“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

Saturday, March 17, 2007

Oh sir... it's only wafer thin ...

“A man's errors are his portals of discovery.”

~James Joyce

Orthopaedics residency, for me, was a wonderful experience. The
camaraderie between residents and surgical services was wonderful. It almost felt like being in a fraternity. You scratch my back and I'll scratch yours. We looked out for each other. I always felt I could count on my fellow residents to cover my back. On the same note, we always had attending supervision. Therefore, when things became a little more difficult, there was always someone senior to step in and complete the task. During this time, I never felt sick. I never felt a sense of doom.

As an attending, especially in the first couple of years in practice, there are times when you just want someone to take over the case. You may be in a trauma or revision total joint and have planned everything out. You have all of the equipment, etc.. You feel you are well prepared. You even looked in the "books with pictures" and reeducated yourself on the complexities of the procedure at hand. You have looked at all of the bold faced and italic items. You may have even checked with your senior partner to make sure you have not missed anything. Now you are ready.

After the case has begun, you go step by step. Things are going well. Then, something changes. An alteration from what you saw in residency or a change from what you read in the book. Maybe there is a bleeder you can't get or a critical screw that has broken out or you lose motor and/or sensory evoked potentials. This is what separates the men from the boys. At first, you will have a sinking or nauseous feeling. This is the time you need to become very focused and concentrate on what needs to be done. This is not a drill. You have to start thinking clear and concise. You have no one to bail you out. As in a code situation, first stabilize the situation (i.e. for a bleeder, put your finger on it or pack it), then calm yourself down (your adrenals will have been squeezed, and you will be shaky), gather your thoughts, and begin to go stepwise through and fix the procedure. The most important thing to understand, if you have a partner in the OR or close by in the office, REQUEST HELP. This is not the time to be bull headed and feel you can do everything. It is not a sign of weakness. It is smart to get someone who is not involved to look at the situation objectively.

Once the situation is stabilized, and the patient is out of the room, I feel it is important to look critically at the case and understand the errors you may have made in initial assessment, surgical approach and exposure, surgical technique, and emergency management. In the military, this is known as an After Action Review (AAR). I feel this is an important step in the growth of a surgeon / physician. The ultimate AAR is M&M (morbidity and mortality) or D&C (deaths and complications). In M&M, we can learn from others mistakes or misfortunes and hopefully apply that experience to our own practice.

This situation does not only apply to the OR. It can also happen in clinic. You may be in clinic and have a patient that comes with the same complaint and you realize they have a different problem than you initially thought, or maybe a fracture reduction has lost it's position, or a wound looks infected, or your surgery has fallen apart. You will get the same sense of impending doom. It is important that you act on these appropriately. You may ask a partner what he or she thinks. This is an objective view and takes away our biased view of the situation. It is always easier to see someone else's error. DO NOT neglect the situation. If you think there is a problem, prove it is not. When I was a junior resident, one of my chiefs said to me, "If you think it is infected, it is infected until proven otherwise." These words stuck with me.

In the end, remember we are all human. It is important to know your limitations. These limitations become more evident with experience. When you get to the extents of your knowledge base, experience level, or comfort level, ask for help. We go in this specialty to help not harm patients. It is not time to have an ego. If you do what is right and are honest with yourself, you will gain the respect of both you peers and patients.

“Good judgment comes from experience. Experience comes from bad judgment.”

~Bob Packwood

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