The Making of a Plastic Surgeon: Two Years in the Crucible Learning the Art and Science
Chapter 3- Back in Training
Chapter 3- Back in Training
“Toto, I’ve a feeling we’re not in Kansas anymore”.
Dorothy in The Wizard of Oz
As the high-speed metal burr cut through the hard outer cortex of Dave’s skull, a fine mist of bone dust and blood hovered over the surgical field. Lance Raiffe, the chief resident, continued to cut the bone as I dripped sterile saline onto the burr to keep it cool. Finally, the burr cut through the hard outer table of the skull bone, into the marrow space. Blood seeped into the cut. His completed cut outlined a rectangle of bone.
Raiffe now took a fine, ultra-sharp, slightly curved chisel, called an osteotome, and began to lightly tap the chisel with a hammer as he slid the blade into the marrow space under the rectangular piece of outer table bone he had just outlined with his cut. With a final tap, he levered up the chisel and freed an eighth-inch thick rectangle of bone about one-and-a-half inches wide and two inches long. The spongy marrow space was now exposed. Below it was the intact, hard inner table of the skull which remained to protect Dave’s fragile brain. We had just harvested a bone graft from the skull which we were going to use to repair a blowout fracture of the floor of Dave’s right eye socket.
A blowout fracture occurs when pressure inside the bony eye socket rises explosively. In Dave’s case, the cause was a line drive in a softball game. The ball bounced off his glove and struck him full in the eye. The floor of the socket is comprised of bone so thin it is almost transparent. When pressure rises suddenly in the socket, this will give way, dissipating the pressure into the sinus space underneath, and protect the eyeball from rupturing. Without the support of the floor, however, the eye can sink down into the socket. Muscles that move the eye can be entrapped by the sharp edges of the hole in the floor of the socket, causing double vision.
Dave presented to the emergency room with his eye swollen shut. X-rays showed an obvious blowout fracture. In addition, the arch of his cheek bone was shattered into several small pieces, flattening it. Because the main muscle that closes the lower jaw runs under this arch, he had difficulty opening and closing his mouth as well. Thanks to the safety valve of the floor fracture, his eye was undamaged.
Raiffe had exposed the fractures by making an incision across the top of Dave’s scalp, from ear to ear, and peeling the forehead down, all the way to the top edge of the eye socket and around the side to the fractured, flattened bony zygomatic arch that normally gave fullness to the cheek. He also made an incision under the right eye, along the lower edge of the bony eye socket. Taking a fine spatula-like instrument, called an elevator, he had stripped away the lining tissue of the floor of the socket, exposing the gaping hole. I used a thin retractor to hold the eyeball and the fat surrounding it out of the way. The tiny fragments of bone were too small and thin to be repaired. After picking the bone fragments out of the sinus, Lance took a thin piece of sterile plastic sheeting. From this he cut out a piece the shape of the floor of the socket, making sure it overlapped the edges of the hole. He then used this as a template to trim and file the bone graft to the exact same shape.
Finally, he slid the bone graft into the socket. The natural curve of this bone graft perfectly conformed to the curve of the floor of the socket. The graft fit so snugly that we did not have to use any screws to secure it. I released my retraction and the contents of the socket filled the space with the eyeball now supported in its proper position by the bone graft. The graft would heal solidly to the floor of the socket, permanently restoring its integrity.
Next, he turned to the shattered zygomatic arch. He was able to elevate the pieces into their proper position, but the arch was unstable. Raiffe took a tiny, narrow stainless-steel plate with multiple holes and bent the plate to match the curve of the arch. Using an air-powered drill with a fine drill bit, he drilled holes in the bone fragments and secured them to the plate with tiny screws. I assisted by stabilizing the fragments while he drilled and placed the screws and, as before, I dribbled saline as he worked to cool the drill bit and avoid heating the bone, which might further damage it.
Once the bone work was completed, we stitched the incision under the eye, pulled the forehead back up and stapled the incision across the top of the head. When fully healed, Dave’s scalp scar would be hidden by his hair and the eyelid incision would be almost invisible.
As we wrapped Dave’s head in gauze, the thought crossed my mind, as it had several times in the preceding weeks, “So, this is plastic surgery………….”
Some hospitals seem to have a personality. I imagine Boston’s venerable Massachusetts General Hospital would be that of a bow-tied, bespectacled New England university professor. The University of California Medical Center, in San Francisco, on the other hand, would be a long- haired, free-spirited intellectual in a tie-dyed T-shirt, bell bottoms, and sandals. Jackson Memorial Hospital would have a split personality, alternating between Dr. David Banner and the incredible Hulk, the former educating young doctors and latter beating them to a pulp.
Named for Dr. James M. Jackson, a prominent Miami physician, it grew from its modest beginnings as a 13-bed city hospital in 1918 to become, by 1987, a 1600 bed behemoth, the third largest public and teaching hospital in the United States. The physical plant was a huge sprawling mélange of old and new buildings haphazardly scattered across a campus covering several acres bordered by some of the poorest inner-city areas of greater Miami. Some of the most advanced and sophisticated medicine was practiced in its inauspicious, sometimes threadbare surroundings. There were few private rooms and the interior décor, if you could call it that, was on par with that of any large inner-city hospital. It was a place to go if you were indigent or needed treatment of a complex, unusual, or rare medical condition; required an uncommon or unusually extensive operation; or for severe trauma. It was not the place to go for your routine hernia or gallbladder operation and, definitely not the place for those seeking any creature comforts in their medical surroundings. Your surgery might be delayed or indefinitely postponed to accommodate emergencies and a never-ending stream of trauma courtesy of the heavy, high speed Miami traffic and very active knife and gun club of greater Miami and its surrounding neighborhoods. Jackson attracted excellent nurses and doctors, drawn to the challenges posed by working in a demanding, chaotic, and exciting environment.
The volume of trauma coming to Jackson was such that in 1992, the Dade County Public Health Trust, which ran Jackson, opened the free-standing Ryder Trauma Center, one of the first such facilities of its kind, to handle all trauma cases, giving the main operating rooms some respite and allowing them to function more efficiently. You would see pathology there that you might never see again in medical practice. Jackson drew patients from all over the world, especially from the Caribbean, Central, and South America.
Many of the clinics were reminiscent of a third world hospital with masses of patients and their families crowded in waiting rooms and hallways. All that was lacking was the occasional stray chicken or pig wandering about to complete the picture. The diversity of the South Florida population was clearly reflected in the patient demographics with English, Spanish, Portuguese, and Creole intermingled in the din of the waiting areas. There were twenty-four operating rooms several of which ran around the clock. The Naval Hospital in Okinawa had barely one hundred beds and four operating rooms, only two of which were used regularly. On returning to Jackson after three years in Okinawa I truly felt like the country mouse coming to the big city. Changing into scrubs in the huge surgeon’s locker room I felt the same sense of excitement, and butterflies typically associated with stage fright. Jackson was a big stage.
On July 1, 1987, the first day of my residency, I entered the surgeon’s lounge and beheld a common scene: Dr. Millard seated in one of the chairs with a large group surrounding him. These would be medical students, interns and residents, fellows, and typically one or more visiting surgeons. A listing of the doctors who came to Miami to observe him operate was a veritable Who’s Who of plastic surgeons from around the world. As I approached, he looked up. I said hello and was acknowledged with a perfunctory nod. He remembered me.
Without preamble, he asked, “So, what have you been reading?” Being caught by surprise at his questions soon became routine.
I began to answer, “Grabb and Smith…..” (This was a somewhat basic, slightly outdated textbook on plastic surgery and the only one on this subject in our meager library at the hospital on Okinawa).
“No, no,” he interrupted, “what else have you been reading?”
“Well, I just began Principles and Art ………….”
At this point he cut me off, declaring, “Well, you’re never going to make it here,” and turned his attention back to the group around him. So much for making a good early impression.
I stood there silent, not knowing how to respond. My emotions were a roiling mixture of surprise, embarrassment, anger, frustration, disappointment, and, not far below the surface, fear. To be greeted in this fashion after all the anticipation of the preceding months was deflating, to say the least. Despite being isolated thousands of miles away, I had done my best to obtain current reading material, albeit unsuccessfully. I was angry that this was not taken into consideration and frustrated in not being more assertive and articulate in defending my efforts and explaining the challenges my isolated location posed. As a fully trained, board-certified general surgeon with several years of practice experience I was embarrassed at being dressed down in this fashion in front of other surgeons, several of them residents younger and less experienced than me, not to mention the medical students.
The thought occurred that, perhaps, I could have done more to find reading material before leaving Okinawa, even though I knew I had scoured the hospital and written to Miami several times asking the Division to send me something to read. It was not until we were packing up our household goods to leave Okinawa that I received the two-volume work, Principles and Art of Plastic Surgery, by Dr. Millard and Sir Harold D. Gillies. Although a classic in the field, it was now also somewhat outdated.
Dr. Millard’s comment also played on a fear that I might not be up to the demands of going back into residency after years away from an academic environment. Being back in this medical center where I had gone to medical school nine years earlier, brought back some of the insecurities and feelings of inadequacy of those early days. That afternoon, I stopped off at the medical bookstore and bought several books on plastic surgery, including Dr. Millard’s recently published Principlization of Plastic Surgery. I spent the entire evening poring through the books trying to absorb as much as possible before the next day. My two years in the pressure cooker had begun.
The residency at Miami was a two-year program divided into six 4-month blocks. There were two blocks at Jackson Memorial Hospital, one as a junior resident and one as a senior resident; and one block each at the Miami Veteran’s Administration Hospital, Victoria Hospital, and on the Hand Surgery Service of the Department of Orthopedics at Jackson. The remaining block was the reason so many applicants sought a position in the residency at Miami. During those four months the resident worked directly with Dr. Millard, assisting him in surgery and seeing patients with him in his office.
There were six residents at any one time in the Division. Two began in July, as I did. One began in December. The other resident who started with me was Mark Lovaas. Lovaas was a legacy in that his older brother, Greg, was the ex-fighter pilot with the helmet headlight. Lovaas was everything that I was not. He was several years younger than I and had only completed three years of a general surgery residency, but he had spent a year in Germany with a highly respected plastic surgeon who was a personal friend of Dr. Millard. As such he arrived at the program with a degree of familiarity with the specialty and a level of confidence that I could only envy. In appearance and dress, he exuded the casual, rumpled elegance that one associated with Ivy League schooling and family money. He drove a late model BMW. I was counting every penny and drove a decrepit Audi Fox purchased from a salvage yard. Mark and I got along well but, alongside him, I felt shabby and ill-prepared. If plastic surgery was a private club, he was already a member and I was still outside the gate, looking in.
In addition to Dr. Millard, several other plastic surgeons made up the primary attending staff of the Division: S. Anthony “Tony” Wolfe, Walter “Buster” Mullin, John Cassel, John Devine, and Leo MacCafferty. Dr. Millard and McCafferty were the only two who operated routinely at Jackson. McCafferty finished his residency the day I began mine and stayed on as an attending surgeon at Jackson.. Until 1987 there had never been a full-time attending plastic surgeon in the Division, salaried by Jackson. Although part of McCafferty’s role was to oversee the residents at Jackson, we continued to manage our patients and operate largely on our own.
Jackson had two categories of patients: service patients and private patients. Service patients were those who were admitted through the emergency room or one of the resident’s clinics and who did not have a private physician. Private patients were those admitted by one of the attending physicians. As Jackson was a university-affiliated teaching hospital as well as a public county hospital, all patients were cared for largely by the residents, supervised by the attending surgeons. On some surgical services, the attending surgeons were very hands-on while on others, residents had a great deal of autonomy. The Division of Plastic Surgery functioned more like the latter. I was surprised with how much autonomy we had in seeing patients in our clinic, scheduling cases, and performing surgery without an attending surgeon being present most of the time.
While Dr. Millard and the other attending surgeons gave us a lot of free rein, this is not to suggest that there was no oversight as they were medically and legally responsible for the care our patients received. We had our Monday morning breakfast with Dr. Millard in the Jackson cafeteria to discuss the cases for that week and weekly Grand rounds at which we presented upcoming patients for surgery to all the attendings. All the attending surgeons were available to us if we needed them, and it was expected that we had enough experience and good surgical judgment to call for help when we needed it. For the most part, this was true, and the system worked well, albeit with an occasional hiccup. A few residents just didn’t seem to know when to seek help. After my experience with Jim’s vasectomy years earlier, I did not have any hesitation in asking for assistance. It could not have been easy for the attending plastic surgeons to juggle the demands of their own practices with the periodic requests for their help from the residents, but I none ever balked at having to come in and assist us in a difficult case, even in the middle of the night.
The Division of Plastic Surgery was housed in the Memorial building, one of the oldest edifices on the medical campus. It was one of a cluster of buildings surrounding a small park to which the original Jackson Memorial Hospital building, known as The Alamo, had been relocated years earlier. The other buildings were Jackson Memorial Hospital and its newest wing, the University of Miami School of Medicine, the Mailman Center for Child Development, a large rehabilitation unit, and the medical center’s multi-story parking garage. Walking into the building, you entered a long corridor. To the left was a small office out of which the Division of Plastic Surgery was run by Evelyn Shields, the administrative secretary. She had been there seemingly forever. If Dr. Millard was the head of the Division, she was its heart and soul. Shields was the first point of contact for all doctors seeking a residency at Miami. She maintained all Division records, including applicant and resident files. She kept charts for all the patients of the multi-disciplinary cleft lip and palate clinic that was Dr. Millard’s pride and joy. The apparent chaos of her office belied an effective organizational system that only she could navigate, and she always seemed to be able to come up with a file or document on demand. Evelyn knew Dr. Millard and the program better than anyone and she was invaluable in helping residents navigate the sometimes-turbulent waters of those two years. Many would have foundered without her. I know I would have.
Nearly ten years after I had been there as a medical student, the Memorial building was in even worse shape, if that was possible. It was now largely abandoned, containing only the Division of Plastic Surgery on its ground floor. The second floor had rooms for residents to sleep in when they were on call on those rare nights when they weren’t busy with emergencies or patients on the Jackson wards. At night the poorly lit hallways, with their many doorways and dark alcoves, could be downright spooky. The frequent blare of sirens on the streets outside added to the foreboding atmosphere and should have made sleep difficult, but exhausted residents learned to sleep right through them. Next door to Evelyn’s office was a small office for the residents. This was where we saw our cosmetic patients for their initial consultation and all their pre- and post-operative care. To call it inadequate would have been a galactic understatement. It was little more than a large, high-ceilinged closet. There was one door to the hallway and a pass-through window to Evelyn’s office. The high ceiling accentuated the already claustrophobic feel of the tight quarters. A confused array of pipes and ducting ran across the open ceiling. Seating consisted of mismatched, molded plastic chairs. The floor was dingy, cracked vinyl tile, its color a sickly, bilious green, probably as old as the building. The examination room was painted a drab, bureaucratic beige and so much paint was peeling off the walls that they looked almost fuzzy.
The residents’ office did not contain a proper examination bed. Patients had to be examined sitting in one of the plastic chairs, or standing. In a pinch we could lay them uncomfortably across the row of chairs. There was a battered gray metal desk and a matching ancient metal locker in which to hang our white lab coats. In one corner was a small, low table where we kept our surgical supplies and dressings. The lighting, from old fluorescent fixtures overhead, was marginal and supplemented by an ancient goose-neck lamp with a bare incandescent bulb which made every patient look slightly jaundiced. Compared to my generous, sunny office in the surgery clinic in Okinawa it was a cramped, dingy cave.
Our clinic was apparently not on any restocking list in the medical center’s supply department. One of the junior resident’s duties each week was to make a trip over to the main hospital to forage for whatever supplies he could pilfer from the clinical supply closets on the surgical wards. I sometimes half expected to hear shouts of “Stop him! Stop, thief!” as I scurried across the campus with a bag full of dressings, suture removal kits, needles, syringes, etc. There was always a little pride in a successful foray to the main hospital. This absurd system had apparently been in place for so long that it never occurred to us to stock the clinic any other way.
There was no waiting room. Patients waited in the hall outside our office. Across the hall we had a locked closet in which we kept the only intrinsically valuable thing in the entire clinic- our inventory of breast implants.
The entire clinic setup was so unprepossessing that it begged credulity that it could yield any patients for cosmetic surgery. Even the most austere private waiting room I have ever seen looked positively sumptuous by comparison. I often tried to picture myself as a potential patient coming to Jackson to seek cosmetic surgery. After looking around that office I think I would have run out of there as fast as my legs could carry me.
Remarkably, we never lacked for patients. It was a tribute to Dr. Millard’s reputation, the draw of Jackson as a university medical center, and to the high caliber of the work of most of the residents that the Division had acquired a reputation as a place where one could get high quality cosmetic plastic surgery at very reasonable rates. We did no advertising and referrals to our clinic came almost entirely through word-of-mouth recommendations from former patients. The quality of work was directly related to the abilities of the residents working there at any given time, but on average was probably as good as much of what was being done out in the community by the plastic surgeons in private practice. Having seen some of the work out there, I think we often did better.
Filling our available operating time for cosmetic surgery was never a problem. It would never have occurred to any of us to complain about the woefully inadequate clinic facilities. Instinctively, we knew that these things just weren’t important to Dr. Millard. He would have expected us to work through, or around, such minor obstacles. Besides, we were just too busy with surgery. Several years after I left Miami, the clinic was moved to a newer building.
After the unpromising start in the surgeon’s lounge at Jackson, I left the main hospital and walked over to the Memorial building to meet my chief resident, Lance Raiffe. I was to begin my training as the junior resident on the Jackson service. Raiffe was a soft-spoken, stocky guy with thick, black, bushy hair and a black moustache that reminded me a bit of Juan Valdez, the fictional spokesperson for Colombian coffee. He drove a late model Porsche, lived in Miami Beach, and, I later learned, ended most days of his residency with a relaxing massage. I soon began to appreciate my good fortunate to have him as the senior resident at the start of my training. Raiffe exuded an air of quiet confidence and seemed imperturbable. He was a technically proficient surgeon. Most important, he was unselfish and willing to turn cases over to the junior resident, me. We got along very well, and he taught me a lot in those first few weeks when I was still getting my bearings.
In every hospital across the U.S. July 1 is the first day of the residency year for all specialties. It is a truism, universally acknowledged within the medical community, but largely unknown outside of it, that you don’t want to get sick and be hospitalized on July 1, because that is when new newly graduated doctors begin their internships and interns and residents transition to their next level. Raiffe and I were about to assume care of patients left by the residents that had just preceded us at Jackson. They had checked out their patients to Raiffe but he had never actually seen them and, of course, neither had I. Together, we headed over to the main hospital building to make morning rounds. The first patient was a revelation and a stark reminder that I wasn’t in Kansas…..uh, Okinawa, anymore.
Juan was a homeless Cuban man in his 60s who lived under an overpass in downtown Miami. One evening, some dude(s) beat him in the face with a baseball bat, breaking every facial bone. His skull was intact, his face taking the brunt of the assault, so he suffered no permanent brain injury, but he did lose vision in one eye. It was remarkable that he survived at all. He perfectly fit the profile of the typical Jackson service patient: non-English speaking, indigent, homeless, traumatic injury. The senior and junior residents at Jackson before us had operated on Juan late into the night before, with the assistance of Wolfe. They had reconstructed his face using tiny metal plates and screws to reassemble the innumerable fragments of bone. The following morning, when we saw him, his face was swollen to twice its size, his eyes swollen shut, and his lips resembled two large, purple plums. He had incisions across the top of his head, under both eyes, and inside his mouth. His jaws were wired shut. He was in surprisingly little pain- severe facial injuries often result in more numbness than pain- and responded to our questions appropriately, thanks to my rudimentary Spanish.
Looking at his x-rays, there was so much metal that the screws and plates alone formed a reasonable likeness of a face. This was my first exposure to such severe craniofacial trauma. It was a revelation that this type of surgery was a part of plastic surgery. I had much to learn. In the days that followed, Juan made a surprisingly smooth recovery and was discharged a little over a week later. Social services found him a place at a local homeless shelter. After he was discharged, we saw him once in the resident’s clinic to remove the wires holding his jaws closed. He never returned after that. A lack of long-term follow up was also typical for Jackson service patients.
With Juan as my introduction, my first two months as the junior resident at Jackson were a continuous stream of patients with one new revelation after another as I discovered the unexpectedly broad scope of the specialty. My time on the plastic surgery service with Cave at Oaknoll had been relatively short and the range of cases I saw, while enough to cement for me the appeal of the specialty, did not reveal just how broad it really was. The volume and variety of cases that we saw at Jackson was as astonishing as it was unexpected. Every surgical service in the hospital from neurosurgery to orthopedics referred patients to us for reconstruction so we worked, literally, from head to toe. From the standpoint of expanding my knowledge and learning new procedures I was, as the saying goes, drinking from a firehose.
Richard T. Bosshardt, MD, FACS, Senior Fellow at Do No Harm, Founding Fellow at FAIR
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