Joris J. Blok

Introduction and importance: Heparin-induced thrombocytopenia (HIT) is a severe adverse immune mediated reaction to heparin therapy, particularly relevant in vascular surgery due to its potential life-threatening thrombotic risks. Case presentation and clinical discussion: This report describes a case of refractory HIT following aortobifemoral reconstruction in a 66-year-old patient presenting with peripheral arterial occlusive disease. Initial treatment with argatroban failed to resolve thrombocytopenia, necessitating intravenous immunoglobulin (IVIG). Thrombocytopenia recurred, requiring a second IVIG cycle. Subsequently, the patient developed acute limb ischemia, which was successfully managed with repeated urokinase catheter-directed thrombolysis. Conclusion: This case highlights the challenges of refractory HIT with life-threatening thrombosis, emphasizing the potential role of repeated IVIG treatment and fibrinolytic therapy in this context. Awareness the treatment options for HIT and refractory HIT is crucial for adequate management in vascular surgery.

The future of surgery is challenged by two major issues: declining medical students’ interest in a surgical career and increasing burnout numbers among surgical residents. Addressing these issues is vital to maintain a vital and attractive surgical profession. Recruitment of suitable surgical trainees is there for increasingly important. In the Netherlands, the number of applicants for a surgical training position is stable, with a significant increase in female applicants. The applicant-training position is also stable. Nevertheless, as a surgical community, it is our responsibility to ensure that this situation is sustained in the long term in a durable manner. Encouraging medical students, functioning as role models, mentoring surgical trainees and addressing burnout is essential to keep our profession attractive for all.

Surgery is a demanding and stressful profession. Unfortunately, inappropriate behavior is still not banished from the daily surgical practice and we are dealing with the negative consequences (e.g. negative working environments or burn-out). To adequately treat this type of behavior we first have to acknowledge its existence and create a proper path to discuss it inside our own ranks. The only manner to achieve this, is through an open culture. An 'open surgical culture' is the key, as it creates an environment with psychological safety and allows all involved parties to be able to speak up without fear for retaliation. Theoretical models such as Bateson’s pyramid, McClelland’s iceberg, and Dweck's Growth Mindset Theory can serve as valuable sources of inspiration to addressing cultural change by approaching both individual and organizational levels. Examples of cultural change attempts can be as small as discussing inappropriate behavior through pocket cards with statements of certain behavior or during national conferences, e.g. the annual meeting of the Dutch Surgical Society (Chirurgendagen). Only together we are able to achieve an open surgical culture, in order to ban mistreatment from the surgical profession. Here a roadmap to achieving an open surgical culture is presented and discussed.