All right, good morning. We're going to move on to Elbow, and we're going to use some musicians, some athletes, we all take care of athletes, as models, maybe even some chess players, as models for us to avoid complications. I'm going to start with a musician who's also a composer, who's probably the most famous violinist of his time, and he gives his most memorable concert in Italy. It's a new composition, so the audience is excited about it. Early in the performance, he breaks a string, and he makes a frown, he makes a face, but he keeps going, and then breaks a second string. Clearly, he's having what we would call an intraoperative bad day, and then he breaks a third string. He's got one string left. Rather than get a new violin, he plays for 15 minutes on one string, and the audience loves it. This is where the teaching is going to come in for us, and for me. Some athletes, surgeons, chess players, others, they excel during a crisis, they elevate, they accept responsibility, and others, even in the surgical environment, unfortunately, they succumb to the duress and maybe don't get the result that they want. So intraoperative complications are about comebacks. This motivates me. If you look at basketball at the collegiate level and at the professional level, teams that are slightly behind at halftime win more often than teams that are slightly ahead at halftime. There's something about being behind that motivates us, and if we're having an intraoperative situation, we can use it as motivation. I'm going to just tell you about this kid. He troubles me. I think about him all the time. He had neuritis and needed a UCL reconstruction, and thought everything went well. This is his actual photo, transposed the nerve, and when I'm doing another operation, I examined him already. His nerve was at baseline. During another operation, another Tommy John, the resident comes in and says, that kid from the room one, the last case, he's got nothing in his ulnar nerve anymore. Can't move his fingers, and he's having terrible pain, and we don't do blocks on these patients so that we can get a post-op exam, re-instruct him, loosen the dressings, and I'll come see him after the case. Part of this is what Matt said. You still have to focus on the operation at hand, but now I have a nerve that's out in a room next door. Should I scrub out? Assess the nerve? Anyway, I looked at his arm. He had a big fat arm in the recovery room, and so I spoke to mom and dad and the kid, and brought him back, and he had a massive hematoma that started, and he did have a bleeding vessel, cauterized the vessel, and his nerve came back with some motor function the following day. It took about three weeks for it to fully come back. Here's some disclosure. My wife's an orthopedic surgeon. She was actually here today. She presented today. You guys can guess who she is. When I get home, she asks, like any spouse would, how was your day? I say, it was rough. I had some cases that didn't go right. I had a problem. I had this and that, and her question always is, well, how did they come out? How did the surgery come out, even if it didn't go well? We have an obligation to make sure that the surgery comes out well, even if it doesn't go well. Jack Nicklaus says it well, the greatest and toughest part in golf is playing badly well. First rule of holes is if you find yourself in a hole, stop digging. I like this. A butterfly can flutter its wings over a flower in China and cause a hurricane in the Caribbean. What are we saying about this? When you have a small problem early in the case, you may not know how it's going to propagate later. I spend a lot of time on perfect patient positioning. I'm sure you all do, because that problem in and of itself, combined with another problem, combined with another one, bleeding, don't have the right retractor or a piece of equipment, all of a sudden you are having a bad operation. It all started with what could have been poor patient positioning. I think you all know who this gentleman is. He is an icon in the world of coaching. His first day of practice for basketball at UCLA is teaching basketball players how to put their socks on. How annoying would that be if you're a basketball player ready to go? I feel the same with patient positioning and draping. In fact, I can tell within, I think, a few minutes of who's going to be really good by how much the attention they pay to getting a good prep and drape. Here's another example of propagation error. The surgery for me on a, let's say, Tommy John starts in the pre-op area. We do a dynamic exam of the palmaris to see if it's still there. I may do five or six in a day, and you need to know who's got a palmaris and who doesn't. A dynamic exam where they show you their palmaris, we mark it out, and we've all heard of cases where the palmaris was absent and the median nerve got harvested. Low incidence, of course, but when it happens, it is a massive consequence. To further this notion of propagation error, when an airline plane crashes, it's not one mistake. It's a whole series of mistakes, and it actually has nothing to do with knowledge or skill of flying the plane that causes the thing to crash. It's an error in teamwork, so our complications may have something to do with teamwork. This is an elbow, and it's in the lateral position. I flip-flop from room to room. The patient's typically set up for me by my fellow and my residents, so it's already prepped and draped. The first thing for me is, where's the head, where are the legs? Because I need to know what's medial and lateral, everybody in the room. What I'm doing right now is I'm asking the most junior person in the room, what is medial and lateral? We're doing a confirmation before we make an incision because there's that ulnar nerve. That is a problem. The best indicator of a chess player's ability is to sense the climax of a game, and I think as surgeons, we know this. There's parts of the surgery that just don't matter that much. Then there's the parts that are so critical. Typically it's where you decide to make your tunnel if you're doing reconstructive surgery and things like that, but what we do know is that you can't be perfect with every move throughout an operation. When I start an ACL, I feel like it's a round-the-golf. This could be my best ACL ever, not have a single mistake. I've never had a perfect ACL, ever. I've never had it. It always has some little something that happens that's not right, but the best know what the most critical parts are that have to be perfect and when they can get away with it. In fact, detecting a crisis is different than solving a crisis, like solving the problem. You know experts who are great at treating post-op infections? You don't want to be that expert at solving that problem. You want to be the person who detects it. In fact, the word for crisis in Chinese really means danger, but also opportunity. I hear a lot about elbow complications as you and I have had my own. I'm sharing them with you, but this is a patient who disturbed me and gave me a lot of thought. He's about to get an elbow arthroscopy. We do the nerve exam ahead of time. His nerve, without even having surgery, is in an anterior position. Now, if we did an open approach to this and did not appreciate that nerve, his nerve would get cut. I know of all the nerves that have been cut, and it is such a horrible consequence. For me, things like making, say, multiple incisions during a palmaris harvest, for me gives me confirmation that we're not going to harvest the nerve, but I know lots of surgeons who make one incision, but I'm just sharing. For me, I will do everything possible to avoid nerve complications. I'm going to move a little quickly because we're running out of time, but I'm going to talk to you about chess. This is my son playing chess. In the world of chess, if you play in a chess tournament, you're obligated. It's not just like a thing. You have to write down your moves if you're in a chess tournament. If you guys watch Queen's Gambit, even at the highest level, the Netflix series, it was great. You have to write down your moves because he's writing, he's so young, he's writing his letters backwards. As soon as the chess game's over, he meets with his coach, he's playing with his school team, and they go over move by move. They say, that move was great, that move was a blunder, you lost your queen. This is what it's like in resident education. You see a patient, you present, or you do an operation. You talk to people about it, you say, bad move. That didn't work out well. We have a surgical techniques conference where we go over move by move of a surgery, and we look where the moves were good and where the moves were bad. Let's use elbow. We're hearing about elbow complications. During a distal biceps repair, the case is being presented by a resident, and I stop and say, hold on, I think your exposure could be better. Let's talk about enhancing exposure. I can do this, I can do that, and then something comes up about a retractor. Where are you going to put it? What type of retractor? They'll say, I'm going to put it on the radial neck, on the radial side, and it's going to be a helmet. For us in elbow surgery, knowing nerve anatomy is so important because that's your key to avoiding complication, anatomy knowledge. You put that retractor on the radial neck, you're going to have a PIN palsy, and we're going to solve that problem in a conference setting, not in an actual patient environment. But asking those questions and having somebody, as we talked about before, think about the things that they weren't is actually really hard. It's got names, it's called counterfactual simulation, and that's like looking for the problems before they happen. Chess players who are really experienced, like surgeons who are really experienced, a lot of it is not calculation, like what's the next move? They actually recognize patterns, and that's true of surgery, and they see collections of chunked information. They see things in a much broader sense, and they can assess weakness and strength. That's what chess players do, and this is how I think of it in the chess world. You play these simul games. This guy's name is Bobby Fisher. He's playing 50 games. He walks around, makes a move, and then the other opponent has as much time as he needs. When he comes back to that board, he can tell if the other player has cheated and moved this position. He has so much mental library capacity to see what, because he's been there before, and to me, that seems like so impossible because we're not chess experts, but think about the times that you've been at the OLC, or many of you, instructed at an OLC learning environment. You walk around, and you see somebody's portal is off, and you walk all the way around. You know that they're going to have a problem with something else later in that case, and it just sticks out in your mind, and you know that portal is a problem. So what's the best predictor of chess ability? When patients ask you, how many of these have you done? Probably you add a few, and then let's face it, or if you happened to do one yesterday, you said, well, I just did one. So because the patient thinks the amount of surgery you did correlates to how good you are, you know what the best predictor of chess ability is? It's not the amount of games you played. It's the amount of games you analyzed. Analyzing chess predicts chess ability. Maybe we should be analyzing our own surgeries more. I'm going to go through this quickly. This is a play by Derek Cheater. It's considered the number one best play in all of Yankee history. There's probably a billion plays that this goes for. It's a playoff game. The Yankees are on defense. The reason why this is considered one of the best plays, this guy overthrows two people, and Derek Cheater from shortstop runs across the diamond and then flips. It's called the flip play to Jorge Posada. When you ask Cheater, you're playing shortstop. What are you doing running to the first baseline, and how did you make that happen? He says, I don't know. He just did it. Some people can see complications before they happen the same way that fighter pilots or firefighters can see things before they happen. We call it game sense. When we learn from psychologists who study decision-making, the thought was that you generate all these options, and then you analytically choose which one has the most advantage. No, that's not what happens. You do not generate a series of things. You just make decisions based on intuition. How do we get intuition? We practice mental rehearsal we talked about before. The more you practice, the more it becomes automatic. The more you have cognitive freedom to think during the operation. This is written by a bridge player who's a social psychologist, and he said it about surgeons. What differentiates a great surgeon is how much they have on automatic. Wayne Gretzky was thought of to be one of the best hockey players in our history because he can anticipate better than other players. He's Paolo Maldini, soccer player, top defender in all of Italian soccer, so he's got to have the most tackles of all time. Not at all. In fact, he had some of the least tackles in his history, even though he's the top defender, and he said, if I have to make a tackle, I already made a mistake. He was a professional guy at decreasing passing lanes. I'm going to pass over this just a little bit, but I think for myself, and I'm sure some of you have the same thing happening. I've got an operation going on, and if that operation is on enough automatic exposure, you actually have some cognitive capacity to think a little bit ahead, so you're thinking of the next instrument in advance. Usually they don't have the right something, so you're telling them in advance of when you need it, usually about 30 seconds in advance of what we need. Please be prepared for it. There's a third operation, and that's I have another room going, so sometimes I'm thinking about that next patient at the same time, making sure they're going to have the C-arm or whatever it is. There's a fourth operation. Sometimes these are all happening at the same time where I'm videotaping the surgery. Videotaping the surgery is like in front of the camera while we're trying to show this while I'm still trying to do it, and so that gets a little complicated. Then the fifth operation for me is I'm having this thing in my head about where the nerves are at all times. In the back of my mind, I know where the nerves are at all times. That went over this, so in the interest of time, I'm going to jump over this, but just say in the world of military, they do what's called after-action review. They do a military exercise. They review it, and when military people consult, maybe CO comes, consults in a surgical department, they cannot believe that we don't do after-action review on surgery. How are you not spending six hours talking about your day of surgery? We just go home, and then we do it again. In this world of after-action review, it was proven to be so effective. I'm going to talk about self-awareness for a second because for me, we got a couple of minutes. Self-awareness is incredibly important. Do you know that 75% of drivers rate their abilities above average? If you had an accident, you think you're even a better driver instead of a worse driver, and if you're asked to rate your own personal self-awareness, like, hey, are you self-aware? Of course I am. Your rating of your own self-awareness is extremely high, even though it's weak. This is studied consistently. People overestimate their ability, and I think it's true of us. Some of the most confident surgeons, this is a radiologist. This is Jerome Groopman, a Columbia physician. He wrote that radiologists who are incorrect with interpreting films are often the most confident in being right. I'm going to jump over some of this because these are just examples of how self-awareness isn't great and how you can test it. For me, I have a running game with my fellows. Any time during a Tommy John's surgery, a fellow can ask me, the tourniquet time is behind me, what the tourniquet time is. Any time during the case, if I'm off by three minutes, I'm buying the drinks on Friday. Within three minutes, they buy the drinks. I still buy the drinks. You know that, but it's still fun. Okay, we have blind spots. I'm sorry I'm going fast, but I know that we're pressed for time. By the way, my daughter watched Top Gun Maverick last night. This thing about after-action review was highlighted in the first Top Gun movie, and now our kids get to enjoy it with the second Top Gun movie. This Navy fighter weapons school, Top Gun, can teach us about how we can be good at what we do. I'm just going to spend a little bit on equipment because we're in a world where equipment is getting so sophisticated. It allows us to be so reproducible and make tunnels that are always perfect. We have drill guides. We have all kinds of things, and it's going to make the surgery come out perfect. I've heard of more complications using instrumentation than people who don't. Maybe it's a learning curve and things like that, but what happens is some of these guides are not useful in certain settings, and you have to understand their limitations if you're going to use guides. If you use guides all the time, what do you do when you're in a situation where you can't use guides? I say that because be careful of using equipment and think of concept over method. Concept being you understand the principle, whether it's a Latter-day or whatever it is, you can get through an operation. If you're just a recipe person, I'm going to ... My wife's a baker. Bakers tend to follow recipes. Chefs tend to ... I'm going to be in trouble later. Chefs tend to be innovative. If you don't have lemon, you got to figure out how to make this dish work. Then finally, I'm going to talk about choking. I get punched all the time. Mike Tyson said it well, but there's something about when things are going wrong, as Matt said, if you have ability to change your approach to it, you're going to be better. When we think of astronaut training in the world of astronaut, we think of them selecting the best pilots in the world. You know how astronaut selection works? They test people for their ability not to panic. How great. The patient said to me, instead of how many of these dones, how often do you panic? That's probably a better question. Okay. My question's about poor driver. I'm going to tell you that for me, if I have negative thoughts before an operation, something bad happening, something ... I actually will leave the operating room. I won't start. I actually leave. I'm like, I'm not ready yet. X-rays are upside down. Something I hear the anesthesiologist arguing about something. I'm not ready to go because part of my pre-shot routine is everything's got to be in place and I got to feel good. If not, I'm going to walk away. I do kinds of things like if there's an anesthesia delay, I go to my office. I got a guitar there. I'll play some guitar. I'll review a paper. I'll feel like I did something accomplished and then I'll go back and be like, I did something great. I have the luxury of operating at a facility that is adjacent to a soccer field. It's Columbia University Sports Complex. I played soccer in college on that field and it was my dream to be an orthopedic surgeon, a sports medicine specialist while on that field where I had my knee injury, like a typical personal statement. I take a photo of the field before I stop my OR day to express gratitude and I have a believe sign in my closet above where my scrubs are and I touch it before I leave to the operating room. We have a lot of pressure. A couple of years ago, I did a Tommy John surgery live for this audience for this meeting. Probably the most stressful day of operating I ever had. I got to talk to people. I'm an introvert. I don't talk to anybody. So I had lots of strategy which we can talk about in discussion. I'm going to stop here, sorry about this, just for the interest of time and just tell you about Finish With Paganini. This guy was thought to have marf bands. He's got the longest fingers in the world and maybe that made him great at playing the violin, but how did he play with three broken strings? He practiced playing with broken strings. So for us, the message to us is we need to be ready to play with broken strings. The equipment breaks. Something happens. We have to be ready for it and get through it. So these will be in the handout about how I personally do it, but I want to apologize for being too long. Thank you for your attention and we're happy to have more discussion.

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