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Residency Diary: The Gift of Learning

2018; Lippincott Williams & Wilkins; Volume: 476; Issue: 11 Linguagem: Inglês

10.1097/corr.0000000000000506

1528-1132

Lisa G. M. Friedman,

Health and Medical Research Impacts

April 2018 This year, my resident class spent a month with a cadaver. It is a month of late nights as we practice all the surgical approaches and identify the anatomy as we go. Each night, two residents are assigned to a region of the body where they spend several hours performing a prosection and sharing it with the group. We usually order take-out, which is typically delivered to the front of the building. But, one night, the delivery person was inappropriately directed to our lab, and much to her horror, she arrived just as we were flipping the cadaver from a supine to a prone position, affording her the perfect view of the cadaver with much of its front section dissected. She turned pale and walked backwards slowly before stammering that she would leave the food on the table outside the lab. I once had a similar view towards cadavers. My initial cut as a timid first-year medical student, having never used a scalpel before, was an incision down the abdomen that went too deep and pierced the bowel. I felt instant remorse. “I hurt her,” I thought, even though I knew that was a ridiculous sentiment. I was overwhelmed by the smells and by all the death. We spent 2 years with the same cadaver, and in that time, I never got comfortable with how I should feel toward the body: Reverence? Gratitude? Rapport? Fear? I wanted every cut to be an action that the cadaver would have approved. I wanted to be a good doctor and advance her interests, but I did not know how to help her. I had no skills and wondered if she still would have agreed to be dissected if she knew her body would be turned inside out by a bunch of clueless medical students. But as a resident, I approached the cadaver with purpose. I had seen enough death that the fear, which once clouded such a foreign and unfamiliar process, was now gone. Death was now just the routine end to living. I had smelled so many different odors that the smell of the cadaver was now bearable. There were structures I needed to find, but I had seen them before, and I knew where to look while properly handling the instruments. This was a great learning opportunity; it was not overshadowed by the spectre of death and mortality that had hindered me before. The month we spent with our cadaver helped the class bond. Like many other orthopaedic residencies, we showed our affection for one another through gentle taunts and loving ribbing. New hairstyles never went unnoticed, a poor choice of words was remembered and embellished for years. There was the rhythmic beeping of a sensor that I suggested must be the “Tell-Tale Heart.” We did impressions of our favorite attending. We took the assignment seriously and got the work done, but we also enjoyed one another’s company. Even though we could be somewhat ruthless to one another, without a word, we all shared an underlying respect and appreciation for the cadaver. If a joke ever came too close in subject to the cadaver, one of us would raise an eyebrow in stern admonishment and we would quickly take our conversation in another direction. While none of the residents or faculty were ever off limits, we would approach the cadaver and be ready to turn it over when a resident would take pause from the cheerful chatter and remind the group, “be respectful,” and we would respond with a solemn nod. In residency, we are grateful for the gift of learning from our patients—in every stage of their lives. July 2018 Hip fractures in older patients are considered sentinel events. Although, I knew this as an intellectual premise, until recently, I did not really feel it; none of my patients had ever died from a hip fracture. Dwight (name and other identifying characteristics have been changed) recently had transferred from an outside hospital after a THA for a femoral neck fracture. An elderly man in his 90s, Dwight had been walking in his nursing home when his leg gave out, and ultimately sustained a major acetabular fracture that left him in discontinuity and with protrusio acetabuli. We took him to the operating room for an open reduction internal fixation (ORIF) of his acetabular fracture and a revision of the acetabular component. My attending is our arthroplasty expert—a man I regard as something of a wizard; there is no surgical problem too complex for him. Even considering Dwight’s advanced age, I didn’t think this time would be any different. We removed the old cup and placed a plate on the acetabulum. Dwight’s bone quality was terrible, like sawdust. It was easy to understand why he had fractured his acetabulum without any trauma. As we put the screws into the plate, the bone gave way and our fixation failed. We started over. Again, we reduced the fracture, but the fixation failed again. After a third try, and with my attending’s frustration mounting, I sensed that I was seeing someone who had used up all the life he had. After several hours and three attempts at ORIF, we placed a distal femoral traction pin and closed. We returned later to complete a more-extensive ORIF of acetabulum with a large plate and then an additional operation to finally revise the acetabular prosthesis. Dwight survived all that surgery, and although he wasn’t able to walk well, he managed to make it out of the hospital. When he didn’t turn up on the day of his first scheduled followup, I asked our physician assistant to check in on Dwight. He had passed away that morning. Dwight had a severe injury, but I felt confident that everything had gone as well as it could—he received quality care from the right surgeon at the right hospital, at the right time. And yet, as we tried to get fixation on his bones, it was as if I was literally watching the biblical adage of “dust to dust.” Still, for a moment when he discharged out of the hospital, I felt that maybe he had cheated death. But with the physician assistant’s words, the reality of the solemn privilege and heavy stakes to do this work came crashing down upon my mind. September 2018 I provided coverage for one of the local high school football teams on a chilly Friday evening in rural Minnesota. While strolling the sidelines during an otherwise uneventful game under the lights, I found myself reliving my own high school experiences. That is, until the athletic trainer for the team told me she thought a player dislocated his shoulder. “Are we sure it’s dislocated? What does the x-ray show?” I asked as we walked over to where Nate (name and other identifying characteristics have been changed) sat on the bench. The athletic trainer shot me a glance. Right. High-school football. Not the NFL. There was no x-ray. I would need to rely on my physical exam. I approached Nate, who had trouble moving his shoulder after being tackled a few plays earlier. I gently palpated his shoulder. The posterior aspect of his shoulder felt soft and when I pushed my fingers in, I could feel the surface of his glenoid. In the front of his shoulder, I felt the humeral head jutting out anteriorly in sharp distinction from the smooth contours of the glenoid rim. I went to abduct and externally rotate his shoulder. Nate grimaced with apprehension. His shoulder motion was blocked. Yes, dislocated. Beads of sweat dripped down Nate’s sinewy arm muscles, which were growing increasingly tight the longer his shoulder stayed dislocated. I lightly pulled traction on his arm. He began to slide down the bench as I struggled to maintain a good grip. I took a step back and toweled off his arm. I pulled traction again. Generating just enough force, I could feel the humeral head clearing the rim of the glenoid. I instructed the trainer, who was stabilizing the player on the bench, to place a gentle, posteriorly directed force on the arm. There was a satisfying “thud” and a sudden look of relief on Nate’s face. There had been no radiographs, no conscious sedation, and no fancy equipment. And more than ever before, I felt like a real doctor.