A surgeon's “I should have...” notes
My computer has several hundred surgical photo folders. When an operation is finished I name the folder, and I have a habit of adding one line after the date and the name of the operation.
“Should have...” “Look at...” “Next time, like this.”
It is not written to show to anyone. It is a note to myself, left so I can open it again the night before the next operation. Today I want to take out a few of those notes. I have changed the details so that the patients cannot be identified.
- Patellar fracture internal fixation— Be careful if it feels too tight. Be sure to look at the skyline view
- Medial meniscus posterior horn root tear— Should have just drilled the bone tunnel
- Periprosthetic femur fracture— Should have used a slightly smaller screw
- Arthroscopic rotator cuff repair— I think I did it well, in my own opinion
01“Be careful if it feels too tight. Be sure to look at the skyline view”
It was a patient with a broken kneecap (patella). The operation is to fit the broken fragments together and fix them with cannulated screws. The cannula placed along the path of the screw felt like it was biting tightly into the bone, and I took that feeling as a sign that it was “gripping well.”
But on the post-operative images, the upper screw was touching the cartilage surface on the inner side of the kneecap. It was at an angle that could not be seen on the front and side images alone. If I had taken the skyline view, bending the knee and looking up at the kneecap from below, I would have known right away in the operating room.
The note I left in the folder that day is two lines. A solid feeling in the hand is not always the right answer, and there is no harm in taking one more confirming image.
02“Should have just drilled the bone tunnel”
It was a patient with a torn root of the medial meniscus. The meniscus root is like an anchor that ties the meniscus to the bone, and when it is torn the meniscus cannot do its job.
There are several ways to fix a root. I wrestled for a long time in the narrow space at the back of the knee trying to stitch the torn site as it was, and in the end I finished with another fixation device. The operation was done, but it would have been simpler if I had chosen from the start the method of cleaning up the damaged root, drilling a small tunnel in the bone and pulling the root down to fix it.
The folder name also has a note that reads, “Don't force a stitch at the back.” It means that it matters far more to decide a second plan before surgery, “if this doesn't work, we go with that,” than to change plans in the middle of the operation.
03“Should have used a slightly smaller screw”
This was a patient who came with a broken thighbone near a knee that had been replaced. It is an operation in which the knee replacement already occupies the space, so there is not much room to place screws.
The inner surface of the lower thighbone slopes more obliquely than you would think. I knew it in my head, but when it came to choosing a screw my hand went toward “the longer and thicker, the stronger.” Looking at the post-operative images, I thought that if I had considered that slope once more, a shorter, thinner screw would have been enough.
The same folder also has a note: “Holding the top of the bone with the instrument is harder than it seems.” There is always a difference of a few degrees between the textbook anatomy drawing and the real patient's bone, and those few degrees can only be learned in the operating room.
04“I think I did it well, in my own opinion”
It is not only confessions. The day I arthroscopically repaired a small tear of the shoulder tendon (rotator cuff), I carefully wrote on the folder name, “I think I did it well, in my own opinion.” I added the words “in my own opinion” because I know the real verdict comes months later, from the patient's shoulder.
There are also many folders where I wrote down tricks I learned from other surgeons.
- In ankle surgery, where to open the skin so as not to cut the ligament twice
- When inserting a rod for a hip fracture, which way to push the entry point
Some tricks were used in the very next operation, and some are still waiting for the day they will be used again.
In closing: why I took out these notes
Patients facing surgery often ask, “How many times have you done this operation?” It is a good question. I would like to suggest one more to add to it: “What do you look at again after an operation is over?”
The number of operations tells you the amount of experience, and the habit of looking back tells you whether that experience turns into skill. My “should have” notes are an embarrassing record, but they are also the surest way to make the next patient's operation a little better.
This evening too, I will probably create a folder and write a line after it.
Hee Seung Nam