Hand surgery view from PGY6
I am in my final days of training at an integrated plastic surgery program well-known for hand surgery. I am confident that I have received the finest educational experience in both basic and complex hand surgery. Yet when my mentor, Dr. Neumeister, asks me to write a short 5-page article focused on mistakes made and lessons learned from a resident’s viewpoint (due the next morning), I find myself at a loss for words. The authors of this book are the leaders in hand surgery, and they have presented reviews filled with invaluable education about anatomy, pathology, surgical indications, and tips/techniques in the field. These are the experts and sort of articles that I still rely heavily on at this point in my career for most of my decision making. Sure, there are tips that I’ve learned such as: hold a cut flexor tendon out to length with 22 g needle, but don’t pierce the neurovascular bundle as you’re putting it in; replant digits structure-by-structure, not digit by digit so you don’t have to keep bringing the microscope in and out; and I prefer cysto tubing (hospital cost of $2.70 at our institution), chlorhexadine injected into a 3L bag of saline, and a soft scrub brush for irrigating wounds, because Pulsavac is more expensive (hospital cost of $34.40 at our institution) and soap is cheaper than antibiotic solution. I have a ton of pearls and tips I could share with others in training ( Box 1 ). However, all of my lessons learned are at the hands of my mentors and what is found in the literature. My unique contribution to this body of evidence is that hand surgeons are trained differently now. In July of 2003, the Accreditation Council for Graduate Medical Education mandated a reduction in resident work duty hours. Over the last decade, there has been increasing pressure from the public, medical community, and regulatory agencies to demand a greater accountability of resident training in the face of increased work hour restrictions and limited resources. These regulations have been met with varying opinions from both educators and trainees ; nonetheless, these points have prompted a dramatic change in surgical education. Since I began residency six years ago, an important lesson that I have learned is how to become a competent hand surgeon in a time of evolving surgical education. At this point in my career, I don’t feel like the expert in much – but I do know what makes a good resident in training.
Be honest with your outcomes
In microsurgery, make all your set up adjustments to make you feel comfortable, not just the attending
If a lumen is not absolutely clear on the inside, don’t complete the microsurgical anastomosis…smudge or a hint of clot needs to be removed
If a stiff joint release is still stiff at the end of a procedure…it will never be supple post-operatively
It’s a myth that wounds on a fingertip over 1 cm need a graft…if its my finger, let it heal by secondary intent even at 2-3 cm
Be meticulous with revision amputations. Patient hate nail remnants and poorly contoured stumps
Embrace replantations…patients deserve your expertise
A compromised flap or replanted digit will not get better in recovery…fix it now (in the operating room the first time)
Hand fractures: If the function is normal don’t operate…you can only make it worse than normal
A successful reconstructive outcome demonstrates good range of motion, normal digit alignment and sensation, and a pain free hand…pain free is key
Flexor tendon repairs deserve respect. A tendon must glide normally through the pulley system without gap formation…before you leave the operating room
Therapists are invaluable. Tell them exactly what you did in the operating room and what needs to be protected in rehabilitation
Distally based flaps are precarious. Use them as a last resort…if at all
Fix it right the first time. Reconstruction is more complex
Debride complex injuries and mangled hands like they were pseudo-tumors. Be complete and extremely thorough
Never dispose of any tissue until the dressing is on. Spare parts are very valuable
Love what you do!
Be an Active Learner
One of the attractive things about plastic surgery is that there are a lot of different ways to approach any given problem. A solid foundation in surgical principles and anatomy allow a young surgeon to treat basic or complex hand cases in a number of ways. Residency exposes you to various solutions, and the options are to either do what you’ve always seen done, or to go to the literature and try to find good evidence to support a different technique. Unfortunately, in our hunt for evidence-based literature a lot of what we find is level III & IV – anecdotal evidence, case series, and “how we do it articles.” A lot of us are drawn to the field of plastic surgery because we enjoy creativity and problem solving, but as a soon-to-be graduating resident – I find myself questioning my every decision. From the smallest details of whether to routinely give pre-operative antibiotics to diabetics undergoing elective hand surgery, to the more complex decisions like how to use spare parts in a mutilating hand injury. Now, more than ever, there is a focus on the cost of healthcare that we provide our patients. As the new generation of hand surgeons, it’s important that we participate in high level research, get involved in committees, and understand the changing hospital environment with evolving policies and regulations.
Learn About Our Past
In Dr. Peter Stern’s Journal of Hand Surgery article entitled Management of Fractures of the Hand Over the Last 25 Years , he chronicles how, when he started his training in 1975 (before I was born), patients with unstable proximal phalanx fractures were admitted to the hospital the evening before surgery, stayed the night of surgery, and had a general anesthetic. K-wires were manually inserted with a hand-driven Bunnell drill and biplanar x-rays were obtained with time-consuming plain films between each attempt at fixation. This is fascinating to me. It’s important to learn what was done in the past so we can appreciate where we’ve come and because, as they say, a lot of things old become new again. Surgical treatment for thumb basilar joint arthritis has evolved from a simple trapeziectomy first described by Gervis in 1949, to the addition of tendon interposition in 1970 by Froimson, and to intricate ligament reconstructions introduced by Eaton and Littler in 1973. A lack of consensus as to the best surgical technique has given surgeons the opportunity to utilize a hybrid of options based on their own education and experience. Today a literature review yields a vast number of surgical techniques and modifications for treatment of CMC arthritis, with the majority of these techniques showing satisfactory outcomes. Ironically, the highest level of evidence supports Gervis’s original plan of trapeziectomy alone. Two attendings may treat the same patient in very different ways. This is a testament to the variety that we see in training, but ultimately one day we will have to decide what works best for our patients in our hands. And as long as there is good evidence or experience to support our decisions, we should feel justified in our plans. Along those same lines, never criticize the work of other surgeons or physicians because you weren’t there. You could not see what they saw to make the decisions they had to make at that point in time.
Learn from Others
Technology has changed the way information is dispersed and has made it much easier for us to learn from others. We don’t carry around the eight-volume Mathes texts, but many of us do use the computer or iPad to look at online resources such as journals, PSEN, and even Google. When preparing for an anterior interosseous to ulnar motor nerve transfer babysitter procedure for ulnar nerve injury, I found Dr. Susan Mackinnon’s YouTube video to be my go-to resource. All residents love videos! Be open-minded and try different things. Suggest trying something you read or saw work in the past to your attending. They’ll either tell you no (and hopefully explain why that won’t work), or they’ll try it and you can see if the technique really works, or whether it just works in someone else’s hands. Either way, you’ll learn.
There is Opportunity to Learn Even on Routine Cases
I have performed a lot of carpal tunnels throughout my training. So much so, that I would consider them routine. I no longer read for the case or review the position of those 9 structures in the carpal tunnel. The other day, I saw a shiny angel hair pasta-like structure coming through the transverse carpal ligament. I didn’t cut it, but it was a great learning point illustrating Lanz’s classification of the course of the recurrent motor branch of the median nerve. I know the classification now but I am a little sad that as I finish residency and go into a solo practice, I’ll never have the opportunity to impress someone who really cares with that little tid-bit of trivia. I have learned that knowing classifications are less important than knowing the big picture. In this case, anomalies and variations happen. Never let what we do become so routine that we miss out on learning experiences. More importantly, never miss the opportunity to do no harm . I have learned tissue planes. I have learned the structures that traverse those planes. I have also learned to concentrate on things that look odd or weird in planes that are supposed to be free and clear of harm. And I’m good with that.
Learn Anatomy
A perk of mutilating hand injuries is that the anatomy is amazing. Identifying structure as they are sketched in the textbook cartoons is vastly different from identifying normal, or more impressively, severely injured anatomy. Become comfortable with where things should be, either with text or cadaver labs or surgery, and then it becomes easier to treat an injury because you can see what is where it should be and what is out. A great tip I’ve learned on a spaghetti wrist is to tag each structure with mosquitoes as you come to it and label with stickers. This way you don’t waste time re-identifying structures throughout the case. I also learned to repair it when you are sure where to attach or coapt it…don’t waste time.
Be Present – Both Mentally and Physically
With increasing duty work hour regulations (or restrictions depending on your viewpoint) our exposure to cases is less than our predecessors. They may have been tired, but older surgeons certainly saw more, operated more, and felt more responsibility for patient outcomes. Some of the stories of how it used to be may be embellished for dramatic effect, but there is no denying that working long hours and operating all the time does expose you to more personal experience. For better or worse, residents in training do rely more on the experience of others and the literature for guidelines in how to develop indications, formulate surgical plans, and manage outcomes.
Never Complain
An old wise man (Neumeister) once told me that it is a privilege to do what we do as surgeons. We hold the life or fate of others in our hands. Patients need champions…the sick can’t help themselves…the injured can’t mend themselves…we can! We are their champions. We all should, as I do, love what we do. We should do the right thing and do a good job. I love being creative and innovative for the betterment of patient care. Never complain about our position in life. I’m sure we will all do well. This stuff is awesome!!!
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