We got Dave Bernholdt from Campbell Clinic, Brian Lau from Duke University, Kelly Middleton from Northside Hospital Orthopedic Institute just outside of Atlanta, Georgia, and then Jordan Cancian now at Midwest Orthopedics at Rush. Oh, yeah, perfect. So yeah, Brian's gonna put out some microphones that we can pass along or to come up to the table and ask them if you have any questions. All right, perfect. We'll wait for Brian to get up here. Awesome. All right, so first question, I think it'd be great just what would you say was one of your top challenges in the operating room when you first started out and how did you handle it? And I'll remind our faculty members, you know, keep your answers concise, but effective. We got a lot to cover today, so we can just kind of maybe go down the line. So Dave, like give me a challenge that you either were or were not expecting and how you dealt with it. Morning everyone. Is this working? Can y'all hear me? No. Are these working? They should be. We can grab one of those other mics if needed. Or I'll just talk really loud. So I think the most apparent thing to me, the biggest challenge is, you know, we're used to working with all of our faculty, residency, fellowship are generally people who have things figured out. They've got their team. They've got the routine figured out. So you go from this really well-oiled machine to being on your own. So that's that's the most eye-opening thing when you start out, is how do you recreate what these guys had? And obviously you can't do that overnight. And you know, so it seems daunting to do this all at once. But you know, you show up for your first day, you have a first assist you don't know, you have you know, maybe a new resident if you're in an academic setting like me, or you have a PA you're just meeting, or you don't have a PA yet. So figuring out how to recreate what you just got used to working with on your own is it's a hard thing to step into. Very good. Awesome. Kelly, what about you? Any challenge that that you had to deal with and how you dealt with it? Yeah, I would say starting off first, I would start with the mindset or the mentality of being in an unfamiliar environment. Beamer's first point of you're the least experienced, right? And you literally have the worst support usually. You have Team C, because Team A and even Team B are with the established surgeons and they have their own team. You have an x-ray tech that just started and has never done ortho before, but they're in the OR. Your rep is usually a junior level rep, unless you have partners that are like, no, you take the good rep, or you take... So literally, it's usually you're the only one who's there who kind of knows what you need based on where you trained. And you don't get that same support. So really you are doing everything kind of on your own and managing people. That's one of the biggest things for me that was different in the OR. Bruce Lee always said, be like water, and that was my goal for, and it still is my goal, but sometimes you're not. Sometimes you're like rocks. Sometimes you're like lava. But the key really is to be fluid and kind of go with the flow early on, because there's so many things that you can't control, but you got to focus on the things that you can when it comes to your patient. Were you expecting that, Kelly, to be working with a C team? Were you ready for that? No, I wasn't. I was not. And it's funny because I didn't really, also, I didn't think about it, because you kind of just like, you're right, you move into this perfect situation. You move from this perfect situation, and then all of a sudden, like, you're with people who, your scrub tech's never done ortho, or, you know, like, it really is, it's crazy. You have the worst of everything when you first start. Absolutely. And I think if you just assume that, and you've got to have that mindset of be like water, like, everything is fine as long as you focus on your patient. For sure. Yeah, no, I had one of my first experiences. I had a scrub tech that every time I asked for the Cobb elevator, they handed me the Hibbs retractor, and it took about seven times throughout the case till they got it right. So it's hard to keep your cool when those are your, you know, circumstances. So what about you, Jordan? Give me a challenge that you kind of had. Maybe it was an unexpected one, maybe it wasn't, and then how you dealt with it. Yeah, I would just echo, you know, the two things that have been said. Make things as predictable as possible. Control what you can control. You're gonna go to great fellowships, and you've done great residency training programs, and you have these fantastic techniques. But I learned very quickly that a lot of those techniques and strategies rely on very high-level help that you do not have. That's a great point. So to replicate what you've seen is near impossible, and don't get discouraged. You just need to come up with new ways to do things, which just adds more stress to the case when you're thinking about how you're gonna do it. So show up early, look at the back table, talk to everyone in the room, tell them I'm new. If I get frustrated, deal with it. But it's gonna be challenging, but you're gonna get better. Absolutely. What about you, Brian? Yeah, I'd say that echo everything that everyone said. You're with the C team, you're not new to, you always get the new instruments, and so the best advice I got was when you're booking the cases, book extra time. So everyone's watching you that the worst thing you can do in the ASU setting is go over your booking time. You know, people are watching you that. So it may take you an hour doing ACL and fellowship, you know, book that for an hour and a half, hour 45 minutes. Just give yourself that extra time, then suddenly do the case an hour and 20 minutes, you're like a hero, you know. Call the night before, you know, check with the team, make sure you have all your instruments there, check with the rep like the day before, the morning of, just make sure everything is there, because a lot of times they won't be. But the biggest thing I think is just allot yourself more time. Don't be booking six cases that first day. I mean, I don't know if you have that many patients to schedule, but just a lot more time. Because everyone is watching you, ASC management, your partners, they just want to see where you are on that board and finish your cases on time. When you finish early, everyone's like, oh, he's doing pretty good. But if you book four cases and you're running late past the ASC time, everyone's gonna remember that and it's just gonna pass on. So that's probably the biggest advice I'd give you. Yeah, and I think that's a good point because I think I didn't do that starting out and then you run late and then you kind of get the reputation of being a slow surgeon. It's not so much that you're a bad or slow surgeon, it's just that you have no help. It takes a little longer. Maybe you're overanalyzing things and it's definitely a good point. So let's talk about the actual stress in the OR. So one of the most stressful parts of being in your first couple years, you're doing these cases on your own for the first time and you learn pretty quickly. There's certain things in fellowship maybe your attendings didn't let you do a lot of, whether it's like drilling the femoral tunnel or drilling Tommy John tunnels or putting in a Latter-day screw or cutting the coracoid. There may have been like critical parts of the case that you may not have done a lot of during fellowship or residency and then obviously it's on you to have to do it. How did you just overall, and we don't have to go down the line, we can just see whoever wants to answer this, but how did you deal with just the stress and the weight of like this is my patient, their well-being is in my hands and I'm doing things for the first time with no attending looking over my shoulder to say, you know, give that even implicit approval of like, because in fellowship and residency like if you're if you're making a bad cut like they're gonna adjust your hand before you do it. There's none of that. The bumpers are gone. So how did you manage that stress and did you struggle with managing that stress and what'd you learn from that? Yeah, so, you know, this is one of those situations again preparation for me helped keep that stress level lower just making sure you are as prepared as possible. I think the biggest thing I can tell you all to help you in those situations when you're doing all the parts of the case that maybe assistants were doing before is try to decide how you're going to do something not at the end of fellowship. Try to decide early enough that you can really pay attention to the finer points. So that that was huge for me and still despite trying to focus on that I still got hung up a few times, you know. It's it's one of those things good enough. If you're worrying if something's good enough on setup, for instance, do I have enough hyperflexion beforehand when you're going to do an ACL to get my screw where it needs to go? Good enough is never what you should aim for. You should aim for it's good. Not is this good enough? So paying attention to all the little things that way you can get the details you need to get and that's much easier if you're aware of the way you're going to be doing something so you decide you're going to do a flip cutter ACL femoral tunnel with BTB or with with quad. If you know that six months left with or with six months of fellowship left you can pay attention to all those finer points that everyone else in the room is doing. So that you don't end up in one of these scenarios where you know, it's all on you and you're questioning am I doing this right? Did anyone on the panel struggle with managing that stress or like morphing to like have a hard time controlling anger, emotions, anything? And I'll just break the ice. So I had my senior partner sit me down like six months into practice. He was like, hey, you're a pretty nice guy, right? I was like, yeah, I feel like I am. He's like, is it possible like you're not a nice guy in the OR? And I was like, what are you talking about? Like of course I am and he's like, well the staff's a little like, you know when they don't have what you need and you kind of ask them why they don't and they feel bad about it. Like they feel really bad and they like maybe like trying to correct it in the moment just isn't the right move. And and really what I realized was like I was kind of being a prick and being like guys why don't we have this? It was on the booking sheet. Like what, you know? And all I was doing was just making the staff like, you know, feel bad. They already feel bad. They felt kind of ashamed that you know, they didn't read the booking sheet. It was beyond me that they wouldn't read the booking sheet, but that wasn't the point in the moment. So like I'd never like thought I would be sat down by a senior partner and be like, hey man I just don't want you to be like a reputation of being a prick in the OR because like I would like to think people who know me would think I'm like the farthest thing from that. So Gabby's like laughing because you like can't even imagine, imagine that. So, but it's true. So like despite our best efforts like it's very easy to morph into something. So did anyone else on the panel like struggle with that? Maybe I'm the only one? Anyone? You're definitely not the only one. You're definitely not the only one. It's almost like a day-by-day, almost minute-by-minute decision that you have to make. So I learned a couple of things. One, one of my joints attendings when I was in residency had given, he sent me this book on like Catholicism. I'm Catholic, not that that matters, but he sent me this book on Catholicism. I was like, thanks, you know, like as a graduation gift and he was thank you. He was like, you know, make sure you stay close to your faith during practice and that's so true. Like I, you know, not to get too personal or whatnot, but like I pray before every case while I'm scrubbing, like while I'm scrubbing in. And I think about how I was as an athlete too. So I always, you know, gotten in my zone. I meditated and then visualization, so techniques for preparation, like all these things like I did as an athlete and all the things that you do or you did as an athlete, I basically do as a surgeon. So meditation is incredibly important. Spirituality, it doesn't matter where you lie or your connectedness, the universe, it does not matter. But that's another thing that keeps me grounded and in those moments. And then little tiny, little tiny tips and tricks. So I I'm like, my co-fellows would know this too, like I love people. So I like know their names in the OR from everybody from the janitor to the CEO, whoever it is, and treat them with respect. Being nice to people goes a long way. And so when you do start dropping F-bombs or being like, why isn't this ready? You know, this is on my pick sheet or whatnot. One, when you're nice to people and you respect them and you treat them well, no matter what environment, they will want to do more for you. So they'll help you out. Not everybody's like that, but you'll find people who will support you, right? So like one of my nurses the other day, to your point, Beamer, I was getting like majorly frustrated during the case because like my assist had let go of the suture that we, you know, I just passed and we had to basically repeat the step. This is a tibial spiroid avulsion repair, essentially, ACL repair. And so long story short, my, one of my nurses who knows me very well, like she could hear me mumbling. Thank God I mumbled because otherwise people, if they heard what I was saying. So she came up behind me, she goes, and I was like, now Mel is treating me like a psych patient. Like everybody just started like busting out laughing. But to have those people who know you and who know you're frustrated about something and they can bring you back and like check you and be like, Kel, it's all right, you know. Obviously, she doesn't call me Kel, but I mean she can. She's Miss Mel. She's like an older nurse. But you know, that's something that kind of helps me. And then the other thing that helps me is I listen to music in the OR and one of my scrub techs knows that like if something happens, like if somebody drops an instrument that I need, I've started like you know, I just take a deep breath. I go back to my Zen zone. And what she started doing is she puts on Sade because that is like my relax music. And so literally. So that's the key, just listen to Sade. So I need to go back and listen to Sade. Yeah, nice. But like little things like that, you'll kind of learn. But it really is, it's a day-by-day because you're not necessarily in that environment that, you know, when you played with your teammates, like everybody had their job and they did it. You're playing at an all-american slash professional level with people who do not play at the same level nor do they want to and nor is that their job, but you're trying to win. It's almost like LeBron with Cleveland. Hey, hey, he won one at Cleveland. So, so yeah, so I want to switch topics there. And I think one piece of advice too that I got from my senior partner was don't necessarily in the moment try to fix things if it doesn't need to be fixed. And try to avoid taking out your frustration on the people who are there to help you, the nurses, the scrub techs. So people aren't reading the booking sheets, if things aren't being done, right, go to the head of the ASC, go to the charge nurse, go to, go to the people whose job it is to fix those things and kind of lean into them a little bit more, not in a bad way, be like, tell them and really kind of put it on them to fix it and don't try to, you know, put it on the people who are there like in the moment trying to help you. So we have about five or seven more minutes for this panel and I want to get into kind of a big topic, obviously, in the OR. So complications and how to get out of them. So again, as a way to kind of break the ice, I probably had one of my worst complications probably about six weeks ago where everything was going great on ACL, I was putting in my femoral screw and the back wall just gave out and I wasn't expecting that to happen. I thought I had a good tunnel, you know, I think it got more narrow, the more posterior it got, like my angle was probably just off and I didn't have a good back wall. I couldn't use suspensory fixation. It was just a bad, you know, place to be in and it's one of those days where you wish you were wearing like your brown scrubs and peas like dribbling down your leg and you're like, what the heck am I gonna do? So you know, I got out of it. I was able to, you know, downsize the femoral block, move my tunnel more anterior and the x-rays looked reasonable and the patient so far has been doing very well. So it was, you know, but it still remains to be seen. Like I kind of fear her follow-up long-term because my tunnel is not exactly where I want it to be and I fear that that lack of isometry might set her up for a failure down the road. So it's really hard to kind of go home and be like, gosh, like I hope I didn't set that patient up for failure down the road. And it's really hard to handle that weight. So I know Jordan, you're a very open, honest guy and would love to maybe start with you in terms of any experiences you want to share and kind of how you got out of it, how you handled it, any tips and tricks for managing those intra-op complications because they do happen no matter who you talk to, they definitely do. Thanks, Beamer. Jordan's my rep buddy from residency, so I can pick on him a little more. Yeah, so I think you have to prepare for complications. I always ask the reps during the case, you know, more or less to see where they are and how prepared they are. What if this anchor pulls out? What if this breaks? What if this screw doesn't bite? What's next? So anticipate the worst thing happening in the OR. It's a good exercise because when it does, it'll still, you know, ruin you, but you'll be more prepared to do it. Are you looking for specific examples? If you want to share any. Sure. So I was doing a reverse, probably no more than a year out, and basically had catastrophic glenoid loss of fixation, glenoid intraoperative fracture. And so there's no way to get fixation of the glenoid. It's not something I'd ever seen at Fellowship or Residency. So I'd say the first thing you do is you stop, wash out the wound, take a deep breath, and then think about, one, if you don't know what to do, think about who else is in the hospital that can help you or where your partners are. So hopefully someone older than you. If you don't have anybody, I think I would scrub out. You can call a mentor. And then if things are really going poorly, I would always go talk to the family. If something's not going as anticipated, you need to start, you know, preparing for the worst and communicating with the family. So ultimately for that case, I called my partner in. He had heard of it, seen it. So we did basically a reverse hemiorthoplasty where you get, you don't get glenoid fixation, but you're able to put a base plate in a glenosphere and you leave the humerus unfinished. So there's no stress on the implant. I think the next thing you do is you, and Winston Glothney taught me this in Residency, he said you have to stare your complications in the face. It's easy to tell that patient to follow up in six weeks and forget about it, but the right thing to do is to exhaustively call that patient. I called that patient every day for three weeks and you know, give that patient your cell phone number as painful as it may be. But I think another thing I learned is that from a spine surgeon, he said, you know, lawsuits come from poor communication. They don't come from bad outcomes or complications. It's really a lack of communicating what's going on and the patient doesn't, loses trust in you. And they don't feel safe anymore. So yeah, your turn. That's great. Brian, any, any experiences you want to share? Yeah, we all have complications and I think that as for an echo, on the beginning of the day, just see who's in the OR there that day. Hopefully it's a partner you can trust. But there, there are a lot of situations where some of you may not have something like that or you're, you don't know who's around. We have fellows that will contact me, especially in the first several months of practice, like hey, today's a big OR day. They called, so they called their mentor and was like, I have a big OR day coming up. These are my cases. I may be calling you. So you have someone on backup that you trust from your, from your fellowship and mentor. Just, you know, even if there's all straightforward cases, like hey, I got an ACL. I got a bank card. I got this. I think everything's gonna go well. This is what I'm thinking. This is what I'm gonna do. But just so you know, like if something happens, I may be calling you during the day. And so that's the nice kind of backup that you have and say something happens. Again, it kind of goes back to your OR timing. If you have a lot, a lot more time, you feel like, not like you have to be super rushed. And what Jordan said, like just stop, take a deep breath. You know, sit down, like just, you know. In Ren's case, the advice was always like wash out the wound, which is kind of like arthroscopy. You're like always washing out the wound. But you know, like take extra time, wash it out a little bit. A specific complication that I had in one, one, since we're doing a BTB, femoral block as we're arranging at the end. So we're like done with the case. We're just checking it. For some reason, the bone block on the femoral side broke off. So now I've got like one plug and the other plug's off. So I had to take out the screw. You're like, eff, oh my God, this never happened in fellowship, you know? And so I just ended up flipping it around using the, what I had on the tibial side, put it in the femur and then just did, I put the tape like I would for a quad and pulled that down distantly for my tibial side. Never done that before, but that's what we came up with. And you just have to take, take a deep breath, think about all the things that you did in fellowship and something you did for a different case may be helpful. But know who's in the OR, other sports people, other people you trust. Have a mentor on speed dial that kind of knows what you're doing that day so that they're not caught off guard when you call them randomly. And people, we have fellows do that for the first several months, you know, in practice, just so that they have someone that they can trust. Yeah. And make sure you have all that backup equipment at your facility. So where you do fellowship, they probably have everything known to man on the shelf. Um, where I operate, I'm primarily at an ASC and you know, keeping stuff on the shelf costs money. And so if I need something for backup, like a BTB tight rope or suspensory fixation, it's not going to be there unless I ask for it. So you have to go to your supply people and say, look, I need at least one of these on the shelf at all times in case I get into this situation and tell them why. And most people are very accommodating for that. Um, but the worst feeling, you know, with theoretically be like, you know, you don't have what you need. You're desperately calling the reps. They're like burning down the highway, trying to get it there to you and you're just like, what the heck? And I think the best thing that was said by all the panel members here is, is take a deep breath. And, you know, I had an attending that said, it's kind of like the fog of war. Like once, you know, once the bullets start flying, you're just like, you just start, you know, getting shocked and stunned. And, and, and next thing you know, you start making bad decisions and it just kind of snowballs on itself. So as soon as you see that avalanche starting or starting, like just stop, don't let the snowball get any bigger, you know, really take a step back, assess your options, talk it through. Sometimes the reps have some good ideas. Maybe they've seen it before, not to rely on them, but just, you know, pull the audience if you will. And just, you know, give you time to think through it. So, um, any specific questions, we're going to kind of wrap this panel up now. Any specific questions from the audience in regards to this topic? Sure. Awesome. Well, thanks. So hopefully this part's been helpful. Um, just to summarize as we're swatching, uh, swapping out. So it kind of take home points. It all starts with good indications. So you need to have good indications for who you're bringing to the OR. Failing to plan is planning to fail. Uh, take extra initiative to ensure that you have proper equipment and implants. So it's really on us to communicate over communicate. It seems simple to ask for the guide wire for this interference screw or the one you want, but you need to make sure they have the guide wire for the interference screw, um, because it doesn't always come in the same kit and they may or may not have it. Simple things like that. You have to literally think of every step, be prepared for plan ABC all the way through Z. Think of the worst possible scenario and be ready for it. Uh, your day will go as your attitude goes. So don't let the stress get to you. Um, I saw in residency and fellowship, you have attendings where the room is like, Oh yeah, we're working with Dr. So-and-so. It's going to be an awesome day. And then you have some attendings like, Oh man, we got to work with Dr. So-and-so. Oh, I just want to get through it. Like I hope he or she doesn't like, you know, yell at me today. So you really can determine like, you know, how, you know, how you want to be perceived and then really start keeping your composure when things, you know, aren't going your way and just avoid that tilt or, you know, fog of war mentality. So, um, so thank you very much to our panel members. Um, we're going to switch now to building a practice.

panel discussion

challenges

operating room

transitioning

preparation

communication