“All human wisdom is summed up in two words - wait and hope”
~Alexandre Dumas Père

Perspective is everything. Depending on your stage in residency, you will be concerned about different things when you perform a surgery. Depending on your practice, you may have cases that are routine to you, and then there will be cases that you may consider your "big cases." You may develop a system of how you approach these larger cases. I have my own way of approaching big (i.e. more challenging or risky) surgeries. I tend to approach them like when I was involved in sports and right before big game. I will give you a picture into my mind on the day of a routine big case, a scoliosis case.


5am: Damn alarm. I don't want to get up. No you have to, time to run. Where are my fff --, oh there are my shoes. Ok, oatmeal, coffee and then time to run.

7am: (ring ring) Clerk say, "Hello." I say like I am just happy to be here, "Hey it's Dr. P, I am here in the hospital."

715am: Discussion with family about surgery and answering any additional questions. The same questions I answered in our preop conference.

730am: Scrubs are on. It is now game time. Head phone in my left ear. Tool is playing.

"10,000 Days (Wings Pt. 2)" TOOL

We listen to the tales and romanticize,
how we follow the path of the hero.

Boast about the day when the rivers overrun,
How we'll rise to the height of our halo.

Listen to the tales as we all rationalize,
our way into the arms of the savior.
Fading all the trials and the tribulations.

None of us have actually been there,
Not like you...

The ignorant fibbers in the congregation.
Gather around spewing sympathy,
Spare me...

None of them can even hold a candle up to you.
Blinded by choices,
hypocrites won't see.

But enough about the collective Judas.
Who could deny you were the one who illuminated?
Your little piece of the divine.

This little light of mine it gives your past unto me,
I'm gonna let it shine to guide you safely on your way.

Your way home...

I walk in to the room, silent. The x-rays are on the board. Ok, double major curve, 80 over 80. Screws at ... I begin writing on the white board, acknowledging only my scrub person. No one speaks to me. I don't like the small talk. I am focusing on the task at hand. Screws at T3-9 ... Resident comes over, he says nothing. I finish my notations on the board and my scrub starts making note of the number of screws and sizes. Disturbed is playing. This is my favorite part. (You know the part they won't play on the radio)
"Down with the sickness" Disturbed

No mommy, don't do it again
Don't do it again
I'll be a good boy
I'll be a good boy, I promise
No mommy don't hit me
Why did you have to hit me like that, mommy?
Don't do it, you're hurting me
Why did you have to be such a bitch
Why don't you,
Why don't you just fuck off and die
Why can't you just fuck off and die
Why can't you just leave here and die
Never stick your hand in my face again bitch
I don't need this shit
You stupid sadistic abusive fucking whore
How would you like to see how it feels mommy
Here it comes, get ready to die ....

(Guitar riff is playing) I look over at the patient. Fuckin' ansethesia. Why does it have to be like groundhogs day? Why do I always have the CA-1? Why does it take them 1 hour to get lines in a normal child? FFFFUUUUCCCCKKKK. Be patient, breathe.

Spine instrumentation rep, Joe, says, “So, you been busy?" Why does he feel the need to speak to me at this moment? He knows I don't like small talk now. "Well, you know its summer. Busy season for us," I say and smile.

My resident today is Paul, ortho year 2. He has never done spine before let alone a deformity case. UUURRRGHHH, this is going to be painful. My only hope is he knows how to use a cobb. "So, Paul, while anesthesia is getting the lines in, give me the Lenke Classification of this curve." I wish the Guano Apes didn't break up. That lead singer, man, she totally rocks out.

"DICK" Guano Apes

Don’t say a word
life is like a sin-phony
brave as you dare
there’s nothing but your gain
so take off your shoes
and coming down from ecstasy
hide and turn loose
that’s why i force you to

walk like a stag
talk like a stag
come watch yourself
walk like a stag
who could wear my pants

no dick
you got no
yeah yeah how come ...

To Paul, "Ok, let's start getting the table ready. In the prone position, you need to paf here ... here ... and here." Good they are finally putting in the foley. I close my eyes. Ok, posterior approach. Knife, retractors, bovie. Watch for the bleeders, they are always there. X-ray. Burr, gear shift pedicle probe, tip out, probe pedicle, tip in, enter the body, probe pedicle, measure tap, screw. This is standard. Remove facets. Release concave side well. Rods cut. Place. Done. Simple. You have done this many times before.
"Are we ready to flip," I say. "Ok anesthesia count." She says, "1 .. 2.. 3." The patient is flipped. Everyone starts to scurry around the room. Breathe, patience, slow your hands.

"Bill, do you have good wave forms?" I say to my neuromonitoing guy.
"Sure do, Dr. P."

"Ok, you all ready? Go head and prep." Last song, focus.

"Judith" A Perfect Circle

You're such an inspiration for the ways
That I'll never ever choose to be
Oh so many ways for me to show you
How the savior has abandoned you
F*ck your God
Your Lord and your Christ
He did this
Took all you had and
Left you this way
Still you pray, you never stray
Never taste of the fruit
You never thought to question why

It's not like you killed someone
It's not like you drove a hateful spear into his side
Praise the one who left you
Broken down and paralyzed
He did it all for you
He did it all for you ....

I walk into the bathroom to pee, the last one for a little bit. Time to wash my hands. I take my head phones off. While washing, I close my eyes. Lord please guide my hands today so that I may do good and cause no harm. Please watch over us so that we may do what is right for this child. AMEN.

We finally begin the case. "Knife to the young doctor. Ok Paul, go from here to here." Ok, with the next pass, you can actually go through the skin. "Good job, wheaty to me. Paul take your bovie and cut between my snap. So, where are the normal bleeders we will encounter while approaching the spine." I know he will have no idea. They never do.

OK, it is 930, we are exposed. "Let’s pick a level we know we are going to fuse. Alright, burr." Patience, same steps every time. "Tap, screw..... OK, C-arm. let's verify these levels." .... "Good we have enough exposure."

I put in all of my screws. Now it's Paul's turn. Be patient. "Ok, Paul have you looked at the pedicle screw chart."

Paul says, "yeah."

"Ok, well then let's go. Burr to the young doctor." He picks up the burr with one hand and starts to go towards the spine. "Stop! Now, Paul, everything over the spine is a two handed instrument. Brace yourself, and don't plunge, because that would make me sad." I show him how to place 5 screws, but I put the rest in because of time.

"X-ray!" Well that wasn't so bad, that stressor is over. "Bill, how are those signals." Bill shouts, "great." Good, xrays are good. Ok, what time is it? 1030am.

"Paul, can you cut rods this length?"

"Sure," he says.

"Ok, rods. Cap." FFFUUUUCCCCCKK, why do they always have to go on break when we are at this part, god damn, mother fucker, shit, bastard, Son of a bitch. "The cap is in that tray, use the blue handled ... Joe help her." I close my eyes. Breathe, breathe. Why me, what have I done? I think they must hate me.

"Xray ... That looks pretty good. Let's see how the xray looks."
"That looks FFT baby." FAN-FUCKING-TASTIC. "Final tighten and let's close. Put on the Idol man.”

Shouting out, “Bill are you happy?"

“Yes Dr. P, I am happy.”

“Well, alright. Let’s rock out.”

God, I thank you god guiding my hands. Amen


“The two most powerful warriors are patience and time.”
~Leo Nikolaevich Tolstoy

 ORTHOPAEDIC RESIDENCY: The attending perspective.  A blog specifically for medical students interested in orthopaedics and orthopaedic residents. It is orthopaedic residency from the attending's perspective.