“Look at every path closely and deliberately, then ask ourselves this crucial question: Does this path have a heart? If it does, then the path is good. If it doesn't, it is of no use.” ~Carlos Castaneda

Wednesday, April 25, 2007

Patience young padawan ....

“All human wisdom is summed up in two words - wait and hope”
~Alexandre Dumas Père

Perspective is everything. Depending on your stage in residency, you will be concerned about different things when you perform a surgery. Depending on your practice, you may have cases that are routine to you, and then there will be cases that you may consider your "big cases." You may develop a system of how you approach these larger cases. I have my own way of approaching big (i.e. more challenging or risky) surgeries. I tend to approach them like when I was involved in sports and right before big game. I will give you a picture into my mind on the day of a routine big case, a scoliosis case.


5am: Damn alarm. I don't want to get up. No you have to, time to run. Where are my fff --, oh there are my shoes. Ok, oatmeal, coffee and then time to run.

7am: (ring ring) Clerk say, "Hello." I say like I am just happy to be here, "Hey it's Dr. P, I am here in the hospital."

715am: Discussion with family about surgery and answering any additional questions. The same questions I answered in our preop conference.

730am: Scrubs are on. It is now game time. Head phone in my left ear. Tool is playing.

"10,000 Days (Wings Pt. 2)" TOOL

We listen to the tales and romanticize,
how we follow the path of the hero.

Boast about the day when the rivers overrun,
How we'll rise to the height of our halo.

Listen to the tales as we all rationalize,
our way into the arms of the savior.
Fading all the trials and the tribulations.

None of us have actually been there,
Not like you...

The ignorant fibbers in the congregation.
Gather around spewing sympathy,
Spare me...

None of them can even hold a candle up to you.
Blinded by choices,
hypocrites won't see.

But enough about the collective Judas.
Who could deny you were the one who illuminated?
Your little piece of the divine.

This little light of mine it gives your past unto me,
I'm gonna let it shine to guide you safely on your way.

Your way home...

I walk in to the room, silent. The x-rays are on the board. Ok, double major curve, 80 over 80. Screws at ... I begin writing on the white board, acknowledging only my scrub person. No one speaks to me. I don't like the small talk. I am focusing on the task at hand. Screws at T3-9 ... Resident comes over, he says nothing. I finish my notations on the board and my scrub starts making note of the number of screws and sizes. Disturbed is playing. This is my favorite part. (You know the part they won't play on the radio)
"Down with the sickness" Disturbed

No mommy, don't do it again
Don't do it again
I'll be a good boy
I'll be a good boy, I promise
No mommy don't hit me
Why did you have to hit me like that, mommy?
Don't do it, you're hurting me
Why did you have to be such a b!t@h
Why don't you,
Why don't you just f#%k off and die
Why can't you just f#%k off and die
Why can't you just leave here and die
Never stick your hand in my face again bitch
I don't need this shit
You stupid sadistic abusive f#%king whore
How would you like to see how it feels mommy
Here it comes, get ready to die ....

(Guitar riff is playing) I look over at the patient. F#%kin' ansethesia. Why does it have to be like groundhogs day? Why do I always have the CA-1? Why does it take them 1 hour to get lines in a normal child? FFFF#####%%%%%%KKKK. Be patient, breathe.

Spine instrumentation rep, Joe, says, “So, you been busy?" Why does he feel the need to speak to me at this moment? He knows I don't like small talk now. "Well, you know its summer. Busy season for us," I say and smile.

My resident today is Paul, ortho year 2. He has never done spine before let alone a deformity case. UUURRRGHHH, this is going to be painful. My only hope is he knows how to use a cobb. "So, Paul, while anesthesia is getting the lines in, give me the Lenke Classification of this curve." I wish the Guano Apes didn't break up. That lead singer, man, she totally rocks out.

"DICK" Guano Apes

Don’t say a word
life is like a sin-phony
brave as you dare
there’s nothing but your gain
so take off your shoes
and coming down from ecstasy
hide and turn loose
that’s why i force you to

walk like a stag
talk like a stag
come watch yourself
walk like a stag
who could wear my pants

no dick
you got no
yeah yeah how come ...

To Paul, "Ok, let's start getting the table ready. In the prone position, you need to pad here ... here ... and here." Good they are finally putting in the foley. I close my eyes. Ok, posterior approach. Knife, retractors, bovie. Watch for the bleeders, they are always there. X-ray. Burr, gear shift pedicle probe, tip out, probe pedicle, tip in, enter the body, probe pedicle, measure tap, screw. This is standard. Remove facets. Release concave side well. Rods cut. Place. Done. Simple. You have done this many times before.

"Are we ready to flip," I say. "Ok anesthesia count." She says, "1 .. 2.. 3." The patient is flipped. Everyone starts to scurry around the room. Breathe, patience, slow your hands.

"Bill, do you have good wave forms?" I say to my neuromonitoing guy.
"Sure do, Dr. P."

"Ok, you all ready? Go head and prep." Last song, focus.

"Judith" A Perfect Circle

You're such an inspiration for the ways
That I'll never ever choose to be
Oh so many ways for me to show you
How the savior has abandoned you
F#%k your God
Your Lord and your Christ
He did this
Took all you had and
Left you this way
Still you pray, you never stray
Never taste of the fruit
You never thought to question why

It's not like you killed someone
It's not like you drove a hateful spear into his side
Praise the one who left you
Broken down and paralyzed
He did it all for you
He did it all for you ....

I walk into the bathroom to pee, the last one for a little bit. Time to wash my hands. I take my head phones off. While washing, I close my eyes. Lord please guide my hands today so that I may do good and cause no harm. Please watch over us so that we may do what is right for this child. AMEN.

We finally begin the case. "Knife to the young doctor. Ok Paul, go from here to here." Ok, with the next pass, you can actually go through the skin. "Good job, wheaty to me. Paul take your bovie and cut between my snap. So, where are the normal bleeders we will encounter while approaching the spine." I know he will have no idea. They never do.

OK, it is 930, we are exposed. "Let’s pick a level we know we are going to fuse. Alright, burr." Patience, same steps every time. "Tap, screw..... OK, C-arm. let's verify these levels." .... "Good we have enough exposure."

I put in all of my screws. Now it's Paul's turn. Be patient. "Ok, Paul have you looked at the pedicle screw chart."

Paul says, "yeah."

"Ok, well then let's go. Burr to the young doctor." He picks up the burr with one hand and starts to go towards the spine. "Stop! Now, Paul, everything over the spine is a two handed instrument. Brace yourself, and don't plunge, because that would make me sad." I show him how to place 5 screws, but I put the rest in because of time.

"X-ray!" Well that wasn't so bad, that stressor is over. "Bill, how are those signals." Bill shouts, "great." Good, xrays are good. Ok, what time is it? 1030am.

"Paul, can you cut rods this length?"

"Sure," he says.

"Ok, rods. Cap." FFFF#####%%%%%%KKKK, why do they always have to go on break when we are at this part, g*d d@*n, mother f#%ker, sh1t, b@$t@rd, Son of a b1^ch. "The cap is in that tray, use the blue handled ... Joe help her." I close my eyes. Breathe, breathe. Why me, what have I done? I think they must hate me.

"Xray ... That looks pretty good. Let's see how the xray looks."
"That looks FFT baby." FAN-F#%k!n-TASTIC. "Final tighten and let's close. Put on the Idol man.”

Shouting out, “Bill are you happy?"

“Yes Dr. P, I am happy.”

“Well, alright. Let’s rock out.”

God, I thank you god guiding my hands. Amen

“The two most powerful warriors are patience and time.”
~Leo Nikolaevich Tolstoy


Anonymous said...


Better not plan on moving to Massachusetts any time soon. What if you blew out a pedicle and 5yrs later the patient has back pain once in a while?

I can hear the lawyer now: "If he wasn't listening to that rock'n'roll music, he wouldn't have destroyed the spine bone and the plaintiff would likely have fulfilled her dream of being an Olympic gymnanst."

You know there is probably a chiropractor somewhere who would agree. Its only a matter of time before "they" (whoever makes the decisions about malpractice) decide the doctors are all colluding and that you do not need an equally qualified peer to testify, but only a "specialist" in the same field.


Happy days, happy days!!!

Someone interested medical student and resident education. said...

as you notice from what I wrote, the music ended right after the prep and and was only through my own earphones. it picked up again at closure. :).

video taping, it is another expense. who is going to tape, process, and store all the surgeies? another governmental expense? patient? insurance carrier?

as far as the chiro's go, they know musculoskeletal treatments. they are very much like physical therapists. patients love them because they put hands on them, but there abilities are limited and they need to know their limitations. some don't. if i have 1 more chiropactor tell a family without scoliosis that they have it an their manipulation made the nonexistent scoliosis better or the patient with the 70deg. curve their manipulation will make it better. i think i will, well do what i normally do, shake my head.

i have friends that are chiropractors and i learn a lot about non op treatments, stretches, etc.. so they are not all bad :).

as far as the OR, during the case, you always have to do what is right for the patient. i think the more distressing thing about the OR is that the other conversations are about 10x's more distracting than any music that is being played. i like toby lightman while we are working around the cord. opening and closing something that rocks out a little more. the idol is great for closing because who can't love white wedding

Anonymous said...

Sounds like a hospital expense under a threat of fines/sanctions. Expecting providers to accrue expenses for the sake of regulations is nothing new and I doubt anyone's health plan for the 2008 election will list that as another out of control healthcare cost.

I, and I think a majority of people in ortho, have a similarly guarded respect for chiropractic care. They clearly help a lot of people and likely help a lot of people who under a more surgeon directed treatment course would have had an operation. I think everyone shares the same fears - the missed surgical urgency/emergency. This is often made worse when you review the films brought in from the chiropractor's office - it is hard to believe they ruled out a tumor or fracture when we cannot rule in that there was even a patient in front of the cassette it is so over penetrated. The only other concern I have is a lot of patients who have seen a chiropractor are locked into some big payment plan at the first visit.

I think the conversations would disturb outside observers more than anything case driven ("gross" factor aside). Anyone overweight would be offended when they hear how poorly regarded their body-type is by those who do the cases - particularly as you approach the axial skeleton.

I'm still over a year away from picking the music - can't relate.

Midwife with a Knife said...

That was great. I particularly liked the musical interludes. :)

And, ftr, some chiropracters can do particularly nice things with musculoskeletal back pain/SI dysfunction in pregnancy. Others refuse to see pregnant women. And others still are quacks. Kinda like any other profession, I guess.

Someonetc said...

thanks all for the comments.

i do believe chiropractors have a role. i think we all need to know our limits. some of them don't and that frightens me.

to my girl MWWAK, it's funny to see how people take the musical interludes. the music i listen to running and prior to cases is pretty hard. that is why i have my head phones on, don't want to subject my staff to my swearing "angry white boy music" (that's what i call it). it is more the driving bass beats that focus me.

everyone has there own system of what gets them going. i have a friend that love a little john denver (puking sound). that's not me. i do feel that as far as music is concerned, you must be respectful of others and play what is appropriate to those who are with you. i use to bring music into the room for the cases. no i let the residents choose. they all have those 60 gig ipods and speakers. i just have final veto power.

Taylor's Dad said...

Hello friend,
I enjoyed this little peek into your mind in the OR. You are not alone. Some may think that music + 4 letter words + prayer are an odd combination during such a case. I think otherwise. I, too, pray, curse, and listen to music while very deliberately appearing cool as a cucumber to all around me during surgery. I find my actions and appearence very much influence the staff during surgery. However, a peek into our minds would often show a different picture. I think all it means is we are human.
Strong work on letting the residents fully participate in your cases - this is a needed skill/characteristic that most of us (me included) do not have.
Someone recently gave me some good advice that I'll restate here: stay open-minded but keep doing what works. Stay strong.