Once upon a time, I was working on an anterior L5-S1 interbody fusion. In this case, the patient had degenerative disc disease, and the vertebra were literally rubbing up against each other.
On the x-ray, you could see giant osteophytes and an obvious compression of the disc space that even I could see.
The patient was complaining of back pain, not pain radiating down his legs. Down the leg is more of a nerve root pain where you would do a posterior approach to help free up the nerve root.
On this day, we were doing an anterior approach. We cruised down past the epigastric vessels, past the rectus muscles, and eventually got to the psoas. You could palpate the ureter and the kidney. Pretty fricken cool. I’m in the OR 5 days a week, but I’m never in this particular space.
The last time I palpated a kidney was in a pig lab when I was still a very green laparoscopist. My hospital had sent me for some training (I think they thought I was awful so I could use the work)
Yes, the pig was intubated and everything. Weird, but still cool. We did a hand assisted kidney-ectomy. You make a small incision, just big enough for your hand to manipulate the kidney, then you have laparoscopic instruments for visualization and scissor and what not.
Feeling warm organs is crazy. It’s a sensation that still seems surreal.
Back to the spine case. We made a small incision, just big enough to fit your hand in. We made our way down to the iliac artery and the iliac vein. And that’s where progress stopped like rush hour on the beltway. Eight lanes and no one is moving.
The dissection down to this point took about 15 minutes. Now the iliac vein was completely stuck down to the disc we were trying to get at. It may have been a little scar tissue, but it’s hard to tell and it really doesn’t matter. It won’t move.
That vein HAS to translate about 2 cm in order to see the disc space and it was not moving a millimeter.
Here’s the question for you: How long did we work on that vein? How long did we spend trying to move it so that we could see what we needed to see to get the surgery done?
That answer is…
UNTIL
Until we could see. We spent just over an hour on that one blasted vein. We worked on it UNTIL.
A baby is learning to walk – how long do you give him to learn? 1 month? 2 months?
You go tell the mom, “I’m sorry it’s been 2 months and he’s pretty wobbly and still using his hands… you should call it quits.”
No, No , No.
That baby keeps trying UNTIL he gets it. There is no giving up. There is no quitting. There is no other choice. He keeps trying UNTIL.
How long do you take to learn cardiology? To learn pulmonology? When do you stop and say, “Well, I guess that’s it? It’s been a full two weeks, and I just don’t know this cardiology stuff.”
No, No, NO!
You keep at it UNTIL you get it. You keep working UNTIL.
You get the books; you get the videos; you get the extra help until, until, until.
You get the course; you burn the midnight oil. You keep working, and you don’t stop until you’ve got it.
That’s the secret to surgery and it’s the secret to PA school. There is no not-getting it. There is no closing the patient up and saying, “Sorry it was a little tough and it was getting close to lunchtime, so we decided to throw in the towel.”
Nope, not you. Now, although you’re going to put the work in, you can work a little smarter. I mean jeez we worked on that patient, but we didn’t decide to do the surgery with a butter knife and a spoon. We chose the proper tools and then did the work.
In your case, the proper tools should include a copy of The Final Step. Burn the midnight oil with that book, and I guarantee the material sticks in your head like gum in my son’s hair. Work that book UNTIL and your exams should be like a walk in the park.
Click here to get yours:
Brian Wallace
P.S. We did get the vein moved without incident, and the patient did great.