Timely Aggression – Lesson from Poker

I’ve been playing poker ever since beginning of high school. Started with $10 buy-in tournaments with friends, then $20, $50… Eventually I was playing $1/$2 cash games, then $2/$5, $5/$5 PLO, and eventually capping at $5/$10 home games.

I was able to roll up my bank roll with disciplinary money management, reading away from tables, watching Youtube videos, googling advanced strategies, etc. One key lesson, among many others, is what I call timely aggression. It might take a long time to build up the image that you’re a manic gambler, but once you flop that made-hand, you play it aggressively like you would with your marginal hands and bluffs. People eventually pay you off with their marginal hands, while you hold the nuts. To sum this up in simpler terms – you appear aggressive while doing damage control with your bad hands, and you get similarly aggressive with your big hands.

Now, contrast this timely aggression with the management we choose in vascular surgery. This is appropriately illustrated in a case of endovascular case in a patient with previous open AAA repair with Dacron. The plan was to stent cover a new stenotic segment within the right common iliac portion of the graft. The surgeon met quite a bit of resistance when trying to advance the sheath before stent deployment. He forced it up, but angiogram after adequate positioning showed blowout disruption of the distal anastomotic site on the right, between the Dacron graft and the native subclavian vessel.

This image is pretty similar to the one I saw during M&M.

Instead of acquiring proximal control from contralateral side with balloon and opening up the groin (aka timely aggression), the surgeon decided to deploy a Viabahn stent over this rupture, basically creating a free floating tube with only radial force of Viabahn keeping itself in place. Meanwhile, patient continued to hemorrhage and became hemodynamically unstable, in the end requiring opening laparotomy to control the hemorrhage and repair of the anastomatic rupture.

Another option besides primary repair of the ruptured site is a aorto-uni-iliac stent graft, fem-fem bypass, and ligation of the proximal side of ruptured side.

When the situation calls for it, timely aggression with open vascular surgical procedure is needed. With endovascular approach being increasingly prevalent, the open procedures are a lost art due to decreased utility, training and some might call “laziness”. I firmly believe in the importance of betting my strong hand aggressively in poker, as well as being ready for open procedure and damage control when situation calls for it.

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