From Different Planets

It was 1997 and I was a first year post graduate orthopedic student taking emergency duty on Diwali night. We usually received a lot of minor blast injuries on Diwali. These were often sustained from crackers exploding in the hand, sometimes accidentally, sometimes intentionally in a fit of bravado. The injury pattern was similar. There would a spilt down the base of the thumb with variable bits of fingertips blown off. We were always swamped in the casualty, so it was a free for all with the juniors left unsupervised to do whatever they could. The case I got that night was a young man with an injured right hand. “Patch him up,” said the casualty MO, “I’ll ask for a plastic consult.”

I patched him up beautifully. The hand had multiple web space splits in addition to the usual pattern. I cleaned it all thoroughly and sutured the split web spaces. The fingers posed more of a problem with exposed bone protruding out from the tips. I disarticulated them all down to the nearest joint to get a good closure. I inspected my work in the end with pride. The wounds were all nicely sutured, not a bit of raw flash showing. The finger stumps stood at varying lengths, all short, some really short, but that was from the injury, I thought, what could a man do?

The plastic surgeon came calling some time later. I told him I had finished the job. “Finished?” he seemed annoyed, “your MO asked me to come, I wouldn’t have come down at all if I knew you had done the job.” I took him to the patient. “Well, open it, I want to see the wound. I have to write something in the case sheet.” I took down the bandages and he examined my work. He looked stunned. After a long moment he said,“You have cut them all down?” His voice was hushed. Yes, I replied. “I wouldn’t have believed this if I hadn’t seen it,” he said. He looked at me and said, “You will make a fine orthopedic surgeon, son.”

I thought at the time it was a compliment, but looking back I think it wasn’t. Orthopedic surgeons are not reputed to be the brightest in the medical fraternity, and he probably was thinking I was a dumb ox who deserved to be right where I was. That hand left to a plastic surgeon would have meant hours of repair work and reconstruction.I had finished the job in half an hour, efficient perhaps, but not good work. In fact a shoddy, incompetent job.

Looking at the way orthopedic surgeons and plastic surgeons work you would think they were from different planets. The orthopod is obsessive about operating time and sterility. The plastic surgeon is finicky and thinks nothing of spending hours suturing a small wound. The orthopod prefers to reach bone as fast he (its usually a he) can because bone is safe, an oasis of comfort within a dangerous body. There are only so many ways in which you can damage a bone. The Orthopod is in his element here. He can always put in some bone graft and fix a plate with screws and solve the problem. But cut through a nerve and there will be hell to pay. Cut nerves must be repaired and even then may not work well.

All surgical approaches are designed to avoid dangerous structures. Nerves are dangerous, so are blood vessels, and the best way to avoid injuring them is to not see them at all. Thus orthopods have devised techniques to avoid these structures except when it is absolutely not possible. The radial nerve, for instance, is one of those nerves which must be seen and kept safely away when operating on a broken humerus. But we still try not to see it. One of my professors would go right down to the humerus as fast as he could, as though his life depended on speed. “If you don’t see something,” he would say, “you can’t damage it.” The logic was impeccable although most of his patients ended up with radial nerve injuries. But it never seemed to change his belief.

In fact this obsession with getting straight down to bone and staying there is a time honored principle. It is even written down in our textbooks. Hoppenfeld, the standard book on orthopedic approaches, mentions this at regular intervals. He also instructs us not to cut round structures. Round structures are either nerves or vessels, says Hoppenfeld, so one shouldn’t cut them. I suppose you can’t make it simpler than that. But even flat structures can be dangerous. I once had to open a displaced pediatric supracondylar fracture to fix it, and the first thing I saw was something flat winding across the bone ends. “That’s periosteum, nice and flat,” I told my assistant, “pediatric periosteum can be quite thick,” and proceeded to cut through it. It turned out to be the brachial artery. It wasn’t round like Hoppenfeld said because it was stretched across the fracture. Thankfully there was a vascular surgeon in the theatre. She came over and repaired the vessel without much trouble.

Orthopods believe that the fastest surgeon is the best. There was an orthopod who actually advertised in a newspaper that he could replace a knee in fifteen minutes. No matter that taking a little more time may not be a bad thing, considering that the patient must live with the surgery for the rest of her life. This orthopod is the direct descendant of the great Robert Liston of London who used to prance around the operating floor shouting, “Time me, gentlemen,” before finishing an above- knee amputation in half a minute. Liston could claim he had to work fast because he didn’t have the luxury of anesthesia or blood transfusions. The modern orthopod with all his latest equipment still remains driven by speed, an aspiring Schumacher of the knife.

Another area of orthopedic obsession is sterility. The orthopod believes in layers of draping as a barrier to infection. He cocoons the patient withins acres of sterile sheets until the anesthetist must burrow like a mole underneath to access some part of the patient. He then paints all around the operating zone with various multi-colored sterilizing agents. We had an orthopod who was widely reputed to paint the walls of the operating room with povidone iodine before he started on the patient. Another keeps a large bowl of some sterilizing solution outside the operating room into which anyone who seeks entry must dip his or her feet.

Contrast the plastic surgeon. He or she dons a single pair of gloves, unlike the orthopod’s mandatory two. Draping and prepping is perfunctory at best. The plastic surgeon believes in tracking down and exposing every little nerve that might cross her path, every little vessel. To debride a wound the orthopod is content to pour saline solution into it, followed by a mixture of iodine and hydrogen peroxide, before he starts his main job- affixing metal to bone. The plastic surgeon spends hours for the same procedure, and removes every bit of dead material and debris from the wound. He wouldn’t ever think of pouring betadine or hydrogen peroxide into raw wounds. “The surgeon who does not debride properly is not sure of Anatomy,” I remember an old plastic surgeon commenting while watching me pour liters of saline into a mangled leg.

The orthopod and the plastic surgeon is often forced to work together in trauma surgery. This can lead to conflicts. The average orthopod is as comfortable operating on a limb prepped and draped by a plastic surgeon as he would be dining inside a train toilet. No self-respecting plastic surgeon trusts an orthopod near a wound unless there is bone work to be done. I was once assisting a hand surgeon with a finger re-implantation. It was the dead of the night, the plastic surgeon was doing his thing through a microscope which had no eyepiece for an assistant and I was retracting something, when I heard him say, “Okay, that’s it, you go off and sleep somewhere. I will call you when I have finished.” “Its alright,” I said, “Im fine.” But he was adamant. “No, I cant do anything with you snoring and leaning all over the microscope.”

The question that naturally arises from all this is the old nature versus nurture one. Is the difference between the orthopod and the plastic surgeon a genetic one? Or has it been shaped due to environmental pressures? Is it acquired, in other words, or is it inborn? Is someone born with the temperament to spend hours handling minute blood vessels and tiny sutures? Is it in the orthopod’s genes to rush through a surgery like an elephant in a sugarcane plantation? These are moot questions, I’m afraid, with no easy answers.

One connecting bridge between the two specialities is hand surgery. Hand surgery is a demanding field which needs plenty of training and patience. When we were trainees these injuries were treated largely by orthopedic surgeons. They would come at the bottom of our priority lists because there was no metal to implant. They would be allotted to the most junior member of the team. The results were invariably bad with permanent stiffness and loss of function. This was accepted as the unfortunate lot of the patient. The first time I saw a trained hand surgeon at work I stopped operating on the hand.

But there are orthopods who gravitate to hand surgery. They are a rare breed and can be exceptionally good because they combine the principles of plastic surgery with a knowledge of rehabilitation. In time they gradually come to resemble plastic surgeons. This link between the two species is my main observational evidence of a genetic predilection. I believe that the orthopod turned hand surgeon is a plastic surgeon at heart, a wolf in sheep’s clothing, who has taken a wrong turn. It is only natural that he turns his heart to plastic at the first opportunity.

A colleague of mine, an ideal orthopod we always thought, once went to a big centre to train in bone cancer work for a couple of years. Soon after he returned we called him to help us out with a multiply injured patient. We were fixing the patient’s femur and he was working on the humerus. We finished the job and went over and saw that he was busy dissecting all around the arm. “Is there a problem? Where is the bone?” we asked him. “Well,” he replied, “I have identified and marked the ulnar nerve and the radial nerve. Now I need to see the brachial artery and the median nerve before I expose the fracture.” We were aghast to see his plastic nature exposed, naked under the operating lights, like a werewolf on a full moon night. It turned out that he had spent some time with reconstruction surgeons in the cancer centre, and genetics had asserted itself. I haven’t yet got over the shock.

I personally think these are inborn traits. We all tend to settle into jobs we find most comfortable. I have only anecdotal evidence with me at this time but I’m sure we will eventually find a plastic surgery gene, the absence of which makes a person suitable for orthopedics. The orthopod gene on the other hand will make its owner a bad prospect for a plastic surgeon. Time will, no doubt, bear me out.

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