The Life & Education of a Surgical Intern…
The breaking point in a physician’s career, the time when they are all planning how to quit, takes place almost immediately upon completion of medical school. This very first year owning an MD diploma is dedicated to internship, and is make or break. For surgeons, the pinnacle grind of internship is the vascular surgery rotation. In 1996, I spent 4 mentally and physically exhausting months on vascular surgery. It was during that time that I first met David Cone.
As a vascular surgery intern, patient care began at 4 am with pre-rounds. This involved seeing complex patients with vascular disease at their bedside, changing wound dressings, assessing the viability of their extremities and toes, checking their vital signs, assessing their calves to make sure they don’t have blood clots, and then reviewing the results of blood work and other various tests. Many patients had painful slow healing wounds as a byproduct of their vascular disease and changing their dressings before the sunrise often required pre-medicating them with a pain injection 30 min prior to peeling bandages from open flesh. On the way to the hospital from home or when leaving the hospital call room each morning, I would contemplate my luck. If lucky, the nurse would have pre-medicated as indicated in the chart orders, and my pre-rounds would be smooth. When unlucky, the nurse would neglect to pre-medicate and my start of the day would be hindered.
Our vascular team included a senior resident and 3 interns. Following pre-rounds, actual rounds took place where the team walks to each patient’s bedside and the intern presents the patients’ status to the senior resident. The senior resident then calls out tasks that need to be immediately completed. Get a CT scan, draw repeat coagulation profile, prep for OR, etc.
The interns comprised the lowest ranks on the vascular team. Each intern was assigned patients according to specific hospital units; 7 garden south, 7 garden north, or the “outliers”. I was originally assigned 7GS, conveniently close to the call room where I could occasionally sleep for a few hours. The 7GS patients were all located in a single corridor making it easier in the morning to go bedside to bedside. The intern assigned the outliers had it the worst. The outliers were patients located in various locations all over the hospital. The ICUs, the medical floors, and the private section on the 9th floor called the McKeen Pavilion are examples. After 3 days on the vascular service, the senior resident instructed me to stop 7GS and instead take care of the outliers starting the following day. What was already hard, just got harder. My initial reaction was that I must be getting punished for poor performance. Yes, we often got punished for poor performance! Instead, the senior resident felt comfortable letting me know the original intern assigned to the outliers had a problem with his ACL and felt all the running around the hospital was unhealthy for his knee. Interns were quickly labeled as either “weak” or “strong.” Weak was the most derogatory term an intern could acquire, and once you got it, it was hard to ever shake it. The resident with the ACL somehow played golf every weekend. He was quickly labeled as weak. The resident on 7GN was not so secretly dating the senior resident. No chance that intern would get assigned the outliers. I, therefore, found myself assigned the outlier patients. Sounds like Grey’s Anatomy because internship was exactly like Grey’s Anatomy. I took over the self-made travel box that was constructed to be about twice the size of a shoebox with a taped strap, which was filled with gauze, wraps, tape, Vaseline, etc. A supply to last a few days of dressing changes as I ran hallways and stairwells at 4 am.
Vascular surgery was not merely hard because of a disturbing lack of sleep and exposure to unsolvable disease. (There were no work hour restrictions at that time, the way they are currently now in place). The training was psychologically abusive. Interns were tasked with assignments where their experience was lacking and when the assignments were managed less than perfect, interns received daily chastising. The abuse took place even when doing an exceptionally good job. For example on rounds, the chief instructed me to remove a chest tube from a patient. After rounds, I removed the tube, sutured the hole closed, made the patient feel as comfortable as possible, and ordered a chest x-ray. I wrote notes. All done before the operating room starts. Job well done, or so I thought. Later in the day, I returned a page and a cardiologist who aggressively asked if I was the intern who took out the chest tube. When I replied yes, he scolded me for several minutes and explained my incompetence and danger to patient safety. He concluded by commanding me to never participate in the care for his patients in the future. I still don’t know what the issue was. I let my senior resident know (who did most of the chastising) how irate the cardiologist was and asked if I had done anything wrong. His response — “forget about it.”
A few days later, a nurse called me that a patient was having shortness of breath and a rapid heart rate. I performed an EKG and determined that the patient was in atrial fibrillation with a heart rate of 150 beats per minute. A normal heart rate is 80. Immediate treatment is to administer cardiac medication to reduce the heart rate. Each cardiologist has personal preferences as to which medications and dosages. This was a private patient so I called the patient’s cardiologist to ask if he had a preference as to which medication or any other management preferences. The cardiologist asked me why the hell I was calling him and hung up. It was 1 am. I gave the patient medication and his heart rate normalized.
The training of interns during the 1990s was similar in concept to Navy
Seals BUDS training. Surgical training developed grit, resilience, and
decisive action under pressure. I and most interns would have preferred a
hard slap across the face or even punch in the mouth than the daily set up
for stinging belittlement. But that is what we signed on for. And like BUDS training, several interns quit.
McKeen Pavilion was two floors up from 7. This was an area of the hospital on the 9th floor where patients paid extra for private rooms, better views, and better food. Outside of the patient rooms was an atrium with a piano, well decorated with fresh flowers. McKeen is where the VIPs and the wealthy stayed. Many Mckeen patients had unfortunate conditions that limited their appetite, such as cancer. The uneaten food was hard to resist for an intern who could easily hide a snack in a white coat pocket. I would eat at some point during the night when I was in a stairwell going from the 9th floor to the 7th floor. Interns were not supposed to be seen eating (a sign of weakness!) so I would eat in the stairwell.
May 10, 1996. The Yankees had a record of 20–13, and the starting rotation was Andy Pettitte, Kenny Rogers, Jimmy Key, Dwight Gooden, and David Cone. Derek Jeter was in his 2nd year in the majors.
That day the New York Times piece ran — “David Cone of the Yankees is scheduled to undergo surgery this morning to repair the aneurysm that has suddenly brought his pitching career to a halt. The Yankees confirmed last night that the surgery at Columbia-Presbyterian Medical Center will seek to repair the condition in the posterior circumflex humeral artery, near Cone’s right armpit. Stuart Hershon, the Team Physician, said he expects Cone to be able to resume his career but would not suggest any timetable for the 33-year-old starting pitcher’s return.”
What’s an Aneurysm?
An aneurysm is a vascular condition that afflicts arteries. Arteries carry oxygen-rich blood to the target tissues in the body. The walls of the artery are strong like a garden hose. But if the walls get weakened, the pressure of blood can cause the weakness to expand like a balloon coming off the middle of the hose. Pitchers repeat over and over a shoulder motion as they hurl the five-ounce ball that can stretch the artery that supplies essential blood to the shoulder. The stretching weakens the vessel walls which then expands like a balloon with the normal pressure of blood flow. Blood needs to flow. Blood that does not flow has a propensity to form blood clots. For Cone, the blood that was inside the dilated aneurysm would not flow. This static blood formed blood clots. When he pitched, his arm would go violently through external and internal rotation and the subclavian artery and posterior humeral circumflex aneurysm would get compressed spraying bits of blood clot into the stream of blood. The blood clots would travel downstream going into tributary vessels that got smaller and smaller in diameter until finally the blood clot would be bigger than the vessel and clog the artery. The clogged artery would prohibit oxygenated blood from getting to its target tissues. This would cause pain in the areas starving for oxygen. Most commonly this would occur in the tips of the fingers. In fact, finger pain in a pitcher is a signal for a dangerous aneurysm.
Rounding on D Cone
Soon after I was reassigned to the outliers, Cone became one of my patients on the McKean Pavilion. He was electively admitted to the hospital and had undergone surgery that removed the diseased dilated portion of the artery. The defect in the artery was then repaired with a vein taken from his leg. Cone was a Yankee with an unusual medical disorder, and the media shifted into high gear reporting on his condition. The interest in Cone’s condition was so intense that while in the hospital his medical information was kept under an alias for protection. (He was using a name of a former umpire) My job was to check his vitals, check his blood work, change his dressing, and basically make sure he had everything he needed. I purposefully rounded on him last, every early morning, so as to delay disturbing him. I would gently knock and enter his room, he would respond by tidying newspapers that were detailing his surgery and recovery. Different than the other patients, he was awake when I entered his room and all the lights were on. Newspapers scattered on his bed and his chair. I had a small sense that he was embarrassed to reveal that he was reading about himself. I kept it professional. I asked if he was having any issues with pain or drainage from the incision. I would change his bandage and occasional peek at the impressive view his room gave him of the Hudson River. I let him know everything looked to be healing well and that Dr. Todd, his vascular surgeon, would be in later to see him. He was polite and grateful. Looking back, I should have been more nervous to be seeing a Cy Young award winner each morning but at that point, I was quite numb to angry patients, happy patients, crashing patients, and thankful patients. Satisfaction came from eating the McKeen shoplifted pudding in the stairwell.
I was however curious about Cone’s diagnosis and surgery. After all, my goal was to be a sports medicine physician and eventually care for baseball players. I learned that Cone’s diagnosis was difficult to establish, even with a team of world-renowned specialists. This aneurysm condition in high-level throwers was not yet well documented in medical literature. As an intern, I was receiving a crash course in resilience training and also seeing true medicine for the first time. Cone’s aneurysm struck me with the realization of the immense uncertainties that come with practical medicine. Surgery is an extreme of technical proficiency acquired from years of training combined with confidence and mental toughness. Dr. Todd garnered tremendous respect from his trainees and his colleagues. Yet he and all surgeons know deep inside, that medicine and surgery have fallibility and unknowns.
Several months ago Jack Curry hand-delivered a signed copy of Full Count and inscribed “ Dr. Ahmad — I think you will recognize some of these stories, especially chapter 13.” When I read Full Count, the Education of a Pitcher by David Cone and Jack Curry, I had intense reactions and emotions. Chapter 13 recounts David’s aneurysm experience 25 years ago and made me recall the most challenging months of my surgical training. My education as an intern.
Cone and Curry stated in Chapter 13, “Before my second start of the season, my fingernails turned blue, another obvious sign something was wrong. For most of April, my hands were cold and clammy and my fingers were discolored. After two straight sluggish starts in which I had trouble gripping the ball, I agreed to have an angiogram on April 26 and missed my first start in nine seasons.“ Unfortunately, testing did not divulge an aneurism. Cone continued to pitch with numb fingers and eventually underwent a second angiogram which revealed the aneurysm and the need for surgery. The media that follows the Yankees so closely was learning this diagnosis and had much to write about. The thought of blood vessel injury evoked life and limb concern. Some reporters and outside medical experts criticized the medical decision to let Cone pitch leading up to his diagnosis indicating he risked blood clotting and gangrene.
After Cone had surgery, he explained his emotional state in Chapter 13. “As I convalesced at Columbia Presbyterian, I had the New York newspapers scattered across my bed. I was antsy and tense, and I spent hours reading the accounts of my surgery, the potential timeline for my return, and what the Yankees were planning to do in my absence. It was depressing, incredibly depressing, to be a pitcher who couldn’t pitch anymore.“ Incredible that my recollection of his room some 25 years ago coincided with his accounts. Cone eventually did a press conference at Yankees Stadium which is located a short 1.7 miles away from New York-Presbyterian. “I almost cried a handful of times while trying to guess when I might pitch again. The surgery had sapped me of some mental and physical strength, and it was uncomfortable to not know
exactly what the future held.”
Cone waited six weeks for the vein graft to heal and then started his throwing progression. Less than four months after the surgery, he started against the Athletics in Oakland. “I wanted to kiss the mound and kiss the baseball because I wasn’t sure this would ever happen again. Not only did it happen, I was rejuvenated and strong, and I tossed seven no-hit innings on an unforgettable and blissful day. “By far. That return game was more emotional than the perfect game I would pitch in 1999 and more emotional than any World Series game.” “That game gave me my life back.”
Despite Uncertainties, Medicine Paves Miracles
Every day, surgeons are faced with uncertainties such as Cone’s diagnosis, treatment, and ability to get back to his prior performance. Medical information is lacking; the science of the arm vascular system and how it responds to the biomechanics of pitching is ambiguous, and a surgeon’s skill to correct is not 100%.
Why does abusive surgical training attract a certain subgroup? I can’t speak for all but for me, as a medical student, I was amazed at the ability to explore the inner workings of a patient using a scalpel and handheld instruments. And then develop the skills to repair biological tissues that have gone wrong and essentially save limbs in frightened patients. It was and still is, the most humbling position to be in when a patient grants you that privilege to operate on him or her while they are anesthetized.
I knew I wanted to practice sports medicine as early as middle school. As a general surgery intern, my first sports medicine patient was David Cone. Sports medicine is a discipline that broadly involves all medical and surgical aspects of athletes and goes well beyond orthopedic surgery. As an intern, I made time to look up medical literature on aneurysms in baseball players. David Cone’s surgery and recovery gave me enthusiasm, insight, appreciation, and revival to my mission: To become the best surgeon and position myself to change the lives of patients that I would be fortunate enough to treat.
The Start as Yankees Team Physician
I started working with the Yankees in 2008 and was promoted to Head Team Physician in 2009. My first Yankee player that I had medical involvement was Cone in 1996. During Cone’s hospital course, I met the Yankees Head Team Physician at that time, Dr. Stuart Hershon. I was impressed with the complexity of sports medicine and the pressure-filled position he was in. Managing the health of the most recognized athletes in the world induced pressure, plain and simple.
Perhaps the abuse & nature of vascular surgery was necessary to gain strength and confidence and immunity to pressure which is even more important when managing elite athletes. What if I was never was assigned the outliers? As Marcus Aurelius has taught us, “What stands in the way becomes the way.” In some ways, that second week in May 1996 was the start of my career. I will never forget it. Looking back, I would not trade the experience. It would be 12 years later that I would assume the role of Yankees Head Team Physician.
Cone and Curry’s Full Count not only resonated with my internship experience, but it also gave me new insight and appreciation for Cone’s balance of grit, determination, skill, and analytical approach to pitching.
His traits are the same traits exhibited by surgeons and really most people who excel in their chosen field. Cone responded to his aneurism surgery by pitching a perfect game. These are the lessons we teach our kids and examples I use to comfort patients who confront injury.
My Current Mission and Full Count
Interestingly, Cone and Curry’s book not only resonates with my past pursuit for sports medicine excellence, but it is also amazingly practical to my current sports medicine mission. Cone and Curry do a wonderful job explaining the skill of pitching. The art of pitching is broken down so that a surgeon like myself can fully understand the tactical nuances.
How Can This Book Help Developing pitchers?
Velo isn’t everything. Deception is everything.
Deception comes from the interplay of varying arm angles, timing, pitch selection, and changing velocity. Not maximizing velocity. Cone stated in Full Count, “I set numerous traps against hitters by getting them to swing at poorly located pitches.” “When I retired a batter on one of those trap pitches, I shot a sly smile because I had outwitted yet another hitter.”
Deception is more important than max velocity. That being said, I have never seen a high school or college pitcher in my office with arm trouble practicing deception to improve their performance. I have never heard parents brag about their kid’s deception or the number of clever strikeouts achieved. What I do hear day after day is velocity, weighted balls, and arm pain. That is why I loved Cone and Curry’s Epilogue and will recommend it as required reading for developing pitchers and their families. It will save elbows. In my 11 years as Yankees Head Team Physician managing the day-to-day crises of Tommy John Surgery, I can attest that if you’re subscribing to Cone’s approach to pitching it will be very beneficial to those who wish to avoid Tommy John Surgery.
SPINNING THE BASEBALL
Cone believes it’s totally OK to tinker with curveballs as early as age twelve. He states “I know there’s a risk, but I think it’s smart for a young pitcher to learn how to spin the baseball.” Cone also explains that curveballs should be limited in number in both practice and games to avoid overuse. Cone’s dad monitored his curveballs per game and in some games, he wasn’t allowed to throw any at all.
From a Tommy John Surgeon’s perspective, using chronologic age (age according to your birthday) to start throwing curveballs is subject to questioning. First, athletes develop physiologic maturity at different ages.
For example, we have all seen a 6 foot tall 14-year-old who is shaving, standing next to a teammate with a height of 5 feet and no physical features of a growth spurt. In addition, some young athletes have coordination and athleticism that will allow them to spin the ball with proper mechanics while others need more time to develop that strength and coordination. Finally, many who throw the curveball at a young age will abuse the privilege. Either because they wish to better develop the break, or they have success and they want to use it too much too often in their pitching! For these reasons, Cone’s approach to curveballs in youth throwers is medically sensible.
In summary, curveballs can be instituted when appropriate physical
maturity, supervised mechanics, and governed use in practice and in
ADMIT WHEN THERE’S SOME PAIN
Cone states that “if a pitcher feels some soreness in his arm, he needs to report it to his parents or his coach. Don’t be a hero.” I could not agree more. I have blogged previously about our research that shows as much as 70–80% of young pitchers play with elbow pain. And 50% of them feel pressured to do so. And even more alarming is, if you get injured as an adolescent pitcher and recover, you have a greater risk of needing Tommy John Surgery later in your career. It is therefore the responsibility of everyone involved in youth baseball to establish a culture where it is OK to say you have elbow pain. We observed the recent culture change in the realm of concussion. A football player in the 1980’s would regularly continue to play with his bell rung. And he was applauded for his toughness. Then the evidence came along showing that concussion has a relationship with permanent brain damage. Our current
culture has improved to a level where most believe it is no longer cool to play with a concussion. We are not there yet with pitching. My book “Understanding Tommy John Surgery and How to Avoid It” is a tool to establish a culture in young athletes so that they can feel comfortable doing what David Cone has suggested — tell your coach or parent if you have elbow pain and don’t push through it!
MENTAL AND PHYSICAL TOUGHNESS
“Everyone who has ever thrown a baseball will experience some horrendous games, but a pitcher must be mentally tough enough to forget about the dreary performances and move on to the next game.” “Failure is inevitable for pitchers, but the way we deal with failure will help determine how successful we will be.” As I read about Cone’s experience with injury and how he overcame obstacles, it resembles surgical training. Cone was in his darkest moment in his professional career recovering from aneurysm surgery and I met him in my darkest moment of surgical training. Overcoming internship set my stage to dream big, as Cone has. As most who achieve, do.
In 2009, I was establishing myself as the Head Team Physician for the Yankees. The team with the most world series expects to win every year, and also expects the best from its medical staff. One summer evening, I received a late-night call from the triple AAA Yankees trainer. They were playing in Rochester NY and the number one Yankees pitching prospect left the game with stinging pain in his fingertips. The immediate thoughts of those observing him were that he was reacting to the cold weather. I immediately instructed the trainer to send him to the nearby medical center ER. I called one of my former fellows who was currently practicing in Rochester and explained that I have a pitcher with a suspected aneurism and will need anticoagulation. He was seen in the ER, anticoagulation started and then he made his way see me at Columbia-Presbyterian. He had discoloration of his fingertips and fingernails typical of what blood clots can cause. I asked a respected vascular surgeon to evaluate him and an MR angiogram was obtained. The vascular surgeon told me he ruled out an aneurism and that pitcher had Raynaud’s disease. Raynaud’s disease is a condition where cold
temperature causes vessels of the fingers to constrict. Pain results similar to the pain of reduced blood flow from blood clots. The vascular surgeon recommended vasodilator medication which dilates constricted blood vessels and special gloves to keep his fingers warm.
I remained concerned and quite frankly skeptical about the diagnosis. My intuition was that he had an aneurism. I recalled how challenging it was to make the diagnosis for Cone some 13 years earlier. I contact Dr. George Todd, Cones vascular surgeon, and whom I was an intern for, who had left Columbia to work at another hospital and requested a second opinion. He read the angiogram and in fact found the aneurysm. Dr. Todd performed the vein graft surgery as he did for Cone, and I observed in the OR. This promising pitcher recovered and continued his career. As of this date, there have only been 2 Yankee pitchers with this condition that I am aware of.
We think of medicine as structured, orderly, and procedural. What it really is, is an imperfect science, an enterprise of constantly changing knowledge, incomplete information, mortal individuals, and limbs or lives on the line. Surgeons train to make quick, perfect decisions, and to execute seamlessly. Habit, intuition, and fortitude fill in the gaps. When I read Full Count, Education of Pitcher, I also projected the teachings beyond pitching. I am always inspired by athletes at every level who overcome injury and I am gratified when I can play a part in that return. I am grateful for what David and Jack were able to share in Full Count. I encourage everyone to read it, and then read it again.