By: Jessica R
Jessica: Hi, welcome back. This is Jessica, the podcast host of Absite Smackdown. I'm here today with Dr. David Kashmer. He is the writer of the Absite SmackDown! study guide. Hi, Dr. Kashmer. How are you doing today?
Dr. Kashmer: Jessica It's good to be back with you again today to talk all about the Absite and Absite Smackdown.
Jessica: We are going to talk about the Absite, but I think we'd be remiss if we don't at least acknowledge we're now in month six of the ongoing COVID situation. I know we don't usually touch on it because it doesn't have anything to do with our content and what we're doing, but I think at this point we're going to have to, because it may be helpful and related to the Absite.
Dr. Kashmer: Well, sure. I think, you know, talking about the Absite and how it relates or may have helped take care of COVID patients with our study and preparation for it, I think is a great idea. We did of course do a previous podcast that just included the basics all about COVID. And we anticipate that our colleagues, a resident colleagues and attending colleagues, are going to be taking care of COVID patients. So because it did relate to and does relate to the patients we see and sometimes need to cancel elective surgery for...I agree with you. I think it's time to come back to it now and get some more information and timely information about COVID out there.
Jessica: Right. And so what's interesting is right now, because like you said, elective surgeries, aren't really a thing and it's changed the way people are going to the hospital and the surgical schedule you and your role and what you're doing right now is a little different.
Dr. Kashmer: Yes. I've been helping out with a COVID response, abroad and in the United States. And, for the last several months, it's really gotten me thinking all about how preparation, preparation for our exams, like the Absite and others really helps out a great deal with how we take care of COVID patients. And so when you made that the topic for this week's podcast, I thought that's a great idea. And I'm excited to talk about it.
Jessica: Well, you do know how I was inspired to do this topic, don't you? Well, when you were talking to me that you're now working and how COVID has changed things about together, you're working with someone that was a resident when you were first being an attending.
Dr. Kashmer: Yeah, it's amazing how a small world is in Surgery. You know, you say for the rest of the things in the world that it's six degrees of separation or for surgery, it's much less--it's a really small field. And so really for everybody, you know, when you work with a particular surgeon, there is not much distance social distance (in a different context and social distancing like COVID) but there's not much distance in their social network from you because it's a really small world.
So related to that, yeah, just about a month ago, I started helping out in Texas where it's been a really an emergency and there'd been emergencies all over, but they really feel it in South Texas. Sure enough another attending was there and that is an attending who was finishing her residency as chief resident when I was a fellow in trauma and acute care surgery. And that, like you said, you know, you and I were discussing it and you felt, "Hey, what a small world." And it brought back memories and, you know, something very interesting to talk about, how our preparation in residency got us ready to help take care of these pandemic patients.
Jessica: Exactly. Yeah. It's just so nifty to me that, you know, at that time when she was going through her residency and Absite was obviously on her mind and you were working with her and now you guys are working again. And I just thought it would be a cool tie in to talk about and be able to cover some of COVID, but also still keeping in line with what we try and do on this podcast, which is all Absite all the time.
Dr. Kashmer: Yes, absolutely. Dr. Alli Fagan is a very talented burn and trauma surgeon. And as a coming attraction, she's going to be on one of our future podcasts with us to just talk about, you know, her experience with COVID response and also how a surgical training prepared her for that. I think talking about it today is super useful and I'm happy to share kind of my experiences with it and how it relates directly to app site preparation.
Jessica: All right, well, let's get into that. What do you think has been most helpful from your app site prep and applying it to how you're treating patients right now
Dr. Kashmer: So many things. When I teach residents in the intensive care unit, you know, when we're in that venue, we make rounds. I was taught a problem list for each patient to kind of write your note at the end--with a problem list. Other people do other things like organ system based notes, et cetera.
I really like problem lists because it helps me filter signal, important things, from noise. You can get a lot of data for individual organ systems and not ever really come to a conclusion or be able to put it together or make decisions. It's at least it was tougher for me. Well, I shared that because as we go around, we notice that many of the patients' issues in the ICU are the same every day. What lines tubes and drains can come out? And what GI / DVT prophylaxis do they have?
What's their nutritional status? These are some of the several, you know, what are the weird labs and outliers they have that we have to adjust. And then the first problem on everyone's list is what's keeping them in the intensive care unit.
COVID patients? Are they on a ventilator? Are they on pressors to support their hemodynamics? These things, well, I bring that up because it turns out that much of the problem list is the same for every patient every day. It's actually not COVID it's COVID related, it's their GI DVT prophylaxis. It's their surgical nutrition. So it's COVID related because, yes, they're stressed by Covid and the ventilator. They may need 30 kilocalories per kilogram body weight, nutrition, but really what we give them, how it works, different things that we do. It's really core, critical care surgical, critical care, medical critical care, and that all comes from the Absite.
So it's a very long way of saying that most patients' problems on their problems each day are things we didn't really learn from COVID. It was just good ICU care with a COVID twist with a focus on, you know, things like how COVID may make you hyper-thrombotic. Sure. But people still need to be on DVT prophylaxis. What is it for them...are we surveilling them with ultrasound of their legs, et cetera. These things that we really learn in studying for the Absite. And it's really fascinating to me that so much of the core good ICU care is still what it is without respect to the disease. In many instances,
Jessica: Well, that makes sense. What do you think is the number one surgical issue that you guys are having with COVID
Dr. Kashmer: There are several, and when you say surgical, you probably mean operative surgical, not like surgical critical care and decision making. And there are lots of things that come up: timing of tracheostomy for those patients who are fortunate enough to do well enough on the ventilator to progress, but maybe not be extubatable. We can't remove the breathing tube. and they need a tracheostomy for one reason or the other several things come up with that. What is the timing of that? There's some consensus papers on when certain people, some ENTs out of New York, think that COVID patients should have a tracheostomy. So one of the surgical things I've found is timing of tracheostomy, which we kind of had settled in a lot of the acute care surgical literature. It's kind of now up in the air again. It has sort of come back around again and people are sort of saying, well, when are we going to do this tracheostomy? Also, the patient's coagulopathy with COVID. Are they hyper-thrombotic?
Do they have diffuse intravascular coagulopathy? What tests do we use to assess their ability to clot their blood? Do we use thromboelastography or do we use, you know, rotem, heptem, teg bleed time, D dimers...where do they all fit? So the surgical issues that come up often center around bleeding, timing of different decisions, tracheostomies, et cetera.
And then the routine stuff like putting in central venous catheters, putting in chest tubes for those patients who need it. So those are the mostly the technical things we do now.
Patients do have interestingly some unique surgical issues, like many patients develop subcutaneous air on the ventilator, and some feel that they have a pneumothorax that x-ray can't see all the time. Some, you know, 10% at least are not seen on x-ray. They can have anterior pneumothoraces, but, interestingly, we've gotten in these situations because so many patients are on the ventilator. We may even see what looks like free air under the diaphragm.
There are some benign causes of free air under the diaphragm, but not in these patients. So then if the patient can travel to CT, we've done CT scans on them. And we see that the subcutaneous air has dissected down into the layers of the abdominal wall. And most of it is not actually in the belly. It's preperitoneal. It's in between the layers sort of outside of the belly. And it looks like free air. So it's really fascinating, these novel surgical issues that create unique problems that otherwise we don't see very often, but because we have so many COVID patients, we see them more often. And then routine, surgical issues that arise in the intensive care unit like perforated cecum, comes from patients who have a dilated cecum from an ileus. and then, you know, should they receive exploratory laparotomy or not, like other people might, or is it considered futile?
These are the situations we're facing a lot. Clearly you've touched on a subject that has come up all the time for me. So pardon me, I'm going on for a bit. But the last one is, taking patients to the operating room and aerosolizing COVID throughout the OR. How do you protect against it? Do you need to, should you, what sterilizes the room after these things? That comes up a lot, not to mention timing of elective cases in people who show up with COVID symptoms who may need an semi elective case or otherwise. What do you do with them? So many novel surgical situations. I think we named at least five there, but that's what we see coming up. At least that's what I've seen.
Jessica: So it kind of seems like with COVID, it's just giving a lot of opportunity for surgeons and surgical residents to learn, practice and use the Absite as building blocks, to, you know, dig in there and figure out exactly what's wrong.
Dr. Kashmer: It is. We talk a lot about test preparation and we focus in this podcast and in the book on things that are correlated with doing well on the test. But ultimately I feel like, you know, the test really is every day. It's every day once you become an attending. It's every day, even while you're a resident...that's the test. So to my mind, you know, we study for the Absite, but really the Absite facts are tested every day as we go through the intensive care unit. And just as important, what's really tested is decision-making. There's a book called Gordon's Guide to the M and M...The Morbidity and Mortality Conference. And it asserts, I think rightfully so, that most complications and problems in Surgery are not technical. They're really decision making. We chose this and balanced this risk against this risk and decided and then here's the outcome we got.
And, I won't even say error, but outcomes are due to decision making. Each outcome has a probability of a certain thing happening. It's not always about right and wrong. It's just about the risks you take. What's acceptable risk. If you go left, you have these risks. You go right, you have these risks. And I say that because studying for the Absite helps give you a sense of if I turn left, I have these risks. If I turn right, I have these risks. I think on balance, this is the best pathway for this patient complex decision making in the real world with uncertainty and imperfect information. And COVID acutely reminds us of that everyday imperfect information, inadequate supplies, often tough situations, and we're seeing a lot of them. So we rep on these situations all the time and do the best we can, a difficult situation. I think that is excellent for training, because it really teaches you the sense of decision making in uncertain situations. And I think doing that well is what makes you a good physician or surgeon.
Jessica: Dr. Kashmer, thank you so much for coming on today and for talking about this. I know you're really busy, especially with what is going on and you traveling and being such a big part of this right now. So I thank you so much for coming on. Hopefully we can get Dr. Fagan on and talk to her a little bit more about this and thank her for giving us the idea of today's podcast.
Dr. Kashmer: It's amazing how this situation, you know, brings people together. A wish Allie could have been with us today, but I know she's committed to come on in the future. I'll share that. it, it seems to me that, you know, COVID really has pushed us, whether you're a surgeon or a medical provider into an interesting kind of space with what it's done to the healthcare system already and kind of where it's going next. I think preparation for the Absite gives us the foundation to take care of many things that COVID patients show us.
Like I said, surgical nutrition, whether they're in shock, you know, what's oxygen delivery for them, what is their, the hemeoxy dissociation curve look kind of look like all these things come from the Absite. And that body of knowledge has just been incredibly useful in taking care of these patients. So I can't wait to kind of talk more about it and what it means. I hope that the book remains valuable for everybody. I've noticed since COVID, started, you guys have shown me kind of how the course attendance and books have been doing and they've been doing really well. So I hope everybody finds it useful, you know, and it matches the intent of what we put it out there for.
Jessica: Thanks for tuning in everybody. And again, #AbsiteSmackdown!