Dr. Woo Do - Pediatric Surgery Fellowship In Review

All right, thank you so much, Aaron. So it took me, it was quite challenging for me to come up with this talk because it is my first ever Grand Rounds and I feel like I don't have much to say that is all that grand, but I couldn't help but reflect and just think about how much gratitude I end this fellowship with. So these stories are really dedicated to you all and I thank you from the bottom of my heart. I'm mandated to say that as a member of the military, I have no disclosures and these reviews are my own alone. Perhaps the most important disclosure or disclaimer is really the debt of gratitude I have to my family. Pictured here is my entire family with Beth and my mom and dad in the front and then off to the side is Beth's family right after her graduation from law school. You know, we all came from humble beginnings and being immigrant families, figuring out the world, a new world on their own. Our parents endured a lot and in watching them, I think Beth and I both learned a lot about what it means to have selfless sacrifice and to be able to endure suffering gracefully. And with that, I think I grew the foundation that it required to become ultimately successful here. Unfortunately, unlike when we show up for fellowship, there is no handbook that our parents had when they started to figure out things for themselves. And so I was really lucky. When I came here, there was a nice manual. You can see that it's been revised many times over, started by Dr. Adzick and then revised most recently by one doctor, Alex Cuenca. And as you thumb through this, like I couldn't help but reminisce because when you show up to West Point for your first time, you get your head shaved and you're given a knowledge book. And anytime you're in line, you're required to memorize the facts within this knowledge book. And so this handbook was quite reminiscent of that. For anyone who is curious or interested in what's in this book, it can really be summarized by these two points. One is the motto, duty, honor, country. And the second is to beat Navy. And that's all that matters. Even our own handbook, we have several rules or words of advice. And the one that spoke to me the greatest is this one here. At whatever hour you come, you will find light and help and human kindness. And I think that many of us try to live by this example no matter how tired we are, no matter what we're going through. And so I think this is the driving force behind what we do here at Boston Children's. As you thumb through further, there are 20 commandments of surgical residency or fellowship that apply to our institution. And I find it striking that every medical student or resident that comes through our institution is handed this handbook. And you know this is the page that they're going to land on. And this is the message that we think is most important to send. These are the rules of our institution. Some of them I certainly, you know, harken back to the West Point days. Honesty first, right? Don't complain. Fix it. And then there are some other ones that are quite unique to our institution. Don't argue with idiots. Sleep comes last to on your food. I thought that was interesting, but this is this is our way. And as I went through my first week of fellowship, I came to learn that there is a distinct way we do things here at Boston Children's. So for example, you know, my second week of fellowship, I did my first laparoscopic pilar of myotomy and kind of like the mandalorian, you have your loops on and you never take off your mask. You have to be deaf with a knife, no booby involved. And you learn to cut and spread with your left hand. And so your dexterity is critical. I ended up doing a total of 11 pilar of myotomies. And only one of those was open with one doctor Mooney using his omega incision. I wanted to start by going through a list of my first here that I encountered at Boston Children's and use those as a framework for building upon what I would think would be my own handbook of adages or maxims that I've accrued throughout my time here at Boston Children's. The first case I observed on my very first day at Boston Children's was an EA case. I don't know many of you probably grew very familiar and fond of Thai Hendrix. But that was the very first case I got to observe. And I knew there was a secret sauce in this room. You can see here Peter no peeking under the drapes as he does his endoscopy and Somala giving her gang signs. And I knew that there was a special chemistry in this room and it was contagious and the camaraderie was so compelling. And so I fell in love with working with the EA team and this patient he endured a lot. His story began when he was a neonate he was a preemie and he had an e tube a repulpal place that perforated his upper esophagus. And from that point he's suffered a great deal. But through our institution he's been able to gain a lot of rehabilitation. So over the course of my first year in fellowship I was able to participate in what was his antelateral thigh flap with the plastic seam involved with moving the flap up to the neck creating a spitt fistula which we would allow to heal over time. This was described to me as a canole and I can no longer look at canole is the same way. And subsequently this is a photo from a different patient but went on to get his general under position and here he is seeing eating eventually in these sorts of stories here. We're so routine and so impactful that the EA team made a huge impact on the way I see the treatment of these debilitating conditions. Over the course of my time with the EAT I ended up doing 28 neck dissections, eight of them with TIFs 20 without 40 thoracic open chest incisions, nine of them with TIFs, 14 isophageal replacements. I believe 12 or 13 of them were the full on traditional interpositions, two day operations. And then eight tracheal reconstructions which as we've shifted more towards the tapering tracheoplasties that's generally what is what I considered to be a tracheal reconstruction was when we were actually sewing on trachea. So that was my first observed case kind of to conclusion. The first case I actually performed was on my second day of fellowship and that was with Dr. Kim. This patient also ended up being my first M&M at Boston Children so I quickly learned when you take on big cases here they come with complications and Dr. Kim gracefully artfully showed me how to deal with those complications. And then as a side I wanted to mention some of the transplant experience I had with him. But that first case was unlike anything I had ever seen. Nothing in residency paralleled this. Nothing very few cases here even parallel this but this patient had a prior bilateral renal auto transplant and had ongoing hypertension issues. And so we teamed up with Dr. Francis Fin Thompson and the cardiac team and on bypass performed a bypass graph that was the work of abdominal. And here are two years roughly two years later you can see that the graph is so patent and this patient is doing well. That first complication I mentioned was actually I owe Danielle for this but she showed me on my first weekend of shadowing how astute she was and clinically picking up that the patient had cardiac tamponaut and urgently needed a paracardial drain. So a lot to be learned just within your first week of fellowship. A comment on transplants because I came into this fellowship having done absolutely zero transplants. And so the only way I know how to do a transplant is the Boston Children's way. So with this key I ended up doing 13 kidney transplants here my notes from my initial operations the orders that you need to do to make sure that the nurses have everything that they need where to mark your incision how Dr. Kim prefers his retraction where Dr. Vahkili likes to stand. How the enastemosis is done and with this repeating this periodically over the course of the year over 13 transplants by the end of it I was able to do all three inastemosis and had a blast working with the transplant team. I highlight and green that some of these transplants occurred on holiday times and these were some of the most joyous occasions for us when we got to meet the families and really impact the entire family's life for the foreseeable future. A comment on liver transplant so I ended up doing eight liver transplants two of them happened on holidays. You can see picture here how bad some of these livers look before we place a new one in. Two of them were my own cassais. So my very first cassai and second cassai both ended up going for transplant and I think that was a truly remarkable thing. I don't think many fellows across the nation or the entire world get to see biliary etrusia have such a debilitating impact on families and then get to see the momentous transformation that occurs when you transplant that liver. I kind of wanted to as I mentioned that this number roughly is equal to the number of laparoscopic appendectomy that I ended up performing in this fellowship. Honestly, before I started the second year and we started the pretending rule, I had done three laparoscopic appendectomy. So I think there is some credit to be owed to the new change. I think the first set of maxims that come to mind thinking through these initial sets of cases are one, some fellowships are longer than others. A lot, Dr. Kuenka and Dr. Lee and a hungry tiger is a fast tiger. You two have both taught me an incredible amount. Operating you with you has been a complete joy. You have shown me a lot about operating on sick children. Here is an awesome picture I will cherish of me and Eliza doing that case where I got to do all three in Asimo Cs. Eliza, I tremendous credit to you. You gracefully came into this institution and took on the role of attending but you were like a true friend to me, Aaron and Patrick, yeah, if I back at you. You never made us feel that way that you were superior to us. You really showed us a lot in the operating room. We taught us a lot about the management of transplant patients. You walked us through your thought process. We really owe you a lot. So thank you. I see a very bright future for transplant ahead. Secondly, I wanted to comment on what Dr. Kim showed me through his example. It's that innovation built upon a foundation of mastery stands stronger than creativity alone. He is what I view as the true master of surgery and the true innovator in surgery. This is an example of a child who has alligial syndrome and his mom will describe that he has never been able to sleep a night in his bed without a suit on because he is so badly. He took the principles of Rune Wai as well as the principles of a biliary type of nasimosis combined the two and this was the fourth ever case that was ever done like this. We have been case reports previously and I had the distinct honor of performing the fourth with him. Just to hear, he had his first night of sleep without a suit on for itching was tremendously back full to me. So Dr. Kim, thank you for everything. Moving on, it wasn't until five days into fellowship that I actually truly did a pediatric type of case. The first of those cases was with Somalama Humid. She showed me how to do my first laparoscopic in Guinalhurnia. I wanted to comment actually that she also showed me how to do my first pre-me type C, Saffir, atrija, or T. Fischila. But on the side here, I mentioned that I ended up doing 54 in Guinalhurnia operations. 22 of them were laparoscopic done exactly the way that Somalah showed me and then 10 of them were pre-me. The very challenging open type prepares. So this was the first pre-me type C. It happened roughly, halfway into my first year of fellowship. Here you can see Somalah artfully placing a rigid bronchoscope with me holding the Fogarty balloon to do the T. F. occlusion. This case, I think, builds upon the foundation that I learned operating with the EA team. They taught me a lot about airway anatomy. You can see here on this video, sorry, that it's a little bit choppy. I'll try to thumb through it. So what I wanted to show here was it was quite challenging to get this Fogarty through this one kilogram baby. So we ended up, this was the first case where I had to urgently go to a G-Tube. In a pre-me, it was one of these G-tubes that is just paper thin. You have to be really careful about how you do it. After the G-Tube went in, she showed me how to do the EA in a pre-me type C, the way we do it, the Boston Children's Way. I will never forget this method. And I have a feeling it's going to serve me incredibly well as I go forward. I'll skip through here. This is Princess. She's grown up to be a robust child who can feed, who has a great airway and is now growing and thriving. I think when I think of Somala, I think of the phrase, turn the challenging into the mundane. We just had a patient just within this last month who the family had a baby born postnatal diagnosis of type C, EATF. They were born at another hospital. Dad researched what it means to get EA treated here at Boston Children's. They fought and fought and fought. Four days into this found their way here. Somala operated, reassured dad that this was mundane to us and the baby has had a tremendous outcome. Starting into later in that first week, my first actual general surgery day was with Dr. Jackson. Sure, you may not remember this because you've done many firsts with many fellows. As a side, I just wanted to mention that Dr. Wile was my first Sal during this period of time. And I mentioned this because as we were rounding and I was learning from Dr. Wile, I mean, I think everything I learned about how things happen at Boston Children's I learned from Dr. Wile, how to deal with consults, how to field phone calls, even that he once taught Dr. Jackson what a snap of webo is. And before I knew Brent's sense of humor, I believed all of these things. So this was my first day with Dr. Jackson. I was supposed to do my first gyrogocel ductsist, turned out to be a dermoid. I put an asterisk here because I ended up personally being in charge of no gyrogocel ductsist during my time in fellowship. Thankfully, Dr. Modi helped me connect with the ORL team and I was able to second assist in that sort of thing and actually get some experience during this. I ended up doing my first of what would be seven fund applications. We don't generally do many of them here. And my first of many, many CVLs was with Dr. Jackson. When I came into this fellowship, Dr. Jackson, I viewed you as an icon and someone that was incredibly intimidating based on all that you have accomplished. You quickly won me over with your charm, your Canadian charm. I cherished every moment operating with you. You mentored me beyond many hours late at night when a person who has earned privilege in the surgical community need not be still around those midnight conversations. You taught me a lot, sir. So thank you. When I think of Dr. Jackson, I think of this foresight, he knows he can predict the future because he has seen much of the past and he knows that all will be well. The ordering of this is a little bit different, but Dr. Modi took me through my first BZOR. He took me through my first thoracicality compression and my first pentology of control. This was a tricobenzor that we extracted from the stomach of a patient who had a hikah for a long standing period of time. This patient ended up doing great. He also showed me how to venture into tiger country. This is something that I will cherish for what I hope to be a long career in dealing with thoracicality. You taught me to become passionate about this. You taught me to become comfortable in this area. You taught me that there is no room for a hubris in tiger country, though. Always have help available. Always know when to call for help and how to get yourself out of really sticky situations. So thank you, Dr. Modi. One of, I think my most memorable cases with you was this case of pentology of control and this patient who we actually see on storyboards all across Boston childrens ended up having a phenomenal outcome. My first trauma call was with Dr. Nandavada. I see her over there. Yeah. So I didn't realize fellas didn't have to go to ER. Trauma calls when I first showed up. It's just the way that I was trained and we ended up having two gunshot wounds simultaneously in two different 14 year olds that arrived at the same time. They ended up doing just fine. But I remember being there in the trauma bay kind of triaging the situation and Pratima showed up and was like, hey. You know you don't have to be here, right? But it was the start to many, many, just fantastic nights and crazy cases that I ended up having with Pratima and somehow she attracted a lot. And before I would talk about Pratima, I wanted to do a side note on trauma and this is a little bit of a shout out to Dr. Mooney and the trauma program that he's built. But we see a lot of crazy trauma from around not necessarily at the initial setting, but anything that needs much of anything needs to come to see her first or not first, but secondarily. And so one crazy case that I remember is it taught me that falling is inevitable when you fall from your horse, get back on the horse, live his heel. So this was a 13 year old who was into horseback riding in February fell off her horse, got trampled and had a grade five liver at last rations. Thankfully healed up beautifully, did well was able to get home, got back on her horse and in October 2022 had a grade four, a spleen injury. And I think what this showed me is like when you see tea deliver several months down the line, the liver has a remarkable ability to heal. So the injury to the liver should not preclude you from getting back on your horse. Another kind of crazy situation that I encountered with Pratima taught me that children are worth believing. They made you unbelievable things, but you really should believe children. This was a five year old who came in with a bowel obstruction and for six months had kind of colicky symptoms. We ended up scanning this child and they had what was deemed a like momentous fat density, pedunculated arising from the mucosa perhaps, some mucosa of the small bowel. So automatically the oncology signals are going off, but we took this patient to the operating room and what we found was this really mobile kind of green oblong mass that when we extracted and cut it in half on the back table turned out to be this nerf ball. Claire did a wonderful job finishing out this case. And when we went back to talk to the family, the mom told us, you know, he had been telling me this for six months or maybe like three months and then we all kind of forgot about it. He kept saying that he is missing a nerf ball and he swallowed this nerf ball. And she said, I did not believe him because I myself tried to swallow the nerf ball and I could not. And so I think this showed me you really should believe children. And I think this child has a bright future ahead of him. There's no way that his mom's ever going to take what he says for a lie anymore in his future. Pratima showed me that the fundamentals truly are fundamental. She has an act for everything that goes from obtaining a history and having a charismatic conversation with the family to counseling them, to guiding them through all of the decisions that need to be made. She operates artfully gracefully. She can bag children as better than an anesthesiologist. Pratima, you showed me a lot and going through these many crazy cases together. My first type B, Jajunal Atreja, Massive Maconium, CS was with you. If anything, it just builds upon this notion that fundamentals truly are fundamental. And when you have a good grasp of them, you can build upon them to do these like crazy sorts of case, reportable cases like this patient with Mitchell Riley syndrome, which there are maybe two dozen cases in the entire world. So thank you, Pratima, for all that you've shown me. My first umphalacial was with none other than Dr. Buckmiller. It was my first month, actually second month on my ICU rotation when I met this patient, Jajunal Atreja, I'm phallacial. We painted and waited and we managed a lot of sick complications together for this child. This was a really challenging case to manage. I see Emily here in the background. She helped us with a lot of the management of this particular patient too. Nicole did as well. We were really tight doing all this management. A year down the line, I had the distinct pleasure of being able to join with Dr. Buckmiller once more to do the final closure. Similarly, this is another case of a patient that we were able to do in a stage fashion and ended up having a brilliant outcome. I ended up doing 18 total closures of gastroskycissus or emphalacials. Fourteen of them truly ended up being these large or staged type repairs. So when I think of Dr. Buckmiller, I think always be closing, you know, do a great closure. You know, whether it's patient encounters in the clinic or seeing an ephalacial disclosure, you always wrap things up beautifully. You see the patients that you have met from the first time and make sure their encounters are closed out beautifully. So I learned a lot from you, Dr. Buckmiller. Thank you. My first code ECMO happened in September with none other than Dr. Mengel. We got this page. This patient was on 11th, I know we live a short distance from the hospital for a good reason. Patrick and I live really close by together in Fenway. This was truly the first time I had to run into the hospital and meet the patient for a true emergency. And I remember everything, everything things that I didn't think would shake was shaking in my body. And Dr. Mengel helped keep me calm and get me through this. This was, I think my first, was my first ECPR. He and I had done ECMO SAM the week before. In fact, I think he was like three days before. I ended up doing 22 ECMO cannulations, 12 of them being the initial, many of them being some form of repositioning, recannulation. One of those was with Dr. Dickie. She helped me deal with a cannula that I had sent down to tight that it was causing him all of this. And this patient needed an ECMO recannulation and lasted, I think like two seconds before desaturation, if that. And so I've had a great experience with ECMO during my time here. When I think of Dr. Mengel, not only did he keep me poised in that scenario, but I think he's very grounded. He prioritizes his family. He taught me a lot about this as I went through. And in thinking about the way I want to be as an attending, Dr. Mengel, I will draw an example from the way you have prioritized your own family. Next, I wanted to talk about my Pectis experience here that came up pretty shortly after I started doing most of the cases here, following my ICU time. Dr. Lilla, you took me through my first Pectis. You showed me a lot about how to mark these cases. I still have a video of you walking me through my first marking and I will hold that, hold on to that and use it as a template for all Pectis cases in the future. This is something that will definitely be a part of my practice. And I learned to group passionate about it from Dr. Lilla. We had tremendous outcomes. We saw these patients to spectacularly with cryotherapy. They left the hospital some in as soon as two days after the hospital. And I remember being a resident and taking care of these patients five to two weeks down the line after they had been deep in the K hole with narcotic dependence. And the story is just completely different now. And so I ended up doing 10 thoracoscopic nurse procedures here. Most of them were with Dr. Lilla. You know, when I think of Dr. Lilla, the phrase that comes to mind, like we've all heard him say this and it's become a fixture of what it means to be a Boston Children's fellow, but the absence of options clear some mind. And thankfully, I never encountered a situation where Dr. Lilla and I truly ran out of options. So most of the time I worked with Dr. Lilla when there was, there were plenty of options to choose from. And so what is curious to me is when you have someone as experiences after Lilla, who lives by this principle of what to do when you run out of options, what does he do when he has many options. And what I learned is that when given many options, you choose for rope. And so most of the cases I did with Dr. Lilla high broke was the second scrub. Most of the cases I did with broke Dr. Lilla high was the second scrub. They were a dynamic duo. It was amazing watching them operating operate together. It showed me by example that you want to be like for Oak, be like someone who has a calm, gentle, but cheerful disposition is willing to take on anything is willing to help no matter what the scenario is always, always willing to help. And does the spectabular job doing so. I think broke showed me a lot about trying, about putting in a, you know, certainly having the skill set to do so, but putting in a dedicated effort to try when many people might not be as eager to try. And you know, I mean, why else is broke the guy the fellows go to when we need something done. So the reward for trying is unfathomable. Sometimes the trying was very painful on the left. This was a patient that broke was willing to let me try my first laparoscopic. Do we know what you're going to repair? We, you know, tried at that for several hours completed the enastamosis were unhappy with the enastamosis and then he let me do it a second time open. I'm just a tremendous patient. I broke tries incredibly hard at everything. You know, there was a scenario late at night when he and I were both on and there were just everyone in the NICU seemed like they were dying or an extremist. And broke just like makes it happen. And so for a newborn type C who would eventually go on to be in Reno failure because of their solitary dysplastic kidney and need pertinial dialysis. I abandoned for Oak in that case went on to do another very urgent case and he did that. And so I went to the NICU with a scrub tech. For Oak is willing to just take on whatever it takes to get the job done. And he showed me a lot about the way we should be as surgeons. I think the most memorable case we had together. This is outside of Roman Larusso who, you know, hopefully we'll have a great experience with tomorrow. But this is to me the biggest safe. I was a patient who had a hypoplasic long very severe CDH malrotation needed to go urgently on ECMO. On that same day after the operation needed to go for a blue and a traceptus to me. It was touching go for a long period of time. And I think what this showed me is you really can't count out these kids. And you just don't know like you see neurology notes that talk about dismal prognoses and you really don't know. And so you try and you try and you try your dandist. And in the end some of these saves are truly spectacular and this family still reaches out to us because of this safe. And they're able to enjoy so much cherished time together. And that has made a huge impact on me. So thank you for. I know a lot of people I actually don't know where the root of this quote is. I've heard it attributed to rusty Jennings. I never had the opportunity to work with Dr Jennings. But when I think of this quote sometimes you just got to be good. I can't help but think of Brent while. He has the swagger of someone who knows that oncology is going to be taking care of well in this hospital. And forever they're continuing with a desperate aid program that taught me a lot of things to do. It felt like they were hearing them. And then it felt like if it really led a lot of things, I mean the source will work out. Not just the global health issues like this. But this was just a Galileoviolcus. near Blastoma. Brent was calm as ever, took me through this. We're safely in the PA here. We took out this mass which had some Cheswan vision. Here's the specimen X vivo, noting the Cheswan vision there. We then proceeded on with the reconstruction with the Gore-Tex patch. I remember being at this child's bedside. This was the first humanectomy that I had done, trying to figure out how to best manage this airspace and not shifting the media sign-um too much, but allowing for a little bit of shift and pulling on a syringe and then trying water seal and all these sorts of things. We were able to get through eventually that Ches filled up with space. We were able to see this kid back. For follow-up, he wants to play baseball. He healed up beautifully. Here he is, just doing normal kid things and finishing out his chemotherapy. When I think of Brent, wow, to me these two are inextricably linked. He just has the swagger of someone who can get the job done and shoulders all of their oncology burden here. Thank you Brent for showing me all that. He walked me through the majority of my oncology cases from adrenalectomies and effectomies. Perhaps not the hepatectomies, but we did a whip hole together. The urefectomy showed me in my first muscle-sparing vertical thoracotomy, which we ended up applying to many other scenarios. Thank you. Next, I wanted to talk about Dr. Zeleskis. I think that a good job from some people just weighs more than others. Dr. Zeleskis isn't necessarily going to be the one that talks a lot. She just walks the walk and she takes on these incredibly challenging cases. One of my most memorable with her was this patient that the outside hospital just completely bailed because the CDH had just gone so poorly and came to us with a mesh that had just completely decayed like this. We were able to get this kid through and see them back in clinic with what appears, like a completely normal abdominal wall and is thriving and growing and enjoying their time with their family. Jill, we've gone through some crazy, crazy tough cases together and I just cherished every time you have said good job because I know it means so much when it comes from you. So thank you for showing me that. Jill, of course, is one of the staples of our CDH program. This is the list of the CDHs that I primarily was the lead surgeon on, ended up having some deaths and some really challenging scenarios. The green ones are the ones we ventured into thoracoscopically. I did my last of these with phiroc, which was a type A and then several of them were thoracoscopic done in older children or recurrences. The CDH also cannot be mentioned without thinking about Dr. Dickey. When I think of Dr. Dickey, she is a true leader. I mean that from the bottom of my heart being someone who is valued, the whole reason I went to West Point was because I wanted to learn leadership and Dr. Dickey has showed me more about leadership here in watching her and the way she deals with families and patients. But she has shown me that a leader carries a load and it doesn't matter what that load is. It can be a heavy, heavy burden. Sometimes it's just the largest stool wall that you've seen. And it doesn't matter. Like Dr. Dickey, anything you ask of her, she will say, yes, let's do it. She is allowing me to see to completion a pre-me CDH case that we did together simply because I asked. Dr. Dickey, I think I looked through all the text messages and phone calls that I had with attendings during my time here and you were the one that I contacted the most. You were the one I called. You showed me how to do. You showed me my first ECMO, cannula, thrombectomies. Eventually got me to the point where I was comfortable doing them alone at night when you weren't around. You are the first person I called when there are crazy, crazy situations going on like this. I wasn't the one that called you about this CDH that had a needle through their bowel. But this abdomen, this other abdomen, you're the first person I call. And you've always helped me get through whatever the tough situation was. And so I owe a tremendous debt of gratitude. In addition to Dr. Dickey, when I think of courage, I also think about Ben. Ben is someone that he's not here, but he's someone that showed me have the courage to go for the victory and could be a tremendous victory. Victories that are unachievable elsewhere, but also have the honor to or also have honor and defeat. Ben was the one that took me through my longest case. This was an extensive operation which started at 7.30 a.m. and finished around 3.00 a.m. the next day. And there was no more else to cases like this happen. And this patient ended up being able to eat in swallow and have a normal life again. Truly Ben showed me that with a tremendous team and with dedicated effort and with courage, you can achieve something that is completely unfathomable elsewhere. And then he also showed me a lot about humility. Anytime I called Ben and next to Dr. Dickey, Ben was the person I called the most. I don't know if you guys know this, but we fellows, we contact Ben every single day. Maybe not this week when he's on vacation, but short of vacation, every single day like clockwork, we talked to Ben about how the EAP patients are doing and what needs to be done next. And it's a tireless task that he has before him to manage and leave this team. And this is the dad of one of the patients that I'll remember most fondly. And Ben and I, this is the longest gap that I dealt with in a, a creamy baby. Ben and I were dealing with it thoracoscopically. And we would just watched as the traction system fell apart before our eyes. We converted to open. We eventually got this and Asmosis back together over months. This dad and I still keep in touch. He has a military background. But what I remember from this is Ben has never shied away from talking to families with honesty and sincerity about the challenges involved. And I think they put their trust in him because he does that. And he showed me a lot. When we had terrible, because these are big cases he does, when we had terrible complications, he's always the person I call to let know. And every time I call them, he's come back into the hospital. Even on weekends, he's off to talk to the family. And he has shown me a lot about how to deal, you know, honorably with complications. When I think of Dr. Pewter, I think about wisdom. I think about how in knowledge it builds like compound interest. And that's important in what we do because that which the mind does not know the eyes cannot see. And I've come to this conclusion after all the countless sessions of just being able to talk with Dr. Pewter about his pearls of wisdom in his office. We may not have operated as much together, but he's taught me a lot about caring for patients, picking up on diagnostic clues. So this is a patient that we didn't take care of together. They came in on a shift very early in my fellowship. You know, we had talked about malrotation and how you really need to be careful and have high alert. This patient was underdiagnosed when they arrived. Thankfully, it happened right close to the change of shift. Dr. Kame actually came on and helped us manage this patient. But like in retrospect, in looking over this with Dr. Pewter and thinking about it more, I'd come to learn about what the clues are in malrotation, even if the radiologists may not call it on the get-go. And so this patient had a really good outcome because Dr. Kame came in and helped us manage the situation. But in talking with Dr. Pewter and learning about how to deal with these sorts of patients, I learned more and grew more comfortable with making the decision on the go. And sometimes the decision is made for you. Like this is one of these situations where there is truly an absence of options. Somal and I were on together when we had this baby that was the sickest baby that I had ever seen, come to the ER. It was one of my early pre-attending shifts. We took this baby to the OR before these labs were back. And this is the lowest pH and the highest lactate I've seen. And the worst looking bowel that I've seen in a baby that has then gone on to have a completely normal outcome. You know, of course, in the care program, it has long road ahead of them, but it's thriving. And just the family can spend all their time together. So Dr. Pewter, every sort of case like this going forward, I think about you because you've just embedded in me a lot of these pearls of wisdom. Thank you. When I think of Gus Papadakis, I think about autonomy. I think a lot of people preach autonomy, but very few are willing to live it. Gus, you have shown me that the road to autonomy begins with granted autonomy. And you've been willing to grant me autonomy even before I probably deserved it. You know, this is a bowel obstruction that occurred in a patient that Dr. Quink and I did a Wilms Tumor Resection on and came back. And Gus and I were on call together. And he let me make the decision to approach it laparoscopically. And it turned out to be one that I think many attendings would not have been willing to venture into, but because he let me make the decision for better or for worse, we ended up having a good result. My first, like small and fallacyal closure that was not with Dr. Buckmiller came in on Gus's watch. And I'd never closed an emphalacyal like this, but in learning from principles that I had seen from other attendings, Gus let me make the call on how we wanted to deal with this patient. And they ended up having a really good result. Somehow Gus attracts a lot. He attracts the most eckmo cannulations. He even attracts these crazy cases, indescribable cases. This was a patient that bled down to a hemoglobin of 3.5 and ended up with a mechal scan before we were called. And the mechal scan occurred on a Saturday, no less. But he let me make the judgment call on how we wanted to deal with this mechals. And again, patient had a brilliant result. So thank you, Gus, for truly preaching, or sorry, walking what you preached. This fellowship would not be complete without the classic quote, make MD make do. Dr. Weldon, I never got to operate with you in the OR, but your commentary will always resonate in my heart. There is a Korean quote. It is attributed to the Korean Marine core. It says, Andemyeon, Teortecagi, and it means if it doesn't work, make it work. And Weldon, you are the one that has really shown me that this is the attitude we should live our lives. Even if it means jamming your heavy fingers on a keyboard to get the orders done for Dr. Dickey. All right. Dr. Chen, when I think about you, I think of how much passion you put into cultivating the future. I look back at 2011 when I was a first year medical student here at Harvard Medical School, not truly undifferentiated, a seed with no future. And you took me under your wings. You showed me a lot about pediatric surgery. And I see you doing the same thing for so many, just countless medical students. And I can just, in myself, I can see what will become of them because of what you've done for them. So thank you. When I think about our leaders, Dr. Fishman and Dr. Shamberger, I can't help but think about this quote that's in, it's one of the truths that guides the U.S. Special Operations Command. They're the people we call when we really need something done. The truth is that humans are more important than hardware. People not equipment make the critical difference. The right people highly trained and working as a team will accomplish the mission with the equipment available. And I know that, you know, yes, we're the number one institution, but even we have our equipment malfunctions. And no matter what that is, I see some of our best people in the back. Alicia, I see you seeing Rita. Like you guys just get the job done. And we have tremendous people here. And you know, Dr. Shamberger, Dr. Fishman, no matter all the talks I go to where I see you guys cited, people talk brilliantly about all the brilliant things you've done and all the impact that you've made. But I really think it's the people that you've gathered and mobilized here that has made the biggest impact. You know, these people, I would die for now. Like they, I've truly become like family. And I owe a deep, deep, dedicated to all of them for all that we've done together. I wanted to close on this last quote, which, you know, I won't attribute to any particular staff, but maybe to a patient that everything we do matters, even if you don't think what you're doing matters all that much. So when I was a first year, it was a little bit different because we didn't have to run around to hail and a new building and all that. So everything was pretty close quarters. And so I felt like I really did have an opportunity to truly see even all the outliers. And I would go see all the neck watch babies. One day, I got this in the mail. It looked really fancy. So I opened it up. It came from the city of Cambridge. And it was a citation. It was a citation from the city of Cambridge applied for by one of the families here. And it reads the expert team on eight four children's hospital of Austin worked miracles. And then it goes on to say Dr. Rudo from internal medicine, stopping in every morning at 6am to check on Monti prior to performing his daily surgeries. So families may not know who we are or what exactly we do. But I'm mentioned in this citation right next to Chris Barrett. And Chris Barrett is the one that did the operation and like fix this kid's entire arch. But this family to me, this shows me that even a neck watch baby that you're just rounding on. And it just seems like another checkbox that you're checking. We can truly have a deep impact on. So I think, you know, I've walked a lot in these shoes. I think it's time for new shoes. You know, I recently got to meet with Danielle's daughter, a dare. She wrote me this great note. Congratulations. Life gets better. And I will hold her to this. I look back to my first slide about our families and all the sacrifices they're in born. And I am truly, truly grateful to them to Beth, my honey. I'm so grateful to you for all that you have sacrificed to help me get to this point. Speaking of Beth, we had a wager, a friendly wager going into this fellowship about who would accrue more funds? Me in a suffocates through rigid from Cossick, rigid a suffocoscopy or her in the streets of Cambridge, just finding change on the street. And by the end of my fellowship, I have accrued $2.44. Sorry, Dr. Fisherman, that can't really go towards our renovation. It went back to the families. We took out some eggs, two bottle caps, the popcorn kernel. This picture is from a two-stacked dime. You know, to me, these are the most precious valuable dimes. They're priceless because I mean, it must cost thousands, hundreds of thousands of dollars to fly a child over for a diagnosis of a button battery ingestion. But these are stacks just in the alignment enough. I've tried to make this argument with Beth that a helicopter flight should be counted within the funds that we accrue. But sadly, that case did not gather weight. And so Beth has won the bet. I owe her a polar punch next December. But despite all the funds and the money and everything that we do, truly what has been priceless is the time spent with everyone here. So thank you all so much from the bottom of my heart for everything that you've done to make me a better person. Thank you. Wow. Well, so we all know who we all love boo. Let me start. We heard you had to see the world while he was working. But thank you for loaning into us. I think we can all see the true character of who this was supposed to be about his experience. But what did he do? He highlighted that his experience was based on all of you. Completely selfless. Correct about everything that he said. All those people. All the things you said and all the things you didn't have time to say. In part because of dedication to the patients. But in part because you weren't. And you're worthy of it and yourself. I had the opportunity to. Interview somebody for a senior executive position yesterday who happens to be a senior military officer now well into reserves but has served overseas at great length, including recent times in Afghanistan through the day that we left. And we had quite a lot of discussion about the history of say and he's a health executive. And we had it. The opportunity to talk about the impact of his military experiences, which were far more in depth than I knew from his resume. Upon his leadership. And so we talked about you. And I told him that, you know, when we had to evaluate the surgical resistance in the country. And we trained. A military surgeon. Wasn't a very long discussion. By writing for us to do. And we are so grateful that you chose to join us. Now he did. When I told him about your choice to go to West Point. Having turned down a full ride. I was like, well, I'm not going to be a good person. Because you can get more rigorous education. He said that's true. But it could have gone to Naval Academy. Obviously, it's an even guy. You highlight. The cornerstone of what our department is about. As an individual. And you've done that. In your presentation. I'm going to see a different side of things on Friday evening. When Patrick and Aaron get a chance to tell their side of the story. But I know when they do so, it will be with incredible love and admiration for your partnership. Your mentorship of them. Even if you used to be one of the medical students. And. And your collegiality, which. I'm sure will last. A lifetime. The always late, but I want to Dr. Modi wants to make it a comment. Maybe each of you can take a second. Dr. Modi wants to defer a lot. My goodness, I think the only thing I can reflect upon is that. When we had that session, all meeting together and deciding who that next fellow was. It was a unanimous decision that who we wanted to. And today. And these last two years. Every and for set. And I think it's a wonderful. A wonderful two years. And my goodness, the future is. It's exciting. Thank you. Thank you. Mostly for weathering the transition from a fellowship led by Dr. Lola Hay to a fellowship led by me. You are a tremendous partner in that. And we're a tremendous partner in that. I really appreciate it. I mean that from about my heart. I think that we have been an integral part of the transitions that we've made. And making me feel comfortable in all that we've done. Beth, thank you for. For allowing us to have a roof for the last two years and. And put him through the rigors of this. I think as you. All of seeing he. Not only has weathered it, but has thrived and has become a. To be a tremendous. Somebody were tremendously proud of of having trained great things ahead. Thank you. When additional important thing we should do today. When we walked in this morning. I greeted Dr. Fallon. And that said to me. Is it a special day when the new fellow arrives? I said, yeah, I said my very first experience was was this day. Come again. And she said to me. What are your memories of that day when I came in to watch the prior fellow the part. And I said without having to think for very long. Imposter syndrome. That you are most deserving. Most appropriate. Most welcome. And I am sure that you will be able to have the same experience. That that will has expressed. I know if everybody's had a chance to meet Dr. Fallon or if you say them for a second. Our next cherished fellow to join Dr. Tellplane. I'm a density. Dr. Fallon. You get about a one week honeymoon and then we expect you to perform like these guys. I am. I hope everybody can help us in celebrating. We're going to have difficulty saying goodbye to. And so we're not. I don't understand how the military works, but he seems to think there's a way that he could spend a little time with us, even though he's going to be. And so we're going to have a continued officer station at Walter Reed and it's not that far. So we're hoping that everybody who's benefited from experience with we will continue to learn from him and to cherish this friendship. Thank you. Thank you. You