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