Reflections on My First Day

Seth Greenky, MDBy: Seth Greenky, MD

Amidst the clutter of half-opened shipping boxes and the chaos of three young boys ages one, three and five happily romping in the configuration of boxes, furniture and other odds and ends as if they were secret tunnels deep within an enemy fort, I took a moment to reflect on what had been and what was yet to be. Years and years of education, training and refinement of my clinical and diagnostic skills were now behind me, and I began to envision what the years ahead as an attending surgeon would bring. I had just completed a yearlong fellowship in adult reconstructive surgery (joint reconstruction surgery) at the Cleveland Clinic and returned to Syracuse where I attended medical school and completed a residency program at the Upstate Medical Center. Joining an established and diverse group of orthopedic surgeons here in Syracuse would afford me the opportunity to learn from experienced colleagues while launching my own practice as a joint replacement surgeon. I was grateful that I had a full week to make that mental and physical transition before I actually started with my new group.

My thoughts were interrupted by the persistent ringing of the telephone. I searched for the source of the ringing until I successfully unearthed the phone from beneath a mound of action figures, stuffed animals, and miniature cars buried in the corner of the room. As I shouted "hello", afraid that I hadn’t reached the phone in time, I heard the voice of one of my new partners at the other end of the phone. "Seth" he quickly replied to my greeting, "welcome to Syracuse. Can you do me a favor? I need you to cover the ER for me today. Something unexpected has come up. Don’t worry, I checked with the Emergency Room and nothing is going on." With that, the phone call ended.

A small wave of anxiety swirled inside me but I pushed it aside, recognizing that the likelihood of actually having to respond to anything was minimal. When the phone rang again less than five minutes later, the thought that it could be the St. Joseph’s Emergency Room couldn’t have been further from my mind. I heard the words multiple trauma, motorcycle accident, young guy, and open tibia fracture (the hallmark injury of high velocity trauma accidents). Open fractures are surgical emergencies that require immediate surgical intervention to prevent infection and vascular compromise. As a pit formed in the center of my stomach, I was out the door immediately and enroute to a hospital in which I hadn’t stepped foot in more than four years.

The 12 minute drive to the hospital was surreal, seemingly lasting an eternity, while simultaneously flying by in what seemed to be mere seconds. For the first time ever, I am the surgeon. Alone, on my own, and completely the end of the line. The reality of the phrase "the buck stops here" slowly sunk in. It’s not that I hadn’t done a large number of these types of procedures; however, in my residency and fellowship I had been functioning under the comfort and reassurance that there always was someone else nearby to advise or assist me if needed. Not in this situation. I was headed to a new hospital in a new city to render emergency care to an individual who would be counting on me to make him whole again.

After parking in what I later learned was a patient parking lot, I made my way into the building and was greeted by a guard who escorted me to the ED, undoubtedly wondering if I really was the doctor I presented myself to be. The fact that his eyebrow arched as he introduced me to the charge nurse in the Emergency Room as well as the unspoken exchange between them signaled to me that they were more than slightly skeptical of my identity and my intent.
I next found myself looking into the eyes of a young male patient writhing in pain and surrounded by concerned and anxious parents. I would later learn that he was a college freshman and a baseball star on the verge of greatness, but for that moment he was a terrified kid in requiring my immediate aid. The intensity of his pain filled eyes begged me to reassure him that everything would be fine. We needed to get to the Operating Room as soon as possible.

The next several hours passed in a blur of activity and uncertainty. We were in the Operating Room in a matter of minutes but the real challenge lay before me. What we have in the present day Operating Room is the quintessential definition of the word "team". The individuals assembled on the orthopedic team in the OR today work together in a committed way, displaying a clear sense of camaraderie, and a shared sense of accountability and responsibility for the outcome. The staff assembled for this case was comprised of competent individuals with a common goal to care for this man; however, we were unknown to each other, and the additional burden of this lack of familiarity further compounded the already tense situation.

Not only was I in an unfamiliar environment with unfamiliar staff, I had the additional challenge of unfamiliar equipment and instrumentation. Although remarkably similar, the metal pieces and parts that I would use to reconstruct his shattered tibia were worryingly dissimilar as well because they vary greatly depending on the manufacturer. Not surprisingly, the instrumentation and items available at St. Joseph’s were different than any I had used before. This was yet one more star that fateful night that seemed not to be aligned in a positive path.

After rifling through the sterile supply area, I assembled the items that would best help me reconstruct the contorted leg. The best approach to this scenario was to use external fixation to rebuild and immobilize the bones, affording the broken bone the best opportunity to heal without residual damage. The surgical application of an external fixation device is strikingly similar to the technology used by a child when constructing an erector set. The popular childhood toy consists of metal beams, nuts, bolts, screws and other such mechanical parts that can be used by innovative and imaginative children to construct endless objects such as robots, mechanized cars, buildings, and other limitless creations of the mind. Similarly, external fixation is a surgical technique used to immobilize bones by placing pins and screws into various locations along the fractured bone. They are then attached by bars, sprockets, clamps, and hinges to a main device or frame outside of the skin where it can be controlled and adjusted to attain proper anatomical alignment of the bone. During the course of the next several hours, I used this "operative" erector set to reconstruct the bone.

Never far from my mind was also the concern that he displayed signs of peroneal nerve injury. The peroneal nerve is a portion of the sciatic nerve located near the knee. It is responsible for controlling the muscles that move the foot and toes. Especially worrisome is that damage to this nerve can result in foot drop and other long term problems that could plague him throughout life despite an effectively healed fracture. Addressing this problem during the surgical procedure added another dimension of complexity.

The surgical procedure was successful. The patient steadily improved, was discharged, and gradually resumed the life of a college student. I returned to the process of integrating myself into the Syracuse Community and my new medical practice. He, his family, and I were all infused with an extreme sense of gratitude. They, for the successful outcome and his promised favorable recovery; me, for the fact that my first surgical case at my new hospital was challenging, but extraordinarily rewarding. All the time, never far from my mind during that fateful night, was the fact that my performance and the outcome for this young man would be the first impression that I would make on the patient, his family, staff at the hospital, and the community in which I hoped to spend the next forty years.

Many long-lasting bonds were forged that night. My initiation into the St. Joseph’s family was a fait accompli and a positive experience. More than twenty years later I remain close to the patient and his family. In essence, we grew up together. I have continued to care for him as needed, as well as for his parents and other extended family members. I recently mentally returned to the events of that night when I received a call from this man. He required medical care for a non-orthopedic ailment and contacted me to ask my advice and opinion on this matter. How very remarkable that more than twenty years later, the connection between us remains strong.

This case left a lasting impression on me. The true test in life doesn’t occur when all is going well and the next moment can be predicted and therefore planned. The truest life test occurs when we are faced with unexpected challenges and are able to meet and rise above them, elevating us to achieve great things. Orthopedic surgical challenges are a part of what every surgeon experiences. The story lines differ and the characters differ, however, what we all have in common is that it is stories like this that weave the fabric of our lives.