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Speaker 1 (00:00:10):
Good evening everyone. It’s Dr. Towfigh Welcome to Hernia Talk Live. I am your host, Dr. Shirin Towfigh hernia and laparoscopic surgery specialist coming to you live from the Beverly Hills Hernia Center. Thanks to everyone who’s joining us via Facebook Live and also via our zoom link that’s live. And then as you know, this and all pre prior episodes will be on YouTube, on my YouTube channel at Hernia Doc. And so excited. We have close to a thousand downloads already on my podcast. So Hernia, Talk Live is now a podcast. So if you like the podcast scenario, then I highly recommend you go to wherever you list a podcasts, and that is where you’re going to find our podcast and you can just drive or do whatever. Okay, so I just mentioned that I’m coming to you live from the Hills Hernia Center because guess who else is also live from the hernia? Beverly Hills Hernia Center. And that is my nurse. Your favorite hernia nurse, Isabel Kati. We call her Bell or Nurse Bell. She is an R-N-B-S-N, highly skilled, probably the most skilled hernia nurse in the world. She works with me and you can follow her on Twitter at the Hernia nurse, which is such a cool little tag. So Belle, welcome. Hello.
Speaker 2 (00:01:39):
Hello everyone. Thank you for having me. I’m not sure I’m too comfortable, very nervous, but let’s do it.
Speaker 1 (00:01:47):
So yeah, so maybe some of you remember a while ago I was talking about our team, whatever, and then I mentioned the comment, maybe some of you would like to hear directly from Nurse Bell and those of you who called the office or reached out to us had questions. Most of you have probably spoken to Nurse Bell and know her. She’s kind of our famous person in the office. She deals with everything that’s related to our patients and direct patient care. And if you’ve had surgery, you’ve seen her as well. That’s how amazing she’s Yes. So Belle was a little nervous. I dunno why to come online.
Speaker 2 (00:02:28):
I’m not so used to this, but whenever I have my nurses hat on, that changes, confidence changes. I’m a different person, but on the spotlight like this, yeah,
Speaker 1 (00:02:40):
Has been my nurse. She’s been our patient’s nurses. She’s been the nurses to all of our doctor friends. I mean, she’s been my mom’s nurse. I mean, she is the best at what she does. And hernia, she loves hernias as much as we do, right? Be,
Speaker 2 (00:02:54):
Yes, we do. I have just a little background. I’ve been a nurse for maybe 27 years and half of that I’ve been your nurse for 14 years We’ve been together.
Speaker 1 (00:03:08):
My heart. Yeah,
Speaker 2 (00:03:11):
Half of my practice. That’s
Speaker 1 (00:03:12):
Really cool. And did you ever think that you’d be a nurse that specializes in hernias? Did you ever think of it?
Speaker 2 (00:03:22):
No. Growing up, I never wanted to be a nurse, to be honest with you. Whenever I go to the hospital when I was younger, my knees would shake. I was so scared of the hospital. But then as we get exposed, my parents are like, oh, you need to be a nurse. It’s a good job and all that. And then when I started practicing nursing, I was like, oh, this is not bad when taking care of the patients, seeing the patients get better and all that. And then when we started our practice, when I moved to our clinic back there at Cedars, that’s where I was more engaged and I enjoyed talking to patients. And ever since then, the rest is history. I’ve been enjoying what I’ve been doing with hernia patients. Yeah,
Speaker 1 (00:04:17):
Bell worked at Cedar-Sinai on the wards neurology ward, the general surgery ward where all the complex patients are, where all the VIP patients are housed at the hospital. And I met her within a year I think, of me starting at Cedar-Sinai. She joined our office practice.
Speaker 2 (00:04:39):
We were paired together when I moved to the,
Speaker 1 (00:04:41):
We were paired together. Do you know why?
Speaker 2 (00:04:46):
I was the newest one. I was the newest one. And then everyone was already, that was a bariatric clinic and every once I was certified as bariatric nurses there, I was the only new one. It’s like, oh, you need to work with this doctor right here. She does hernias. And she’s like, yeah, okay.
Speaker 1 (00:05:05):
Do you think that was weird that I only did hernias?
Speaker 2 (00:05:10):
My thought then was like, oh, it’s just a hernia. It’s so complicated. And then when I started learning hernias, it’s like, oh, it’s not just a hernia. This is very interesting, our tagline, it’s not just a hernia. It is true. It’s not just a Hernia. Yeah, and I love it. It’s true.
Speaker 1 (00:05:28):
So Bell is the first kind of introduction of our patients to our hernia care. Many of you who want, let’s say an online consult or want initiated consultation and don’t really know how to do that, you speak with Bell and Bell’s, the one that makes sure that your CAT scans, your MRIs, ultrasounds, all your opera reports, et cetera, are all collated and ready. So that when we see each other for a consultation, it’s very kind of efficient process.
Speaker 1 (00:06:00):
And importantly, she is the one that sees you first when you come to the office after you’re checked in by Sheila in the front, she does the full intake and gets the whole story. So as a result, bell is like she already, and I’ll bet you this is true, be I think when you’re in there and the patient’s giving you their story, you already know what’s wrong and you can already predict what’s wrong. She comes to me and she’s like, oh, this is what’s going on, or that’s what’s going on. And she’s almost always right.
Speaker 2 (00:06:31):
Almost always. Yeah. Almost always. I would already know, oh, okay, you do have a hernia
Speaker 1 (00:06:38):
Or it’s a plug problem, or it’s a diastasis, or whatever.
Speaker 2 (00:06:42):
Complications. Yeah.
Speaker 1 (00:06:43):
Yeah, which is great. What I felt my issue was, so much of medical care has become filling out forms and checking up boxes that nurses are doing administrative stuff and a lot of their direct patient care is diluted by all this taken away, right?
Speaker 2 (00:07:09):
Yeah, yeah. You lose focus. It’s very generalized, it’s very generic. All those paperworks, unlike what we do, it’s very specific to what we wanted to know from the patients that we see. So then even the patients, when we get the feedback from the patients, patients would say, oh, this is very specific. This is a very good form. You’re already right on targets.
Speaker 1 (00:07:34):
Yeah. We have what’s called the hernia health questionnaire, and pretty soon we’re going to publish a complete validation of the questionnaire and hopefully we can use that and disseminate that around the world so that other doctors also use our hernia health questionnaire. I think it’s well done. It’s highly validated now. It’s a great predictive value.
Speaker 2 (00:07:56):
Yeah, I agree.
Speaker 1 (00:07:58):
So the reason why I wanted to have you on is because a lot of the things that we talk about is obviously patient related and I try to make hernia talk and the whole purpose of hernia talk has been to focus on the patient and their needs, and nursing has really been a specialty that focus on the patient. You’re typically the patient advocate. I mean, doctors are too, but really you are often as a nurse, taught to always see everything from the patient’s point of view and protect the patient. That’s
Speaker 2 (00:08:34):
Nursing.
Speaker 1 (00:08:37):
So then your name came up and I’m like, maybe we should interview Nurse Bell and give you some insights. So there’s some questions that have already been sent in. I think we’ll go through some of those. And then for those of you that want to ask questions live, I’m happy to do those too. But let’s go through some questions, shall we?
Speaker 2 (00:08:57):
Okay.
Speaker 1 (00:08:59):
Okay. Why is nursing important after hernia surgery and does it end as soon as the patient leaves the surgery center?
Speaker 2 (00:09:09):
I feel like nursing doesn’t stop as soon as the surgeries end or as soon as should discharge the patient. It’s a continuous process. Whenever you have a surgery, there’s that anxiety that you feel on the fear of the unknown. What do you expect? What do you need to do after surgery? Most of the time those patients doesn’t get all those information. And from the nursing standpoint, you need to give a realistic expectation as to what the patients would expect after surgery. And I do follow up with our patients. I call them the next day and the next few days, actually, the first two weeks after surgery, I keep a close contact with our patients and follow up and make sure that they’re recovering well from their procedure. They have my personal phone number, they text me, they call me anytime day or night, whenever they have questions. And I make sure that the patients are aware that I’m available to them whenever they need it and wherever they have questions or there’s any problem after post-up that’s unexpected. So yeah, I’m always available. They
Speaker 1 (00:10:23):
Send you pictures and they want my wound or my bruising or the drain or whatever.
Speaker 2 (00:10:29):
Everything from the pictures, you won’t believe what pictures I get or what text messages I get middle of the night. But yeah, I like it. It’s heartwarming to know that the patient’s recovery are easier whenever you’re following up with them and that they know that someone’s there for them to guide them through the whole process of their recovery.
Speaker 1 (00:10:59):
How much of the anxiety, either before surgery or after surgery colors, how the patient feels after surgery?
Speaker 2 (00:11:09):
It starts even before surgery. So when I see them here in the clinic the first time, and then when they see me at the surgery center, let’s say we’re going to do surgery, as soon as they see me at the surgery center, they relax the anxiety, I’m guessing, kind of ease them up a little bit. They’re comfortable, they know familiar person that they know the anxiety for sure des bits as they see me, and then we follow up with them right after that too. Sometimes I would even go to patient’s homes to kind of take care of them, their needs. I’ve done that. Do house calls to,
Speaker 1 (00:11:56):
I would say just for everyone who’s listening, this is not normal.
Speaker 2 (00:12:02):
This is not normal. This is not, yeah. Yeah.
Speaker 1 (00:12:05):
Well, what you do is definitely different than what most nurses do or expect it to do, but that’s why we’re special and that’s why we, it’s because we love what we do.
Speaker 1 (00:12:17):
But Nurse Bell actually did extra training so that she’s not only a specialist in hernias and is very skilled and gifted to answer all your questions and do the intake and so on. But she joins me in the operating room. So that’s what she was saying was that in addition to clinical care, she also has a specialty in the operating room where she’s there, sees you before surgery, is there with you during surgery as a circulator for the operating room, and often even takes care of you while you’re recovering, which I felt the nurse, like you said, the patients really feel like they see a familiar face, and so they’re not just another patient in a big busy surgery center. So that really seems to help the plus all my protocols, so I don’t have to start over with a new team. I have the same team.
Speaker 2 (00:13:16):
Correct. Yeah. Yeah.
Speaker 1 (00:13:19):
And then we have out of town patients, or we have patients that have needs at their house, and it’s not common, but if there is the need for care to come to your house, we’ve done that and now we have a cute bag to have our home house call bag. I kind of like it. Nice stuff. Job. You guys did a nice job designing that. That was kind of cute. Okay, next question. What are the symptoms that worry you the most in the immediate postoperative period? Because they can be the sign of serious complications. That’s a good question.
Speaker 2 (00:14:04):
Good question. So the number one worry for us would be those patients who’s coughing, who’s vomiting, and all those. That is a major red flag for us. We don’t want our patients bucking and getting all abdominal pressures with the vomiting because with hernia, we know any abdominal pressure kind of hurt the Hernia repair or might hurt the hernia repair. So that’s why we really want to watch out for all those symptoms after surgery. And of course, pain is expected. I tried to explain to our patients that this is the type of pain that you’re going to be expecting. This is what you’re going to be doing. What
Speaker 1 (00:14:47):
Do you tell them exactly? Let’s say they have a groin hernia, what do you tell them they should expect
Speaker 2 (00:14:53):
After surgery? Okay, so let’s say a patient had a groin hernia repair. I would tell them that an open or laparoscopic, you’ll be sort the incision site ICE will be your best friend for the next couple of days. And then we have this regimen, the regimen, the pain regimen that we give our patients works pretty well for them. So I try to explain that to them before surgery and after surgery. And I always tell them that the first couple of days will be, you’ll expectedly be sore from the incision sites. Mostly there might be a little swelling here and there, which is normal, the bruising and all that. So I just try to make it as a real expectation or the realistic expectation so that the patients won’t be so that they would know what they would feel or what they would watch out for. Of course, those fevers and infections vary.
Speaker 1 (00:15:52):
When I was a resident, the patients almost never got really instructions. They just got very generic instructions, like any drainage from your wound or any fevers called this number that was very generic. And so a lot of patients back then, we did a lot of open surgeries and they all got bruising and swelling of their scrotum and sometimes, so that one is expected. The patients were never told that, by the way, and they all freaked out and they all had to call, go to the emergency rooms because of that. And it’s just so simple just to be realistic and tell the patients what to expect.
Speaker 2 (00:16:30):
Correct. Yeah. Yeah. It helps a lot with the recovery too. What to expect.
Speaker 1 (00:16:35):
What do you tell them for larger hernias of the abdominal wall?
Speaker 2 (00:16:39):
Oh, usually they go home with a binder. I tell them the binder has to be on 24 7. They’re showering what to expect with the swelling, the tightness and all that icing, especially I
Speaker 1 (00:16:59):
Tend ice. Right? And then you make sure that they’re not constipated,
Speaker 2 (00:17:06):
They’re not constipated, that they’re not straining, they’re not coughing. I even teach them how to do it. Brace yourself, brace your abdomen when you try to cough or sneeze.
Speaker 1 (00:17:15):
Yeah. Here’s a question which we get a lot, which is do you have any specific recommendations for a patient coming from out of town alone without a companion? That’s a problem that we have to deal with.
Speaker 2 (00:17:30):
Yeah, it is. As much as possible, we would like our patients to have someone with them the first couple of days because it’s going to be difficult the first couple of days. Although we say we don’t give you any restrictions with your activities, you can go back to your normal activity, but of it’s always difficult the first few days after surgery.
Speaker 1 (00:17:54):
But what do you recommend if they have no one? Sometimes there are patients that have to travel, but they have no one
Speaker 2 (00:18:00):
If they don’t have no one. We have ourselves to take care of patients. I’ve done, we’ve had patients from out of the country actually, that I have to take back to the hotel and follow up with the patients.
Speaker 1 (00:18:19):
Well, the issue is all surgery centers and hospitals have a policy. You can’t just
Speaker 2 (00:18:28):
Discharge a patient. Yeah,
Speaker 1 (00:18:30):
You can’t drive home for sure. And you can’t take an Uber. You have to have a medical person,
Speaker 2 (00:18:36):
A body. Yeah,
Speaker 1 (00:18:38):
A person. Yeah, a person physically take you inside the house, make sure you’re safe there and everything that you need and then leave. So that’s the minimum that is required. So you can’t Uber after any operation. So sometimes that person is Nurse Bell?
Speaker 2 (00:18:59):
Yes. Quite a few times actually. I’ve done that. Yeah.
Speaker 1 (00:19:03):
But we don’t encourage it. We don’t encourage it
Speaker 2 (00:19:07):
Because every time they tell me, I don’t have anybody. I don’t always volunteer myself
Speaker 1 (00:19:14):
Unless we try not to, but we do whatever is best for our patients. Okay. Here’s another question. a lot of live questions coming in. A patient having a laparoscopic angle or hernia repair, how do you distinguish expected level of pain from more severe pain? That may be a red flag requiring emergency evaluation for complication, possibly requiring a re-operation. What’s normal? What’s like, oh my God, you got to go to the emergency room.
Speaker 2 (00:19:43):
So for the most part, what we tell them, the combinational pain, but if their pain is worse than their pre-op pain, that’s probably something that we need to look out for. And the quality of pain. What kind of pain do you have now? How’s this different from your pain before surgery and where the pain is exactly at?
Speaker 1 (00:20:07):
Yeah, so Nurse Bell is really good at kicking up any problems to me if necessary. So the initial call after surgery, so I obviously talk to the patient after surgery and I speak to whoever the person is that they would like me to speak with as well, because sometimes when I tell the patient they don’t remember, so I talk to someone else who hasn’t had anesthesia, but then usually Nurse Bell calls ’em that night or the next day to double check on them. But throughout the process, whatever the situation is, if she feels that the symptoms are a little bit concerning, maybe better that I get involved, then I’ll kick in and call the patient, see the patient. We see patients on the weekends if necessary. That stuff doesn’t matter so much. It’s really matters for us to get the right care of the patient. Oh, here’s another question. Is there a visiting nurse service you recommend that maybe provide companion services if Nurse Bell is not available?
Speaker 2 (00:21:17):
I don’t have any. Yeah. There are a lot of services that offer that. Visiting nurses in companion. Yeah. But we don’t specifically have partnership with a new one.
Speaker 1 (00:21:29):
Yeah. The plastic surgeons around town use a lot of them. And because of where we are, we’re in the highest concentration of plastic surgeons in the world, and therefore, there’s a lot of facilities around us that provide
Speaker 2 (00:21:45):
Nursing for our nursing care.
Speaker 1 (00:21:48):
You just have to pay for it. Yeah. Yeah. Here’s another comment. This is not, oh, here. For patients who have open inal mesh removal, what would be the expected recovery period? And what advice do you provide to those patients? Good question. We do a lot of open mesh removals. What’s your advice to patients who have had open inguinal Mesh removals and what should they expect in their recovery period?
Speaker 2 (00:22:19):
Okay, so for those more complex repairs like mesh removals, I tell them that you’ll be, you’ll expect to be a little bit more uncomfortable, or the recovery will be a little bit longer than the usual first time inguinal or nerve repair, or the first time repair versus the complex repairs. So then I try to tell them to manage their pain, be on top of their pain, a better pain management instead of their pain. Don’t let it get
Speaker 1 (00:22:51):
Behind
Speaker 2 (00:22:52):
Before
Speaker 1 (00:22:52):
You take it.
Speaker 2 (00:22:53):
So I advised them to start taking a pain medication. I usually tell the patients, regardless of how you feel, you have to take your pain medications. The first two days, especially the first, the most critical or the most uncomfortable post-op postoperative phase would be the first two days. So then they can just tap their off as they go.
Speaker 1 (00:23:16):
Just because you’re having revision surgery doesn’t mean it’s going to be worse than your first surgery. So many patients, right though?
Speaker 2 (00:23:25):
Yes. Yes. What do they say? They expect worse, and then after that, when I check on them the next day or two, it’s like, oh, well, this is night and day. This is nothing that I’ve expected. This is actually a better recovery than the previous surgery. Most of the patients would say that.
Speaker 1 (00:23:42):
Yeah, which is telling. Okay, here’s another live question. This may be not much related to today’s webinar, but if there’s time, oh, here’s a question for me. Sorry, bell. You get to rest for a little.
Speaker 2 (00:23:55):
Okay, good.
Speaker 1 (00:23:57):
No, I had 14 weeks ago. Right? Angle Hernia repair robotics, so robotic right angle, Hernia repair with mesh. And since then I’m experiencing right testicle and groin pain 14 weeks ago, scrotal ultrasound shows no issues. And the physical examination does not show recurrent hernia. What will you recommend as the next diagnostic step? Okay, so here’s the situation. It’s robotic inguinal hernia repair with mesh. The size actually matters because usually the larger the hernia, the more inflammation is a part of reducing the sac and doing the operation, the higher the risk of mesh related inflammation and pain. So if you have right testicle and groin pain, then the question is, number one, is the mesh in good position? So is it folded or not? You need imaging for that, and MRI is the best imaging. Number two, is there an early recurrence? Unlikely usually, but also an MRI with Valsalva, which is the hernia protocol that we use, which you can find on our website, will help.
Speaker 1 (00:24:59):
And then number three, I always ask the patient, how bruised did you get after surgery? If you had a typical Hernia repair and you’re super bruised after surgery and it wasn’t like a huge hernia, then it’s possible you had a very traumatic Hernia repair and that causes a lot of inflammation, and then you put mesh on it, which is also inflammation. And then these chromatic cord and the mesh combined together and cause testicular pain. However, 14 weeks is usually too early to intervene in most cases, unless the mesh is completely balled up and there’s very little nerves that can be injured with a robotic repair. So usually massaging the area seems to work really well to try and reduce fluid, reduce inflammation, and see how you do. That’s my trick. What do you think about massaging be?
Speaker 2 (00:25:53):
Yeah, it’s very helpful in those areas. After surgery, it can be tender, but for the most part, the patients, when they start to, well, patients are scared of touching the Hernia, the incisions initially, but then I just reassure them that it’ll make it better, massage it for better reabsorption and all that, and once they start doing it, they feel more comfortable doing
Speaker 1 (00:26:26):
It. Yeah. Yeah, I think that’s a good idea. Okay. Next question. Well, which protocols do you follow for patient’s rehabilitation after surgery? Do they vary depending on the kind of hernia that was fixed? That’s another good question.
Speaker 2 (00:26:42):
Yes. Yes. That’s a good question. Yes. We do have protocols for every hernia procedure that we do. We have protocols for diastasis recti. We have protocols for inguinal hernias that we do follow. I think it’s in our website, those protocols that we have. Yeah.
Speaker 1 (00:27:00):
Yeah. We encourage you to follow as much of the protocol as possible because it’s based on our experience mostly. We want you up and about and active. We want you to not have constipation. We understand most hernia repairs are inflammatory in nature when they have pain. And so all forms of anti-inflammatories are encouraged and walking and being active and even stretching. You want to talk about what we do about stretching?
Speaker 2 (00:27:28):
Yeah. So the first thing I tell our patients after surgery’s like, be as active as you wish to be. She’s like, really? I can’t be, can’t be behave for six weeks. I said, no, no, no, no, no, you don’t. Yeah, no, don’t lay around. You’re going to be walking out of here today. You tell them, yeah, yeah. But the stretching and all that helps. I tell them, especially for open repairs or they feel tighter. I said, when you do stretch, it helps kind of, you sit up a little bit. It’s better for your pain when they’re,
Speaker 1 (00:28:00):
And it breaks the same way with massage. It breaks up scar.
Speaker 2 (00:28:03):
Yeah.
Speaker 1 (00:28:05):
What is the protocol you follow for or we follow for the wound dressings?
Speaker 2 (00:28:10):
For the wound dressings. So for the dressings, we just keep them for two days, take off the dressing, they can shower, and then the stair strip stays for about a week or two. They just fall off. Yeah.
Speaker 1 (00:28:23):
Oh, and then after three weeks, you can start putting three silicone, silicone
Speaker 2 (00:28:26):
Down. Silicone. Yeah.
Speaker 1 (00:28:28):
If you want
Speaker 2 (00:28:30):
Two weeks, I tell them to start massaging the incisions. So that ridge kind softens a bit.
Speaker 1 (00:28:37):
Yeah. Everyone gets a little ridge at their incision and they think it should be perfectly flat initially. And
Speaker 2 (00:28:44):
Yeah, they freak out when they feel that hard ridge over there. So that’s why I tell ’em initially, and it’s like, yeah, you’re going to have a hard ridge over there. That’s normal, just mass massage. Start massaging it, then get better. Yeah. It
Speaker 1 (00:28:55):
Goes only by about six weeks or three months, depending on the patient. Yeah, it even has a name. It’s called the healing ridge. I don’t make it up. This is true for all patients. Okay. Here’s another question. Let’s see what they say. Be, and Dr. Towfigh, for an out of towner having lap hernia repair, how long do you recommend the patient stay in Los Angeles to be sure there is no pain problem that needs to be addressed, invasively or acute or subacute mesh infection in need of treatment? That’s a good question. Okay, so maybe you can tell ’em what we tell out. Like a typical routine laparoscopic angle hernia repair, that’s the lowest recovery of all, the
Speaker 2 (00:29:37):
Lowest recovery out of town patients. When we see them, I said we typically see them a day before surgery. Let’s say they start online consultation or telehealth. So we see them for an actual in-person consultation one day, at least one day before surgery. We do the surgery and we ask that they stay for at least two days after surgery. They come back to the clinic, we check on them, make sure that they’re okay that the pre-op pain and their postoperative pain or what we expect them to have, then they can go back. We don’t give them restriction as to when they can fly back home. That’s the most common question we have is can we fly back home? Is it safe to fly home? Yeah. At least two days. We just want to see, make sure you’re okay after surgery.
Speaker 1 (00:30:26):
And what about if it’s a big revision operation, Mesh removal reconstruction
Speaker 2 (00:30:31):
For laparoscopic Mesh removal reconstruction? Same. We don’t give any restriction except for those big, the open ventral harness. We ask that they stay for about at least a week.
Speaker 1 (00:30:44):
Yeah. Yeah. The more complicated the repair, the longer we like you to be during that important time where, like you mentioned, we worried about infection,
Speaker 2 (00:30:55):
Possibly complications
Speaker 1 (00:30:57):
And other complications like hematoma bleeding or if your pain is out of control,
Speaker 2 (00:31:03):
Especially if you have drains. Yeah. We want you to stay longer if you Yeah.
Speaker 1 (00:31:07):
Yeah. So the routine ones where we expect very little complications like open umbilical Hernia repair or a laparoscopic inguinal hernia repair those patients within a day, you can fly back to your hometown if you wish. We’re always happy to, if you stay longer, I always like to see you the day you leave or the one day before you leave, so I get one extra little look at you before you leave town. More questions, however, what is the optimal time to save for lab repair to make sure no complications? I think two days is fine. Yeah.
Speaker 1 (00:31:48):
Yeah. As a patient, oh, here’s a former patient. As a patient that travels across the country, my advice is not to travel too soon. No need to push yourself and take a chance of damaging your repair that you have put so much time and energy into getting repaired from a specialty surgeon out of town. That is true. That is true. It can get costly. In Los Angeles, we do have a very wide range of places where you can stay that’s super expensive and the somewhat inexpensive and so on. So you can do Airbnbs or just stay in a hotel. What do you think Bell? Do we usually give a list of places or suggestions or,
Speaker 2 (00:32:37):
Yeah, so part of consultation process is we give them a list of hotels around the area, so they have options on where they could go. Sheila formulated that hotel list and she had dollar signs by send the names. Oh, she did? Yeah. We do have that, and then we make suggestions on where they can stay around the area and services that’s available.
Speaker 1 (00:33:03):
Yeah. I think Sheila actually negotiated some rates for some of our patients early on because
Speaker 2 (00:33:08):
They did before. Yeah, because I don’t think they offered that anymore. Yeah, I don’t think they offered that anymore. After the pandemic, they stopped doing it.
Speaker 1 (00:33:18):
Yeah. COVID messed up everything, but you can get medical rates at a lot of hotels that are around the hospitals. Yeah. So that’s usually helpful. And some hotels also offer shuttle service. Some hotels offer shuttle service. You don’t have to drive, but LA is a very driver.
Speaker 2 (00:33:41):
You need drive. You
Speaker 1 (00:33:44):
Can’t not have a car. Here’s another comment. There’s some awesome Airbnbs close enough to walk to Cedars. That’s true to the hospital and around us. a lot of cool Airbnbs. That’s very true. Okay, let’s do the next question. a lot of questions were submitted. I’m kind of excited about these. Let’s see. Can you share a few examples where good nursing follow-up made a huge difference for the patient? There’s a lot of examples.
Speaker 2 (00:34:17):
Let’s see. There’s a lot of them.
Speaker 1 (00:34:22):
I mean, there have been a handful of situations I’ll share with,
Speaker 2 (00:34:26):
Okay,
Speaker 1 (00:34:27):
There was one patient, this was a great story. Do you remember this? So I think the family, we saw the patient, he looked just fine after surgery. We’re like, great, you can go home. He lived a bit far away, and then he called, I think the next day. We literally saw him the day before. We gave him the green light to leave. He called the next day and he’s like, the wife was like, he’s just not looking right, and he’s got a fever. I’m like, how is that possible? Everything looked perfect. So they called you and you’re like, just come in. Even we don’t do the, oh, just come in, kick him straight to the office. He looked horrible. Horrible. I’m thinking, he looks perfect. Why is he so sick? So I think we called ambulance, right? We sent him at the hospital. He was in the intensive care unit, it turned out.
Speaker 2 (00:35:21):
Oh, that’s right. Yeah.
Speaker 1 (00:35:22):
It turned out he had a West Nile virus, totally unrelated to his hernia repair, but he had a West Nile virus, and he remembered he was at a picnic the weekend before his surgery, and he had some mosquito bites at the picnic or whatever. I think mosquito bites at the picnic, and he didn’t really think much of it. And that’s when the West Nlo virus had kind of peaked in the area, and the doctor at the hospital figured it out because he got better after a certain thing, and they sent out a bunch of labs and the west nile virus came back. But you just don’t know. Sometimes you can have completely unrelated diseases around the time of your Hernia repair. Yeah,
Speaker 2 (00:36:11):
Yeah,
Speaker 1 (00:36:12):
Yeah. That was kind of, I was like, oh my God, what’s going on? All I did was that was a simple angle, Hernia repair, by the way. I think it was maybe a recurrent or something.
Speaker 2 (00:36:20):
It’s lap al. It was lap al.
Speaker 1 (00:36:24):
It was open.
Speaker 2 (00:36:26):
Was it open?
Speaker 1 (00:36:27):
Was it lap? Maybe it was lap lab or open, and there was Mesh in there. I was like, it, oh, maybe it’s the mesh. I’m like, guys, it’s not the mesh. He’s too sick. This is not the mesh. Yeah. That was kind a crazy story. And
Speaker 2 (00:36:42):
Then for those patients who knows, the fact that they know that we’re available anytime kind of eases them up with their recovery. Sometimes I would FaceTime with patients. It’s like, okay, let me see you. Let’s FaceTime and see what’s going on. Especially for our patients who are out of towners, that’s what I do. So then as soon as they see your face, like, oh, okay, we’re good. I feel better. Thank you for explaining everything. So even before they go on surgery, I try to explain to them everything so that by the time surgery comes, all their questions and concerns are already answered. And this is true. They already know what they expect.
Speaker 1 (00:37:25):
Yeah. I very diligently ask the patient, so do you have any questions for me? Like, no. Nurse mill answered all of them. I’m like,
Speaker 2 (00:37:33):
Okay, 10 minutes ago. Yeah. Yeah,
Speaker 1 (00:37:37):
That’s so true. Here’s a comment from Australia. I had a specialist tell me he can only remove a Mesh implanted with an open repair, but I had laparoscopic Mesh implant, and the surgeon who did my removal actually removed it openly. Oh, my question is, should there be, or are there protocols or guidelines for surgeons suggesting laparoscopic metas to be removed laparoscopically and open me removed openly? Yes. I believe the European Hernia Society guidelines has made it an actual guideline that laparoscopically placed mesh should be removed laparoscopically, if there is a surgeon skilled enough to do that. Otherwise, the safest way would be to open if you don’t have a surgeon skilled enough to do it laparoscopically, because it is a very technically challenging operation. And if you don’t know your anatomy or you’re not skilled, you can cause harm. I believe that’s in the European Hernia Society guidelines. Most recent one. Oh, here’s a comment. Someone who clearly doesn’t live in Los Angeles says noise may be a problem. In Los Angeles, are there any hotels that are known to be quiet?
Speaker 2 (00:38:50):
That’s a challenge? No. Outside? No. Most of the hotels here are pretty good.
Speaker 1 (00:38:57):
Yeah, they are pretty good. It’s not like you’re living in downtown Los Angeles. You’re living in Beverly Hills or the neighborhoods around here. Very residential. The hotels are quiet.
Speaker 2 (00:39:11):
A lot of the hotels, I feel around our area here, because we have a lot of plastic surgery in hospital here, they tend to be more accommodating to patients.
Speaker 1 (00:39:22):
And they’re boutiquey. They’re not big hotels where there’s major conventions in them or lots of traffic around. We do have traffic, but the hotels don’t necessarily get traffic noise that’s different than let’s say, downtown Los Angeles or Midshore in those areas where it’s very busy and bustling. So the other question I had, nurse Bell is what do you think is the most satisfying part of what you do?
Speaker 2 (00:39:56):
Oh yeah. So whenever I see our patients for our post-op, and they feel better, especially the complex patients, we hear their stories. Sad stories. Yeah, sad stories. Sometimes it’s disheartening. Most of our patients will come in here and say, doctor told me it’s all your mind. You’re crazy. It’s not true. You know that. And then once we operate on them and you see them walking out of here with no pain, change their lives, they’re crying. It’s like, oh, I cannot complete it. Our purpose for what we’re doing.
Speaker 1 (00:40:34):
That’s true. The stories. I love the stories. And you use the stories too
Speaker 2 (00:40:39):
All the time. Yeah.
Speaker 1 (00:40:42):
You get a lot of letters. Bell gets a lot of thank you letters.
Speaker 2 (00:40:46):
Thank you. Letters, yeah,
Speaker 1 (00:40:47):
Texts. And maybe they’re going on vacation for the first time in a while. So they’ll text her pictures of them being on vacation. Yes.
Speaker 2 (00:40:55):
They send her pictures of their vacation. Yeah. Yeah.
Speaker 1 (00:40:58):
That’s really nice.
Speaker 2 (00:41:00):
And they keep in touch with me. Yeah. They text me every now and again just to say hi. Yeah,
Speaker 1 (00:41:05):
They have, everyone has your cell phone number.
Speaker 2 (00:41:08):
They do. Even family members do. Oh, even what I do is I give them updates while we’re in surgery comes the family so they know what to expect, where we’re at, especially if it’s longer procedure.
Speaker 1 (00:41:25):
Yeah. What do you text them? You just say, we started and
Speaker 2 (00:41:28):
We started stuff going on. Patient’s doing good. I don’t give them specific details. I just tell them, just reassure them that the patient’s doing well during surgery.
Speaker 1 (00:41:40):
Yeah. That’s something we’ve always done. It’s a new thing. The new hospital’s also doing, which is, although the hospital automated, did you know that
Speaker 2 (00:41:49):
Here we do it there. We do it here.
Speaker 1 (00:41:52):
No, we do it. So you physically text whoever is waiting for the patient. But at the hospital, it’s an automated system
Speaker 2 (00:42:02):
Too, at the surgery center.
Speaker 1 (00:42:04):
Oh, we have it here too. At the surgery center.
Speaker 2 (00:42:07):
Yeah.
Speaker 1 (00:42:08):
When do they get texts then?
Speaker 2 (00:42:11):
So when the patient checks in patient’s in surgery, the surgery is done and when the patient’s ready to be picked up.
Speaker 1 (00:42:21):
Oh, I didn’t know that. Is that something new? We started
Speaker 2 (00:42:25):
Very recently. I
Speaker 1 (00:42:26):
Didn’t know these things. Here’s a question. Where is the outpatient surgery center with respect to your office and also with respect to the hospital at Cedar-Sinai?
Speaker 2 (00:42:36):
Same building. That’s our office. Very convenient. I know. Very convenient. Two of them actually. Yeah. One is on the same floor
Speaker 1 (00:42:45):
And the hospital
Speaker 2 (00:42:48):
Is about two months away from our office. Cedar-Sinai, very close.
Speaker 1 (00:42:53):
And our two surgery centers are affiliates with Cedar-Sinai. It’s really nice. It’s very convenient. And it’s all in the same building as our office, so it’s kind of nice to come back to the same office. Some people just come to the office and say hi while they’re there for surgery. Yeah. Another patient texted Bell, always answers our texts and calls promptly and makes you feel truly cared for. It is truly appreciated. Thank you.
Speaker 2 (00:43:16):
You thank you.
Speaker 1 (00:43:17):
I know. So sweet. So Bell, what does your family think about the fact that you’re all into hernias?
Speaker 2 (00:43:26):
I don’t talk about much of the hernia. It’s just like, huh? It’s just a Hernia. They do that. It’s just a Hernia. How can it be so complicated? You don’t know the stories. You don’t know what I see. But yeah,
Speaker 1 (00:43:41):
I’ve cried. I’ve had patients where I’ve cried because their story was so horrible because as they’re telling me this story, I’m like, okay, I’m not going to predict what’s going to happen because of this poor decision making. And then they say it and then the patients starts crying because of their story. They have PTSD from their story. And then I get all emotional. And
Speaker 2 (00:44:06):
The fact that we listen to them makes a big difference. Remember we had a patient who almost crawl in here because of too much pain. And then just us listening to the story changes everything. It’s like you’re the first one who listened to our story. And most of the doctors are very dismissive. They just call us crazy.
Speaker 1 (00:44:28):
But it’s also all of the story.
Speaker 1 (00:44:31):
Today we had a patient who clearly has acid reflux, and he’s explaining to me how every time he eats, this is the story. It starts when he eats. He gets sharp pain behind his throat, and then this horrible muscle spasm behind his back, his scapula, and then it feels like his heart’s being squished. So I said, okay, so clearly that’s like acid reflux pain, right? So I said, so what medications are you on? And he told me two heart medications. And I’m saying what they treated heart. It’s acid reflux. Are you on any acid reflux
Speaker 2 (00:45:15):
Medication? They’re treating him for hypertension. Yeah. Yeah. They’re
Speaker 1 (00:45:18):
Treating him for amlodipine and metoprolol.
Speaker 2 (00:45:21):
Metoprolol.
Speaker 1 (00:45:23):
So weird. I’m like, you got to listen to your patient when they say my heart is crunching. Also hear the problem. Also hear the story of every time. It’s the back of my throat. The story is if you don’t listen to the stories, and a lot of times because of the way our medical system is, at least in the United States, there’s not even enough time to be devoted to the patient’s story. It’s all likely look at the CAT scan and they decide to do on something. Then you miss the nuances of what their actual symptom is, and then they get the wrong diagnosis and the wrong treatment or whatever the situation is.
Speaker 2 (00:46:05):
I guess that’s our advantage for being private practice. We can spend time with our patients and listen to their stories.
Speaker 1 (00:46:14):
That’s true. And you’ve experienced how it is when you’re not in private practice the same way I have.
Speaker 2 (00:46:19):
Yeah.
Speaker 1 (00:46:21):
It’s not the best, but it’s a standard.
Speaker 2 (00:46:26):
It’s standard. It’s a standard.
Speaker 1 (00:46:28):
Yeah. Here’s another question. I had large collection of blood in my scrotum following a complex open tissue, bilateral recurrent hernia repair. I now have severe chronic postoperative pain two years, once the large collection of blood predictive of bad outcome and pain. I don’t want to say predictive. I would say if I saw someone like you with chronic pain, and I said, how was your recovery the first week? And you said, oh, it was horrible. I had so much bruising and bleeding and swelling and I couldn’t walk for three weeks and so on. Then I would start questioning that repair and how that surgical procedure is influencing your current chronic pain. I personally don’t like to do bilateral open, recurrent hernia repairs. I think that’s too much surgery. It’s too much swelling and bruising. Patients are miserable. They can’t really heal either side adequately. And studies show that the hernia recurrence rate is higher if you do both sides open at the same time than if you do what’s called stage procedure where you stage the operation and do it maybe three weeks or more. Three
Speaker 2 (00:47:50):
Weeks apart. Yeah.
Speaker 1 (00:47:53):
And you see that those patients, right? Yeah. What are some advice you give people to reduce the risk of scrotal bleeding and swelling?
Speaker 2 (00:48:07):
I tend to tell them to always elevate it or wear the old fashioned brief instead of letting it loose. And paint. Support the support? Yeah.
Speaker 1 (00:48:20):
What kind of support?
Speaker 2 (00:48:21):
I tell them to that you might expect or you might see that it’s going to be bruise, it’s going to be swollen, whatever that happens, you elevate it. When you’re sitting, you wear the old fashioned weaves and have that support. Or sometimes we tell, depending on the procedure that they do, sometimes we have them wear compression shorts to help that minimize and
Speaker 1 (00:48:44):
Scrotal support with a sock. The
Speaker 2 (00:48:47):
Sock, yeah. Yeah.
Speaker 1 (00:48:49):
It can help externally provide pressure because a scrotum could fill with blood and get really heavy and become very uncomfortable. We’d really try our best to prevent that. I mean, we’ve had a couple of patients recently that were at high risk for that because they had either a large scrotal hernia or they had an orchiectomy where their testicle was removed, or they had some other urologic procedure in addition to my procedure, and they all did great because they very efficiently followed the scrotal support, the sock in there, and then the compression underwear on top of it. Yeah,
Speaker 2 (00:49:25):
I get calls. Am I doing it correctly? This is how I do it. I put it here and turn certain positions. But yeah, sometimes you give them instructions. Yeah.
Speaker 1 (00:49:34):
Do you FaceTime with your patients?
Speaker 2 (00:49:36):
Yes, I do. I do sometimes.
Speaker 1 (00:49:40):
Have you ever been
Speaker 2 (00:49:43):
Left? Yeah. Yeah.
Speaker 1 (00:49:45):
Have you ever been in a place where maybe you shouldn’t be FaceTiming?
Speaker 2 (00:49:50):
I think most of the time that’s where the picture is focused at. Yeah. Yeah. In the growing area.
Speaker 1 (00:49:58):
But have you ever been like, I don’t at a party or a wedding or something and then you had to FaceTime the patient?
Speaker 2 (00:50:05):
No. Pictures. Pictures. Yeah. They send me pictures while I’m in a party. It’s like, oh, okay. Hold on. Excuse me for a minute. Then I call them. Yeah, for FaceTime.
Speaker 1 (00:50:22):
I’ve
Speaker 2 (00:50:22):
Had that experience once. Yeah, I’ve had that experience one and I had a midnight, can I have sex? Sex story? You wake me up at midnight to ask me about that. It’s like, sure. Yeah, you can.
Speaker 1 (00:50:37):
Important question.
Speaker 2 (00:50:39):
It’s very important question. That’s why I tell them before surgery that they can do that. So they don’t wake me up at midnight to ask me that question
Speaker 1 (00:50:47):
On a Saturday night.
Speaker 2 (00:50:51):
I love, it’s funny.
Speaker 1 (00:50:54):
That’s why we’re available.
Speaker 2 (00:50:57):
You said you’re available. Yeah.
Speaker 1 (00:51:01):
So recently there’s been a lot of discussion on Hernia talk.com about Hernia as a specialty, like an actual specialty. What do you think about that? Number one, and then what do you think about nursing? Do you think nursing should have a specialty in hernias or there should be a group of hernia nurses that can really understand that patient population?
Speaker 2 (00:51:28):
Yes, especially now where we see a lot of complex hernia patients. I think we’ve been doing well with educating people, but I think we need to just bariatrics, they have center of excellence. I feel like hernia should have that too.
Speaker 1 (00:51:45):
Center
Speaker 2 (00:51:46):
Focus on hernia. I feel like Hernia is under focus and generally speaking, we need a little bit more focus on Hernia. Now we are seeing more and more complex cases.
Speaker 1 (00:52:04):
So Nurse Bell comes every year to usually our American Hernia Society meeting. Sometimes our SAGES meeting, which is our Society of American gastrointestinal endoscopic surgeons, which has a lot of laparoscopic and hernia contents. I mean, I think you’re the only nurse that shows up, is that right?
Speaker 2 (00:52:22):
Yeah, that’s what I was going to say. I don’t see nurses there and I don’t see any topics about nursing there. I feel like part of the American Heart Society or of the Harness Society, there should be some focus on some nursing care too with That’s true. The hernia. Yeah,
Speaker 1 (00:52:42):
It would be nice. There’s a lot of doctors talking to themselves, talking amongst themselves.
Speaker 2 (00:52:48):
Doctors doesn’t consider hernia as a specialty, which should not be
Speaker 1 (00:52:55):
The case. Is there a nursing society meeting that maybe can have hernia discussions or what do you think?
Speaker 2 (00:53:03):
National?
Speaker 1 (00:53:05):
Yeah,
Speaker 2 (00:53:06):
They’re very specific. They’re very specific in specialty.
Speaker 1 (00:53:10):
Like oncology.
Speaker 2 (00:53:11):
Like oncology, bariatric. We have, I used to be a bariatric nurse, so we have annual bariatric meetings too that we attend to. So those specialty certified, we get certified.
Speaker 1 (00:53:25):
Do you think there’s an interest on nurses to learn more about hernias or not so much?
Speaker 2 (00:53:31):
I haven’t heard so much. I don’t hear a lot of interest in hernias with the nurses. It’s just a her net. It’s not just a Hernia. Even my friends at the hospital, it’s just her now. Yeah.
Speaker 1 (00:53:48):
I think the reason why you and I bonded so much at the hospital where I used to work is that you really appreciate my patient population and I felt that the other nurses either didn’t appreciate it or maybe considered them too difficult.
Speaker 2 (00:54:06):
Yes, yes, yes. Especially our chronic pain patients, they’re not easy, but it’s a challenge for us to, how do we help this patient? You’ve seen patients who’s been in pain for 20 years. Those are the patients that we like to see.
Speaker 1 (00:54:34):
Yeah, my friend was saying how excited I get every time I get a chart that’s like super thick today. So today Bell shows me a patient and she brings me a fairly not thin chart, maybe, I don’t know, a hundred pages or something in it. And you said this is the next patient. Everything else, which is not what I’m giving you, has already been uploaded to the chart, like the operative reports and imaging reports and all that. I said, okay, so I’m just going to go through it before the patient shows up so I can get ready for the patient. And then the patient shows up, patient shows up five more.
Speaker 2 (00:55:17):
Here’s four. Yeah, I think there’s like five more folders than you can
Speaker 1 (00:55:24):
Right onto my table. All this imaging and stuff. But it was, I actually like that most doctors just, they say, it’s too much. It’s not my specialty. I don’t understand, blah, blah, blah. But I’ll, oh, they’re so excited. Okay, let’s see how I can figure this out and figure out all of his problems. So I get attracted to that stuff, which I know is not normal.
Speaker 2 (00:55:50):
Right? You’re special. Yeah,
Speaker 1 (00:55:52):
I
Speaker 2 (00:55:52):
Know. That’s why you’re called the mystery mystery solver. It’s like, oh, I dunno what’s going on. So we’ve seen a lot of patients who has this mysterious pain. Nobody can figure it out, but they’ve seen all specialty doctors and no one knows what’s going on until you see them
Speaker 1 (00:56:11):
And then what you there,
Speaker 2 (00:56:12):
It’s, it’s like Hernia right there.
Speaker 1 (00:56:15):
And then what do I say when I come out of the office, when I see these patients?
Speaker 2 (00:56:21):
When what?
Speaker 1 (00:56:23):
When I come out these mystery. Yeah.
Speaker 2 (00:56:25):
I was like, yes, we figured it out. That’s what you always say.
Speaker 1 (00:56:30):
Yeah, we all like it. Here’s another question. How do you evaluate postoperative pain in one of your patients following a laparoscopic repair?
Speaker 2 (00:56:40):
So what do we always do, or what do we always ask our patients is like, how is your pain not different from your pain before surgery? That’s your kind of gauge if their pain is related to the surgery or if we have help them postoperatively. So for the most part, they say it’s hard to tell. It’s like, okay. So then I just follow them for the next, we follow them for the next couple of weeks and make sure that we track the quality of pain that they have postoperatively.
Speaker 1 (00:57:11):
And maybe you wanted to also talk to ’em about how we follow our patients.
Speaker 2 (00:57:16):
So we do a couple of days the next day after the next couple of days after I text the patient, I call the patient, follow up with them, and then we see them two weeks after surgery. We usually see them in clinic. And then if they’re good, we’re okay. And then sometimes three months after, six months after a year, and then we do have the survey that we send our patients, the AHSQC survey and send them through email, send an automatic email that they kind of answer the survey to track their progress
Speaker 1 (00:57:52):
After. So every patient, we are primarily interested to see if what we did address the reason why we did it. So that’s one very important question. Everyone gets enrolled into a national quality Collaborative called the ACHQC, the American, the abdominal core health quality, Collaborative, ACHQC. And that will follow you through the rest of your life. And we are very interested to make sure that if you find a hernia recurrence or pain or whatever, that that’s tracked. And we are alerted about it because we like to make sure we know our outcomes for our patients. And so we know what’s our recurrence rate. We know what’s our re-operation rate, what’s our infection rate. We know all those and it’s comparable to it’s therefore compared to the rest of the nation of surgeons who follow the same protocol. And then lastly, the we’re going to be coming out with as soon as our hernia score. So based on our ability to know how many of our patients actually got rid of their preoperative pain after surgery, we now have come up with a hernia score. So that’s going to come up soon, definitely before the end of the year. And really excited about that because now the whole world can use this predictive tool to see if they undergo her new pair, what’s the likelihood that it’ll treat their pain. So super excited about that comment for you. Be one of our viewers just wrote You were both charming and dedicated tonight.
Speaker 2 (00:59:42):
Thank you.
Speaker 1 (00:59:43):
Yeah. That’s very nice. So I’m really excited about tonight. Wasn’t that bad, right, Bo?
Speaker 2 (00:59:51):
I survived. You
Speaker 1 (00:59:53):
Survived the full hour.
Speaker 2 (00:59:54):
Yeah, yeah, yeah, yeah,
Speaker 1 (00:59:56):
Exactly. The full hour. And I’m so happy. That was exciting. I’m so happy you said yes, because everyone knows you. My nurse be best hernia nurse in the world. You can follow her on Twitter at the hernia nurse. Very easy to remember. And that’s the end of us. Today’s Hernia Talk Live episode is sponsored by Beverly Hills Hernia Center because both Bella and I are both still at Work
Speaker 2 (01:00:24):
Hernia Center. Yes.
Speaker 1 (01:00:26):
Thanks everyone for watching. Please do follow me on Twitter and Instagram at hernia Doc. Thanks for being with me on Facebook at Dr. Towfigh. I appreciate your questions, which were great. You can rewatch this on YouTube at Hernia Doc. And don’t forget to also download my podcast, Hernia Talk Live, wherever you listen to podcasts. And I will see you again next week. Thanks be.
Speaker 2 (01:00:54):
Thank you.
