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

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.

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.

The metaphysics of nursing (part 1)

I am very specific in my clinical instructions. I frequently write them in by hand on the ward round, always in theatre, the drug kardex etc. I speak to the relevant staff. I don't rely on people reading my mind, or following "that's what he always does". There are always important exceptions cropping up: if they already take aspirin I don't want them on rivaroxaban and aspirin; if I very occasionally want 'none weight bearing' I make it clear.

But...

....after a complete, documented and thorough ward round I will frequently get bleeped 10 minutes later to be asked if a patient can mobilise. I will find patients being sent home on subcutaneous heparin injections - which I never do. The wrong consultant's name will remain above the bed despite daily requests to change it. There are many, many examples.

This is one of Leo's funniest matrix lessons, he really gets going in the second half. It touches on metaphysics and welding. It is also entirely true.

The Surgical Gods

Cancel this case!

Much as I would like to think otherwise, I am not a surgical god. In fact, I don't know any, but they do occasionally get in touch. This is a genuine warning in practice, call it the subconscious if you will.

Any surgeon who's done enough operations will be aware of a rare feeling that something isn't right. You want to feel this before you start the case.

I can't put it any better than Leo Gordon. There are lots of orthopaedic examples as well as generic ones. "Why am I removing this humeral shaft plate?" is one that springs to mind.

Cancelling a case is not the worst thing in the world.

Verify it yourself, get the old notes

How often have you, as a clinician, either been told a dud bit of information - or conveyed one- when discussing a clinical case? We probably all have. It's the equivalent of idle chit chat, which in gossip can cause emotional and other harm, but in clinical care it could kill. Such misinformation has almost certainly lead to doing unnecessary operations, tests etc

I had a patient who kept getting put on theatre lists for 'wound excision and exploration'. He had been labelled as a case of pyoderma gangrenosum for years, by various doctors, including dermatologists. This 'clinical meme' had stuck to him. He quoted it himself. He certainly had intermittent cutaneous sepsis, but PG is a very specific condition, the treatment for which includes immunosuppression, which no-one had quite got round to. It all seemed very unlikely to me. It certainly wasn't a classical presentation.

So I got the old notes - they were pretty thick. The meme had been repeated on many occasions, but never proven. No histology, no test of treatment, yet here he was continually turning up and getting listed for surgery for possible deep infections, with this impressive label stuck to him. The notes told a long and confusing but very helpful story, if you took an hour to read them.

I sent him back to see a new, very thorough dermatologist. No evidence of PG. It turned out to be self-inflicted, AKA dermatitis artefacta. A completely different sort of problem.

Likewise, if you do a lot of revisions (I do), you will encounter plenty of patients who have undergone multiple surgeries - occasionally into double figures - with different implants, approaches, rationales etc. There is no more useful exercise in planning treatment than summarising the relevant old notes and imaging - often going back years - and sending a copy to the GP. Clarity is everything here. It can be extraordinarily revealing. It's one reason why when I first meet a patient with a problem joint replacement one of my first questions is: why was this done, did they ever have painful arthritis in the first place? That may sound daft, but it is incredible how frequently the answer to their dissatisfaction lies in a poor original decision to operate.

So back to our wise surgeon, Leo Gordon. The Four F's are a bit outdated, and there's a mention of something called the World Wide Web, but this is the voice of experience. Get the old notes!

Surgical teaching and the mating habits of the pheasant

A tenuous analogy, to be honest

As a trainer, Philosophy #1 is tempting, particularly when you're a new consultant.

The trainees in my deanery have pretty full logbooks, and we get trainer feedback that tells us if we're not giving trainee cases. But, there is an unhappy and impractical obsession with some surgical trainees putting operating as a priority far beyond clinical assessment, ward work, outpatient clinics and all the other stuff that doctors - as surgeons, believe it or not are doctors - should be doing.

To be fair the UK ISCP system using work based assessments does make an attempt to deal with this, albeit there's a limit to how much you can bureaucratise clinical work and clinical education.

At the very least Leo Gordon's phrase: awarding surgical responsibility without demanding (such) knowledge sells the resident short. In a greater sense it sells short the discipline of surgery...merits a little bit of contemplation.

And the penultimate paragraph is 100% true.

Preparing for nemesis***

Brueghel: Landscape with the fall of Icarus (victim of hubris, bottom right) Musee Royaux des Beaux Arts, Brussels, 1560ish **

I once had a consultant colleague who regularly boasted that his hip replacements didn't dislocate. He was a fan of the cementless 32mm Ring implant with a polyethylene cup, done through an anterolateral approach. They all failed after abut 5 years with wrecked abductors, but he was right: they didn't dislocate (much).

This was a perfect example of both the Sin of Denial in Orthopaedics (SODIO) and also hubris. Which is where Leo Gordon's next matrix lesson comes in. Hubris is a word that should be used a lot by surgeons, and not just when discussing their colleagues' errors and complications.

Note the painful description of the attending/consultant: the overeducated overbearing surgical attending who had no insight into his own failures

Ouch.

It also contains one of a number of Leo's references to the mysterious pantheon of the surgical gods. Do not upset them. Heed their warnings. And note also olbos and koros. We've all been there.



**If you're interested in the painting and some poetry (yes, this is orthopaedics), then read this

***Everyone knows nemesis don't they

Avicenna did not have a phone

It's for you, doctor..

This is one of the great Leo Gordon's finest matrix lessons, which is saying something. It is also a near daily decision that I have to make at the hospital, on the wards and in theatre. You just want to be helpful and after all, what harm can it do to answer a phone? The matrix lesson references Dorothy Parker, and the quotation is not dissimilar to Ogden Nash's line: Middle age is when you're sitting at home on a Saturday when the telephone rings and you hope it isn't for you. Which is, rather pathetically, where I'm at - home and work - most of the time. 

 The list of awful possibilities is a long one. Leo provides some classics, I would emphasise my own pet hates: staff wanting to discuss their off duty; relatives wanting an update on someone who is not your patient; the labs raising a potentially important test result about someone whom you have never met or been involved in their care.

Part of the problem these days in the UK is that in many hospitals bleeps  have virtually been abandoned and random phone calls (and email) have filled that void. Bleeps are good, and it was my fellow consultants who began the trend to leave them in a drawer with the airily offered alternative of "just try my mobile", which doesn't get answered, usually. A good doctor makes themselves available if at all possible.

Which is not the same as answering an unattended telephone.

Sitting Bull

Master the use of this 

When I was a general surgical trainee, learning the ropes, one of the most technically accomplished consultants was a urologist. He'd actually trained as a thoracic surgeon, and unlike a lot - not all I should add - of the current general surgeons, he was completely unfazed cracking open a chest, say for trauma, even if he'd not done it for 5 years.

He gave me two excellent pieces of advice. Firstly, avoid cutting with scissors, use them sparingly, the best surgeons use a knife as much as they can. I still recommend this, although I occasionally permit myself a bit of blunt dissection with scissors - isolating the sciatic nerve for example. I saw him do a nephrectomy very quickly and deftly, without using the scissors once, as far as I can recall. The second piece of wisdom is probably the reason why he switched to urology: always sit down, "as you never know when you'll next get the chance". When he asked me what I wanted to do, and I said probably orthopaedics, he advised me to subspecialise in hand surgery, as "they seem to sit down a lot". He had a point.

We brings me back to Leon Wiltse, who also advised sitting down - primarily to be better at humanising the inevitably hierarchical doctor/patient relationship. A hero of this blog, Leo Gordon, said something very similar, in his usual way, "the most basic of surgical actions":

Funny Guy

The joint worst film ever made is Patch Adams, where Robin Williams, with his hallmark excruciating sentimentality, convinces a bunch of crusty old medical school professors (who understandably hate him) that laughter really is the best medicine.

Voltaire, for whom I have a lot of time, stated the "the art of medicine consists of amusing the patient while nature cures the disease", about which more on another day. His short novel Candide is genuinely hilarious for a 257 year old work.

So does humour have a role in medicine? Well, be careful.

Quite a few years ago I did bilateral hip replacements on a rather feisty lady in her 50's. A couple of months later she appeared in the review clinic. We had a nice chat, there were a couple of students there, a nurse, and the patient's husband. Just as I was leaving the room she called after me, "oh, one more thing doctor, what about sex?"

It was a gift really. Perhaps I should have hesitated, but:

"Well it's a pretty busy clinic, but if you want to come back at the end I'll see what I can do."

Luckily, as they say, we all managed to see the funny side of it. 10 years later at the audit review she repeated the story - with embellishments - to a new audience.

As ever, Leo Gordon has the wise advice. In fact his second example has some similarities with the above. Note especially the last two paragraphs:

Beware the "senior surgeon"

I would hope that if I end up like this - assuming that I haven't already - that someone might find a diplomatic formula of words to point it out to me. Leo Gordon is writing re the US system and general surgery, but these archetypes are global, and in the NHS tend to drift into doing less and less whilst demanding more respect and acclaim. The NHS is probably the softest employer in world healthcare and it's perfectly possible to showboat in the last 10 years before retirement, if you're so inclined. It doesn't take long before a degree of affection is replaced by irritation if they don't tone it down.

They can always hit you harder

In these days of the UK New Deal and the frankly-ridiculous-and-possibly-soon-to-be-abandoned-European Working Time Directive, the young (and sometimes old) surgeon is relatively protected from this concept. Not so when I was a lad - the 24 hours of  Christmas Day 1986 comes to mind. Anyway, LG is 100% correct about this