My job as a Full Professor of Orthopedic Surgery at Columbia University is to teach young developing surgeons how to manage difficult surgical situations. An early lesson is on holes. The First Rule of Holes… When you find yourself in a hole, you stop digging. So how do surgeons actually stop bleeding? Here is an example. John is a high school baseball infielder with a condition is called scapulothoracic bursitis. He required a challenging surgery to remove painful tissue located between his ribs and his scapula (wing blade). After anesthesia was established, my team and I positioned him on his stomach with head facing down. His affected scapula was then prepped for surgery. I inserted a 4mm arthroscope. I put in a shaving device and began systematically removing the diseased tissue off his ribs. The surgery was going smoothly until suddenly the monitor flashed bright red. Then blood started spraying out of the patient’s incisions. My fellow assistant yelled out that we need blood immediately for a blood transfusion. But we are at a surgery center, not the main hospital, and there are no blood products at hand for a transfusion.

Without panic, I let everyone know in the room we have a situation and that I need the team’s full and immediate attention. I let the anesthesiologist know we are experiencing rapid blood loss and to maximize IV fluid. I asked the nurse to open several packs of sponges. I sliced open his back with a scalpel in line with the small incision that was spraying blood. I calmly pack the cavity between his rib cage and scapula with somewhere between 12 and 15 sponges. The spraying stopped but it was still possible the bleeding was continuing internally. I then began peeling sponges away to try to find the most likely location of bleeding — where the shaver had last been removing tissue. I removed a sponge and spraying started again. I put my finger on the bleeding and applied pressure. It was the dorsal scapular artery. Next I put clamps on both ends of the vessel and the bleeding is now controlled. I put 3 sutures around both ends of the vessel and then tied them off. John’s vital signs remained stable.

Unexpected bleeding during surgery can result in death if not handled quickly and efficiently. Time pressure can punish inaction and small error. Even with perfect execution — death is still possible. Now that John’s bleeding is taken care of and the entire surgical team is at ease, there is still a job to do. The goal of the surgery was to remove the diseased bursa and contour the bone of his scapula so he can get back to baseball pain free. I executed this part through the open incision. Then I repaired the muscle that was cut from the scapula to get to the bleeding. His rehab went well and he got back to high level baseball with a pain free non-crunching scapula.

My wife is an orthopedic surgeon and Sports Medicine Physician at the Hospital for Special Surgery. She routinely performs complex knee patella surgery where she breaks the tibia bone and moves the patella from mal-aligned positions. Colleagues often refer her these cases because they are complex. She is well experienced in the challenges and pitfalls that spark the surgical theater. In fact, as residents we were operating together on a patient with a hip fracture. (We did our residency training together) I was her senior resident instructing her through the exposure of the fractured femur bone, when suddenly the patient went into cardiac arrest. We quickly stapled the skin incision closed, put the patient (who was on her side) onto her back, and started chest compressions while the anesthesiologist infused cardiac medications. Despite resuscitation efforts, the patient died.

Friday is my OR day and when I get home from hospital on those days my wife asks the routine question that most any spouse asks when their husbands walk through the door — “how was your day”, but with a surgeon twist — “How did your cases go.” Friday typically involves anywhere between 10 and 14 surgeries on an array of amateur and professional athletes. My response to my wife depends on the smoothness of the day. “Rough day, started with anesthesia delay.” Or “disappointing, had a revision Tommy John Surgery which took double the amount of time with an ulnar nerve that was embedded in the scar.” Just last week my answer was, “I had to get through surgery with half the normal staff because nurses called in sick and there was no back staff available.” I operated with assistants that I never worked with before. Her follow up question is always the same, “How did the surgeries come out?”

Some athletes, surgeons, chess players, business leaders, and violinists have a unique ability to excel during crises. Instead of mentally and physically giving in, they accept responsibility and elevate their game.

Scapulothoracic Bleeding

This 2021 team got it done in New England against the odds and with a final kick. It was not so in years prior. I vividly recall the 2017 NYCFC playoff campaign that featured home and away aggregate scoring. The away match ended in a 4–1 Columbus Crew victory. The opening goal was initiated by playmaker Federico Higuaín 12 yards from goal. After his shot was brilliantly saved by NYCFC goalkeeper Sean Johnson, forward Ola Kamara was there to tap in the rebound for an early 1–0 advantage.

After a high elbow on Meram during a corner kick only minutes into the second half, Alexander Callens received a red card and NYCFC was down to 10 men for the remainder of the fixture. Callens was also suspended for the second leg a week later. Not good. Soon after, Brazilian midfielder Artur scored his first career goal with Columbus to give the home side a 2–0 lead in the 58th minute.

With a second leg in New York, and 32+ minutes to play in game 1, a 2–0 deficit with 10 men was still manageable. Yet the game crumbled. In the 69th minute, Meram extended the Crew’s lead to 3–0. David Villa got one back for NYCFC. His 180-degree turn, brilliant half-volleyed effort beat Zac Steffen at the near post to give the visitors an important away goal in the 78th minute. Suddenly, it looked as if the tie was not going to be as one-sided as the scoreline suggested. But all that changed late into stoppage time, with NYCFC yielding one of the most special goals in the history of Crew Stadium. In the 93rd minute, defender Harrison Afful, who had only three goals previously in his Black & Gold career, received a pass at the edge of the penalty box from Meram. He beat a staggering five NYCFC defenders and slotted the ball past Johnson for a monumental 4–1 victory. Conceding 4 goals dug a massive hole.

In the second leg at Yankee Stadium, NYCFC won 2–0. But the aggregate 4–3 score eliminated NYCFC. I performed end of season NYCFC physicals in the solemn training room. I will never forget the horrible and overwhelming feeling of disappointment in the dressing room after that game.

In Columbus that year, things went wrong. NYCFC began digging themselves into a hole. NYCFC’s failure to stop the bleeding would be a very important lesson learned…

NYCFC vs. Philadelphia Union

Sunday, Dec 5, 2021, NYCFC faced the second-seeded Philadelphia Union. The stadium was once again cold and windy. Ronny Delia inspired the boys in blue with his pregame speech. Yet in the 63rd minute, NYCFC suffered an own goal. Another broken string. What is the best response to an own goal on the road with rowdy hostile fans? Score and equalize in less than two minutes. That’s how you stop the bleeding. In the 65th minute, NYCFC center back Maxime Chanot attacked the space given and launched a swerving shot on frame that goalkeeper Matt Freese parried away. A deflected ball landed at Moralez’s feet and he blasted the tying goal in from the edge of the six-yard box. How do you advance to the MLS cup finals? Talles Magno provided the heroics and made history for NYCFC. In the 88’ minute Talles hit the back of the net and sent New York City FC to their first-ever MLS Cup. The boys in blue defeated the Philadelphia Union 2–1 in the Eastern Conference Final at Subaru Park after being down a goals and without Taty Castellanos! This team knows how to get a good result.

Chess — Kasparov On Getting A Good Result

“Everybody has a plan until they get punched in the face.”, Mike Tyson, Boxer

How you react to adversity defines you as a person and as a team. It may be that those who know how to succeed and come back have done it before and have strong beliefs and confidence. It may also be that they have failed before and studied their failures, giving them confidence to continue to forge ahead in the face of looming failure. Garry Kasparov the highest rated chess player to ever live explained it well in his Masterclass series. He said each loss was devastating to him because he felt the loss was entirely his own mistake or blunder. He felt he was never outplayed by his opponent but instead made terrible mistakes that enabled his opponent to win. In other words, he took extreme accountability. The mistakes he made in chess he described the same as experiencing physical pain. But, the anger of losing became energy to work for the next day and motivation toward a future positive result. Chess matches typically consist of many games, so how you react from one game to the next has a tremendous impact on winning and losing the overall match.

1984 Chess Championship

The 1984 World Chess Championship took place in Moscow. The young Garry Kasparov was challenging the defending champion Anatoly Karpov. The match began on September 10, 1984 and would last 5 months. It began with Karpov in typical good form, and after nine games he was ahead of Kasparov 4–0. In a match that declares a winner after 6 wins, it seemed Karpov would shut Kasparov out 6–0 quickly and decisively.

Kasparov had to stop the bleeding. After losing game 9, with the overall score 4–0, many felt Kasparov was mentally broken. Interestingly enough, it wasn’t his coach, but rather Kasparov’s mother who turned the tables for him. She advised him to stay in the game, not for the sake of winning the championship, but for learning for the future. She told him “Change your style of aggressive play to a style that creates draws and keeps you in the match longer. You can then learn more with each game you play against him. It’s about survival and strength to continue under the pressure.” She created a way for him to stop the bleeding and to stop digging his hole.

With Kasparov employing a vastly different style, the draws came. He battled Karpov to 17 successive draws. Still, Karpov advanced to 5–0 but it took him 18 games to get that one additional win. Kasparov was now 1 game away from a 6–0 defeat that would permanently damage his confidence. He asked himself “was there enough steel in my spine to survive”

After losing game 27, he fought back with another series of draws until game 32, his first game won against the World Champion. Another 14 successive draws followed, through game 46. The previous record length for a world title match had been 34 games; the 1927 match between José Capablanca and Alexander Alekhine. Games 47 and 48 were both won by Kasparov. With the score 5–3, the eventual outcome was far less certain given Kasparov’s momentum. After 5 months and 48 games, the match was abandoned in controversial circumstances with Karpov leading 5 wins to 3 (with 40 draws).

The match was ended without result by Florencio Campomanes, President of the World Chess Federation, and a new match was announced to start a few months later. Campomanes cited the health of the players, which had been strained by the length of the match (5 months: 10 September 1984 to 8 February 1985).

159 days of playing is a record in any sport, not just chess. Kasparov who would become one the most famous and accomplished chess players in history has said that “From game 27-to game 48 is probably my greatest career accomplishment!”

Back To Paganini — Practice & Rehearsal

Paganini’s violin compositions were technically imaginative, and he personally expanded the timbre of his instrument. He somehow imitated sounds of different musical instruments and even animals. One such composition was titled Il Fandango Spanolo (The Spanish Dance), that featured a series of humorous imitations of farm animals. Even more outrageous was a solo piece Duetto Amoroso, in which the sighs and groans of lovers were intimately imitated on the violin.

Paganini had exceptionally long fingers and was capable of playing three octaves across four strings in a hand span, an extraordinary feat even by today’s standards. In fact, it is speculated that he may have had a genetic condition called Marfan Syndrome that is associated with long fingers. His technical ability was complemented by his showmanship and snappy humor.

But still, how is it possible he performed so well with multiple broken strings? Answer… Paganini actually had practiced excessively and composed music on a violin with less than 4 strings, including bizarrely, a single string violin!

Many who get out of trouble, have rehearsed those unusual and unexpected scenarios. The more challenging, the more they step up and thrive. As a surgeon, I have rehearsed how to stop patient bleeding, deal with broken equipment, and really most anything that can go wrong in an operating room. It requires ability to regulate emotion that often comes with practice. Those who know how to win, practice how not to panic, stop digging, and find solutions to get out of a hole. I rehearse how to manage ACL graft complications more often than airlines rehearse how to handle unexpected turbulence. I did not rehearse management of an injury specific to the dorsal scapular artery during a scapulothoracic bursectomy, but I have rehearsed injury to blood vessels during other procedures such as fixing broken clavicles and have exercised the principles to gain proximal control of a bleeding artery. Rehearsing problems and troubleshooting allows you to frame a problem, even if it is not exactly the same as your rehearsal.

In Josh Kaufman’s brilliant book The First 20 Hours, he explains the concept. “Imagine the opposite of what you want. A counterintuitive way to gain insight into a new skill is to contemplate disaster, not perfection. What if you did everything wrong? What if you got the worst possible outcome?” He calls this technique inversion. By studying or even practicing the opposite of what you want, you uncover important and unobvious elements. If you want to kayak fast flowing rocky rivers, you would practice getting flipped upside down, the kayak getting flooded, losing a paddle etc.

In golf, even the best players in the world routinely miss a third of the fairways on tee shots. They therefore must adapt to challenging situations in order to score well. In a nutshell, this means being able to hit any shot, from any situation, at any time. Of course, practicing a few trick shots isn’t going to magically turn you into the best shot maker at your club, but it can help you get yourself out of some difficult situations. All the pros practice those shots that amateurs neglect.

Indeed NYCFC had practiced a multitude of game scenarios. Rob Vartughian is a master at designing set pieces. And NYCFC took the lead on a set piece against a Portland side that did not concede a set piece goal in 20 games… They had history of red cards during critical playoff games, conceding goals, and winning penalties.

MLS Cup Final

Portland was the final test for NYCFC and the only team left standing in the way of an MLS cup. As I left my hotel room for the bus to the stadium on game day, I realized in an attempt to wear layer upon layer, I was wearing a green tightfitting long sleeve running shirt as one of my deep layers. Green is not the color of NYCFC, and is very much the color of Portland! I took it off and made sure I had nothing green on whatsoever. Portland’s stadium was indeed green. The stadium was the loudest we had to deal with the entire season. It was rainy. Green was everywhere.

The game was a bit chippy at the start, with a brief skirmish breaking out in the 25th minute. Players also had to endure rather nasty weather conditions with temperatures in the 40s, steady rain and gusty winds.

NYCFC struck first with a Castellanos header off a free kick from Maxi Moralez in the 40th minute. The goal celebration was marred when it appeared that New York’s Jesus Medina was struck by an object thrown by a overly enthusiastic fan. It was the first set-piece goal that the Timbers had allowed in 20 games. NYCFC disorganized the Timbers for most of the game. With a goal lead at the end of regulation, the officials announced 4 minutes of stoppage time. Head ATC on the bench by my side Constantine Demetriadis started his watch timer. With only seconds left in the game, the playoffs, the season, and 7 years of team building with NYCFC, the unlikely happened. Strings snapped.

Felipe Mora finally broke through in the final seconds for Philadelphia. It was the latest goal ever scored in regulation in an MLS Cup, and also controversial. NYCFC players argued that it should be disallowed, claiming that Maxime Chanot was fouled by Portland’s Larrys Mabiala in the run-up to the goal. The roar of Portland fans deafened the pitch. Many players had their heads hanging. The cup was in their hands, only to be dropped in the last seconds and with controversy.

But Sean Johnson knows how to get a good result. Especially in the face of emotional devastation. It looked like every piece of momentum had shifted onto Portland’s side with their fans in full support. Before the start of extra time, I stood on the pitch with the team in a huddle. Johnson looked everyone in the eye and I heard him speak three words. Three magic words. “We got this.”

The game would go to penalties. Johnson would keep his three words and emphatically stopped a pair of Portland penalties. Alex Callens would blast his rocket-like penalty to the back of the net once again and New York City FC had won the 2021 MLS Cup with broken strings. It was soon after his three words that a teammate filled the cup with champagne and handed it to Johnson, who took a drink.

Summary

After every surgery, I remove my surgical gown. Often with some blood on it. I remove my surgical gloves. I do a post op debrief with the circulating nurse who asks me if any adverse events occurred. When I leave the operating room, I go and speak with the family. “How did the surgery go?” Everyday thousands of partners and family members will ask this question to their family’s surgeon. Inherent in the question is the reality that the surgery does not and will not always go perfectly. The reality is that there is tremendous variability in human performance based on a myriad of both controllable and uncontrollable internal factors as well as external factors. Professional athletes and their team of coaches and trainers deeply invest to better understand how to decrease this human variability, control modifiable factors and seek peak performance especially during undesirable conditions. Development of appropriate level of confidence, managing emotion by converting stress to challenge, and practicing the unpredictable, learning how to recognize problems early, and learning which aspects of the task are most important can be the difference.

We all should strive to stop bleeding, get better at playing badly, and never yield to a poor result. We owe it to our mission, and the very best have shown us how to do it.

Christopher Ahmad, MD is Head Team Physician for New York City Football Club, The New York Yankees, and author of the book Skill