American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Reflections from ACS Members

International Exchange Scholar Reports on Annual Scientific Congress in Bangkok

Nicholas Parrish, MDNicholas Parrish, MD

May 1, 2019 marked the beginning of a new era in Japan—Reiwa, meaning “beautiful harmony”—with the ascension of the Tenno (“heavenly sovereign”) emperor Naruhito. In Thailand, Vajiralongkorn, King Rama X, was coronated in magnificent fashion in a ceremony lasting from May 4-6. Astride these auspicious events, this wide-eyed Tennessean travelled from Tokyo to Bangkok to participate in the 88th Royal Australasian College of Surgeons meeting May 6-10. Surely even the first half-American British royal, Master Archie Harrison Mountbatten-Windsor, born on May 6, did not receive a warmer welcome by citizens of the Commonwealth.

The first day of the meeting featured many talks about transplantation surgery. Peter Friend (Oxford) and Jayme Locke (University of Alabama at Birmingham) gave very clear presentations, and their motivation to push the boundaries of knowledge to overcome organ failure and shortage for their patients was inspiring. Tumuaki and professor Papaarangi Reid gave an outstanding perspective on organ donation in indigenous communities. Sessions in trauma included a retrospective on pendulums in resuscitation trends by current ACS president Ronald V. Maier, MD, FACS; and a description of concentric anatomic liver packing by John McCall seconded by Mark Stringer. An outstanding reexamination of the foundations of damage control surgery by David Lockwood was particularly interesting. I also enjoyed the high-quality discussions of difficult HBP cases, including management of disrupted pancreatic ducts, and a masterclass featuring a video of a gangrenous wrong-sided bile-bag. I was amazed to hear the rates of common bile duct exploration in some Australian hospitals. However, other discussions about deciding to open, when and how to perform a subtotal cholecystectomy, and how to safely “bail” demonstrated that this incredibly common general surgical pathology can serve as a great equalizer. It is a reminder that humility can serve the patient regardless of where one might practice.

I had the pleasure of meeting trainees and young fellows from the Royal Australasian College of Surgeons (RACS) from all over Australia, New Zealand, and the rest of the world. At the section dinner for trainees and younger fellows, I heard what it was like to be a surgical trainee in Western Australia, Tazmania, Wellington, and Israel. A particularly kind group of trainees from Brisbane (which sounds like a really nice place, at least on one side of the river, depending on who you ask) allowed me to join in their evening activities, as it is definitely safer to travel in numbers in Bangkok. Concerns over case volume during training, work-life harmony, the difficulty of building and maintaining a culture of respect free from abuses of power, and the plight of non-accredited trainees are seemingly universal; I heard no complaints. While I did not anticipate seeing her, I was not at all surprised to find my jet-setting co-resident at Vanderbilt University, Rachel Koch, MD, presenting on national surgical planning in her role as a senior fellow of the Harvard Medical School Program in Global Surgery and Social Change. I had a chance to meet with a U.S.-trained, native Thai surgeon working in Phuket, Art Hiranyakas. I also met a junior surgeon from Cambodia enjoying his first few days of rest this year. RACS seems particularly well positioned to build mutually beneficial partnerships to support development of sustainable surgical workforces globally and at home. Amid global trends towards nationalism, I sure hope I continue to be blessed to cooperate transnationally with folks as affable and generous as those I met at RACS.

Dr. Parrish, Dr. Koch, and other attendees of the 88th Annual Scientific Congress of the Royal Australasian College of Surgeons

Applications for 2020-2021 International Exchange Scholar Program will be open in July. 

Dr. Parrish is a PGY-4 in general surgery at Vanderbilt University.

One Resident’s Brave Beginning

Zachary Sanford, MDZachary Sanford, MD

July is just around the corner and, with it, the beginning of a new chapter in the lives of rising interns across the country. Although an exciting moment, even the bravest and unflinching outgoing medical students feel their enthusiasm tempered with hints of anxiety and humility. Now, for the first time in their careers, they will be privileged with the opportunity to serve as physicians. Patients will rely on them. Their senior residents and attendings will expect ever-increasing maturity and clinical insight from them. And they will certainly watch themselves grow in ways they never before thought possible. 

In many ways, I imagine this mirrors my personal experiences as a new father. During the completion of my surgical research fellowship, my wife and I decided the time was right to start a family. Although nervous, we took our first tentative steps into parenthood with the expectation of a routine and hopefully uneventful pregnancy. Certainly, the long hours and exhaustion of bringing a child into the world would be demanding, yet we felt confident that together we would rise to the challenge to be good parents capable of making a nurturing home for a new addition. 

There is a lot of humor in pregnancy, if you know where to look for it. For one, despite being a surgeon-in-training, I still had enough wherewithal from my obstetrics rotation in medical school to read a pregnancy sonogram. And for another, the obstetrician revealed we would need to begin doubling our decorating plans as my wife was pregnant with twins. As we were still reeling from the sight on the monitor, the obstetrician also cautioned that this was now classified a high-risk pregnancy, although at present everything was well within normal limits. 

Everything changed when, at fourteen weeks, a gushing fluid heralded the ruptured membranes of one of our twins. Chances of the amnion resealing were uncertain, and I quickly retreated to a clinical distance as we discussed questions of possible fetal demise or risks to the other twin. This proved difficult, as in the setting of twin gestation in the literature is exceedingly scarce on clinical outcomes following preterm premature rupture of membranes. Grimly, we felt like we were navigating in uncharted waters. 

We were fortunate to enter the care of a maternal fetal medicine specialist whose unwavering optimism and guidance served as a steadying presence in those uncertain times. With his kind demeanor he often reassured us that despite the long odds, his years of experience taught him to hold out hope even for the slimmest of margins. Although he would often quip that he lacked a crystal ball, each day was met with ambiguous findings but a small step closer towards viability. 

Our care then transitioned to Johns Hopkins Hospital where batteries of weekly imaging scans continued until my wife was admitted at twenty-four weeks. Although her course was harrowing, we joked that my daily visits and overnight stays were not unlike what we envisioned to be a rigorous call schedule. Weekends, holidays, and even our wedding anniversary were all spent together in the hospital as if ordained by an especially unfavorable series of block rotations. 

When the day finally arrived at 29 weeks and two days of gestation, we welcomed twin sons into the world. I held my wife’s hand anxiously as we waited to see whether our son with the ruptured amnion would have the pulmonary maturity to survive out of the womb. To our joy, we were met with crying from two impressively strong lungs. The next six months would prove challenging between two children admitted to the NICU, eventually taking one home while still seeing the other daily in the hospital. Our son would then transition to the general pediatrics floor and ultimately a stepdown facility prior to his final discharge home. 

We are now the happy, if not also exhausted, parents of two precocious boys who rely on us, expecting that we will care for them in ways we never before considered possible. The experience has been a humbling one in which we have matured as individuals while strengthening our partnership together. Now, as we approach the final weeks before starting my internship, I look back on the personal growth I underwent this year, and I’m excited to see how far I will come in the year to follow. Just as becoming a father has transformed me in ways I could not imagine, I can only begin to grasp how my residency training will allow me to grow as a surgeon. 

Dr. Sanford's twin sons

Dr. Sanford is a PGY-1 in general surgery at the University of Maryland Medical Center.