Unstable and bleeding from multiple gun shot wounds to the abdomen, the patient appeared, to my untrained eyes, a goner. Fortunately for this patient, I was a newbie Intern starting my General Surgery residency and nobody asked for my opinion. My job, as second assistant, was to “hold hooks” and position the retractors to optimize the exposure for the real Surgeons doing the case. The abdomen was opened quickly and all I recall seeing was a sea of blood and guts. Over the next hour, the patient was stabilized and the repairs were made. When we were finishing the case I asked the Attending Surgeon, “How do you know where to start when you first open up the abdomen and see all that chaos?” He said, “You start with a basic surgical principal called known to unknown”. Years later when I was a Trauma Surgeon, that simple advice got me, and my patients, out of more trouble than any other advice I received. In fact, I’ve used it for getting out of all kinds of non-surgical trouble as well.
Known to unknown works like this. When it seems you are completely lost on how to solve a particularly challenging problem, begin with what you know. For a Surgeon who opens an abdomen and is confronted with a complex problem like multiple injuries, you begin with what you know from your training. You know about anatomy, pathophysiology and simple maneuvers to stop bleeding and gain better exposure. Once this is done, you can now examine the abdomen more extensively and address the most pressing issues. Each step along the way moves you from something known to something unknown. As you address each issue the number of unknowns becomes less and less. What was once a chaotic and complex environment is slowly and methodically reduced to a more simple, orderly and manageable environment. The key is to train your mind to focus on the knowns first and systematically work out the unknowns. When faced with the complexity of a difficult situation keep in mind you have a choice. Take it one step at a time and move from known to unknown.
