it's radiation only.

Dr. Randy Lehman [17:35 - 17:40]: Okay. Well, we're going to have to make this an annual thing because it's hard to keep up on.

Dr. Mel Johnson [17:41 - 17:47]: They update NCCN guidelines monthly, so it's right on your computer.

Dr. Randy Lehman [17:47 - 18:07]: Technically, again, for that medical student. So, we make our incision. We go down through, we go through the clavipectoral fascia, and we track down using a NeoProbe, C-Track machine, or whatever, if you're tracking down onto a sentinel node, dissecting it free. Do you clip the node? Do you tie when you dissect it out?

Dr. Mel Johnson [18:07 - 18:09]: I clip the lymphatics and the vessels. I still do.

Dr. Randy Lehman [18:09 - 18:10]: Okay.

Dr. Mel Johnson [18:10 - 18:10]: Yep.

Dr. Randy Lehman [18:10 - 18:13]: They're using that teeny tiny clip.

Dr. Mel Johnson [18:13 - 18:23]: Basically, I think it's the blue clips at our institution. They're the blue clips. Yep. They're small and just use cautery for all that I don't want.

Dr. Randy Lehman [18:24 - 18:24]: And you're just sending.

Dr. Mel Johnson [18:25 - 18:26]: So I clip.

Dr. Randy Lehman [18:26 - 18:38]: I understand. And you're not leaving a drain after a sentinel node biopsy or after an ax dissection. And you're not sending them for frozen or anything right there.

Dr. Mel Johnson [18:38 - 18:42]: I do during my mastectomy cases because...

Dr. Randy Lehman [18:42 - 18:45]: Because you would go ahead and do completion if there were positives.

Dr. Mel Johnson [18:46 - 18:57]: If there were three positives. If I have one or two, that patient can still get radiation therapy. So I still... Just for the mastectomies. For the lumpectomies, I don't, because you could always come back.

Dr. Randy Lehman [18:58 - 19:14]: Yeah. You're not like in that same incision. Yeah, that makes a lot of sense. And then if you had one that was biopsy-proven and clipped beforehand. Are you doing, in addition to your localizing technique, a specimen X-ray to confirm the clip is in that node during the case?

Dr. Mel Johnson [19:14 - 19:15]: I do. Yep.

Dr. Randy Lehman [19:15 - 19:21]: All right. And then anything else technical before we start talking about closing up?

Dr. Mel Johnson [19:21 - 20:05]: I don't think so, especially if you're looking at just a standard sentinel lymph node biopsy. Again, your criteria: All hot, hot in whatever way you've localized, hot, blue, abnormal. That's it. The other... And this is a caveat, especially in the days of COVID-19 vaccines, just because it does cause lymph node enlargement. Once I've met with a patient and planned their surgery, I tell them specifically, do not get a vaccine. Whether it be COVID or anything, I tell them do not get a vaccine between now and your surgery. Because, especially when people were getting a lot of COVID vaccines, I did take out seven 2-3 cm lymph nodes. They had a COVID vaccine in that arm. They ended up all being benign. But a 2-3 cm lymph node is abnormal.

Dr. Randy Lehman [20:05 - 20:06]: Gotta come out. Yeah.

Dr. Mel Johnson [20:06 - 20:17]: So I counsel everybody: Don't get a vaccine in that arm between the time of seeing them and surgery because otherwise you hate taking out that many lymph nodes.

Dr. Randy Lehman [20:18 - 20:23]: Yeah. And then do you put any stitches below the clavipectoral fascia?

Dr. Mel Johnson [20:23 - 20:29]: I only... So, I don't even close pectoral fascia. I close dermis and skin. That's it.

Dr. Randy Lehman [20:30 - 20:33]: Okay. And what suture do you use to do that and what technique?

Dr. Mel Johnson [20:33 - 20:41]: 3-0 Vicryl interrupted for the dermis and a 4-0 Monocryl running for the skin, and Dermabond on the skin.

Dr. Randy Lehman [20:41 - 21:07]: Thanks for going to that level of detail. I know it's kind of painful, but I think some of my listeners really appreciate it. All right, perfect. So, I was wondering if we could jump ahead in our program a bit and actually go right to the resources for the busy rural surgeon. Normally my last segment, but if you had anything specific to breast cancer and sentinel lymph nodes. Do you have any resources for us?

Dr. Mel Johnson [21:07 - 21:47]: Again, I would say the primary resource, if you want to be in the breast cancer area of treatment, is the NCCN guideline 100%. You've got to use that as your primary resource, and that's what I refer my patients to as well, except the patient side of the NCCN guidelines. But if you follow those, people really cannot fault you for the type of cancer care that you're providing. So I would say that. And then you've got to find a way to do a multidisciplinary breast conference with your regional center. Again, it's a matter of reaching out and seeing who's willing to include me.

Dr. Randy Lehman [21:48 - 22:31]: Yeah, almost every guest that I have on talks about having a person somewhere else, like people that you're going to call that know you and all that. All right, perfect. Thank you. I was gonna give the guests a bonus "how I do it" because I had an interesting case this morning. I am on call, but it was not at the hospital. The surgery that actually happened was actually 8365 Lehman Road on the farm that I grew up on.

So if you don't mind indulging me, I did do an inguinoscrotal hernia repair this morning on a two-week-old piglet. So this is, you know, a common operation, uncommon location, and type of patient.

Dr. Mel Johnson [22:31 - 22:32]: Yes.

Dr. Randy Lehman [22:33 - 24:42]: You know, we had a bit of a hard time with our January litter. Long story short, she actually ended up getting out of her crate and had her litter in the hallway, and we lost a couple of piglets. It's really sad. These are ones that are supposed to be going to show this coming up. They're spot pigs, and I think I can put some pictures. If you're listening on Apple or Spotify, you may want to go over to YouTube if you want to check this out. But we can probably link in some pictures of the farm and the piglets.

But yeah, so when you're doing an inguinoscrotal, it's a lot of similarities. Right. But the nice part about doing a hernia repair on a pig is that you're castrating the pig too, so you're doing your orchiectomy, makes it a lot easier, you know. So we have video and photographic evidence of this, but I can talk you through the approach.

So I was doing it with my dad. My dad, you know, held the pig up by the back legs. I brought an electrocautery from my clinic and I took it over and kind of set it up. I prepped with betadine. I made a vertical incision right over the top of the main bulge and chased down through the soft tissues, surrounded the entire what is essentially a patent processus vaginalis.

Then exteriorized the entire testicle and everything and then excised the testicle. And then what I'm left with is the hernia sac. So I clamped, not getting bowel, and did a big twist move. Then I clamped up high, did a high ligation with a 2-0 chromic suture stick tie, cut it, let it retract back up. I made a counter incision to take out the second testicle as well. The pig did awesome. It's almost like, you know, it's more bothered by being held upside down than he is by the incision. It's amazing what they can take. Then I just stitched up the bigger wound with a couple of deep 2-0 chromic sutures, but not actually through the skin, and left the other one open to drain. So that's how you do an inguinoscrotal hernia in a pig.

Dr. Mel Johnson [24:42 - 24:44]: Did you use local at all?

Dr. Randy Lehman [24:45 - 25:09]: No. Yeah, you can make a cut. The pig didn't even react to the cut. I mean, he reacted to certain things, but once you get him upside down, he's kind of focused on hanging upside down. They do great. I did prep it. I wore gloves, but, you know, and they're just so—when they're at that age, their blood supply is so amazing, they heal up great even though they're in a dirty environment. You would think there would be problems, but there hardly ever is.

Dr. Mel Johnson [25:09 - 25:16]: And in land races, you just make your incision over the bulge, and that's—yeah, okay.

Dr. Randy Lehman [25:17 - 26:08]: And for the other side, you know, I can identify the testicle and kind of slide it up and down, make an incision right over the top. Now if I'm doing normal castration, the pig doesn't have a hernia associated with it. I actually usually do that at seven days. Hold the pig in my hand, fingers kind of going up underneath the two legs, so I push the testicles out the back end of the hog. Then I just use, actually, a side cuts, and I clip, clip. We cut the tail too so they don't, you know, they'll chew them off, and it gets kind of nasty. They cut the tail and then they just pop right out. You can just pull them out. Don't even have to actually cut or suture anything. Just pull the testicles out, throw them in the bucket, and then, of course, you clip their eye teeth and then notch their ears. That's all part of what we call, like, processing a hog at seven days. The whole process maybe takes three minutes per piglet. I would say once you get it down.

Dr. Mel Johnson [26:11 - 26:32]: I must admit, I have—well, no, I take that back. I used to take lipomas off of my dog when I was a resident in Chicago because I certainly couldn't afford to take them to the vet at that point. So my husband would hold him down. I would bring home some local anesthetic and a basic, like, minor tray, and we would—we'd take off those troublesome lipomas. But that—

Dr. Randy Lehman [26:32 - 26:33]: Do you put a muzzle on the dog?

Dr. Mel Johnson [26:33 - 26:36]: No, no. He was chill enough that he would not bite us.

Dr. Randy Lehman [26:36 - 26:54]: That would scare me, but, yeah, very good. So that's rural surgery in a nutshell. And that is my real life. So I thought maybe the listener would enjoy that. Carry on. We got two more segments of the show to blast through. First is a financial corner. Do you have a financial tip for our listener?

Dr. Mel Johnson [26:54 - 28:04]: I was thinking, I saw that that was coming, and I know that you are way more financially literate than I am, but I do have—I have a daughter who just started college this year. I have a son who's a junior in high school. So again, looking at things like college tuition, I am so happy that we opened 529 accounts for the kids when they were born. Those accounts, again, you just stick the money there and it grows and it grows. And actually we oversaved for both kids, which again, listening to all of my partners back when I was young complain about their kids going to college and all these expenses, I have to tell you, it's not even noticeable that I have a kid in college right now. So I'd highly encourage the use of the 529. You can transfer it between kids. You can even use it if your kid happens to go to a private school for, like, 9 through 12. You can use up to $10,000 a year to cover that tuition. And then someone told me recently too, they can use it obviously for undergrad, they can use it for grad school. They can transfer it to their kids someday. So that's my tip of the day, is you will feel no pain when your kid leaves for college.

Dr. Randy Lehman [28:04 - 28:49]: Yeah, that's a beautiful tip. I just had a buddy of mine tell me about his kid that's going from high school to college. And it's actually gonna—he's gonna be feeling like he's saving money because the money he's using through the 529. The other thing is you can actually use it for yourself if you want to take, like, a course, a passion project or something like later. So if you oversave in a 529, it could go to grandkids, it could go back to yourself. Like you're 60, you're retired, you're 70—whatever. You want to go back to a college and just take, like, a pottery course or something, you can use it for that. So it's a great tip. I love that. Thank you very much. Last segment of the show for us then is going to be the classic rural surgery story. Do you have a story for our listener that your urban counterparts just wouldn't believe?

Dr. Mel Johnson [28:49 - 28:55]: Oh, man, I was not prepared for this one.

Dr. Randy Lehman [28:55 - 28:57]: It's okay if you don't.

Dr. Mel Johnson [28:57 - 29:09]: Most of my best stories are actually—most of my crazy stories are more from Cook County Hospital, which is definitely a very urban environment, but so I'll just briefly tell me.

Dr. Randy Lehman [29:09 - 29:24]: One of those stories that, you know, I read an article said that rural America is the new inner city with drugs and poverty. And it's—no, it's not completely wrong. Now there's pieces that it's totally different. But yeah, just a crazy story because, you know, we just like to hear them.

Dr. Mel Johnson [29:24 - 31:14]: This is insane. So I had my daughter when I was a chief resident, and so she was about six months old for my first Mother's Day. So I had her in October. Mother's Day rolls around. I am the chief resident on trauma at Cook County, and trauma surgery is a totally, totally separate entity from the ER at County because it's just that busy.

So, my husband brought potbelly subs to have, and my daughter, so that I would get to see her because it's a 24-hour in-house call. So he brings in subs. It's a beautiful Sunday. It's sunny. You would think that people could stop shooting, at least for that amount of time, but no. So he gets there with her. Subs are there. Immediately, the nurse comes back and says, "Hey, we have a triple zero gunshot wound rolling in in three minutes." My husband looks at me. He's never seen me do anything surgical. He looks at me and says, "Is this it?" I said, "Oh, yeah, this is it."

A good friend of mine was eating lunch with us. She was not on trauma, so she stood and was the commentator. My husband watched as I ended up having to clamshell the guy. We did an emergency thoracotomy on the left side. The bleeding source was not there, so I cross-clamped the aorta, quickly went across, lifted his chest in a clamshell, and could see that his whole vena cava was blown out. He'd already bled out. This is an 18-year-old kid. My husband and my 6-month-old daughter watched me clamshell a gunshot wound victim on my first Mother's Day, and I – oh my. I have to say my daughter now is a public health pre-med major at Loyola and is contemplating a career in trauma surgery. So, those early life experiences for your kids leave a great imprint.

To this day, I've been married 28 years, and that's the only case my husband has ever seen me do. He looked absolutely horrified when it was over.

Dr. Randy Lehman [31:17 - 31:20]: See, he thinks that's what you do every day now because that's all he's...

Dr. Mel Johnson [31:20 - 31:37]: ...seen. Right? Not anymore, thank God. The patient died, and I think what alarmed him the most was when I declared time of death because it was a non-fixable problem. I ripped off all my stuff and looked at him, and said, "Let's go eat lunch."

Dr. Randy Lehman [31:37 - 31:40]: And he just looked like, "How do you separate it?"

Dr. Mel Johnson [31:40 - 31:59]: He might just rip my heart out some night while I'm sleeping. But, yeah, good news. Still married, two kids, and a full, wonderful career in surgery. So, to any of the med students out there that might be listening, you can have everything. So, that's my advice.

Dr. Randy Lehman [32:00 - 32:07]: That is beautiful and a great way to wrap it up. Thank you so much for all the tips that you've shared. I really appreciate you taking the time to join us today.

Dr. Mel Johnson [32:07 - 32:10]: Absolutely. Thank you so much, Dr. Lehman, for the invitation.

Dr. Randy Lehman [32:10 - 32:35]: You bet. So, thanks to our listener for being here. We appreciate you, and we will see you at the next episode of The Rural American Surgeon. Please don't hesitate to share this with anybody in your network that has a passion for rural surgery. We're here to fight the professional isolation and have a place just to come in and essentially create a rural surgeons lounge for you. So, thanks, and we'll see you on the next episode of The Rural American Surgeon.