This is a phrase repeated many times throughout a medical trainees’ life whether in the classroom or the hospital wards. I certainly heard it many times from preceptors, residents and attending physicians throughout my years as a student and practicing physician assistant (PA). I have used it more than once while teaching a young PA or student.
The origin is believed to come from William Stewart Halstead, MD. Dr. Halstead was the father of the modern surgical residency program in the United States. It is a remarkably simple and effective strategy that has stood the test of time. While its applications are different now and its purpose has evolved with the changing nature of modern medicine, it still holds a place in our medical lives.
What if you have never “seen one”? My orthopedic training in PA school was standardized and met the requirements of the ARC-PA. We were taught the basics of the musculoskeletal exam, common diagnoses seen in the primary care setting, and we were drilled to remember certain emergent conditions, including compartment syndrome. I believed the training was sufficient but I knew I had so much more to learn. I thought that is where clinical rotations and job training came in. Rotations greatly improved my knowledge and skill set. In 5 weeks at an orthopedic practice in Manhattan, I became more comfortable examining patients, diagnosing common musculoskeletal problems, and formulating treatment plans. But, I saw no orthopedic emergencies.
Compartment syndrome fascinated me because it was so urgent and the diagnosis was so clear – “you would know it when you see it.” But would I? I knew it involved extremity trauma, most commonly the tibia, but could affect the forearm, humerus and foot. It was a clinical diagnosis but I was told to remember intracompartmental readings of 20 mm Hg to 30mm Hg below diastolic pressure were criterion for fasciotomy. I memorized the 5Ps but understood I could not rely on them and decreased two point discrimination was a more reliable early sign. Where was my paperclip? I hoped I would never see it but I wanted to so that I would never forget it.
As I progressed into clinical practice, the learning curve improved. After 2½ years of practicing orthopedics in private practice and inpatient settings, I became more confident interpreting imaging studies, diagnosing and managing common orthopedic injuries in the emergency room (ER) and clinic, performing procedures and assisting in surgery, and even teaching graduating PAs. I take little credit for this knowledge, by the way. Due to Dr. Halstead’s pioneering ideas, I had wonderful and caring supervising physicians who shared their knowledge and expertise with me. It was so rewarding to read about meniscal tears, understand how to diagnose them by exam, have your supervising physician show you the joint line, palpate the joint line and elicit pain. It is never enjoyable to hurt a patient and it pains me that to formulate a good diagnosis in orthopedics we have to replicate the symptoms. However, there is so much satisfaction in seeing one and doing one.
Alas, compartment syndrome remained a white whale. I had seen plenty of tibia and both bones fractures and sadly, most of the injured patients in the ER or in clinic were in pain. None had compartment syndrome so the diagnosis remained elusive to me. While it is always fortunate I had encountered so few critically injured people, I could not help but think compartment syndrome was a rite of passage in orthopedics. I never wanted to miss it. However, I wanted to observe it at least once so that I could appreciate its presentation. I wanted “to see one.”
In my fourth year as a PA, I began working at a level 2 trauma center. It was the second busiest ER in the state. In the first 6 months, I had seen scores of periprosthetic fractures, dozens of diabetic ulcers and far too many open injuries from motor vehicle trauma. I had not “seen” and “done” so many things in such a short period of time. It was exciting and challenging but academically rewarding.
Plenty of consults came through to our pagers reading, “Patient in ED. Suspected compartment syndrome.” I would rush to see them and report back to my attending. Most of the time it did not clinically present like compartment syndrome, but I always made sure to examine them with my attending. They had seen it and I had not.
Once, an attending and I ran to the ER to examine a patient. My collaborating physician walked into the room and elicited a thorough history and performed a textbook exam. Lower extremity trauma. Check. Pain with passive stretch. Check. Subjectively decreased sensation. Check. This was it, I thought. I finally saw compartment syndrome. We walked out of the room and my attending whispers to me, “His compartments are soft. His pain is not out of proportion to the clinical exam. I don’t think its compartment syndrome but I am going to watch him for a few hours.” Watch him he did. Every hour for 6 hours he examined the patient until he finally signed out against medical advice. The diagnosis was more intriguing than ever. If the patient has all of these clinical signs and symptoms, how is it not compartment syndrome? “Patients with compartment syndrome have this undeniable pain. They are crawling up the walls. They would rather you cut their leg off than feel the pain anymore,” my attending said, “He didn’t have it.” It was a vivid verbal illustration.
Art of clinical practice
There is an art to clinical practice that Dr. Halstead understood. You must read about it and see it so many times that your knowledge and intuition is just reflex. It is not enough to know all of the criteria and common presenting signs and symptoms. My attending did not just brush this patient off, by the way. Someone had taught him that close observation was critical and now he was teaching me.
A few months later, I received a call from about a lower extremity injury in the ER. It was late on Friday evening and I was on call. I promptly headed down to the ER as my collaborating physician was currently operating. It was not long before I found my patient. I could hear him from down the hall. He was screaming and cursing and laying prone in a semi-fetal position. I elicited from him and his family member that he had injured his leg when a wooden projectile struck it only an hour or so earlier. Radiographs showed a proximal fibula fracture but his knee joint and tibia were pristine. His pain was just tremendous though. He was lean and young, but his calf was so swollen and beefy with exquisite tender. I ran back and reported to my attending, “You have to see this. I think this patient has compartment syndrome.” After examining the patient, he agreed. We promptly took the patient to the OR and performed a fasciotomy. Even though I was scrubbed, I watched mostly. I had never seen or done one. He recovered and days later we performed a primary wound closure and he was discharged. I fear it may never be as clear to me again in the future but at least I can say that I saw it once.
I hope I will never see it again but I am glad that I did. In fact, I know I will if I practice long enough. Due to Dr. Halstead’s three phrases I am more competent in my ability to assess and treat orthopedic problems. While it holds a different significance today than it did at Johns Hopkins in the early 20th century, it is still a viable tool for educating medical providers in training to learn and provide the best care for our patients.
Daniel J. Acevedo, PA-C, is a board-certified physician assistant who practices at the Orthopaedic Center of Central Virginia in Lynchburg, Va. His research interests include physician assistant education and precepting, osteoarthritis, and periprosthetic joint infections.
Disclosure: Acevedo reports no relevant financial disclosures.