Episode 38: Sunday March 28

Who knew a surgical career could risk crippling you permanently? Drs. Sam Jejurikar @samjejurikar, Salvatore Pacella @sandiegoplasticsurgeon, and Sam Rhee @bergencosmetic discuss the challenges faced by surgeons operating for long hours over many years. Previously ignored, OR-related physical stress and injury is now recognized as a tremendous problem faced by surgeons. Surgeon safety is patient safety. How can surgeons protect and take care of themselves in a culture where stoicism and self-sacrifice has been valued above all else?

Full Transcript (download PDF here)
2021.03.28 Maintaining a Surgical Career - Health and Ergonomics
Dr. Salvatore Pacella: [00:00:00] Good morning, everybody. Here we are with our next podcast. I'm Dr. Sal Pacella. My Instagram handle is @SanDiegoplasticsurgeon. I'm out of San Diego. I'm joined by my good friends and colleagues.  Dr. Sam Jejurikar from Dallas has Instagram handle is @SamJejurikar. And then of course, Dr. Sam Rhee from Paramus New Jersey. Who's @Bergencosmetic. Welcome gentlemen, how are you guys doing today? 
Dr. Sam Jejurikar: [00:00:25] Very well doing well.
Dr. Salvatore Pacella: [00:00:28] We're we're going to do a very interesting topic today, which is near and dear to the hearts of three very athletic butt's sore middle-aged men. So we're going to talk about surgical ergonomics.
So I'm going to hand it over to Dr. Rhee for our disclaimer. 
Dr. Sam Rhee: [00:00:46] This show is not a substitute for professional medical advice, diagnosis or treatment. The show is for informational purposes, only treatments and results may vary based on the circumstances, situation and medical judgment after appropriate discussion, always seek the advice of your surgeon or other qualified health provider.
With any questions you may have regarding medical care and never disregard medical advice or delay seeking advice because of something in this show. 
Dr. Salvatore Pacella: [00:01:08] So this is a really interesting topic guys that I really appreciate the fact that we're talking about this. And it's about health and longevity and body positioning in the operating room.
And just as a quick aside here. I come from a a very. Middle-class low middle-class family. My father was an auto worker so to speak a blue collar worker. Okay. And his idea of parenting was to try to get his kids in a profession where they didn't have to, ruin their bodies by standing on a line all day long.
Okay. And as it turns out, I am. I am a blue collar worker. We are not white collar workers. We are not in an office all day long, typing away doing zoom calls. We are in a exceptionally physical and problematic job when it comes to neck, back shoulder, wrist pain, et cetera. And I didn't really appreciate this when I was a younger resident in my thirties, early thirties.
But now I'm 47 and these days sometimes are getting longer and it's a challenge for neck back, shoulder pain constantly, particularly the days that I'm operating. So what, tell me guys what's your experience here? 
Dr. Sam Rhee: [00:02:24] Absolutely. I feel I have to get myself ready every day. If I have a long case.
I have to know what I'm going to feel like afterwards. I know every day that I am operating if for a long case I'm going to feel beat up. I have made many changes in the way I work in order to try to minimize some of this pain, but it's, it sounds stupid because yeah, we're not, lifting 50 pound bags or, hauling, large weights, but it does mess you up. And I know a lot of surgeons who are really messed up and because of long careers in the operating room, 
Dr. Sam Jejurikar: [00:03:02] yeah. To just follow what you said, we are highly paid manual laborers. But my practice is predominantly body contouring. I do a lot of liposuction, a lot of a lot of just heavy lifting throughout the course of the day.
And most days I'm operating for eight 10 hours a day doing that sort of labor. So I have to treat it like you are. Mike, you're working out. I stretch in the morning. I actually will do aerobic exercise in the morning and stretch for 20 or 30 minutes before I go to the operating room in order to try to prevent injury while operating.
Dr. Salvatore Pacella: [00:03:35] Now. Now let's back up a little bit here, so let's talk about maybe your career or your activity level before medicine. And then afterwards I, and the reason I mentioned this is, I don't know any one of my friends or guys, my age, who are in their forties that had some reasonable athletic career prior to being a physician that don't have a major orthopedic injury in their forties.
How about you guys? What did you do? As a younger person, activity level, any sports, et cetera. 
Dr. Sam Rhee: [00:04:07] I was the typical studious non-athlete growing up. Aye. I was not good at sports. I was not particularly coordinated. I think this, the most strenuous thing I ever did was swinging a golf club probably and not that great at that.
I really didn't have a very athletic background and prior to being a surgical resident. I basically sat in a library and read a lot. That was me
Dr. Sam Jejurikar: [00:04:38] bring that based off of your level of physical fitness you have now, Dr. Rhee is the most, both of all of that. So that is a surprising statement to me. I played sports, I played tennis. I played baseball. I will lift a lot of weights. I wasn't particularly good at anything, but but I played all of those sports through high school and lifted weights a lot in college and medical school.
Dr. Salvatore Pacella: [00:04:59] Yeah. Yeah. I unfortunately I've, I think I was going the other way. I I was into a ton of athletics as a kid and in high school I played high school football wrestle track. And then, rugby was my lifelong sport and unfortunately I was playing up until age 35. And just tremendous devastation on my body.
I have a couple ACL repairs. I have some cartilage damage in my knee. Later on a few years after that I had a L five S one herniation and my, my body, sometimes when I wake up in the morning, I'm just feeling it, every single joint. And the regimen of what I have to do to keep myself limber and to keep myself healthy in order to do my job is fairly extensive.
So you, so Sam from Dallas, you mentioned you, do you work out beforehand in the operating room or at home or wherever you go to the gym beforehand? How about you? Dr. Rhee from Jersey. 
Dr. Sam Rhee: [00:05:57] Yeah, I'm a late bloomer when it comes to athletics. That is true. Fitness is a big focus in my life and I think that has helped me in terms of my operating for sure.
I typically work out every morning. It really depends though. If I have something that's I do a lot of body work, just like a. Sam and Dallas does, but if I'm doing something that's like a rhino or something, that's more precise. I will take it easy on the workout because I. I feel like that affects my hands a little bit.
And then but I always work out in the morning. I will typically now do a lot more mobility work than I used to. I do yoga at least a couple times a week. I will I will actually stretch right after I do a case. I will go into my office and I will start. Doing some mobility work immediately because I found after I did a case, I literally could not even bend to touch my shins.
Everything was so stiff. I said, this is not good. And I realized I had, and then I would go home and I would be literally in pain going to bed. So I figured I had to start mobilizing. Right away, as soon as I was done with the case. And that's helped me a lot.  
Dr. Salvatore Pacella: [00:07:15] truly amazing. I think not many people realize just how demanding physically this job is.
When you're sitting there holding a retractor into somebody's breast and you're trying to look like this. For, 45 minutes to two hours at a time, it is just contracts, everything constantly. And we're not in a job where we can sit and drink water constantly, or stretch when things are tightening up it's so it's very challenging for me to get through a long case like that. I have to, I know there was a philosophy I learned in residency where, Paul Siddhartha used to say, you should guys, you should do everything from one side of the table.
Like you should operate on the left side from your right side. And I did that for a number of years and I just found that the entire side was contracting. So I make it a point to go to the opposite side when I'm doing a bilateral case. Just for some relief, 
Dr. Sam Rhee: [00:08:08] I think I've realized, especially in the, or some of the things that really mess me up if I do it a lot is if I have flexing my neck down, A lot flip for long periods of time.
If I, that kills me. So I started to make sure I keep everything closer. To my eyes so that I don't have to flex down or I adjust whatever it is, my, my surgical field. I also, if I'm like you said, if I'm elevating my shoulder a lot, that kills me. That really kills me. If I'm leaning forward, if I'm extending over myself, that, that really kills me if I'm turned and my posture is not if I'm flexed and turned at the same time for long periods of time, that really messes me up.
Just by keeping my distance is closer to me, keeping things elevated as opposed to down and try not to, like you said, keep in a contracted twisted position for a long period of time has helped me because when you're in your thirties and you start as a resident, it's not about you, right?
It's about your attending and it's about you assisting others. And so you're just sitting there in every weird, especially in medical school, weird position imaginable, just to try to help provide exposure or something for somebody else. And so you never learn. How to like, manage your own ergonomics in the know or right.
And then when you start operating, you just transfer that over. Except now you're the one who's sitting there for, like you said, Sam, six to eight hours at a time doing these cases. And so it was only when I got into my forties that I realized. I'm having a lot of cervical discomfort.
My low back is killing me. I'm having I have colleagues, we all know people who've gotten operations for musculoskeletal issues. 
Dr. Sam Jejurikar: [00:09:52] So about three years ago, I had profound shoulder pain. Saw an orthopedic surgeon. Who's a spine, who's a shoulder specialist and basically was told I needed rotator cuff surgery right on the border, but they gave me the option of doing physical therapy doing some steroid injections and physical therapy.
So I got to talking to the physical therapist quite a bit and really gained an appreciation for the importance of. Just like you said, Dr. Rhee flexibility and mobility exercises after surgery before and after surgery to try to balance ourselves because when you do. Sal was saying, if you spend time just on one side of the body and you're contracting your body, you're putting asymmetrical load on your body.
And so stretching yoga huge benefits to preventing injury. Long-term then other tricks that in the operating room, which sometimes we just tend to short change because, during residency it was always about speeds, needs speed, but yeah. Adjusting the operating table. When you're sitting down relative to standing, when you're operating, it relieves a huge strain on your body and you can do them substantially more comfortable at raising a table upwards.
So you're not putting so much strain on your shoulder going to the left and the right side of the body when doing liposuction or breast surgery. So that you're. So loading your body equivalently on both sides can make, it can make a huge improvement. And three years later after really making a concerted effort to change these things in my own practice, I feel substantially better than I did at that point in my life.
And I never had to have surgery 
Dr. Salvatore Pacella: [00:11:15] now, Sam from Dallas you are you right-handed or left-handed I'm right-handed okay. And which shoulder was bothersome your left shoulder? 
Dr. Sam Jejurikar: [00:11:25] No, my right shoulder was predominantly from West assumption. 
Dr. Salvatore Pacella: [00:11:28] Oh, okay. Got it. So one, one just interesting modification here that I learned from my therapist was, I was explaining it to him, the aches and pains that I have at times.
And so sometimes I get some shoulder pain too. So I was explaining, how we're holding a retract or doing your breast augmentation, something so simple as this. Okay. The rotator cuff is not designed to go beyond 90 degrees this way. Okay. And so any sort of stretching or strengthen the exercises for the rotator cuff, the orthopods will tell you don't go beyond 90 degrees.
Okay. So if you're stretching, do this right, don't go beyond. And so that's exactly what we do when we're doing a retractor for a breast surgery. We're doing this right. And that's just devastating to the shoulder joint. And I hear you guys with raising the table. It's amazing to me.
I that they don't teach this in surgical residency in a, how to. Respect your body. I'm very relatively frequently operating with other surgical teams, orthopedics, ENT ophthalmology, general surgeons, and nine times out of 10, these guys are operating. These guys and ladies are operating with the operating room table at waist high.
And so you're just doing this right. And so I get my table up as high as I can go comfortably. It just totally helps my neck and back. 
Dr. Sam Rhee: [00:12:43] The funny thing is, as a surgeons, we can't help, but be. Asymmetric. So when I was having a couple of years ago, the, these issues especially with my low back low back issues and shoulder issues I saw a friend of mine.
Who's a chiropractor and he checked my mobility and the mobility from one shoulder to the other. Is like night and day. And the reason being is just like Sam does, I do, I can't lipo with my left hand. That would be literally impossible. My left hand is my guiding hand for my surgery. I do everything with my right, because he said, you know what you need to do.
You need to start using both hands, brush your teeth with your left hand, do other things with your left hand. And I was like, Okay. But the biggest part of my life, which is operating, I only do with my right hand. I'm not cutting or dissecting with my left hand. I'm only using my right. My left is my South said my power hand, my Rhee retract hand my guide hand.
But other than that, it's really all. On my right upper extremity. And he's can't you do anything to try to balance out what you do? I was like, no, not now. It's a little bit too late to learn how to become a ambidextrous surgeon. I'm sorry, that's just not going to happen at this point. So Sam, you 
Dr. Salvatore Pacella: [00:13:58] said.
Dr. Sam Jejurikar: [00:14:01] I was, I actually learned at that point to start doing liposuction with my left upper extremity. It was actually something during my fellowship. One of my mentors was Jerry Pittman, who I believe is now retired, but really Busy liposuction surgeon in New York city and made the point to prevent, wear and tear on your body to learn, to do liposuction with your left hand, in addition to your right hand.
And that was a big emphasis of what he taught us during our fellowship in Manhattan nine year. And I'm incredibly grateful for that because I probably do 30 to 40% of all of my liposuction and again, a given case with my left hand and I can switch. And I think it's an important thing to be able to do Sam, because it really will protect your right 
Dr. Salvatore Pacella: [00:14:39] shoulder.
Dr. Sam Rhee: [00:14:40] Yeah right 
Dr. Salvatore Pacella: [00:14:42] now Jersey, Sam, you you mentioned you see a chiropractor. Do you S do you see that person regularly? Or what or is it just as needed? 
Dr. Sam Rhee: [00:14:50] It was as needed. I hate seeing doctors in general. I hate seeing people like any kind of getting any kind of medical care. So it was only when I was truly desperate that I sought assistance.
And it was probably also, I was burning the candle at both ends. It was when I just, when I just started CrossFit and you know what the first rule about CrossFit is sell CrossFit, always talk about cross. 
Dr. Salvatore Pacella: [00:15:09] Dr. Jay from Dallas, do you see any other accessory professional, routinely, or how do you deal with some of these body aches and pains routinely?
So I have 
Dr. Sam Jejurikar: [00:15:21] a, I have an elaborate massage chair, which I use three or four times a week. I use NormaTec compression boots for my lower extremities which are, so I use a lot of ancillary massage devices most nights to get me limber for the next morning. And then my workout routine has changed to one that has very little weightlifting involved, but one that's more.
Aerobic and more stretching and mobility. So that I'm limber when I'm doing surgery. I, I used to emphasize weight training substantially more than I do right now, but I try to avoid putting any additional load on my joints. 
Dr. Salvatore Pacella: [00:15:56] Yeah. It's interesting that both of you guys work out before surgery in the morning.
And I used to do that. I was an early riser 5:00 AM. I'd go to the gym ahead of time and I felt. Pretty refreshed, but those are the cases towards the end of the day. I found myself getting very burned out and, not having a lot of longevity the past six o'clock and I'm sorry, I changed my regimen now.
So now I'm concentrating a little bit more on getting a little bit extra sleep. We're still at work, by seven, but the act of working out at the end of the day, I think. Is almost like my little therapy. It hits those muscles where they're stiff. I do some flexibility, stretch the bands get a little cardio in and it's definitely helpful.
The one, the SIG for me, the single most important thing. That I do is I have a great relationship with a a chiropractor, but it's not a chiropractor who does, who cracks. Okay. It's Jen, who does art or active release therapy. It's essentially a deep tissue massage and I routinely do this.
Every week, as much as I can. I have a standing appointment at 7:00 AM on Thursday mornings. That's my office day. I go in there. Whatever's hurting that, that week. He just works right through and it's usually neck back. And most recently it's, the thumbs. We the theater eminence of the thumbs, we're always holding devices and holding retractors and those just get exceptionally school sore.
And, I just feel like a million bucks after I come out of there. Now let me ask you guys a question too. Any any medications that help with you guys, you take any Motrin, ibuprofen, Arthrotec any sort of. Anti-spasmodic medication, anything helpful for you? 
Dr. Sam Rhee: [00:17:41] The first thing I want to say is I have done art and I think it's really helpful.
I've had it a couple of times when I was in acute inflammed like inflamed situations again, mostly from working out, but. It hurts. It's, they scrape the crap out of your, out of the fascia, it really helps. I'm I am I do like it. I think it's really nice. I also a to comment on Sam I've I use, I have normal texts too.
I have the knockoff brand, but I love the squeezy boots. I think anything that sort of helps with blood flow and mobilizing is really good. I don't I find my workout routine to be more about recovery. I don't go as hard every day as I used to. I think it's really important as Sam said, to be less impact on your joints.
I think my body physiologically because I. I do see a lot of former athletes in the gym and they are beat up just like Sal is from previous surgeries and injuries. And I'm pretty, I never beat the crap out of myself in high school. So I guess I'm lucky that way, that I don't have any residual issues to deal with so much, but it is about him joint impact, which is really important.
From a medication standpoint the only, I don't, I've really tried to avoid taking ibuprofen. It makes me feel like a million dollars when I do take it. And it's scary to me that it takes a lot of my little aches and pains away. So I actually tried not to take it about the only thing I take regularly is Melatonin at night because I really want my, six to seven hours.
If I can possibly get it, it makes me feel so much different than if I only get five to six. I have trouble sometimes going to bed right away. My mind is always like running all over the place. So I'll take the melatonin in about 20 minutes beforehand. And it helps me a lot, but that's pretty much it.
Dr. Sam Jejurikar: [00:19:29] Yeah, I don't take any anti-inflammatories on a regular basis. Cause I don't, I'm not really in that much pain anymore. Mountain, not like it used to be. I take a variety of over the counter supplements and vitamins and Take 15 or 20 pills every morning that are all over the counter supplements and for hair growth to take nutraphyl for my hair.
But but I don't I don't take anything to help me sleep. I have no problem sleeping and I don't really take an anti-inflammatories either. 
Dr. Salvatore Pacella: [00:19:55] Yeah. I hear you on the Motrin. Sam I only, I might take it at most once a week and sometimes, just. In a way, sometimes just the way I was laying in bed, I may wake up with a one-sided headache or neck crank or something like that.
And it's just to get through the day. But try to minimize that. One of the things that I think has helped quite a bit which I got on to about four or five months ago is  sulfate. I take an magnesium. So I take a contrarian twice a day, once in the morning, once at night. And it, the human studies are pretty nebulous, but there's actually believe it or not a huge population of studies in the vet in veterinary medicine.
And I actually think it has helped quite a bit with some joint pain and knee pain. The other thing with magnesium at night we, I think. It just helps replenish the muscles. It relaxes the muscles a little bit. I even get a little bit sleepy when I take it. Which is kinda nice.
I think just understanding what you need and what we're seeing not everything is gonna work for everybody else. 
Dr. Sam Rhee: [00:20:55] I'm like Sam, I take a lot of supplements too. I take magnesium too, which I think really helps me a lot. I used to get awful cramps and I think that was one of the things that was very helpful for me.
Dr. Salvatore Pacella: [00:21:06] Yeah. Great. Go ahead. As even though you, your bodies are falling apart, you still look fantastic. I got to say, it's all that Botox and all that skin work you guys have been doing. I love it. Love it. I think we've talked a bit about how to keep our bodies going.
And I do hope that both of you operate well into your nineties and die with a scalpel in your hand. Okay. 
Dr. Sam Rhee: [00:21:25] My last patient really won't appreciate that, but, okay. 
Dr. Sam Jejurikar: [00:21:28] Thanks. Yeah, hopefully for the end of the case, but yeah. So yeah, so a sweet sentiment. 
Dr. Salvatore Pacella: [00:21:35] Alright. I'll sign off guys till next week.
Thanks 
Dr. Sam Jejurikar: [00:21:39] care. 
Dr. Salvatore Pacella: [00:21:40] Bye.