Lessons from the movies - how to be a consultant surgeon

When the more senior trainees approach me, as they frequently do, seeking my advice on how to behave as a consultant, I can offer no greater example than this early training film**:



Of course he's a dinosaur, completely out of touch with the modern world - the labs haven't done the bleeding time for years.

**under no circumstances should you base your practice on this other movie.

PS: thanks to my Greenock colleagues for the recommendation

The midnight hour

Even with the lousy anti-training New Deal foisted on the medical profession by the BMA and their dweebish unclinical negotiators, junior doctors - if the term is still permitted - can still end up doing a true on call, rather than shifts, and can still be called in in the middle of the night.

It seems not to be like it was however, and in many ways that's a good thing.

In the early 90's, before we had consultants in Casualty (which became A&E, now Emergency Medicine, these guys are very into semantics), patients still survived. I do welcome senior Casualty/A&E/Emergency Medicine presence, and I'm sure it's saved a few lives, though there can be a downside in terms of ownership of the case and the early decision making. But I digress.

It was correctly recognised that having a raw untutored SHO trying to resuscitate two polytraumas on his or her own, waiting for the cavalry to arrive, was not ideal. I've been there, it was pretty tough. So in my hospital we instituted the 'Trauma Bleep'. The deal was that there were three pagers held by the senior registrar in orthopaedics (me), the senior registrar in general surgery, and the senior registrar in anaesthetics (the important one, though I hate to admit it). If the bleep went off, you went straight to Casualty, no questions asked. It worked over many miles, so there was no escape. In any event, there were no mobile phones then, if you were out and thought you'd call in to see if you were really needed.

Most of the calls were not that critical, plenty of low grade stabbings that barely made it through the dermis, but there were still quite a lot of people who benefited from rapid resuscitation, airway security and all that. It coincided with the emergence of ATLS in the UK and the whole thing was really a big step forward in quality.

However, it could be bruising. My worst night I went in (a 6 mile round trip, so not too bad) at 11.30pm, got home at 2am, in again at 3am, home at 4.30am, in again at 5.30am, home for a shower at 7.30, staggering in to work for a full day starting at 8.30am. None of the cases was major trauma, but we were there, just in case.

You have to be at the bedside/trolley side to properly assess things, and it's a dying art.

I'm not recommending a return to that, but I still do on call from home, and I still go in. It's easier now as a consultant - much easier in fact, for various reasons - than it was 10 years ago and 20 years ago, when we were always having to go back in.

All this is a long winded preamble to a piece lifted in its entirety from the magnificent GomerBlog, which is mostly written by frontline clinicians. You can always tell....



On-call ophthalmologist heroically manages eye emergency from bed

DES MOINES, IA – Answering his phone in a daze at 2 AM last night, on-call ophthalmologist Reece Barnett reportedly handled a vision threatening eye emergency from the comfort of his nice warm bed.

“It was intense,” says Barnett.  “At first I was propped up on one elbow when I answered the phone. Then the emergency doc told me the patient had severe vision loss.  At that point, I sat straight up in bed with my down comforter only covering my legs.  I started getting a chill, but you gotta take these things seriously.” 

Barnett was able to listen to the patient’s history in between yawns, occasionally having the consulting doctor repeat things while he rubbed the crust from his eyes.  After several seconds of thoughtful consideration, Barnett thought it would be best to see the patient in clinic in the morning.

“This was a tough situation,” reports Barnett.  “By the end of the conversation, my sheet was all bunched up and my pillow was flat in all the wrong places.”  When asked why he elected to see the patient in the morning, Barnett replied, “By the time I get out of bed, get in my car, drive all the way to the hospital and see the patient, it will only be a few hours until morning anyway.  This is the best thing for the patient.”

At press time, Barnett was seen coordinating care for a patient with ocular trauma while wearing his eye mask.

I don't want to just pick on the eye guys, when did the on-call (and paid for it) dermatologist/breast surgeon/nearly all physicians/psychiatrist last come in at 3 in the morning?

It's bad enough trying to get a bedside visit during the day**.

**there are of course many honourable exceptions to this genuine and somewhat alarming trend

Celebrity trauma: Deniz Tek

Deniz with Iggy

In a bland era of X Factor music, you need someone like Deniz Tek. As the great man put it, talking about the onset of punk, following what he calls the 'post-hippie malaise period' of the early 70's (I remember it well):

At last, somebody getting back to basics. You compare it to maybe one or two years before, everybody’s listening to a triple album by Yes called Tales from Topographic Oceans, and if there’s anything more boring in the world, you’d have to tell me about it. That was just the epitome to us of the dreadfulness and horror of what music had become, and it was a breath of fresh air when these New York bands started blowing all that away.

There's a lot out there on this polymath, but put simply, if you like punk, metal, surf music, and the darker edges of those, like fellow Australians (sort of) The Saints playing Nights In Venice, then you'll love Tek and his awesome band, Radio Birdman. Or as this website said, he’s the “axe-wielding rock soldier commanding the legendary Radio Birdman blitzkrieg”, which is about right. Think also Stooges, MC5 (both bands were his buddies), Blue Oyster Cult, early Alice Cooper etc. Halcyon days.

But why am I writing this? Most orthopaedic surgeons these days seem to listen to Ed Sheeran or U2, who make the previously mentioned Yes seem like the Sex Pistols. The above named bands are the antidote.

Well Tek is different. When he was in his band in Australia (he's actually from Michigan) in the 70's he was studying medicine at the University of NSW. He got the textbooks out on tour.

In the 80’s he joined the US Navy, based in Hawaii and ended up as a flight surgeon organising medic evacuations, major trauma protocols and delivering emergency care all over the world, in all climates. His radio call sign actually was Ice Man.

He subsequently went on to run an Emergency Medicine service with a lot of trauma in Montana, and now combines music with painting, writing and doing EM work part time in both the US and Australia. You thought you had a complicated life?

Here he is on the professional medic/rock musician dichotomy:

"usually if it's a busy shift or there's heavy things going down I don't think of anything else until the shift's over. The other thing is you can compartmentalise and whilst I'm taking care of sick people music doesn't intrude. I think that in aviation there's a lot of value in that also. Guys that climb into the cockpit of a jet have to be able to leave their family problems behind. Y'know...the wife's goin' out with someone else or the kid's on drugs. They climb into that cockpit and if they don't do everything exactly right they're gonna die...and may be kill other people too.

One of the requisites for that is to totally compartmentalise your mind.  They screen pilots for that ability in psychological tests. If you're not that sorta person...you're just not right for the job."

Fair point - ever had the stress-inducing bleep about a family matter when you’re  in the middle of a long operation? Compartmentalise!

His website is excellent on many levels, but I particularly commend this tale of being called out to a military plane crash in Arizona. Even the Guardian likes him.

He gives career advice too:

"Any encouraging words to the young kiddies?


Work hard at whatever it is you like to do. Nothing worthwhile comes easy. And stop complaining."

Old farts strike back: surgery and bible edition

...obviously not ALL the old stuff is good

If I may get biblical,  from the Book of Job, 12:12 - With the ancient is wisdom; and in length of days understanding.

With this in mind, although I've nothing against him personally, when I'm urged to read Atul Gawande's books about aspects of surgical practice, particularly outwith the technical skills, I wonder what makes him such an expert.

Here's the evidence:

Qualified in Medicine at Harvard in 1995 aged 30
Master of Public Health degree in 1999, then 6 years of residency training in surgery - ie. junior doctor acquiring experience - till 2003.
He spent quite a bit of time from the late 80's involved in writing magazine articles and working in Democratic politics.

His first book, Complications: A Surgeon's Notes on an Imperfect Science, came out in 2002, when he was still a junior doctor in training, far from the finished product. The next one Better: A Surgeon's Notes on Performance, was released 5 years later. I assume he'd been busy in clinical practice for this time, with possibly some of the previously noted extracurricular activities getting in the way occasionally.

An NHS consultant surgeon, 5 years in, working in a busy hospital is, in my view still very much on the learning curve. 'Surgical maturity', I would say, is at least 10 years in. Some people never get there.

Gawande's Wiki entry implies that from about 2009 onwards he was doing more and more non-surgical things, fair enough, he seems an interested and accomplished fellow, but I feel very strongly that the way you get better in medicine is, I'm afraid, long hours, year in year out, in the wards, the theatres and the clinics. It's a lifelong thing, even if - as I do - one has plenty of other interests.

One of the classic scenarios in the NHS is the consultant who having got to the top - as it was perceived in the old days - realises that he or she wants to get out. Often 'management' and 'governance' are the dubious beneficiaries of their career move, which amazingly usually involves telling working clinicians what to do. Not that I'm accusing Gawande of that, but some individuals closer to home, certainly.

Anyway, this preamble is to praise the benefits of long, hard won clinical experience, especially of the surgical kind. There is a significant difference between prescribing a drug - which could do harm - and opening someone up with a knife, which is intrinsically harmful before it gets better, even if everything goes well.

Is there a plausible alternative to working the hours? I think not. Don't get me started on the world of 'simulated surgery'.

All of which brings me to a fascinating interview with both Stephen Westaby (69), heart surgeon and Henry Marsh (67), neurosurgeon. Both have a public profile, both have performed thousands and thousands of challenging high end operations, for the NHS. With respect to the aforementioned competition, these are the guys that I want to hear from. They've also written books for the general public, as it happens.

There are numerous gems in the interview, here's some tasters:

HM:  We have this very complex relationship with patients. It’s not one of straightforward altruism at all; it’s a very difficult relationship. You have to be both hard and soft at the same time. You certainly don’t want to be empathetic. If empathy means you actually feel what your patients are going through, actually . . . you can’t do it.

...the problem is you could spend the entire national income on healthcare and everybody still dies — there is 100 per cent mortality — so you have to decide somehow where to set your artificial floor on that bottomless pit.

...[When he was PM] David Cameron made this speech about we must have “zero harm” in the NHS, which struck me as the most incredibly stupid thing to say because it suggests that when anything goes wrong, therefore somebody’s to blame. The whole point about medicine is it often goes wrong. The decision whether to operate or not, to recommend an operation or not, is all about probabilities, and these are very subjective, difficult judgments. Everything we do is in the face of uncertainty and a lot of the time patients come to harm. It doesn’t necessarily mean that anybody’s at fault. So I thought that was a very, very naive and rather silly thing to say.

SW:  The job is difficult enough without having the press and everybody else on your back. A British heart surgeon had the idea when he became the medical director of the NHS that surgeons’ death rates should be published and available for the newspapers. Let me ask you: which surgeons would have the highest death rates, the worst ones or the best ones? The best surgeons attract the worst patients like a magnet. So if you want to make your best surgeons defensive, you start counting the bodies and putting it into the public arena. My particular branch of the profession is now risk-averse. Fewer heart surgeons want to come to Britain to do heart surgery and the British especially don’t want to do heart surgery. They’re long operations, you can end up operating all night, every day of the week, and it’s taxing and it’s rotten when people die. It’s totally rotten to have to go out of an operating theatre and tell a couple of young parents that their baby’s just died on the operating table. It’s misery. None of us lose patients because we’re careless or don’t care. So I’ve seen my profession wrecked, I’m afraid.

HM:  Forty years ago, the power structure in hospitals in this country was very simple. There was a senior doctor, a senior nurse and one manager, and basically the hospitals are run more or less by the senior doctors, for better or for worse. Now you have a whole series of competing pyramids. The management, the doctors, the nurses — more or less autonomous now — the other paramedics and physios and people like that, so there’s a real sense of nobody being in charge. I would go to work in the morning and I wouldn’t know what I was going to do that day because it all depends. Is there a bed? Is there an intensive-care unit bed? Is there a bed on the high-dependency unit? You have to negotiate with each of these individual power structures, it’s deeply chaotic

...Another example is that, after the Stafford scandal [over nursing care] and the Francis inquiry [into it], the General Medical Council wrote to all the doctors saying that when a mistake is made you must apologise and then it said that this is usually the duty of the senior clinician; in other words, whoever makes the mistake, muggins here has to go and say sorry. And then thirdly it added that for an apology to be meaningful, it must be genuine. If the GMC can’t see there’s a problem here — if an apology is compulsory, how can you force it to be genuine? Well, the answer is that it is genuine if the senior doctors have a sense of authority, if they feel they’re trusted and then they do feel responsible for what happens in their department.

Just superb, and not calculated or self-serving, simply real world experience of something very important. Westaby's line "The best surgeons attract the worst patients like a magnet" is very very true.

I'm also ending with a bit of biblical advice, Jeremiah 6:16 - put yourself on the ways of long ago and enquire about the ancient paths: which was the good way? Take it then, and you shall find rest

Trainees, your aged consultants will guide you in 'the ways of long ago'. Catch them before they retire.

The earthquake dislocated my hip replacement

When I was training, one of my distinguished bosses, an academic, used to tell me about one of his trainers back in the 70's who used to listen to the occasional patient in the clinic who'd not had a good outcome. He'd acknowledge their unhappiness, and indeed, empathise very effectively. When the frustrated patient eventually left the consulting room, he'd turn and face his registrar (my boss) and say sadly:  "funny fellow that".

The moral of the story - as it was emphasised to me - was never blame the patient.

Own your own mistakes and bad results. Be brave, dig deep. Good advice, I suppose.

Later, as my boss approached retirement, he'd show me an X ray - often of a knee replacement who'd got some residual pain - and say something like "I can't see much wrong with it. He's a strange fellow though. You never succeed with people like that"

For any one case he may have had a point, but he'd forgotten his own advice. Never blame the patient.

So blame can be an issue. Not in the medicolegal sense, more in terms of peer respect and apportioning embarrassment. Maybe that patient fell because your hip replacement dislocated, rather than your assertion that it dislocated because they fell. We're only human after all.

So in the spirit of making excuses for cock ups, I give you a short video of a  handy set of excuses for the next time you have had a hand in a surgical complication.  One of them will apply, I'm sure.

Parachutes and the pelvis

*

That old saying, that an X ray is just a 2-dimensional snapshot of what actually happened, is true.

When the acetabulum fractures, the femoral head may have been halfway across the inside of the pelvis before it bounced back to where it sits on the X ray, to give one example. The injury is everything that got damaged then, not just what that 2D X ray shows. The average pilon fracture is equivalent to a small explosion in your ankle.

Most of this less obvious damage is soft tissue of course, hence the appeal of Oestern and Tscherne's slightly clunky classification of soft tissue injury, as a counterpart to Gustilo in open fractures. It seems fairly accurate, but does anyone actually use it?

A lot of pelvic ring fractures and related injuries are essentially internal dislocations of the pelvis through the symphysis and SI joints. They spring back usually, even the vertical shears to a large extent, but can you imagine what it's like at the moment of injury?

Well, imagine no more.

A big hit at the moment is Admiral William McRaven's very short and readable set of life lessons, expanded from his speech to graduates at his alma mater, the University of Austin, Texas. Rest assured, it's not a mindfulness manual. McRaven was the chief of the US Navy SEALs, and ran the operation that took out Bin Laden.

In fact it's not unlike Leo Gordon's matrix lessons, a staple of this blog.

The more general point that McRaven is illustrating with the following excerpt is that we all need help sometimes, and success in something is rarely down to ourselves alone. He describes his very tough rehab after what I think was a very bad 'open book pelvis', which happened in midair. Honestly. His description is pretty vivid...





....the book is genuinely worth reading. This particular episode confirms what we don't know from discharging people three months after injury, but one does rapidly learn doing medicolegal reports - all trauma has rehabilitation challenges, and many injuries leave you with lifetime symptoms, long after your injury has officially 'healed'.

Celebrity orthopaedics: Gabriel Batistuta, Marco van Basten and a disquisition on pain

Here's a scary description:

I left football and overnight I couldn’t walk. I wet the bed even though the bathroom was only three meters away. It was 4am and I knew if I stood my ankle would kill me.I went to see Doctor Avanzi (a world-renowned specialist in Orthopaedic trauma) and told him to cut off my legs. He looked at me and told me I was crazy.I couldn’t bear it any longer. I can’t put in to words just how bad the pain was.
I chose the right leg (to be operated on) as the doctor couldn’t do both.I didn’t care. My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone. That’s what generated the pain.

And here's the author of that description, in action, wrecking his ankles, for our benefit...



Batistuta was probably the best striker of his day, and one of the best ever. If I can quote from the well known biting South American striker of today, Luis Suarez:

The ultimate? Gabriel Batistuta. He was a spectacular No 9 - great at finding space, shooting from outside the box, good in the air. He was always a reference for me and I used to watch the way he played. He took free-kicks as well. I don’t get to take them here! (laughs) but I’d copy him and watch videos of him all the time.

I agree with the sharp toothed Uruguayan. Not only was Batistuta an awesome player, he was a modest appealing person, who always looked super cool. He scored 300 club goals, and 56 for Argentina in 78 games, which is better than Messi.

However, he was wrecking his ankles. He had numerous steroid injections to get him through, and they probably didn't do him any favours in the longer term. 

The assessment of pain severity is one of the hardest things in orthopaedics - one man (or woman's) agony may be another's "well it hurts but I try to ignore it", and yet it's the basis on which we offer complex operations with significant complications. 

Most surgeons would recognise the claim "I have a very high pain threshold, doctor" as probably meaning that the opposite is true. For what it's worth, I never use the VAS 1-10 scale. A waste of time. However, Batigol's description is pretty good, as is (most of) his understanding: My problem is that I have no cartilage or tendons. My 86 kilos are supported by bones alone.

It sounds to me like he had an ankle fusion, not, note, an ankle arthroplasty. He had "two screws surgically placed into his ankle to help alleviate the pain and support his movement" and the outcome?  "Since I’ve had the screws put in, I’m much better now than I was three years ago.” 

"I left football and overnight I couldn’t walk", rings true. Batistuta actually had a long career, 1987-2005 at the top level. I've seen quite a few professionals with completely wrecked knees play into their mid-thirties by limiting training, watching their diet, NSAIDs and probably most importantly, great positional sense. They run about that bit less. When they stop playing though, it goes downhill quickly.


Everyone thinks of knees, with ACL's and menisci, when considering sporting injuries, but ankle problems prematurely wrecked the career of all time Dutch great Marco van Basten, although worringly, he blamed the surgeon. He also appears to have had a fusion, he certainly had bone fragments removed from the joint, back when the unnamed maligned surgeon was trying to salvage things. When the weight bearing surface area is as small as it is, then you know that's going to be associated with major problems. I've done hips and knees on relatively youthful ex-footballers, who still play in kickabouts with no problem. Ankle fusion is not that good, but it's not bad either.

In case you're wondering how good van Basten was...




Here is van Basten's description of his pain. Not dissimilar to Batistuta:

After three years of pain I wanted a normal life again. Just imagine feeling pain every minute of the day, somewhere in your body. And that for three years! It dominated my life. From my ankle the pain bounced back into my whole body. As long as there's still hope you can still recover, you're willing to accept the torture, but after so much treatment and so many medical experiments I finally realised I was running up a dead end street.

And the outcome?

Now I'm glad I made the decision, because I'm finally free of pain and I'm dealing better and better with my handicap

It all goes to show how lucky we are that knee and hip replacement are so good. These other procedures don't really come close, but it's all about the pain.

Remember kids, low impact activities are best when you're old

The surgical ego

You probably need to have a degree of egotism to be a good surgeon, albeit one that is cloaked with a true essential for surgical practice: humility.

Not an easy balancing act. We all meet surgeons who have an excess of the former. I doubt think that I've ever met one who had an excess of humility (myself included, he added humbly).

Anyway, our patients and their complications will help provide the latter, hence the well known perils of schadenfreude.

I give you the following short video from Steve Martin's The Man With Two Brains to illustrate the problem.




 Indeed the whole film is something of a surgical primer, and is one of the more accurate representations of neurosurgery that I've seen. The little girl in this clip is at least an ST2.

Why did you want to be an orthopaedic surgeon?

According to Wikipedia, a Venn diagram is a diagram that shows possible logical relations between a finite collection of different sets."  History buffs will further be fascinated to know that Venn diagrams were introduced in 1880 by John Venn in  a paper entitled On the Diagrammatic and Mechanical Representation of Propositions and Reasonings in the "Philosophical Magazine and Journal of Science", about the different ways to represent propositions by diagrams.

The author takes his role in applying such concepts in science and graphical representation to this blog very seriously.

So here, according to Facebook, I believe (not my scene), is the genesis of an orthopaedic surgeon...

Makes sense to me.

The 654 year old surgeon

The oldies we quote are usually Hippocrates, Galen and folk like that. Here is a new one for me:

Guy de Chauliac makes some good points. It gets a bit tricky towards the end for some surgeons, perhaps. He appears to have been an early proponent of simulated surgery or skills labs, according to Wikipedia:

 "It was seemingly from books that [Chauliac] learned his surgery.... He may have used the knife when embalming the bodies of dead popes, but he was careful to avoid it on living patients".

Dead popes can't be easy to come by.

Bearing in mind the bafflingly poor knowledge of anatomy in UK undergraduates now, he makes another observation:

"A surgeon who does not know his anatomy is like a blind man carving a log"

I've assisted at operations like that.

Probably not peer reviewed. 

Orthopaedic heroes: the sage of Oswestry

Back in the day, about the time when the FRCSOrth examination changed from being voluntary, with a less structured format, to compulsory (though even then it was still a moderately agreeable experience), there were relatively few examination preparation courses. This was the mid 90's, and the main course, I would say, was the one run in Oswestry, overseen by a relatively small group of surgeons, one of whom was David Jaffray.

He was an eye opener to many of the attendees, for quite a few reasons. He had an unreconstructed North East Scottish accent, an unusually informal approach to meeting strangers ("is NAME REDACTED still ******** NAME REDACTED?" he immediately enquired when learning which hospital we'd been working in), a very caring attitude to trainees and patients, and he was an awesomely good teacher. Quite superb, and very funny.

An example might illustrate some of this,  I think I remember it accurately.  He'd been up for a job in the university department of orthopaedics at my hospital, quite a few years before, as Senior Registrar/Lecturer. He came up the day before, to have the standard look round, and try to meet people (still essential, by the way). In the course of this, he began to feel that he didn't particularly want the job. He probably hadn't met the cream of the department, to be honest, but I knew exactly what he meant. The trouble was, he was manifestly the best candidate, and was almost certain to get it offered to him. Backing out at this point was considered very bad form, and difficult to explain. As he put it "I realised that I had no choice. I had to sabotage my own interview". The next day dawned, and the interview panel was the usual mix of university, management, potential NHS colleagues, an external and so on. The questions began, and it came to the turn of the extremely famous and acerbic professor of general surgery, representing 'undergraduate education'. "Mr Jaffray, tell me, what would you suggest to improve our undergraduate course in orthopaedics ?"

I will pass you over to DJ's words, which I still recall: "This was my opportunity, I had to act fast. I looked at him and said firmly 'abandon it!' " This apparently did not go down too well.  "It did the trick. After that I had no chance".

Perfect. And there are lots of other similar anecdotes .

I can't say I knew him really, but we had the odd contact about trainees. He was unfailingly helpful and completely up to speed on all aspects of training, as well as being very frank. Ask around, the man is a bit of a legend.

All of which leads me to the short memoir he put into BJJ News, which is a pure and perfect gem.

If you read this blog, you'll see that one of its themes is the value of listening to the wise older surgeons, many of whom are both highly rated as surgeon/clinicians but also funny, smart and charismatic figures. There are lots of fine surgeons about. There are probably fewer really gifted  trainers. There are even fewer who combine the two at a very high level.

The paragraph on the right is a tad pessimistic , and I can vouch from my own experience that being ...er...candid  (as opposed to confrontational) is often welcomed by senior management who may be as sick of the daft aspects of bureaucracy as you are. Meeting colleagues face to face is nearly always the best way of dealing with issues. Beyond that, the whole article is laden with  reflections, wisdom, humour and practical tips, culminating in a profound final bit of maternal advice.

Read and learn!

Old farts may be correct shocker!!

From a recent BMA News (normally awful), presented without comment, other than to say: good points, well made.

True dat

Our orthopaedic ancestors

Could you think up an operation like this?

There are an awful lot of very good surgeons about these days. And of course we all consider ourselves at least slightly above average - I know, a statistician's nightmare - but how many great surgeons, or surgical pioneers are there?

Answer - not many.

So when you meet these people, or more probably, when you work with one of their previous trainees, you should cherish it and realise that you are indeed the recipient of significant accumulated orthopaedic wisdom. It is a privileged position,

In my own case I worked with Colin Howie, who worked with Robin Ling (Exeter hips for young readers), and I learned a lot. I also worked with David Rowley, who worked with Reg "not quite a genius" Elson, who worked with the ne plus ultra of hip arthroplasty, Sir John Charnley. In addition, David Rowley worked with John Insall on developing the next stage of the enduringly good Insall Burstein knee replacement. These are not negligible figures. I learned hands from John Dent who worked with Harold Kleinert  and  Graham Lister. I worked with Jimmy Innes who'd been a colleague of Marvin Tile and Robert Salter. I learned  a lot of trauma surgery from Jeremy Martindale, who worked with Chris Colton and the whole AO group. My own AO course involved Alan Apley (possibly the most natural teacher I ever heard speak), Maurice Muller, Hans Willenegger, Tom Ruedi and many more. I'm old enough to have met and heard lecture Bernie Morrey, Emile Letournel, Allan Gross, Gus Sarmiento, Charles Rockwood, Reinhold Ganz (a legend), Derek McMinn and quite a few others.

None of this makes me as good as these guys, but they are 'names' for a reason. Of course, I also worked with several outstanding surgeons who may not be quite as storied, but are just as great as surgeons, mentors, colleagues and teachers,

My point is this - treasure such encounters and listen to the details, the 'small print' of their lives and careers. They are potential treasure troves that will benefit you and your practice.

Most recently I met Diego Fernandez, the multilingual Argentine working in Switzerland, now in his seventies, and still working hard. He was charming and friendly - not everyone of these big names is -  and gave a marvellous talk on his life as a surgeon. Clearly brilliant technically, the unspoken messages were: be humble, think laterally, retain an interest in general orthopaedics, commit to a problem case, and have other facets to your life - in his case, incredibly, ocean surfing, still. Also, don't retire if you don't want to.

I mention Dr Fernandez partly because of this recent encounter, but also because of his influence on my practice. Let's face it, most of our reading - BJJ, JBJS, CORR, JArthroplasty, J Trauma etc etc - contains papers of some interest, but only very rarely something that changes one's practice. At the end of this post is Diego Fernandez' outstanding and exceptionally original paper on correcting post-traumatic problems of the distal radius, and doing it properly (ie. anatomically). Simply outstanding, and I use these techniques to this very day.

Graham Lister's comments at Harold Kleinert's death are what we would all like to have said about us, as surgeons and trainers: he had a profound effect on me as a person, on my career, and on how I approach the many problems we deal with in our discipline.

Cherish your orthopaedic lineage!

!!!!!!???????

This may be a dying problem, particularly if the admonitions of GO ASYP are not heeded.

Have you ever been irritated by a differential diagnosis in the notes, for a basically simple clinical  presentation, such as chest pain:

?angina
??MI
??? PE
???? reflux
?????Boerhaave's
?????? Tietze's syndrome

I could keep adding. It tends to be less of an issue in orthopaedics, rather than acute medicine and general surgery, if only because it's hard to look past a broken femur.

That said, Leo Gordon provides some rich examples, noting the history of punctuation, and the philosophy underpinning this nonsense. More usefully, he suggests punishments for this terrible crime. If I may add a few musculoskeletal essay titles to make offenders think before they do it again:

Discuss the public health debate regarding osteoporosis

Discuss the suggested 'treatments' for osteoporosis, and the evidence for their use

Discuss the similarities between osteoporosis and wrinkles

Discuss Camilla Parker Bowles' public statements on osteoporosis

I could probably find some more. Unlike Leo Gordon, I have fewer problems with exclamation marks, they rarely seem to be used in orthopaedics and trauma. We are a phlegmatic, calm bunch, ordinarily speaking.

However, if electronic records really catch on, I expect to see emojis all over them.  Perfect for that dislocated hip replacement.

My broken leg

At the morning trauma meeting, a closed spiral distal diaphyseal tibial shaft fracture was presented for tibial nailing. Working male, <25% displacement, good alignment, minimal shortening, no rotational deformity.

He was consented for internal fixation, with a nail. That is of course routinely referred to as informed consent, and if you're being appropriately thorough (not pedantic), the information required to make a balanced decision would have included the pros and cons of conservative treatment in a cast or brace. Traction, external fixation, plating are all in the mix, but lets stick to conservative v nailing.

Is there any published evidence worth having?

Why, yes there is.

What do you think the incidence of knee pain is after tibial nailing? Patients frequently mention it, and it can be a real problem. 10% would be OK, 20% perhaps. Well, in a very good study from Vancouver's ace trauma unit, of 56 patients at a minimum of 12 years, it was 73%.  That's knee pain, related to the nail, not fracture site pain. Of course, there are quite a few other potential problems with surgery and anaesthesia.

OK, there are still plenty of arguments for nailing, but I actually knew one surgeon who put circular frames on instead of nailing, because of anterior knee pain. A little extreme, but it makes the point. Here's the Vancouver paper.




But is there any good evidence for conservative treatment in this group of isolated fractures?

How about nearly 1000 patients treated with early functional bracing? Sarmiento's study is pretty impressive, with acceptable angulation, shortening and union rates. I won't go through it all, read it for yourself. Not the same follow up, but the point is, while each treatment has its own advantages and disadvantages, they are both valid, and should both be available to the patients. We have emphatically not 'moved beyond' tibial bracing because of our brilliance at tibial nailing.



For what it's worth, in these isolated  closed fractures, I would indeed fix those with an intact fibula - they nearly always angulate too much - and the very comminuted ones, plus the compartment syndromes. Everything else is up for discussion. Nailing is often 'fix and forget', and casting/bracing is not necessarily easy, but that's not the point. I've seen plenty of complications of nailing. It's not always in the patient's best interests.

Back to the trauma meeting. No-one seemed able to quote  a paper on either treatment. When asked "what would you have done if it was your tibia?", only one person spoke up. It was the anaesthetist, who'd had a problematic infection after orthopaedic surgery.  "Stick it in a cast" was her response.

And if consent was truly informed, a few other patients might well join her.

I always fix them in polytrauma, personally

GO A S Y P

Here's an edited email from another specialty about a patient with an ischial pressure sore. There are no patient or doctor identifiers. The writer of the email had not seen the patient concerned.

Thank you for your email. I have discussed this with the registrar who received a phone call  from a Foundation doctor regarding this patient.

Note the sniffy tone. What was the F1 doctor meant to do? The specialty concerned refuse to carry pagers, and are routinely a hassle to track down. The point of all the specialties being under one roof - which is called 'a hospital' -  is undermined by such difficulties in access.

Advice was given with regards appropriate dressings, ensuring good nutrition (albumin of 21 is not optimised) and appropriate pressure relief with mattress, cushion, turning, etc.

As the ward nurses concerned said to me: "appropriate dressings and nutrition! Brilliant. We'd never thought of that". Furthermore, the patient was verging on being morbidly obese. Malnutrition was not an issue. Isolated albumin results are not the gold standard. This was an obvious 'end of the bed assessment' point.

He also made it clear that we do not routinely operate to close pressure sores, and would certainly not do so in the presence of osteomyelitis.

This was not requested. The specialty concerned are just one part of the appropriate multidisciplinary input the the patient needs (and can reasonably expect). A bedside review would be the obvious first step

I have reviewed the recent MRI scans, which show destruction of the ischial tuberosity and oedema of the surrounding muscles.

'destruction' suggests something dramatic. In reality it was typical superficial osteomyelitis at the base of a sore. The ischium was essentially intact. MRI is very sensitive and needs to be interpreted with care

He should continue with dressings and antibiotics. The pressure sore will never heal unless the osteomyelitis is adequately treated.

The first bit is misleading,  he definitely needs an operation, which is why the second bit is true. Established osteomyelitis is not treated by antibiotics without surgery. If there's pus, let it out (the old ones are the best).

As it turned out, the pressure sore was excised and the osteomyelitis debrided back to healthy bone, there was plenty of soft tissue to allow a tension-free closure, so there were no secondary soft tissue reconstructions needed. This was exactly what could be expected from even a brief visit to see the actual patient. 

Hence the title, GO A S Y P  or 'goasyp' to keep it catchy. Go and see your patient.

This is not picking on any one specialty - we are all capable of making this mistake. I don't, to give a common example, think you can properly assess an acute abdomen without a bedside assessment. In that example and in others more orthopaedic, like possible compartment syndrome, it may easily need several such visits. That's your job.

Once the problem has been referred to you, it becomes to a variable degree your patient. Act accordingly. When was the last time you let Kwikfit sort out your car over the phone?

Being easily available (why do people not want to carry their pagers - mobiles are no substitute?) makes a huge difference and will enhance your reputation.

This is not just  kind and humane - the patient always appreciates a bedside visit - but how the hell can you make a key decision without all the relevant facts? You can't, at least not consistently. Relying on data from your work PC instead is part of what I call Google Medicine (more another time). Anyone can look stuff up. It is not equivalent to taking a history and examining your patient. How could it be?

Not only is this advice good for the patient, it is good for you too. It will protect you when if, one day, there is a clinical mishap because of advice given over the phone or by email, though there had been nothing stopping you from actually doing what every doctor since Hippocrates has been routinely taught.

GO A S Y P !!!

....old school (in every way). Note that the surgeon is at the patient's bedside.

Country music meets total joint replacement

Nobody closes over an actively bleeding surgical site. Do they?

In my handwritten operation note it says 'haemostasis' followed by a tick symbol. In the dictated note I use the authoritative phrase 'haemostasis secured', which has a nice feel to it. Obviously I won't get any postoperative haematoma, and if I did, which I won't, it wouldn't be my fault. Or something.

So I will never have to use the phrase  'it was dry when I closed'.

In this matrix lesson, Leo Gordon notes the unusually fruitful use of Country & Western lyrics as applied to surgery, thus creating a new composition: 'Don't the Fields All Get Drier at Closing Time'. It's true that near the end of a big case you often just want to get out of there.  Songwise, one might add 'Does My Ring Hurt Your Finger' by Charley Pride, when examining for anal tone in a patient with a spinal presentation, or 'Life Has Its Little Ups and Downs' for when the MMC results come out (which has just happened)....



....I digress. Basically, not all complications are preventable, but bleeding is one that certainly can be. It doesn't help that in orthopaedics we've been trapped by what Gus Sarmiento aptly called 'the orthopaedic-industrial complex' as a variation on the medical-industrial complex theme (AKA Big Pharma), such that we dose all our arthroplasties with chemicals of extremely dubious value on the recommendation of physicians who are, to put it politely, remote from the consequences for the patient who has a bleeding complication.

Leo also describes the dreaded 'knee-jerk suspicion of surgical sloppiness' that we cannot banish from our mind when we confront the offending haematoma. Our own suspicion, and inevitably that of our friends and peers.

I blame Big Pharma, it was definitely dry when I closed.

The Germans have a word for it

um....nice screws

There is an orthopaedic 'walk of shame', more literally a walk in the old days before digital X rays, when one had to go to the front of the room in the morning trauma meeting to put up the latest X rays of one of your hip dislocations. Every man/woman and his/her dog will then opine confidently on impossible-to-verify topics such as "your cup is too anteverted on that X ray". Their faces betray no hint of sympathy for your pain, and indeed that of the unfortunate patient. Disappointingly, there may be seen traces of joy. Dislocation, being so blatant on X ray, is probably the best example of this meme.

Thanks guys, I never knew you were all so expert on this.

However, they will regret it.

Many years ago, one of my bosses who was an erudite and witty man, and something of a Germanophile, introduced me to the now ubiquitous subject of schadenfreude. I have seen countless examples since then. If guarded against, it induces the salutary virtue of humility, something all doctors, especially surgeons, should cultivate.

Schadenfreude is a human response, but also a human failing. As Leo Gordon tells us in his vivid example below:

The gods of surgery giveth, and the gods of surgery taketh away.

You have been warned.

Surgery is a serious business

I was searching for a suitable metaphor to encapsulate certain aspects of surgical training, particularly - as in orthopaedics - those areas that require the use of potentially injurious high tech equipment.

I think I've found it.

Enthusiasm alone is no substitute for adequate training, and if trainers lack interest in their trainees, failing to assess their capabilities and not showing the necessary respect between colleagues, bad things can happen....

Surgery as a zero sum game (Hadden's Law)

This is probably a historical law, rather than one that applies to current orthopaedic elective practice. It fits more with the days when the treatment for hip and knee arthritis was osteotomy and fusion rather than our zinging arthroplasties.

But.....

I have recently been reviewing detailed audit outcomes data from parts of elective orthopaedics outwith our gold standard joint replacements, and it's not such a pretty sight. I won't say exactly what it refers to, but essentially at 6 months and 1 year there's an approximately 30% patient dissatisfaction rate with surgery.

Is that good? Is it better than the natural history of the condition with conservative treatments? The trouble is that we orthopods are very self-critical. Our only rival in the life-changing elective procedure stakes is cataract surgery. A 30% dissatisfaction rate, I would hazard a guess, might be quite a favourable result in some other specialties. Breast implants, anyone?

Anyway, back to Hadden's Law. It is named after one of those rare surgeons who is not only a very fine clinician and operator, but also a mentor, in this case Bill Hadden, now retired, but one of the most humane and likeable surgeons that I have ever met. Neither Bill nor I are sure who invented it but it was he who introduced me to the concept nearly 30 years ago. It's straightforward:

For every operation you do that does good, award +1

For every operation you do that does harm, award -1

For every operation you do that probably makes no difference in the long run, it's zero

If, over the course of a list, a working week, month or whole career you're achieving a slight positive surplus, then you've done alright.

I know, I know, it sounds awful and nihilistic, and if you're knocking in Exeter hips all day you'll be very positive indeed. But look around you: is it completely wrong, even in 2017?

Early neurosurgery. They "all did very well" (thanks to Hieronymus Bosch)

Celebrity orthopaedics: U2

....specifically their dreaded singer Bono/Bonio. This is when he fell off his bike in Central Park in late 2014.

The talented trauma surgeon whom you can blame for Bonio's ongoing career is Dean Lorich at HSS in Manhattan. To quote the sanctimonious caterwauler himself: "The recovery has been more difficult than I thought. As I write this it is not clear that I will ever play guitar again."

Well he made it. Nice X rays, Dean

The Bonio distal humerus

An orthopaedic Christmas Carol, sort of

With a nod to Charles Dickens, this is about the ghosts of Orthopaedics Past, Orthopaedics Present and Orthopaedics Future. The reminiscences and reflections of surgeons late in their career or at retirement are a regular feature of this blog (label: wise surgeon). They really are  fascinating, and a treasure trove of useful thoughts.

This is Gordon Bannister, one of the best known British orthopods of the past 30 years, a very fine trainer and researcher, and generally a good guy, part of the Bristol centre of excellence.

He is no Luddite, but I draw your attention to a few things:

1. In the old days "senior consultant staff..had long since delegated acute trauma to their registrars. As a result, registrars acquired a wealth of experience". That's what happened to me much of the time. It doesn't happen now, which is both good and bad.

2. "At that time (the 80's) a 1:2 rota was common, occasionally tiredness ensued. The number of trainees increased whilst their experience declined". There is no way round this fact - you have to do the operations (and see the acute presentations) to get good. Most of my rotas were actually 1:3.  The promotion of the surrogate experience of 'simulated surgery' tells you how far things have gone. Note this from the former president of the RCS, Norman Williams. My view is that the New Deal has been even more damaging to training, morale and running a unit than the EWTD.

3. It was (and still should be) a lot of fun. If it consistently is not, then you may be in the wrong job.

4. I could not agree more that the demise of the true generalist to be replaced by self-anointed 'superspecialists' has been both stupid and damaging. It will be interesting to see what all the hip arthroscopy specialists will be doing in 10 years time.

Lastly, I would highlight the segment on NHS management and the conclusion. It's actually surprising how many empathetic and quality managers you encounter, but the long lasting damage wrought by the bad ones (and their political masters) is quite something.




(Thanks to BJJ News, September 2015)

Celebrity orthopaedics: Paul Stanley

Post THR exercise routine

One of my occasional pleasures is seeing how once youthful rockers grow old, get ill etc. I remember a picture of Rod Stewart coming out of a New York pharmacy clutching a large box of anti-inflammatories. A few weeks ago we had Joe Perry with his walking stick.

Well, here's Paul Stanley (65 last month), the guitarist with the star on his face from Kiss. He's an orthopaedic case history:

"What I do has taken its toll. I've had both my rotator cuffs surgically repaired. They're all similar to sport injuries. I've torn my meniscus in both knees and had a hip replacement. This is all from onstage performances. It's like doing a triathlon with a guitar around my neck. You have to jump, sing, swing your arm and play the right chord. With that combination, anything can go wrong. I used to jump up in the air and land on my knees. It didn't hurt then, but it does now."

He was 52 when he had his hip done. Last year he had a torn biceps fixed, with all the vital technical details:

Not only that, he identified the difficulty deciding whether to undergo a hip replacement in a tweet after bandmate Gene Simmons was critical following Prince's OD on analgesics for his hip disease (keep up):

As he said about his own decision:

"I wound up postponing my hip surgery and, you know, it's like reading in the newspaper your own death, you know, when you keep reading about your hip surgery, and I haven't done it, but I'm just postponing it for awhile. I have, you know, every intention of continuing doing what I've been doing, but little by little I'm turning bionic."

Interestingly Paul did have a complication - recurrent dislocation. Money can't guarantee that you avoid it. When I did private medicine I always felt my complication rate was slightly higher in the private sector. . It would be interesting to know what the salvage procedure was, because he looks like he's functioning at a pretty high level. Although...

"You know things did not go as well as they could have or perhaps should have. Hip replacement is major surgery yet it's fairly routine. It's done so often. The actual procedure has changed so much that you basically have the surgery and are walking that day. But there's a saying, minor surgery is what somebody else is having. This clearly was not minor surgery and the first one did not go well and kept pulling out or dislocating almost immediately. So within two months I went back and had it done again, which seemed to fix one problem and start others. The recovery has taken way longer and been more painful than I expected. It will never be great."


And that fits with the evidence that although patient satisfaction after dislocation soon catches up - if the hip is stabilised - the functional scores are frequently less than in the uncomplicated hip arthroplasty. 

I'm not a huge fan of Kiss, though I kind of like the whole trashy metal showbiz thing. Here they are in 2014. That's a 10 year old revision hip in a 62 year old you're looking at. Not bad.