We’ve all been there. We’ve been at the difficult junction in a case or found surgical progress stalled. We’ve planned for all possible paths a procedure might lead us down, but we operate on the human body, and not everything is predictable in every case. Perhaps something irreplaceable has fallen onto the floor or is broken. Maybe every step we take seems to lead to something worse.
When we find ourselves in this predicament, what is the most appropriate next step? How do we restart progress and complete the procedure? Do we find calm in chaos, or do we allow the difficulties to paralyze our decision-making abilities? In dire circumstances, when a life or limb is on the line, we can find ourselves in a fight or flight scenario, but with another human’s outcome on the line.
There are rare times when pausing for contemplating and conversation is not possible. Rapid hemorrhage, spreading infection, or hemodynamic instability are all examples where decisive action must occur instantly. However, in a lot of scenarios, finding some zen in confusion is essential.
We have to learn when trying less is the right move. In the field of orthopaedic surgery, hammering harder or choosing a larger screw is rarely what brings us to the finish line. Multiple brute force attempts to get a screw into the right place or the implant out at all costs may lead to an unsavory outcome.
My approach to these scenarios has been to take a second. Irrigate the wound. Step away from the table for a few minutes. Scrub out and walk out into the hallway for 5 minutes, if necessary. Take a second to review images and ensure there are not any unrecognized details missed during pre-operative planning.
If you are genuinely stuck, don’t forget that you are not there alone. Ask an assistant or trainee what they are thinking. Involve the entire team. Bring other personnel in the room into the conversation. If you have a partner next door, ask their thoughts.
Maybe you are operating alone and need another set of hands for better exposure. Perhaps the incision is too small. Inadequate exposure is often a cause for difficulties. Remember, incisions heal from side to side. A 3-inch incision will heal just as well as a 6-inch incision if that is required to complete the case safely; never hesitate to be more invasive. For example, in a hardware removal, extending the incision might make an otherwise 1-hour surgery a 10-minute procedure.
In fracture care, reduction and 3D visualization are a couple of pitfalls. In closed reduction attempts, it is never wrong to try. If closed reduction attempts aren’t successful, there is NOTHING wrong with using open techniques that respect soft tissues to get it right. For example, in intramedullary nailing, a small incision at the fracture site for manual assistance with the passage of the guidewire is a soft tissue friendly technique that can save a significant amount of time and facilitate appropriate length and alignment rotation and a successful procedure.
3D visualization is a complex skill to master for some. One of the things I discuss with learners is utilizing every surgical procedure to understand anatomy better. For example, visualize the starting point for an intramedullary tibia nail when doing a total knee arthroplasty. Pay attention to the cruciate ligaments for potential arthroscopy during the same procedure. There is something pertinent to your future surgical practice in every case you participate in for residents and fellows!
A part of planning is expecting things might go wrong. When preparing for surgery, understand how to respond when everything seems to be going wrong. Don’t let yourself get stuck in the quicksand. Slow and smooth are often the most appropriate way out of the worst situations.
What thoughts do you have? Fell free to continue the conversation at https://twitter.com/rkh_md.