This guy Paganini is one of the best composers and violinists in our history. He gave one of his best performances ever in Italy with a new composition that was just amazing and thrilling the audience. And then a string breaks. He pauses for a second, and then he keeps going. Then a second string breaks, and it's got to be impossible to keep playing. He keeps playing. And then a third string breaks, and he's got one string left, and he finishes his performance to the amazement of the crowd. How did he do it? For athletes and surgeons, I'm going to make a lot of references here because what we do is much like anybody who's a performer. We have to excel during a crisis. And if we accept the responsibility and are able to excel, of course our patients are going to do well. But it's hard, and sometimes we don't do as well as we want. Think of intraoperative complications as an opportunity to make a comeback. And here's something that I like. Basketball teams that are down at halftime marginally have a better chance of winning statistically in the end. There's motivation to come back. I'm going to tell you about this case. He's 19. He's a shortstop. He's got an ulnar collateral ligament problem. He's got baseline neuritis. I mean, he's got decreased sensation on and off all the time. So we're going to transpose his nerve as part of doing a UCL surgery. And the PACU after the surgery, which went very well, his nerve was at baseline. You know, a little decreased sensation. He's happy. I'm happy. Now I'm doing another Tommy job. I'm going to keep going. I've got a full day. The resident comes in, tells me that his nerve exam has changed, that he's got nothing. Motor function is gone, including absence sensation. So I tell him to loosen the dressings. I'll be out in a moment. I've got to get through the operation I'm doing right now, but my mind is on him. I look at his arm. He's got a big, fat elbow. It's tense. His nerve is completely out. He was dressed, ready to leave. He was in his pants. Get him undressed. We bring him back to the operating room, talked to him, fortunate enough to get an operating room that could allow us to bring him back. And this is what was in his elbow. This is a full jar of jelly. And yeah, I took video of it. Elbow surgery for me is about managing this nerve, the ulnar nerve. I've lost more sleep because of this nerve than anything else, I think, in my life. So here's the situation. He's got a bleeding arterial vessel that's running along his triceps, actually, the artery that runs with the nerve. So problem solved now. They didn't even put stitches in it, just cauterized it. Very quickly, his nerve came back. That evening, the nerve was coming back. First post-op visit, his nerve is back. The greatest and toughest art in golf is playing badly well. We've had bad days. We've had bad days in the operating room. You've got to get through it, and you've got to give the patient a good result somehow. What's the first rule of holes? If you're in a hole, you've got to stop digging. When problems are happening, you have to stop the propagation. I love this. A butterfly can flutter its wings over a flower in China and cause a hurricane in the Caribbean. This is from a movie called Havana, but it's actually a scientific principle. When things are going wrong, it often starts well before the problem actually happened. For me, elbow arthroscopy is a great example. If the elbow's not positioned ideal, you can't move instruments as well as you like. You button into the chest and things like that. Then you get into bleeding, and you can't move. All of a sudden, everything compounds, and you have a massive problem. Something happens to, say, a nerve. John Wooden, famous for so many wins, he used to teach his players how to put on their socks. That seems ridiculous, right? But it's these small principles right at the beginning of a practice or a game on putting on your socks and shoes. For us, it has to do with prepping and draping. I am so meticulous with prepping and draping. I don't even care how the dressing goes on, but the start of the case has to be perfect. Preparation of error happens right from the beginning. This is a patient who's going to get a Tommy John. I make sure he's got a palmaris, and I make sure I mark it. I did some cadaver work with studying Tommy John surgery, and I was harvesting grafts and full arms, and I was putting them in cadavers. There was a cadaver. I'm going to say it again, a cadaver, thank goodness, that didn't have a palmaris. I harvested the median nerve on a cadaver. I mean, thank God. And so now I have so much respect for making sure that the median nerve is protected during a harvest. Can you believe this? Airline crashes happen with a series of problems. It's not one problem, and it's not related to a pilot's ability to fly when they have a crash. They all can fly. It's a communication thing, and when we hear about wrong site surgery, the research on wrong site surgery, someone in the room knew but didn't speak up, or had an inkling about it but was afraid to communicate. This is an elbow surgery, and I do elbow surgery lateral, and I also do it supine, and I'm running two rooms. I go in the room. It's not wrong site surgery, but wrong side of the elbow surgery means the nerves, all the nerves are going to get damaged. So I ask the most junior person in the room, where's the nerve? And then we get confirmation again. That's what we were doing in this video. This is a case from last week. So the point is, there are some parts of surgery and some problems that are horrible that we want to avoid. And so Boris Spassky, Russian chess champion, his feeling about chess players was the best chess players have ability to sense when there's an opportunity to win the game. There's things that change. It's not static, and they know that opportunity. And it's impossible to play the best moves all the time. But when you have the opportunity, that's when you slow down and you make your opportunity maximized. Well, detecting those opportunities, detecting a crisis is actually different than solving it. It's like, can I see it, or do I need to solve it? The best surgeons, they know when the hard part's coming. In elbow surgery, the most critical part in a Tommy John, I mean, there's lots of critical parts. But making the tunnel on the epicondyle influences how the graft is going to work more than any other part of the surgery. When we're making that tunnel, I actually change and walk around to the other side of the hand table so I can see it perfectly. That's when we pause and slow down to make sure we get a great tunnel and a great surgery. So in Chinese, crisis is two characters. It's for danger and opportunity. The degree of consequence. Great surgeons know when there's a consequence, like problem. Keep talking about nerve. It's my thing, nerves. This guy's nerve, he never had surgery before, lives anterior to the epicondyle. Shame on him. I'm angry at him. If you don't know where the nerve is, that is the most catastrophic injury you could have. When I speak to senior surgeons, now I'm a senior surgeon, if you ask them what's the worst complication you ever had in your life, guaranteed they're going to say if they're an elbow surgeon it was a nerve injury. Their hand doesn't work after that. So know where the nerves is. I make multiple incisions because I want to know on a palmaris harvest, I want to know that I'm not getting the median nerve. All right, this is great. This is in the industry area. Make split seconds decisions. I'm going to start talking fast because I love this stuff and I want to give you all, but I also don't want to take up too much time. My son, he's in a chess tournament in New York City. When you play an opponent in a chess tournament, if you ever watched Queen's Gambit, she was doing it too, you write down your moves. After you finish your game, whether you won or lost, you meet with the chess coach and you go over move by move and the chess coach would be like good move, bad move, excellent move, blunder. That was the bad move that cost you the case. When we do medical training, we see a patient as a resident, we come out, we present to a master surgeon physician and they say good, bad, no, the exam was off, I didn't get, and you get feedback. We have a surgical techniques conference year after year. Our residents say it's the best conference. A resident will go up and we'll give them a workout. I ask them ahead of time, like, are you ready for a workout? Do you want to just get on the Peloton and pedal a little bit or do you want the guy who's going to give you the workout and push you? We ask them questions throughout a surgery that they're presenting and we stop them every second of the way. This is an example. This is a distal biceps case and while they're presenting, I'm like, hold on, what if you don't like your exposure? What do you do? You got a vessel in the way, you can tie it. All right, you don't like your exposure, what do you do next? Just keep pressuring. Well, I'll put a retractor. Where are you going to put the retractor? I'm going to put it on the radial neck. What side of the radial neck? The radial side of the radial neck. And then I roll my eyes and I say, that's how you get a PIN injury. So we're stopping complications by going through this process. It's not, it's kind of simulating things that are going wrong before they happen. It's actually really hard because it's all mental. We're doing it in our heads, it's really hard. So back to chess. Are you ready for this? And this is true of my career. When you're young, you're calculating everything about the surgery. As you get more experienced, it's all about automation. So the most experienced chess players, they're not calculating. The inexperienced chess players are calculating. That's how guys can play like blindfold chess. They see chunked information, just like we do as we get more comfortable with surgery. And so when you have this chunked information, you can see, you have so much more ability to see things that are happening. You can assess problems and you can see weaknesses. And I think that's true of us. This is Bobby Fisher. Look, he's playing about 50 games. He wins every one of them. He may tie one, but he wins every one. These are all top chess players. Like, how can this guy do it? He spends 10 seconds on the board. Many of us have gone to the OLC or the learning centers. If you ever have the opportunity, if you're an ACL surgeon, you walk around, you're like, oh my God, that tunnel's off. Why would they put that there? Just because you know this operation so cold and you can walk around and you'll remember every one of them. What's the best predictor of chess ability? When patients ask you, how many of these have you done? Yeah, I've done a bunch. I did a couple this week already. I've done a bunch. It's not about how many you did. You know what they should be asking you? How many surgeries do you analyze? Because the best predictor of chess ability is how many games you analyze, not how many games you play. Okay. Okay, I'm going to just go right to this. F-4, it's a jet, fastest jet in history during its time, had all kinds of guns and missiles and the United States had real superiority in warfare when it came to the air. But against Vietnam, the United States was losing planes like crazy and these planes are expensive and they're losing lives. So they stop all combat in the air, stop, moratorium. And then during that stoppage, the Navy begins a new training method and the Air Force, they continue doing what they're doing, called the Navy Fighters Weapons School. And what they would do is they'd go into a combat situation, a dogfight practice situation. Afterwards, they would view it right away and it would be brutally honest. It was filmed and they would go over it and they would discuss how they could get it better and they'd do it again, almost like chess. After the moratorium, they went back to fighting. Air Force didn't do any better. The Navy like dramatically improved, like tenfold improved. And so the lesson here is when we have a complication, our natural instinct, because it's so painful. I mean, it is so painful to think about the complication. So we don't really analyze it that much. Best surgeons analyze it. This is the best pilot in our history. This is the LeBron James of fighter pilots. He says it's people who fight, it's not the planes. So this Navy Fighter Weapons School is top gun. My daughter saw this last night, the new one. Okay, I'm gonna talk about instruments and then I'm gonna try to finish up very quickly. We think of instruments as great because they help us, they get us through it. You know, instruments, they make the surgery more reproducible and predictable. This is an exposure to the ulnar collateral ligaments, the blind tubercle there. There's this instrument, it's a guide, it's gonna make you have this perfect bone bridge and all this kind of stuff. I have heard of more complications related to using this guide and it's supposed to help you. Instruments have limitations. We're still obligated to use the instrument correctly. Sometimes there's changes in morphology of the bone and things and it makes the instrument actually detrimental and not beneficial. So we need to understand the limitations of instruments and always pay attention to the concept rather than just the method. It's like cooking. If you follow the recipe, it should come out good until you don't have an ingredient. You have to improvise. You have to do things. When things are off and anatomy is off and always can be off, you have to be ready for it. And this is Emerson who said this. If you grasp principles, you can get through anything basically. But if you rely on just knowing methods without the principles, you get into trouble. For me, latergé is a big one in bone deficiency. If you understand bone deficiency, you can get through it with different things like we just heard about from Allison with a, say, distal tibial allograft. Okay, this is the eighth best play in Yankee history. This should have audio. Our audio is off here. Get that knob. The throw misses a cutoff man, shoveled in a plate, out of the plate. Derek Jeter with one of the most unbelievable plays you will ever see by a shortstop. Both cutoff members missed. Probably in the history of the Yankees, there's been about five billion plays. So many plays. Every pitch, there's a play. What makes this ridiculous is that the outfielder overthrew two cutoff guys. Derek Jeter, the shortstop, ran to the first baseline, got the ball that was overthrown, and flipped it and got the out. If you ask Jeter why he did that, he's like, I don't know. Why'd you do that? Some people have this game sense. A firefighter in a building says, everybody out. And then the building collapses. They have game sense. When we think of that, the theory initially was, well, they think of all these options. And then I choose the options. That's what this guy Gary Klein was thinking early in his research. Completely wrong. When we're playing in the so-called state of flow, if we're operating, we're not making decisions every time. Things are happening. But in our mind, the intuition is that we have a quick mental thought of, that'll work, and we take it. It's actually not even always the best option. It's just a feasible option. So the more we practice, the more it gets automatic, the more we have ability to improve our execution, be creative. And I love this. What distinguishes a great bridge player, or a great surgeon, or a great pilot from the rest of us mortals, is how much they have on automatic. You can see the complication. Like, Jeter saw that play happening. You see the complication before it happens. I'll give you an example. You're harvesting the palmares. We showed it already. I was doing a case earlier this week. This palmares was massive. I thought it was FCR. I asked the people, like, is there a chance we got FCR here? It was massive. You know what that meant to me? Right away, we're going to have a problem with passing the graft. We're going to have to do something with our bone tunnels later on. We've got to move them distal, make a bigger bone bridge, we're going to fracture all kinds of stuff. So you see it before it happens. I'm going to go a little quick on this because I want to be respectful. It's actually my wife who's speaking next, so I better be respectful. There's three operations going on at once. And there's actually more on my mind. The operation's going on in time, and it's automatic for me. I've got another operation that's going on 30 seconds ahead of it. So I'm saying things like, while we're operating, I say things like, can we get the C-arm in the room? Because I see a problem happening, and we may need to image this, for an example. And then there's another operation, because I'm running another room, and I'm making sure, hey, do we have the allograft for the other room? Check on and send somebody out. And then I often record video. If you're recording video, you know how hard that is? You've got to stand out of the way while you're operating, all that kind of stuff. And then this operation is going on all the time. While I'm eating dinner, I'm just thinking about the nerve all the time. I'm going to go over some things about choking. I'm going through a little bit of this, because as surgeons, I've personally had choking experiences. I'm not doing well. Choking is that you're able to perform, but your performance is compromised because of anxiety. We accept challenge and pressure. We're surgeons. We've got a lot of pressure on us. In situations, it's not the talent that you have or the skill to execute, it's your ability to manage anxiety. Astronaut training is directed not at how to fly the spaceship. It's about how not to panic. That's how they train astronauts. In fact, if you want to select an astronaut, it's not how good a pilot you were. It's about how well you're not panicking. Emotions drive our anxiety for poor performance. And for some of us, including me, you can get angry. Things aren't going well, you get angry. In fact, some research says motor vehicle accidents are most commonly caused by fear and emotion. If you hit something or have a fender bender, it's before texting, of course. I'll give you an example. Matt talked about this. I'm starting my first case. I think about it so hard about how we're going to get through this case efficiently so the whole day goes to work. For first knee scopes, I don't put a tourniquet on. I haven't used a tourniquet on a knee scope. We've got to get going. I'm about to start. We do our timeout. The first anesthetist says, can't start. The antibiotics are not fully administered. It's going to be five minutes. I'm like, that just, I have about eight hours of operating and now I can't start? So instead of just sitting there and stomping my feet and I'm all upset, whether it's equipment or this and that, you start to have positive talk. What I did was I left the room. I said, okay, I'm going to go do something else. This positive talk that Matt talked about, it's been my dream to be in orthopedic surgery. How can I be upset about two minutes? I have a patient who trusts me. There's no place I'd rather be. So we have choke remedies and maybe we'll talk about it in the discussion. But as far as if the routine is off, I make it a habit at least once a month to stop. About timeout and we're about to start, like knife, and I say, I'm not ready. X-rays upside down, anesthesiologist is doing something. We're not ready. We're going to walk out and we're going to start this over again. This is the hospital I work at. I've taken a photo outside the room. When I get upset, I go outside. I took a photo outside the room. This is the soccer stadium at Columbia University, just right outside my hospital. I played soccer on that field as a Columbia University athlete and I was kicking balls into the hospital parking lot and I had the dream of becoming an orthopedic surgeon and doing what I do, so I go and remind myself. I love this guy. This sign, my wife will attest to you, lives in the area where I get dressed every day. I'm staring at this sign while I'm buttoning up this shirt and this is my coffee mug, if you guys watch this. I love this guy. Okay, three years ago I did live surgery and it was extremely stressful. I did live surgery in New York that was piped into the feed at AOSSM and cameras and all this kind of stuff. Before the surgery, I went in a room, sat by myself, I rehearsed the surgery, I visualized it like a skier, went in, let's go. I prepared, more than anything, jokes. Because when you're anxious, if you can make a joke, everybody gets more comfortable. All right, I'm going to stop there just in the sense of time. I was going to talk more about more technical aspects to get out of trouble, but I'll finish with Paganini. We can talk more technical aspects, but this guy had long fingers. They think he's got Marfan syndrome. He could do anything with his fingers. So how did he play with the broken strings? He practiced playing with broken strings. He broke strings on purpose. So the message to us is we have to practice complications, not react to complications. I'm going to stop there. Thank you so much.

surgeon

crisis management

lessons learned

problem propagation

surgical skills

anxiety management