EPISODE 25

Rural Emergency C-Sections with Dr. Dave Kermode

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 so honored today to have my guest, Dave Kermode from Iowa, who has been a podcast guest on the "Really Rural Surgery Podcast" several times. I'm so pleased to have met you at the North American Rural Surgical Society. Dave, thanks for joining us.

Dr. Dave Kermode [00:01:05]: Well, thanks for inviting me.

Dr. Randy Lehman [00:01:07]: Yeah. So, let's dive into a little bit of background about you. Can you just tell us about your training, your background, and your practice in rural surgery, what you've done, and what you are doing now?

Dr. Dave Kermode [00:01:18]: Okay. I went to undergrad in Missouri and went to medical school. I'm an osteopath. I went to medical school at Kirksville and did that on a Navy scholarship, then went into the Navy. I thought I wanted, I went to medical school to be a full-spectrum family medicine physician. I did my first year in the Navy post-medical school as an intern at Naval Hospital Jacksonville in the family medicine program. I fell in love with surgery during that and so then wanted to do something in surgery. So, I had to look for a billet for my General Medical Officer tour that was only a year. This was because I had talked to a program director who would take me the following year, but he wouldn't guarantee anything after that. So, I needed a one-year slot. The Navy had three one-year slots. One was Diego Garcia, one was the USS La Salle in the Middle East, and then one was in Antarctica as a winter-over medical doctor at McMurdo Station. Fortunately, I got the McMurdo Station one and went to be a General Medical Officer at McMurdo Station. It was real remote medicine for a year.After that, I did my general surgery residency in Missouri. Then, getting out of that, I went back to the Navy to fulfill the rest of my scholarship in Corpus Christi, where I was a general surgeon and department head. I then went to practice in a small town in Iowa and did that for a decade, where I think we had 16 family medicine docs. There was an older surgeon, myself, and then just myself for about six years. Then, the whole critical access hospital thing happened. I was doing a lot of bariatric surgery and had to go to a bigger hospital. I joined a practice where there were four of us doing bariatrics, and we were, for a time, the busiest bariatric practice in the state. Then, I got a call from my medical school saying, "Hey, how would you like to come down and teach?" I'd always had residents, mostly primary care residents, for my entire career. So, this was a chance to teach surgery residents and also teach in medical schools. I did that for four years. My wife did not like leaving Iowa, so we came back. I’ve been practicing now, going back to teaching at a bigger hospital, but I’ve always done some work in a smaller hospital, combining the two. I'm getting older and pretty soon I want to retire.

Dr. Randy Lehman [00:04:05]: Understood. So, the next segment of the show is why rural surgery is special to you and why you keep coming back to it?

Dr. Dave Kermode [00:04:12]: I grew up in a town of 8,000, so for people like me, we like going to the big city. But after about three days, we're like, "Ah, I gotta get back to someplace that's smaller." Just the relationships are like my wife's. When we came back from our second stint in Missouri, she basically said, "I'll live here," and we live. She grew up here, was born here, and said, "I'll live anywhere I can see the water tower." So, that's pretty much it.

Dr. Randy Lehman [00:04:49]: That's awesome. That draw home is really powerful. I completely understand it. There's definitely a country mouse and city mouse dynamic at play. It's not just any old town; it's her water tower. So, she must have at least some fond memories of her childhood.

Dr. Dave Kermode [00:05:07]: Oh, her parents are great. The whole. Well, you know, I never, when I talk to my friends that are living in bigger cities. Cities and stuff. Like I said, I still practice part-time in a big city. But, I never worry when I drop my car off to be fixed. I know the right work's going to be done. I'm never going to be overcharged. I go to church with all those guys. You never worry about anything. I probably shouldn't say this over the internet, but our doors are always unlocked, the keys are in the car. The whole town's that way.

Dr. Randy Lehman [00:05:42]: Yeah, that's exactly the feeling that we have in our small town. Of course, I moved back to the house that I grew up in, so that's where I'm living now. My wife's from this town too. Now, how far away did you grow up from the place you're now living?

Dr. Dave Kermode [00:05:57]: Well, my dad was a Marine, so I was born in Quantico, Virginia, and then spent most of my early, most childhood in California by Camp Pendleton.

Dr. Randy Lehman [00:06:10]: Okay. Well, it's often the spouse that drives the decision. If you've got someone from a rural place wanting to be a rural practicing surgeon, but their spouse is from a city, then you might lose a potential rural surgeon. Now it's, you know, we. We're both men, but it's 50/50 now on men and women. So it could go either direction, and it doesn’t matter if it’s male or female. But you now have a lot of families with two working spouses too. The other thing that I have heard from several people is when one person would really like to have a rural practice, but their spouse is a computer engineer or has a job with better opportunities in the city, they end up going to a city because of that. The spouse dynamics are quite interesting.

Dr. Dave Kermode [00:07:16]: Yeah, I mean, and where we live is definitely driven by my wife, so.

Dr. Randy Lehman [00:07:22]: Yeah. Okay, well, kudos to her, but she's.

Dr. Dave Kermode [00:07:26]: Great in every different way. She only made one bad mistake in her life. She married me.

Dr. Randy Lehman [00:07:29]: Oh, that's marrying you? Yeah. That's very predictable. That's beautiful. How long have you been married?

Dr. Dave Kermode [00:07:35]: This is our second marriage for both of us. The Navy wasn't real kind to marriages with deployments and things, so we’ve been married 23 years.

Dr. Randy Lehman [00:07:47]: Okay, wonderful. All right, well, today for the "How I Do It" segment, we're going to go into extreme detail about a particular operation, as we always do. Today, it's C-sections from a general surgery perspective. Let me lead in for just a second. I trained at the Mayo Clinic rural surgery track. I had no idea. How do you know as a resident what your practice is going to end up being like? But I knew in concept that a rural surgeon is different from an urban surgeon in their scope of practice, in that there are pieces of general surgery that you won't do like Whipple's, esophagectomy, liver resection.

Dr. Randy Lehman [00:08:17]: I didn’t know about chest cases, but I really don’t like them. I don’t do lobectomies. I don’t do rectal cases either. I didn’t really know that either.But then there are other things that are typically from other specialties that you will do that are more appropriate, like those quick, easy, mostly outpatient operations. Patients generally do well, and they should be kept local. They're pretty straightforward cases if you have the training. You don't necessarily have to be an orthopedic surgeon to perform a carpal tunnel release, for example. The problem is, in residency, I didn't know with what frequency I would see parotids. I went out of my way to go with the ENTs and do parotids, but there's no parotids. Like, let's be honest, I'm not going to do parotids. It's a 1 in 100,000 type of operation. It seemed almost equally important to me, all of the different things, whether that's scopes, C-sections, or other gynecology like hysterectomy, oophorectomy, and tubal ligation. In urology, I was sort of requested to do kidney stones. I spent extra time with urology to learn about that. It ended up being kind of a long story, but I don't do them. However, I feel pretty comfortable doing it. I used the lithotripsy ureteroscope for my Coladoca scope. It's the same exact thing. Let's not get off on a tangent there. Each specialty like ortho, plastics, and ENT has certain things. What I found out when I came out was the things that really increase your value. You talk about like the 80/20 rule: 80% of your value comes from 20% of your activities. It's scopes and C-sections. When you look nationally, it might be different for each individual hospital. Nationally, the things that will increase your value as a rural surgeon are those two things right now as we sit in the 2000s. That's why I'm excited to talk about C-sections. I think fewer general surgeons are comfortable doing it, and there's a lot of reasons for that. Maybe we can touch on that, but we'll start by talking about the actual technical components. My first question for you is, are you doing them now, and how has the practice looked in the past?I'm not primarily doing them for the last two years, and we can get into why that is. But prior to that, I'd done them my entire career, and I quit counting after about 1,300. So somewhere north of 1,300, probably close to 1,500. Now, we back up the primary care docs, fellowship-trained primary care docs doing the procedure. We can get into why, but I think that's probably the best model given the general situation in the United States with general surgery and C-sections and what the residents feel comfortable doing. Like I said, I'm still working with residents.Yeah, but having a backup person doing C-section backup for a family med resident who has done 1,300 in their lifetime is a lot different than having a new grad general surgeon who hasn't done many in their residency backing up a family med.Right, so we're really getting into the weeds here. But first of all, I'm going to acknowledge right off the bat, my OB-GYN colleagues are better at doing this than I am. You have to have that humility going into it. When we do a C-section, we are what we accuse other doctors of being sometimes, which is a point-and-shoot sort of proceduralist. I am not making the call, and I never have made the call, and would not feel comfortable making the call on whether a C-section is needed.That person managing the labor is either a family medicine doctor, an OB-GYN, or sometimes a nurse midwife, and they're the ones making the call. That's where a lot of the discomfort from residents comes from, and it's rational because doing C-sections as a general surgeon involves seeding some of your agency. Now, how do you do that professionally? That's the conundrum. In this conversation, we're getting a bit more into technique.Yeah, that's the sort of philosophical aspect going on. You're not making the primary decision about whether or not to operate, which is tough. You really have to have a close relationship with those professionals. Professionals are anyone primarily taking care of patients. So, a PA can be a professional, or a nurse practitioner could be a professional. Physicians should be professional. Every general surgery resident should know this.In an emergency, for instance, the first C-section I did as an attending was in a state where I didn't have privileges. I was visiting a friend, it was snowing, the weather was horrible. They asked, "Can you help?" And I said, "Sure." I called the state board the next day, explained the situation, said I wasn't charging for it, and I wasn't licensed in their state. They were very cool about it, and the outcome was good. Everyone has to know their C-PR. We all have to recertify in CPR. I would argue that every general surgeon or every general surgery resident should do 20 or 25 C-sections just in case they're ever in that position.Okay, well maybe let's take a breath and dive into the details. Say a nurse midwife has been managing the labor and decides the patient is arrested. What are the most common reasons why they're calling you to say we need to do a C-section now?Yeah, great question. Failure to progress remains the most common indication despite active management of labor. All right. Were you doing elective C-sections?Yes.So the elective reasons would be twins.Yeah, all those reasons are true, but we were not doing VBACs ever. In a small situation, you should never do a VBAC. It doesn't make any sense. Those patients, the nice thing is if they need a C-section and you know it upfront, you can meet them. It's not an emergency. You're meeting them beforehand in the office, treating it just like an elective procedure. It's a semi-elective C-section. It's just a repeat.Did you have any rules at your hospital for who could not have an operation there, like a BMI over or if they had any comorbidities or preeclampsia?For most of my practice, we didn't, but there were cases I'd say, "This is unwise to be here." For the repeats, once you get past the third C-section, the chances of bleeding post-procedure and complications are much greater. That should be done in a setting where you're at a bigger hospital. If there were any truly crazy things that had happened with the prior C-sections, then you would not want to offload risk as much as possible. I would argue that we shouldn't be doing BMIs greater than 45 or 50.And I have. That hasn't been anything that anybody's bought into.

Dr. Randy Lehman [00:16:58]: At least that's been a hard rule. Actually, 50. At several of the critical access hospitals, I work at. That's why I was kind of asking. I should also tell the listener that I came out doing C-sections, but then the hospital I was employed at closed the OB department. They were down to about 60 deliveries a year post-COVID. Couldn't get nurses and made the decision. And I'm super against it because I have an anecdotal story, I guess, about our deliveries and our kids.

Dr. Randy Lehman [00:17:28]: When I was a resident at Mayo Clinic, my wife was. We had just got married. We got pregnant immediately. She took a job at Olmsted Medical Center, which is an ironic county hospital, like right down the road from the two big Mayo Clinic hospitals. Or everybody flies in from Abu Dhabi to go to those hospitals. And then, like, the Mayo Clinic employees often go over to Olmsted for anonymity. And anyways, she was. She set up her primary care there and her OB care there.

Dr. Randy Lehman [00:17:59]: But then, you know, we got further along her pregnancy, and then she quit working at Olmsted. So our insurance then was no longer made us. So that we had to go to Mayo. And we went to Mayo and the. In Rochester, you have two options. Either you have a resident or you have a nurse midwife. You can't have an OB-GYN period. So I'm like, okay, well. And I had a rotation set up out in Owatonna that's 45 minutes west of Rochester. And it's a Mayo Clinic health system. Doctors at an Allina Hospital, I think it was, or something like that.

Dr. Randy Lehman [00:18:29]: And out there, they had three practicing OB-GYNs that shared a traditional, like, here's your doctor practice. And they had call, but if it was like during reasonable hours or they were in town, they would still deliver their own and everything. So I did a rotation out there, and then she, we liked it, and she set up her OB with them. And then I actually set up my second-year OB elective at that time. So I did a few deliveries and then kind of warmed up in a way and then got to deliver my own daughter while I was on my OB rotation out in Owatonna.

Dr. Randy Lehman [00:18:59]: But then what happened after that is my daughter set up her primary care out there, and my wife had her OB-GYN and primary care out there. And so they would go out there periodically and do things. And then I had a couple of minor things that I wanted to see a doctor for, and I ended up driving out to Owatonna to do that, setting up primary care, seeing a specialist out there. And then two years later, I was in La Crosse, which is an hour the other direction from Rochester, but we delivered our second child in Owatonna.

Dr. Randy Lehman [00:20:00]: So, you know, I was waiting for the call, and then I just peaced out and drove all the way over there. And then he set up his primary care, of course. So, like, we just keep all of our care was then in Owatonna. And then we go back to Indiana, and my wife has to have another operation. And because of the trust, she chose to go three states away to get an operation. When we lived. And I was working in Indiana to a town of 25,000 critical access hospital with four operating rooms in Owatonna, Minnesota.

Dr. Randy Lehman [00:20:31]: And what happened there is they bought our family by delivering our babies. So if a rural hospital can deliver a baby, that's a very generally positive experience. And why do I care so much about working at this hospital across the street from me? It's because I was born there on the second floor. Okay. Saturday, December 3rd, 1988. And they helped bring me into this world. And I just feel like I didn't, I don't remember that experience, of course, but it, it was a. It matters.

Dr. Randy Lehman [00:21:01]: And it's, it's just a positive experience that people are going to then associate. And then, of course, the women are generally the healthcare directors of their family. And so when they set up the kids' appointments and they set up appointments for themselves, they drag their husband in for the thing that they have. That is typically how it goes. And if you can make that experience good for that woman and you can, then, then, then you buy their family by delivering the baby.

Dr. Randy Lehman [00:21:32]: Now I went back to Winamac and I told this story to the former CEO at the first hospital, the job that I took, and I got a different response. So, you know, a lot of administrators obviously want to shut down the OB department because they. It loses money. Well, you're just not seeing the downstream elective knees and hips and, you know, the labs and the imaging and all the ongoing stuff that are going to. Like I said, you buy the family by delivering their babies.

Dr. Dave Kermode [00:22:22]: Ooh, gold.

Dr. Randy Lehman [00:22:24]: Yeah. And we don't really want to capture those people. That was kind of the message that I got. And so it is what. Maybe that's the harsh reality of certain situations. But they have closed the OB department that I was born at. It's a professional goal of mine to get that restarted, but the administration there has told me very clearly it is not our goal to do that. And then there's debates of safety in terms of how many deliveries you need to have per year to have a safe OB department, you know, quality. And it's. There's a lot of different ways to slice it, but it's. It's an increasing challenge. What happens is you lose your OB department, and then 10 years later, you don't have a hospital because you have this slow spiral after that of, yeah, you delivered all those babies. You carry on those families for a while. But eventually, like, the people around me now, they're not getting their. The people that are my age are not getting their care in our rural hospitals. Like, the people that I know that, like, go to church with me, for example, they. They have now delivered their babies down in Lafayette. And now they're very accustomed and used to going to Lafayette, and then they just go down there. That's what we're dealing with.

Dr. Dave Kermode [00:23:36]: Yeah, it's. It's a tough thing. So one of the. So the hospital I, you know, other than the big hospital in Des Moines, the hospital that I work at most of the time is actually a small hospital right on the border with Missouri. And there's nobody doing OB within 60 miles in any direction, some places within 120 miles. And so they need to do OB just to maintain, just in case somebody goes into active labor. And every year we have one or two people that come in, like, with a cord prolapse or. Or, you know, just where they have to be delivered right away. So the place needs to be here.

Dr. Dave Kermode [00:24:52]: And you probably need a place every 60 miles or so that can do a C-section. And if you think about it, if you're talking about life years saved with a, with a, with a procedure, C-section is by far where you get the most life years saved. You get a brand new child plus a mom. Add those two together, you're looking at, you know, maybe 150 years or whatever life years saved if you intervene or truly critical situation. So we need better planning. We need, you know, we're never going to have a, apparently a really robust conversation in this country about what, what healthcare looks like and what it should look like. But hopefully someday we will.

Dr. Randy Lehman [00:25:32]: And then there's too many challenges. There's challenges, you mentioned of the, the resident being comfortable doing it. That's maybe step one. Then there's financial challenges. Right. There's perception too.And it's just, you know, it'd be great if, you know, every street corner had a hospital and there's full services right next door. But how far is too far before it becomes an OB desert? Could we get by with one hospital in every state? You know, a giant hospital in every state? You know, that's obviously the other extreme. So, somewhere in the middle, we're figuring out what is appropriate care. Yeah.

Dr. Dave Kermode [00:25:32]: I don't know if we're figuring it out, but I think that conversation is.

Dr. Randy Lehman [00:25:35]: Yeah, that's a good point.

Dr. Dave Kermode [00:25:38]: Hasn't been had, or nobody can come. This is one you'll have to edit out probably. But politically, we've reached a point where politics is just coming to conclusions about how to solve problems that are acceptable to all parties. We've gotten to the place where we can't talk to each other and realize that the object is not to win or lose. The object is to come up with an acceptable compromise. And that's where we're at, as we are unwilling to compromise on both sides of the political spectrum. So, it's just very disheartening.

Dr. Randy Lehman [00:26:14]: Yeah. The other issue is 80% of our payers are government payers anyway. We have socialized medicine. It's, in the view of trying not to be socialized. We've let major insurance companies come in that are profit-driven, which are even worse. Now, we have the government in our place. There's Medicare, Medicaid, and then you've got other people working for government entities. Then you have the VA as well, which I see a fair amount of patients in a non-VA setting now on the Community Connect thing. So, you look at everybody, and it's like we're working for the government. How policy changes drive where the care is delivered becomes a big part of it.

Dr. Dave Kermode [00:27:11]: Yeah. It's not so much the money as it is the commitment to come up with a comprehensive system because we do not have a comprehensive system. We have a disjointed, uncoordinated system that does not promote health as it should.

Dr. Randy Lehman [00:27:28]: What's the solution?

Dr. Dave Kermode [00:27:31]: Well, you know, socialism doesn't completely work. The private system doesn't completely work. I don't think anybody knows what the solution is. We're large enough that we could experiment in different regions and try to come up with what works best. But it's an ongoing conversation. The problem is, I'm a Calvinist. We're all sinners, and nothing’s going to be perfect until the return of Christ. It's like we're trying to do the best we can while we can, waiting for the ultimate solution. So, the idea that we're going to come up with an ultimate solution is ridiculous.

Dr. Randy Lehman [00:28:06]: Yeah. And the point of this podcast is a place for a surgeon's lounge for the rural surgeon that doesn't have a bunch of people they can have this conversation with on a regular basis. So maybe it's not the point of trying to solve all those problems. It's more or less, what are the resources for that person.

Dr. Dave Kermode [00:28:27]: Right.

Dr. Randy Lehman [00:28:27]: That is in the trenches. First off, a little bit of encouragement that you're doing the right thing and to hang in there. And there's no such thing as 100 in our business. It's a mission. Rural surgery is a mission. And, you know, we appreciate you. So, tell me, you've made the decision to go for a C-section. Is it an emergency or is it an elective C-section?

Dr. Dave Kermode [00:28:52]: Almost all the time. That is the first thing you have to filter through: is it an emergency or is it a...

Dr. Randy Lehman [00:28:58]: So, the one we're about to talk about, which one is it?

Dr. Dave Kermode [00:29:01]: The one we're about to talk about would be an emergency.

Dr. Randy Lehman [00:29:06]: Okay, so we have an emergency C-section. They've been laboring for how many hours?

Dr. Dave Kermode [00:29:13]: Not precisely known. It's an Amish patient that has gone into labor, reported by the paramedics, and they're 60 miles away. Paramedics have been with her for at least four hours and...

Dr. Randy Lehman [00:29:29]: No prior abdominal surgery?

Dr. Dave Kermode [00:29:32]: At the time, that was the understanding, but it turns out there was prior surgery. However, at the time, they did not know.

Dr. Randy Lehman [00:29:40]: Okay, so what are your next steps?

Dr. Dave Kermode [00:29:42]: Well, they're 60 miles away, so if we're planning on doing a C-section, which is what they have called for, they said, "Hey, you're going to have to intervene here. She's in arrested labor." There's a lay midwife with her, and she cannot feel presentation. She feels like she's been in arrested labor, and she's hypotensive with a systolic pressure of 90 and a diastolic pressure of 60.

Dr. Randy Lehman [00:30:13]: So are you telling them to do anything there? They're on the phone with you. Is this a real scenario?

Dr. Dave Kermode [00:30:18]: Yeah, this is a real scenario. They're on a cell phone talking to us.

Dr. Randy Lehman [00:30:22]: Okay, what did you do? Did you send a helicopter? How did they get to you?

Dr. Dave Kermode [00:30:26]: They got to us by ground. The helicopter would have been inefficient for the location, which is very remote to the south of us. So, they did a tiered response. The local ambulance got them, and we're receiving the call from the local ambulance, and they're about 20 minutes out. They've already coordinated through the emergency medical services in the different state. We get the call when our paramedics meet the EMTs in a tiered response.

Dr. Randy Lehman [00:31:01]: Okay, so then you're getting your crash team ready for the C-section. Is the patient coming straight to the OR or stopping in the ER?

Dr. Dave Kermode [00:31:07]: No, no, they're going straight to the operative room.

Dr. Randy Lehman [00:31:09]: So, they're going straight to the OR from the ambulance, and you're going to give them a general endotracheal anesthetic.

Dr. Dave Kermode [00:31:17]: Right. The CRNA is going to administer that. We have the best CRNA, and...

Dr. Randy Lehman [00:31:24]: You're going to splash the prep on, use a big wide drape, and plan for a low transverse incision.

Dr. Dave Kermode [00:31:33]: No, so that's where the first departure point is. General surgery is composed of inherently pessimistic people. We always consider the worst-case scenario and how to get the person out of it. Therefore, proximal distal control is crucial at this point. The concern is a uterine rupture, and what we'll find later is that she had a previous D&C with perforation.

Dr. Randy Lehman [00:32:05]: So, you decided to make a vertical incision?

Dr. Dave Kermode [00:32:08]: Lower midline vertical incision, yeah.

Dr. Randy Lehman [00:32:12]: And so, you're making that. Do you take it... Let me ask a couple of real detailed questions because some of our listeners are residents. Do you, when doing C-sections, take your incision sharp all the way to the fascia?

Dr. Dave Kermode [00:32:31]: No. First, I'll use cautery to make a quick incision across the skin, uncut. Then, we'll just grab onto the fascia or subcutaneous tissue on both sides and typically pull down to the midline.

Dr. Dave Kermode [00:32:46]: And then you make a small incision there with the. Once again, just a little bit of cautery. Get your finger underneath the fascia and just zip down it.

Dr. Randy Lehman [00:32:53]: Okay. So you open the fascia with cautery, too.

Dr. Dave Kermode [00:32:58]: Typically, if I'm going into something where they've had a previous operation, no. Then we'll dissect down. It's not, you know, this big an urgency in this particular case. I make a small incision whether I get my finger in there and go. I mean, you can be in the abdomen in 30 seconds.

Dr. Randy Lehman [00:33:12]: Yeah, well, you could be just kidding.

Dr. Dave Kermode [00:33:16]: Everybody can. I'm not special. Believe me, I'm not special. Bring my wife back.

Dr. Randy Lehman [00:33:22]: Well, you're a bariatric surgeon that does C-sections, so you're quite the unique guy. And it sounds like you're not doing the C-sections laparoscopic or robotic, either.

Dr. Dave Kermode [00:33:33]: No.

Dr. Randy Lehman [00:33:37]: All right, sounds good. So once you're in the abdomen and you have a lower midline laparotomy, do you place any type of retractors?

Dr. Dave Kermode [00:33:45]: Well, that's. I pushed for this, and we've never been able to do it because they claim it costs too much. But. And we'll use it in other cases, but. And there are times. Times when I will just use it when I'm not supposed to be using it. I guess using Alexis Wound Retractor, because I think they're great. They work really, really well, and they're easy to put in, and it's lickety-split. In this particular case, that wouldn't have made a difference, because what. What you're confronted with as soon as you get into the abdomen is an amniotic sac that's displaced off to the left of the uterus, outside the uterus.

Dr. Randy Lehman [00:34:14]: Okay, so what do you do next?

Dr. Dave Kermode [00:34:17]: This is the thing that really shocked me. And so, you know, we've talked about the number I've done in the past. I've never seen this in the past. Um, she's full of blood. So when you get into the abdomen, blood's all over the floor. And one of the things. So we can step back a little bit. One of the things that happened that we have two really experienced paramedics that responded to this tiered response. And what they did is they just titrated her pressure to keeping her conscious, but not a specific number. So when she arrived, her systolic blood pressure and she was a very, very fit woman. When she arrived, her systolic pressure, even though she could talk to you, she was confused, but she could talk to you. Her systolic pressure was high 60s, low 70s. And had they strived for 90, they probably would have. She would have died. There was no control over bleeding. So when we got in, it was, boom, there's blood everywhere. You've got this amniotic sac, displays the baby. You can see through the amniotic sac, it's blue. So now what do you do?

Dr. Randy Lehman [00:35:26]: You tell me, man, this is your baby.

Dr. Dave Kermode [00:35:30]: This is the last. Her husband's baby. And this is the thing that really shocked me, and really changed the way I view C-sections because I'd had, you know, a great number of them that had gone great. Let's face it. It's the only operation where you get a prize. But the. The issue here was, okay, the kid's dead. She's bleeding to death. I did trauma when I was a resident out at L.A. at the county hospital. And, you know, our mantra there was, you know, save a life, damage control, go, go, go. And those are the three things that were most important for go, go, go. So it. You know, my thought was, I got to get this uterus out because she's bleeding from it. So she's got to get a C-section. His. The baby's dead. So my first response is, get the baby out. Now, one of my best friends who I'd gone to medical school with, that's who I'm practicing with down there, who's a primary care doc, is like, well, I'm gonna get the baby out. You get and, and so I go down on the right side and start just taking everything really quick and clamping, trying to get down to the uterines on that side. As he's getting the baby out, baby comes out. Baby is, in fact, has no heart, heartbeat, or anything else. Gets handed off to the pediatric resuscitation team led by another good doc. And between my buddy and her, this baby lives. And therein lies the epiphany I came to with this operation is as a general surgeon, we deal with a patient when we're in a C-section. There are two patients, and you got to change your mindset, but you can't do the general surgery thing in a lot of ways. You've got to have somebody else there for that other patient. And that was my epiphany. And so that's where we get to the, okay, should I be primarily doing this or should I be assisting it? Because what we are really is we can be lifeguards for it. It's not a hard procedure most of the time. This is a very simple procedure. You do it through a Pfannenstiel incision. You can't get into any because that's the opposite of general surgery. You know, family medicine docs are optimistic people, for the most part, a lot more fun to be around than general surgeons. And, and so they. They want to get in there, get the baby out through the little bitty and, you know, the smallest incision they can. If they get into trouble, they're like, oh, you know, but that's. Yeah, that's a mean thing to say. But, yeah, I don't...

Dr. Randy Lehman [00:37:58]: It's very fair.

Dr. Dave Kermode [00:37:59]: I don't think they realize all the things that can go wrong. And unfortunately, in general surgery, if you have a long practice, I will tell you that bad things will happen. They're not your fault, but you're going to have to deal with them. And so that. That mindset is different, and that's what we bring to any, you know, any sort of thing in medicine. The general surgeons are. Are the pessimistic sort of fire people of the hospital that say, okay, this is. How do we get out of this?

Dr. Randy Lehman [00:38:30]: So technically, this is a great story. I can't believe it. So first question I have is what my wife always asks me. Was it a boy or a girl?

Dr. Dave Kermode [00:38:43]: It was a boy. And the crazy thing is, so you think, okay, they lived, but they'll have all sorts of different problems. So my buddy, actually the couple came by about two years after, and this was about two years ago. So a year and a half, I guess, afterwards, the kid's normal.

Dr. Randy Lehman [00:39:01]: That's crazy. So that. That's why. Is that why, you know, he was a boy? Did you know he was a boy when you left the OR?

Dr. Dave Kermode [00:39:07]: Yeah.

Dr. Randy Lehman [00:39:08]: Okay.

Dr. Dave Kermode [00:39:08]: Because I watched bassinet and looked at it and go, I can't believe this. I would have killed you.

Dr. Randy Lehman [00:39:12]: Yeah, yeah. Because she. She always asks me and I never know, and she doesn't like that.

Dr. Dave Kermode [00:39:19]: No, I always. I always go back and this is. It's an amazing thing to be part of. It's. It's like. It is truly. It's. It's my favorite operation to do it. But in this particular case, it was also the most frightening thing I've ever been.

Dr. Randy Lehman [00:39:32]: Yeah, no kidding. I always recommend, you know, Randy's a great name for a boy or a girl, but I've never had anybody take me up on it yet.

Dr. Dave Kermode [00:39:39]: You know, I don't know if David is. But, you know, Davida or something.

Dr. Randy Lehman [00:39:43]: David. So let's talk through the technical components of this, though. So, I mean, when the first year, you got a buddy that's standing across the table for you that's getting that baby out, right. They're just opening the sac bluntly, I presume. Pull the baby up, clamp the cord, take him away.

Dr. Dave Kermode [00:40:00]: Oh, yeah.

Dr. Randy Lehman [00:40:01]: Am I right about that?

Dr. Dave Kermode [00:40:02]: Yeah.

Dr. Randy Lehman [00:40:02]: Two seconds.

Dr. Dave Kermode [00:40:03]: Yeah.He had that baby out in no time, and then he packed that side. He's a really smart guy. We went to undergrad together, med school together. So that's the other thing. The dynamic was just boom, boom, boom, both sides.And then we had a fellowship at that time where we took full spec, or we took family medicine docs that had already gone through their residency and had spent a year with us. We do C-sections and endoscopy with them so that they could. They were going to really small settings where they were going to do that same kind of same thing they did up in Canada. And that's what we mimic it like.So he had. Actually, I let him do the incision because he had practiced for all the laparoscopic procedures we do. We do an open approach to get in. And so he had done a number of those open approaches, and so. And he did a great job. I told him, you've got four seconds, and then I'm going to take over from you if you don't, you know, get this thing done. And he just. Absolutely. Fantastic job. So.

Dr. Randy Lehman [00:40:59]: Okay. So when I. When I'm thinking trauma and blood in the belly, for me, it's take the C-section piece out of it. It's five laps. 1, 2, 3, 4, 5 in each quadrant. 20 laps go in the belly.

Dr. Dave Kermode [00:41:19]: We. Yeah, I did not look at think of a blunt trauma. It's not something for the upper abdomen. Yeah. So I didn't put packs in that. Sure.

Dr. Randy Lehman [00:41:28]: So that's what I would do for trauma. And then I would take them out with the quadrants that I don't think the bleeding is coming from in order sequentially or maybe give my anesthesia a little bit of time to catch up. And then as soon as we're ready, then I'll start to take them out that way. I kind of have a routine way of thinking and doing trauma in this situation. And another thing is if you have a full belly full of blood, just a hand scoop to get that blood out and off before I did that. Now in this situation, obviously, you know, the bleeding is coming from the placenta and uterus.

Dr. Dave Kermode [00:42:03]: And so it turns out that it's coming from the. A lot of it's coming from the ovarian artery on the left side.

Dr. Randy Lehman [00:42:12]: Okay. So you said the partner took the baby out and packed the left side. You're standing on the right side, and you're carrying on with pretty much immediately moving towards the C-section [hysterectomy (hist)] [Uncertain]. My question is why not pack, check your own pulse and then do you have time to do that or what's.

Dr. Dave Kermode [00:42:35]: Sure. So I'm coming. First thing I want to do is I want to get the bleeding stopped. Right. So he's. He's packed off that left side. At the time, we didn't know there's some bleeding still coming from the right side. We're packing that. That you know, at this point, the, the fellow had gotten in but the case was complicated enough that, that you really, you have to move to the best person in the room to do it. And so then it was just come down, and we had kind of pre-briefed this, and we talked about, you know, with induction of anesthesia, you're going to need vasoactive drugs to bump the pressure up. We're going to do what we can with both with augmenting pressure with fluids and. And what blood we do have, we have like four units of pack cells and four units of FFP. So that was going to be going right away. That was all prepped before they got there because we had the 20 minutes beforehand.

Dr. Randy Lehman [00:43:22]: Were you calling for blood from another place too?

Dr. Dave Kermode [00:43:25]: We were calling for a helicopter. We called when we first 20 minutes before, we'd called for a helicopter. So, and the longer story is the patient turns out that everything goes fine, and then they don't want to go by helicopter. It's like, ah, you still got to go by hell. So once we packed on that. That. Right. Well, packed on the right side, then you could start marching down with a ligature. And we had that all set up, ready to go. We had the uterus out in probably less than five minutes.

Dr. Randy Lehman [00:43:56]: Okay, good. So you're. It's going to shoot super cervical.

Dr. Dave Kermode [00:44:00]: Super cervical.

Dr. Randy Lehman [00:44:01]: Okay. So you take your ligature, you grab the tube. Is that where you start on the right side?

Dr. Dave Kermode [00:44:08]: I just took everything out because there was. They were still working on the. On the left side and people were in. So I. I took what was available to me and just went straight down. Yeah. And then.

Dr. Randy Lehman [00:44:16]: And got behind the right ovary. So you're starting out with the ovarian artery.

Dr. Dave Kermode [00:44:21]: Yeah, I'm taking. I'm. I'm. Yeah, exactly. I'm taking. I'm taking the ovary.

Dr. Randy Lehman [00:44:25]: Yep.

Dr. Dave Kermode [00:44:25]: And I'm going.

Dr. Randy Lehman [00:44:26]: So you're going behind the infundibulopelvic ligament that carries the artery.

Dr. Dave Kermode [00:44:30]: Right.

Dr. Randy Lehman [00:44:31]: Ovarian artery. You're taking that and then chasing down underneath the. The tube and the mesosalpinks on that side and then work your way down to the uterines. How are you thinking about the. The ureter at this moment?

Dr. Dave Kermode [00:44:48]: At that point, I'm sweeping away, and I can see it quickly on the right side. And what I want to do is get a couple of clamps across the uterus right away, and I'm going super cervical.

Dr. Randy Lehman [00:45:01]: So now that you get down, like the, the tube and the ovary are up and you're down sort of to the side of the uterus, and you got your uterine arteries in front of you. You're using. You're going to put clamps there or you're going to still charge through the ligature?

Dr. Dave Kermode [00:45:17]: No, because I want to get the uterus out and have everything. I want to get. Bleeding is my first priority. I want to get the bleeding stopped.

Dr. Randy Lehman [00:45:23]: Do you use Haney clamps or what kind of.

Dr. Dave Kermode [00:45:25]: Exactly. Yeah, Haney.

Dr. Randy Lehman [00:45:26]: Okay. And you have the tips curved right, the same direction.

Dr. Dave Kermode [00:45:31]: So they're curved up toward.

Dr. Randy Lehman [00:45:33]: Yeah, and they're both curved the same direction towards the uterus.

Dr. Dave Kermode [00:45:37]: Well, they go in toward the uterus, and they're coming from the side. They go in towards the uterus sort of almost at a right angle.

Dr. Randy Lehman [00:45:43]: And then you cut between the two clamps with a.

Dr. Dave Kermode [00:45:47]: Two clamps down. And then, and then I'm gonna switch sides.

Dr. Randy Lehman [00:45:51]: Okay. So just bleeding control. And then you're going to go to the other side and the ligature that you use to take the ovary and the tube up. Which ligature is it?

Dr. Dave Kermode [00:46:02]: It was the, the wide jaw, you know, one for open surgery.

Dr. Randy Lehman [00:46:05]: The open ligature, blunt tip, Big, big open ligature. All right. And then you go to the other side, and now you're taking out. And what do you see?

Dr. Dave Kermode [00:46:14]: Well, you see the ovarian artery. It's, you know, so what I've done now is I've taken a 35.5-year-old.

Dr. Randy Lehman [00:46:20]: And I've put her in menopause.

Dr. Dave Kermode [00:46:22]: Yeah, yeah.

Dr. Randy Lehman [00:46:24]: Saved her life.

Dr. Dave Kermode [00:46:26]: Yeah, yeah, but. And I could have easily saved the, the right ovary, but at the time everybody's there and I'm just doing, you know, it's adrenaline city and it's like, I gotta get this thing out now.

Dr. Randy Lehman [00:46:37]: Yeah. So you then have to do the same dissection, basically, with the ligature taking the ovary and the tube up. And then you get down, you put your Haney clamps on, the bleeding stopped.

Dr. Dave Kermode [00:46:49]: And now we stop. Okay, so when I say that we had the uterus out in five minutes, we had, we didn't have the uterus out in five minutes. Bleeding controlled bleeding was controlled in five minutes.

Dr. Randy Lehman [00:46:59]: And then you're getting ready to divide the uterines next.

Dr. Dave Kermode [00:47:04]: Right, right, right. So now I go. Now, now I go and do a comprehensive search for the ureters on both sides.

Dr. Randy Lehman [00:47:12]: Okay.

Dr. Dave Kermode [00:47:12]: Because I am a little bit nervous. I mean, I've gone fast. I saw it on the right. I'm not sure I saw it in the left going down. I want to make sure. So now I'm going to dissect things out. The bleeding stopped, and I want to give, you know, everybody a chance to rest. I want to make sure that we've got, you know, at that time, you've lost some help too, because there's stuff going on with the kid.

Dr. Randy Lehman [00:47:34]: Yeah. So you did not bag the ureters, I assume. In this, you find them on both sides. You've got them far away, technically. How do you divide between the Haney clamps then, with a scissor or a scalpel?

Dr. Dave Kermode [00:47:50]: I used a scalpel, but I put another one even higher than the two that I put low.

Dr. Randy Lehman [00:47:56]: Okay. And then how do you throw your stitch on that? Do you use a Haney stitch or do you just do a suture ligation?

Dr. Dave Kermode [00:48:02]: Suture ligation.

Dr. Randy Lehman [00:48:03]: Because the Haney stitch is twice behind. Right, right. Okay. But you're just doing a surgeon's suture ligation, and that's what I did. It works fine for you.

Dr. Dave Kermode [00:48:12]: Yeah, it works fine for me. I would tell you if I was doing an elective open hysterectomy, I would do the Haney stitch.

Dr. Randy Lehman [00:48:18]: Okay. How do you... supracervical hysterectomy. So is it just the one set of Haney clamps that you did? And then how do you come across the...

Dr. Dave Kermode [00:48:26]: Opened it up anteriorly and just went around with the ligature.

Dr. Randy Lehman [00:48:30]: So you're marching through the uterine wall with the ligature all the way around, and then is there a... Is there... How do you deal with the cervix then?

Dr. Dave Kermode [00:48:41]: Don't.

Dr. Randy Lehman [00:48:43]: So do you have to put a stitch?

Dr. Dave Kermode [00:48:47]: We did do a running locking stitch all the way around what we'd gone through because I was chicken, but I don't think necessarily you have to.

Dr. Randy Lehman [00:48:54]: Okay. And you're running locking stitches, the front and the back walls of the uterus together.

Dr. Dave Kermode [00:48:59]: No.

Dr. Randy Lehman [00:49:00]: Or just running over the top?

Dr. Dave Kermode [00:49:02]: Cervix is still there. So this is literally adjacent to the cervix.

Dr. Randy Lehman [00:49:07]: Okay. In a circle.

Dr. Dave Kermode [00:49:08]: In a circle, yeah.

Dr. Randy Lehman [00:49:09]: It's higher than the running locking and this. And... okay. Specimens out. What other technical things do we... if... if you'd never done one and you have to do it by yourself the next time, what would you want someone to tell you? Any other technical pieces?

Dr. Dave Kermode [00:49:27]: You're a general surgeon and you've never done that. Okay.

Dr. Randy Lehman [00:49:29]: Yeah. Say I have to go do one right now and I haven't done it.

Dr. Dave Kermode [00:49:33]: Yeah. It's unlikely that you're going to be in a situation where... where you, you know, you have packing and a bunch of people in the way and that sort of thing. So if you're just doing a c. hysterectomy, I would try to preserve the ovaries. So that's... that would be my first thought. And then, you know, this is another thing. All general surgery residents should be able to do a hysterectomy. I mean, at least I hope that that's still happening, but I don't get the sense that it is from talking to some of the residents. So I work with residents, like, for three days a month at a bigger hospital, and they're all very capable. And here's... here's what... we're getting off on a little bit of tangent here. I think that the training that residents get now, despite doing far fewer cases than we did in the past, is better because the attending is always there, and every case is done to an acceptable standard of somebody out in practice. When I trained, there were times when the most experienced person in the room was a fourth-year surgery resident. And so we did things, and I think... and nothing really bad happened in the residency, but I think what we were at that point, the level of expertise in the room is not the same as it is when you have an attending.

Dr. Randy Lehman [00:51:06]: So that's negative learning, basically.

Dr. Dave Kermode [00:51:08]: Yeah, yeah, yeah. I don't know if it's negative learning. It's learning to do things okay, but not great, I guess. And whereas I think residents now get at least good and many times great with every case. Yeah. So I think the training certainly is better for patients that we do now than it was in the past. And ultimately we got to get away from numbers and get away from the notion that the more numbers you do, the better surgeon you are. It's not. The more expertise you've been around, the better surgeon you are, and so you're better off. I know a lot of the residents don't want to be in a case where the practitioner is a little bit slower than others, but they're more precise. I think maybe you ought to think about being around the precise person a little bit more.

Dr. Randy Lehman [00:51:58]: Yeah, but there can be...

Dr. Dave Kermode [00:52:00]: Yeah, you can go too far. I got it, I got it. But it's... I... it's just, don't... don't let the older surgeons tell you that, "Well, I was better trained than you were because I did more cases." That's... yeah, that's unnecessarily true.

Dr. Randy Lehman [00:52:15]: I feel you. Very, very good points. Interesting and pretty much true perspective. So I just had one more question; if you're doing these electively, do you do a low transverse incision there? Yeah, yeah, I just... Okay, that sounds good. Rather than doing a whole second how I do it, is there any, like, one or two things that you would say, big difference between an elective versus this operation? You described everything. Yeah, yeah.

Dr. Dave Kermode [00:52:45]: First of all, you're gonna do a pan still incision, then you're gonna go down, and you're gonna really, for the most part, bluntly get into the uterus. You make an incision, but you know you're going to extend it bluntly. It's plus-minus on whether or not you develop a bladder flap. It's kind of the way the uterus lies and just how far up the bladder is. I think probably at least half the time, you don't need to do a bladder flap, and I don't think you really need to push down like I was taught in the distant past. You don't need to dissect it off the lower uterine segment unless there's a reason to. There typically is not, so... okay. With general surgeons, we typically do two-layer closures. There'll be gyns who do one-layer closures. Theirs are just as good as ours. Some of the best, you know... well, one of my favorite trainers was an ob-gyn, and she always just did single-layer closures, and they look great. So...

Dr. Randy Lehman [00:53:43]: When you get the baby out... so if the mother's been laboring for a while and they don't have a rupture, which would be one of the common scenarios, not this crazy situation...

Dr. Dave Kermode [00:53:54]: It would be the most common.

Dr. Randy Lehman [00:53:56]: Yeah. Then the head can be kind of stuck. Any particular tips for getting that head out?

Dr. Dave Kermode [00:54:02]: This is where you need to talk to your ob-gyn colleagues. There's a bunch of different tricks, and one of them is having them in low lithotomy on the table. If you anticipate this sort of being a problem and somebody can come up from below and push the head up, there's different cups and things that you can use that'll push things up. So people make different devices.And then just breaking that suction with your hand when you go down. So learning how to sweep it on up into the incision.

Dr. Randy Lehman [00:54:29]: And you're always, you're right-handed or left-handed?

Dr. Dave Kermode [00:54:33]: I'm right-handed.

Dr. Randy Lehman [00:54:34]: And you stand on the...

Dr. Dave Kermode [00:54:36]: I stand on the right-hand side.

Dr. Randy Lehman [00:54:38]: The patient's right side. And you're using your right hand to get that head out. Are you using your left hand typically?

Dr. Dave Kermode [00:54:46]: Typically, I use my right hand. There are times when I will use my left hand.

Dr. Randy Lehman [00:54:50]: So you just kind of have to turn your body and get your hand down there. Yeah. And then once you get that baby out, do you let them breathe on the cord for a bit?

Dr. Dave Kermode [00:55:00]: Try to, for 30 to 60 seconds. Yeah.

Dr. Randy Lehman [00:55:03]: And then you clamp the cord and send a cord blood sample off.

Dr. Dave Kermode [00:55:08]: Right. So you have a segment of the cord that you'll send off. It's clamped on both sides.

Dr. Randy Lehman [00:55:13]: And then you send a segment of the cord and the cord blood. Yeah, sure. And so that's good. And then after that, you're focused on delivery.

Dr. Dave Kermode [00:55:23]: Make sure...

Dr. Randy Lehman [00:55:23]: That the pit, Pitocin, is running, and you get good uterine tone. If you don't, then what do you do?

Dr. Dave Kermode [00:55:31]: There are all sorts of different maneuvers you can use, and not so much maneuvers, but different medications. You can talk to the anesthetist. We have anesthetists, CRNAs, and that's all almost protocol driven.

Dr. Randy Lehman [00:55:44]: Okay. Make sure you have a protocol. That's a good lesson. Then uterine massage, to a certain extent, can help those fibers contract down and stay firm for the most part.

Dr. Dave Kermode [00:55:56]: The biggest thing to do to reduce the bleeding is to use ring forceps and use them at both apices of your incisions. Use them top and bottom, and then look for other places where it might be bleeding. You can use another one. So one trick is to have at least four or five ring forceps.

Dr. Randy Lehman [00:56:12]: Do you routinely take a clean sponge and sweep?

Dr. Dave Kermode [00:56:17]: I do. I know there's talk of not doing that, but I still do it.

Dr. Randy Lehman [00:56:24]: If you're having ongoing bleeding, that would be a good trick.

Dr. Dave Kermode [00:56:27]: I do it every time. I told you I don't do it primarily anymore for the last two years, but I always did it. That was routine for me.

Dr. Randy Lehman [00:56:38]: Fair. And so then everything contracts down. Do you always extracorporeal the uterus?

Dr. Dave Kermode [00:56:45]: I do. When dealing with bariatric patients, if someone's got a high BMI, sometimes you can't. That's another reason to use the Alexis wound retractors, even if the administrator doesn't want you to use it.

Dr. Randy Lehman [00:57:01]: Yeah. We're talking about the Alexis O wound retractor, right? The pink and orange one that's a circle? It's the biggest one they make, very rigid. I agree, I think it's awesome for a C-section. How do you close, then, once it's got good tone? You bring it out, you bring the uterus out, you close it when the uterus is up and out?

Dr. Dave Kermode [00:57:27]: It depends. Thin gal, yes. Bigger gal, maybe not.

Dr. Randy Lehman [00:57:30]: So now you're ready to close on the skinny lady. What suture do you use to close the uterus? Vicryl on a taper needle?

Dr. Dave Kermode [00:57:45]: It's on a non-cutting needle.

Dr. Randy Lehman [00:57:46]: Yeah, and a big needle. For your first stitch, do you leave your ring forceps on when you throw the stitch?

Dr. Dave Kermode [00:57:55]: Yeah, they make ring forceps with a little cut in them so if you go through one of the rings, you can get it out.

Dr. Randy Lehman [00:58:02]: That's interesting.

Dr. Dave Kermode [00:58:04]: Various parts of my career, they've been around. It's frustrating if you go through it.

Dr. Randy Lehman [00:58:11]: Yeah.

Dr. Dave Kermode [00:58:12]: It doesn't happen often, but if you go through it...

Dr. Randy Lehman [00:58:14]: So you go behind the ring forceps?

Dr. Dave Kermode [00:58:16]: Yeah.

Dr. Randy Lehman [00:58:16]: And you go out to in?

Dr. Dave Kermode [00:58:19]: Yep.

Dr. Randy Lehman [00:58:19]: Into out. You tie your knot out lateral?

Dr. Dave Kermode [00:58:22]: To where the corner is and tag that.

Dr. Randy Lehman [00:58:24]: And you tag that tail and then run with the rest of it?

Dr. Dave Kermode [00:58:30]: Yeah.

Dr. Randy Lehman [00:58:31]: Is it just a baseball over-under stitch the rest of the way? That's what gives you a one-layer?

Dr. Dave Kermode [00:58:37]: Right.

Dr. Randy Lehman [00:58:37]: So one or two-layer closure?

Dr. Dave Kermode [00:58:40]: Yeah. There is no difference if you look at the literature, no difference in complications relative to the closure used. So this is an opinion-based statement. I am uncomfortable using a single-layer closure, even though scientifically it's just as good as a two-layer closure. I do a running locking suture to snug things up with the first layer, then a running suture to bring over the last muscle coat.

Dr. Randy Lehman [00:59:20]: Okay. I just wanted to know how you do it. The issue is there's not necessarily a right answer, so it doesn't end up being an apposite question. When I first came out, I had this book where I wrote down when I watched different attendings do things. There's more than one way to do it, but what do I want to do? Then I'm calling people for these finer details, which is why I'm focusing on it in case it's helpful to the listener. Thank you. Next question, do you close peritoneum?

Dr. Dave Kermode [01:00:01]: I don't think there's any strength in it. Most OB-GYNs do not. Having done a lot of repeat C-sections, having the anatomy intact so you know what you're getting into as you go down in layers is crucial, especially with learners. So yes, I do.

Dr. Randy Lehman [01:00:25]: Okay. Before you close the peritoneum, do you pull the omentum down and lay it over the uterus as much as you can? Then you close the peritoneum with like a 3-0 Vicryl?

Dr. Dave Kermode [01:00:35]: Yeah, exactly.

Dr. Randy Lehman [01:00:37]: I did a bunch of C-sections with OB-GYN, mostly with them. Most preferred to close the peritoneum.

Dr. Dave Kermode [01:00:47]: They don't around here.

Dr. Randy Lehman [01:00:49]: Okay. I saw one complication in residency where there was actually a.Either incompletely closed, or the top part of that peritoneal closure tore through. And there was actually a small bowel herniation with bowel obstruction and dead intestine about 2, 3 days postpartum. Just into that pre-peritoneal space was hard because on exam, there's no hernia. But then, of course, you can see it on the CT scan, and she's in severe pain. That was dead bowel, so we had to do a resection through the vein of Steel and everything.That just kind of anecdotally made me wonder, what do we think about closing this layer? Because theoretically, the peritoneum doesn't heal that way. It heals by whatever stem cells in the peritoneum, you know.

Dr. Dave Kermode [01:01:33]: Right.

Dr. Randy Lehman [01:01:34]: Regenerating. Okay. And then you close the fascia with what?

Dr. Dave Kermode [01:01:38]: Double-shaded OPDs.

Dr. Randy Lehman [01:01:40]: Okay. And then there's some data about, like, the depth of fascia or the depth of the sub-Q and whether you should put a sub-Q stitch or not. If it's greater than 2 cm, you could put like a 3-0 Vicryl. Reapproximate the sub-Q. Did you do it that way or any other tricks there?

Dr. Dave Kermode [01:01:56]: Yeah, we'll go across what essentially Scarp's fascia is almost, you know that.

Dr. Randy Lehman [01:02:00]: Yeah.

Dr. Dave Kermode [01:02:01]: Middle layer.

Dr. Randy Lehman [01:02:01]: And if they have nothing there, then you don't close it.

Dr. Dave Kermode [01:02:05]: Typically, yeah. Because we use a running subcuticular suture of 4-0 Monocryl, so we will still bring it together. Because you don't get a whole lot of strength in your closure with just a Monocryl.

Dr. Randy Lehman [01:02:16]: So pretty much exclusively.

Dr. Dave Kermode [01:02:17]: All right.

Dr. Randy Lehman [01:02:18]: And then you put glue over the top of that.

Dr. Dave Kermode [01:02:22]: Typically, glue.

Dr. Randy Lehman [01:02:23]: Glue. And then, a la casa, I guess.

Dr. Dave Kermode [01:02:27]: Yeah, exactly.

Dr. Randy Lehman [01:02:29]: So that's good.

Dr. Dave Kermode [01:02:30]: Then watch them. As a general surgeon, even though you've just been the proceduralist in this, you own that patient now, too, for their operation. So you see them every day when they're in the hospital, and then you see them post-procedure. I always see them twice, or would see them twice.

Dr. Randy Lehman [01:02:46]: Okay. And that would be, like, what, two weeks, six weeks kind of thing?

Dr. Dave Kermode [01:02:49]: Exactly, exactly.

Dr. Randy Lehman [01:02:50]: Okay, very good. Well, thank you so much for that deep dive. That was a lot of fun for me. I don't know if it was for anybody else, but that's okay. Not too worried about it. Yeah. We got to keep moving here.The next segment of the show is called the Financial Corner. I was wondering if you had a money tip for our listener.

Dr. Dave Kermode [01:03:07]: Don't get divorced.

Dr. Randy Lehman [01:03:10]: That's a good one. That's a very good one. You hear often, one house, one spouse. You've moved around and had a divorce. And you're coming at us with the biggest financial tip that you're. Your takeaway from this is try not to get divorced. But it's easy to say, how does someone not get divorced? On The Rural American Surgeon podcast today, we're talking about how to not get divorced.

Dr. Dave Kermode [01:03:46]: Oh, wow. Yeah. It's an interesting question, and obviously I've pondered it. I think people make the decision to get married based upon age and not maturity. Some people, and we've had friends where their kids have gotten married at 18 and have great marriages. We've had friends.And, you know, I've seen it in my own life where you can be in your 20s, mid-20s, and get married, and you're just not mature enough to be married. So have an accurate assessment of both your and your potential spouse's maturity. If that maturity is sufficient that you can take on, and even if you don't want to have children, if, quote, unquote, there was a mistake and you had children, that you could take care of them. I think that's a litmus test.If you're somebody that can't subvert their own interests to the interests of another that you love, that's not going to work out well, no matter what. But if you can subvert your interest. So if, you know, for us, we wanted to have kids, so that wasn't an issue. So we met that maturity mark.We did not meet the maturity mark of saying, okay, what's attracting us to each other? It was physicality. It wasn't, you know, we. She's a rich gal from New York City. I mean, what am I doing with her? And that all came into play.She had even, she's a Christian. But there is a wide variety of Christians, and some Christians can accommodate behaviors that other Christians can't. So you got to have a similarity there too.

Dr. Randy Lehman [01:05:28]: So I wish I could say, be a Christian and you won't have a divorce.

Dr. Dave Kermode [01:05:34]: That's not true.

Dr. Randy Lehman [01:05:35]: But it turns out that right now the rate of divorce is similar between professing Christians and the general population, still sitting around half. Now, I attend a church called Absolute Christian Church of America. It's kind of an interesting church. It's a church I was raised in. We have a 3% divorce rate in my church.

Dr. Dave Kermode [01:06:02]: Did you have covenant marriage then?

Dr. Randy Lehman [01:06:03]: No, we don't have that. But I think there's definitely social pressure not to get divorced. You say that to people, and there will be others that will say, well, maybe there's these marriages that shouldn't be stuck together, and people will go the wrong direction with it. The reality is marriages in my church are actually working. I know so many people with such good marriages in my church. I think it actually is one of the biggest things with my particular church, which is a small denomination, that says something really positive. People are sincerely trying to, you know, there's a triangle. The idea is that you have a husband and a wife, and they're the base of the triangle. If they can both get closer to God, they get closer together as they move up in the triangle. I think that that's being done. I want to propose that to people. But, you know, you have to look at the data, if you're an objective person and say it's not just about being a nominal Christian. But I do think that first off, you have two people that just really don't want to get divorced. They really want to, they really have, like you said, the maturity to understand what that means when they make the commitment in front of all their friends and family, saying, I'm going to stay with you forever. Knowing what that means to go through. Then the question though is, you know, I just had my nine-year anniversary and my grandpa just, I just took him to Hawaii and he's, I think he's like 72 years into marriage, something like that. It's crazy. Yeah, I mean, he's 95, so it's something along those lines. But, you know, you ask him how long has he been married? "Oh, two or three good years," you know, and you want to maintain a good attitude. Now I've been married nine years. It's not always been great. There've been some bad overall years. But we have to have that long-term focus and that never-quit attitude. That's what's helped us. What I was kind of wondering if you would say is things like having a counselor or going on marriage retreats or, you know, anything like that. But for us, it means taking a barometer of where you're at in the relationship and when it's not good, doing something to fix it actively. People say things like, never go to bed angry.I've gone to bed angry, and I'm still married, you know, and maybe not having that fight is better, I don't know. But I'm definitely not the marriage expert.

Dr. Dave Kermode [01:08:56]: Expert.

Dr. Randy Lehman [01:08:57]: Okay. I'm asking this question just like I'm asking all the surgery questions, which is as a learner, you know, but since you brought it up, we want to take steps to try and avoid it. And I guess if you were asking me, I would say being sincere and open, having good communication, and working on your marriage. Consider it not to just be something that's serving you, but consider it one of your most valuable assets that you want to kind of continue and maintain working together.And then also, you know, keeping God in the center of your relationship. Sometimes I say to my wife, and we've kind of played this off to each other, "If Jesus is sitting in the room, how am I going to talk?" You know, that makes it a lot easier for me to have those conversations. Do I always live up to it? No, but those are my thoughts. What do you think about that?

Dr. Dave Kermode [01:09:53]: Yeah, so if I had my druthers, I wanted to be a pastor. I did not want to be a doctor. That was my first choice. But I've had a horrible temper, and I constantly fight that. Most people, it's always such a surprise, you know. He seems calm, but inside my mind, I have this horrible temper.I would say that the thing that makes this marriage work where the other one didn't is this one is built, you're right, around God. The other one was not. We were in the middle of medical school, which was stressful, and we came from two entirely different upbringings. Whereas, this one is, you know, she's a small-town girl. Her father and my father are very similar people. Her mom and my mom are not quite as similar, but still somewhat similar.If you were doing an arranged marriage, this is the one that would have been arranged for both of us. My Indian friends with their arranged marriages, those all work.

Dr. Randy Lehman [01:11:16]: It was like somebody's being objective on the outside, looking at it. Right? So arrange your own marriage. Next segment of the show is called Classic Rural Surgery Stories. And this would be a story that your urban counterpart just couldn't believe. But you just told us one. Do you have another canned story that you might want to share with the listeners?

Dr. Dave Kermode [01:11:38]: So I'm out walking the dog two houses down from us, and we live in a historic neighborhood. Two houses down from us, I hear what I think is the radio. It's an opera singer, and it just sounds fantastic. So I asked that neighbor, "What were you listening to?" Oh, it's a Romanian student. We have a college half a block away, and he's a music major and also an opera singer. Oh, that's cool.Well, it turns out that he's been having troubles, getting hoarse once in a while. At that point, I was doing a lot of Nissen fundoplications. Obviously, he's not on our insurance. So the hospital just, you know, worked him up. He's got pretty bad reflux. He needed a Nissen fundoplication.This can only happen in small towns. I talked to the administrator, who said, "Sure, we'll put it in the paper, and you can go ahead and operate on the guy." So we operated on this guy, preserving his voice. That only happens because you're in a small town, where you think it's the radio, but it's a guy who's actually singing. He's now a prominent opera singer in Romania and a cultural minister. This was probably 20 years ago.

Dr. Randy Lehman [01:13:12]: Wow. What a fantastic connection. See, you can work with your administrator in a small town. I have found that to be true myself. So, thank you for sharing that story. The last segment of the show is resources for the busy rural surgeon. Do you have one great resource that every rural surgeon should have?

Dr. Dave Kermode [01:13:27]: Friends. The biggest thing is maintaining contacts in different specialties, especially during COVID. That worked out great. Practicing in two different places, one large, one small, having the ability to call the big place when you can't take care of it in a small place, is critical. Don't isolate yourself. If you're a rural surgeon, go to morbidity and mortality conferences, even if you have a complication. I can't imagine that anybody wouldn't want you to. Reach out to residencies and offer if someone wants to spend a month or even medical students who want to go into surgery.

Dr. Randy Lehman [01:14:23]: That is the most common thing people say on the show. Other people are the best resource. I didn't know where that would go when I started the program. I thought it might be books, selected readings, or conferences, but definitely, a personal contact is the number one thing. Thanks for sharing that yet again Dr. Kermode. It's been my pleasure and honor to have you on. Thank you so much for joining us. The last thing I wanted to talk about was you've been a guest multiple times on another podcast, the Really Rural Surgery Podcast. Am I saying that right?

Dr. Dave Kermode [01:15:07]: Correct.

Dr. Randy Lehman [01:15:07]: And that's with you and Dr. Bachelor, who is a generalist in Canada but does some surgical procedures. Am I correct on that?

Dr. Dave Kermode [01:15:15]: Yes, they have a program where they go through family medicine residency and spend an additional year doing procedural medicine. They are often geographically isolated, where they practice without specialty coverage. We talked about being programmatic, not custom-fit. In these rural settings, they're linked with OB-GYNs and general surgeons they can call. They usually come in every six weeks as I understand it, and practice various procedures with those ESS (Enhanced Surgical Skills) physicians.

Dr. Randy Lehman [01:16:10]: And that podcast was started in late 2014, but it hasn't been updated for a while now.

Dr. Dave Kermode [01:16:18]: We're doing another one soon. It doesn't come at fixed intervals. Brett tends to do three or four in a year. At one point, we were doing more than that.

Dr. Randy Lehman [01:16:33]: Well, I appreciate what you have done in just sharing your experience, both with your trainees that you've continued to be involved with, with the shows that you've been involved with, and obviously with each individual one-on-one patient. You should feel very accomplished and proud of the body of work that you've done. Because it seriously is, you sit back and you think about it from an objective perspective, from your wheelchair looking back, and you've done great work. So, I really appreciate you taking the time to spend with us this morning and come back anytime.

Dr. Dave Kermode [01:17:12]: Oh, no problem. And then I'm also involved with the Rural Medical Training Collaborative. So that's another really good organization here in the States.

Dr. Randy Lehman [01:17:20]: Okay. So you can check that out. We'll throw a link in the show notes. Thank you for listening to this episode of The Rural American Surgeon Podcast. Please don't hesitate to share this with anyone that has an interest in rural surgery. If you don't mind giving us a rating or review, like or subscribe, join us on Facebook, and interact with us. We appreciate you being here, and we'll see you on the next episode.