“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, September 22, 2007

Think before you shoot ....

“I know that you believe you understand what you think I said, but I'm not sure you realize that what you heard is not what I meant.”
~Robert McCloskey

I really enjoy the interaction with my medical students and residents. I like to see their eyes light up with new knowledge and experiences. It is like hitting the sweet spot on the golf club; it is what keeps you coming back for more. As much as it can be a joy, it can be an enormous headache.

For many surgeons, there are cases that we commonly do. We do them so often that it becomes like second nature. Our moves are effortless. We have our favorite instruments and our favorite retractors. We know what works for us. When teaching someone your techniques, you have to put into words what has become second nature to you. This can bring on some frustration from both the educator and the learner.

In my practice, the most difficult techniques to teach are the percutaneous techniques. What makes this difficult to teach? For percutaneous techniques, you need to have a mental picture of what is underneath the skin without seeing. Using skin land marks, 2-D xray images, and other room indicators of position, you should be able to determine your position in a black box. For most novice surgeons, there 3-D understanding of anatomy is very limited. They rely a lot on vision and fluoroscopic images to determine position. In percutaneous procedures, vision is taken away. The lack of visual input created a void of input and the causes an extreme reliance on fluoroscopic images. With only one input, they become confused and frustrated; they lose orientation; they lose focus. I lose hair.

For the pediatric orthopaedist, the supracondylar humerus fracture (SCH FX) is the most common fracture that we operatively treat. In my hands, >95% of SCH FX can be treated closed or percutaneous. If I do a Type II or Type III SCH FX, after draping, it takes about 10-15 minutes. Quickly, my routine. Patient in the room and intubated. Metal anesthesia Christmas tree on the operative head side with a foam pad. Patient moved to the edge of the bed, on the operative side. The bed is turned. The C-arm is turned upside down and used as a table. The are is prepped and draped. Using fluoroscopy, the elbow is reduced and arm is held flexed with a coban. Then I place 2-3 lateral to medial 0.625 K wires. The coban is released. The positions are checked and the fracture is stressed. Pins are bent and cut. Easy as pie right. But, the hard part is placing the pins. This is where I struggle.

The placement of percutaneous pins or any percutaneous procedure requires a specific understanding of the anatomy and the ability to uses references to identify the position of what you cant see. If you can imagine, you have a black box that you can not see into and you have to place instruments in a specific position based on references and a 2-D image. Oh, and the box is moved to get the opposing 2-D image. This is difficult. Because the young surgeon relies so much on the fluoroscopic image, they are easily disoriented. They start randomly placing pins without much other reference/sensory input. This is what I refer to is the Young Skywalker Effect.
Ben: Remember, a Jedi can feel the Force flowing through him.
Luke: You mean it controls your actions?
Ben: Partially, but it also obeys your commands.
Han: [laughs] Hokey religions and ancient weapons are no match for a good blaster at your side, kid.
Luke: You don't believe in the Force, do you?
Han: Kid, I've flown from one side of this galaxy to the other. I've seen a lot of strange stuff, but I've never seen anything to make me believe there's one all-powerful Force controlling everything. There's no mystical energy field that controls my destiny. It's all a lot of simple tricks and nonsense.
Ben: I suggest you try it again, Luke. This time, let go your conscious self and act on instinct.
[Ben puts a helment on Luke covering his eyes]
Luke: With the blast shield down, I can't even see. How am I supposed to fight?
Ben: Your eyes can deceive you. Don't trust them.
When doing percutaneous procedures, you must begin to take away variables in the room. You must make unknowns a known. You must take what things you know and make assumptions about the unknown. Of course the more you do, the easier it is. I ask my residents to "think before you shoot." That means, before you take an x-ray, think about where you position is in relation to your other knowns (skin and bone landmarks). (One thing I hate is x-raying without a purpose.) Then I have them place a pin in the best position. We check both an AP&LAT x-ray. If it is good, next pin; if not, leave the pin and USE IT AS A REFERENCE. You know where you pin is on the AP&LAT x-ray, place you next one using the first one as a reference. Use it like a compass. It is just that easy. Well, it sounds easy. It is easier said than done.

For all of you novice and advanced beginner surgeons, think before you sho0t. Learn your anatomy and find ways of making the unknown of the "black box" known. If you are using a fixed anatomy, pinning a hip on a fracture table, use fixed room land marks (the floor, the fixed fracture table post relative to the floor, alignment of the C-arm) to help guide you. At times, it does feel like you are using "the force."

“You are rewarding a teacher poorly if you remain always a pupil.”
~Friedrich Nietzsche


Chrysalis said...

I am amazed at what some of you are able to learn and do. It sounds like this is an area where you would need good spatial skills. Not everyone can do this easily. Isn't this related to the temporal region of the brain? I'm uncertain. I only know some are better at it than others.

It was interesting reading this, and learning how you would use the one pin to help you figure out the placement of the second and so on, "Like a compass". Glad to see you've posted again.

Someonect said...

thanks for coming back. i am still searching of ways of making teaching technical skills easier. you have any suggestions, i would gladly try them. thanks for your comments chrysalis

Chrysalis said...

I doubt I could be much help to you in this realm...

I really like your site here. It's interesting, and I love to learn. There is a certain something else here as well. I'm glad you post when you can. Don't worry about doing it though. You won't lose your readers.
Come here when you can.

make mine trauma said...

Very interesting post. I have a better understanding now of the frustration of percutaneous procedures. I assist a "new" (he's in board collections now) orthopod regularly. He uses some of those tricks, leaving a misplced pin for reference, aligning the drill with the c-arm for drilling the distal lockers on a femoral nail.
Got any tricks for getting the guide wire through a femoral shaft fx while only using the AP view? I have often wondered about using two c-arms with one set up in AP, and the other lateral, as they do in kyphoplasty.

I love the reference to "The Force" Can't wait to use that one on him!

Someonect said...

make mine trauma,
i don't have any special tricks. there is a new c-arm called the O-arm (http://www.medtronicnavigation.com/procedures/intraoperative/o-arm.jsp)

there are tons of little tricks. the key is having a picture in your mind of how things should be and superimposing the 2-D picture over your minds view.

by the way, i hate distal locking screws.

thanks for stopping by.

Anonymous said...

why can't they have a jig (like the one for the proximal neck screws) for the distal screws as well?

Someonect said...

they have tried. the distance from where it attaches and the distal screws creates too much error.

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