#043 How to do the impossible

This is impossible.

The thought ran through my head as I peered at an exposed brain at 2 am. I was a new consultant and had taken a young patient back to theatre for a post-operative infection.

She was a pleasant young woman, the most unfortunate ones always are; perhaps that's what makes them unfortunate. She suffered from recurrent brain tumours called meningiomas. Since adolescence, these often benign tumours had continued to appear in her brain, year after year. Her surgical résumé was impressive and spanned over a decade.

Often fate likes to twist the knife and her last operation had been complicated by an infection. Her scan was bad enough for me to decide that she needed to have surgery in the middle of the night and the diseased bone thrown in the bin.

From the moment I met her, I knew her operation would be challenging.

Her scalp was a roadmap of healed and partially healed scars. Beneath her scalp laid another puzzle of bone cuts, fashioned on a near bi-annual basis.

My job was to remove the infected bone, wash the infection away and close her patchwork scalp, the only barrier between her brain and the world.

18 hours into my shift and the prospect of putting this lady's scalp back together short-circuited my brain.

I stared at the 3D puzzle that I had made even more complex after clearing away the infection. I could see no way to reoppose the skin edges without creating significant tension. Creating tension on wound edges is a fine skill. Too much and the skin can lose its blood supply and die. Too little and the wound will fall apart.

When things don't go to plan in theatre, and the situation allows, I often turn and stare at the scans I have loaded on the monitor. I'm sure my team think I am contemplating my next move. The reality is I am composing myself. After even the shortest of breaks, this allows me to start again and see things with fresh eyes.

And so I turned back and began.

3 hours later we were done and I was satisfied with the result. Her wound healed without problem, and after a long course of antibiotics, she went home no worse for wear.

These are the 3 techniques I used to overcome the seemingly impossible.

Plan (and then abandon the plan)

“In preparing for battle I have always found that plans are useless but planning is indispensable.” - Dwight Eisenhower

When faced with a daunting task, we are daunted because our brains cannot predict the steps needed to reach our end goal. The elephant is too big and our mouths are too small.

So we need to take one bite at a time.

Having a plan, any plan, reduces the task into bite-sized steps. Each step needs to be manageable and something we know we are capable of achieving.

The step where I used to go wrong was obsessing over the plan, revising it, gathering more information and making it "perfect". The problem with this is that it prevents you from starting. And there is no perfect plan.

Once you have a plan you have a first step. Once you have a first step you can start. The importance of starting is that you gather more information. And that information is invaluable.

Tissues I thought wouldn't hold did. Others I thought would, didn't. With each stitch, I gathered more information and unconsciously revised my plan on the go.

You need a plan to get started and tackle any daunting task. But do not dogmatically tie yourself to the plan. Adjust it as needed as you gather more information.

Microgoals

“…I advocate passionate dedication to the pursuit of short-term goals. Be micro-ambitious. Put your head down and work with pride on whatever is in front of you… you never know where you might end up." - Tim Minchin

Even after you have a plan and have started you can doubt yourself. The Devil on your shoulder whispers that you can't do it. You're not making progress. It's not going to work.

This is where having microgoals will help. Instead of looking at the big picture, turn your next step into the only goal and think of nothing else.

As I closed the Spaghetti Junction incision, I focussed only on stitching the next few centimetres. That became my end and only goal.

This did two things. Quiet the doubting voice in my head because I know I can do this next step. It also gives positive reinforcement from a sense of achievement. Once you have completed any self-directed goal, no matter the size, your brain releases dopamine and serotonin, hormones that make you feel satisfied and motivated.

Anyone who has run a marathon or an all-out 400m knows that you can trick yourself to keep going by telling yourself you just have to get to the next tree or bend on the track.

When executing your plan, set achievable micro-goals to cultivate a motivated mindset.

Vision for focus

"Action without vision just passes the time." - Joel Barker

This next step is baked into surgery. When we focus intently on an object in our visual field, the aperture of our eyes narrows. With this narrowing the way your brain "slices time" also changes. Time is "cut" more finely and with that comes increased focus. Odd as this sounds it isn't surprising as your brain is a direct extension of your brain.

I couldn't help but focus intently on each bite of the needle as I worked. But you can leverage your vision in two ways to boost focus on your micro-goal.

The first is to "pre-load" focus by staring intently at one spot a couple of inches in front of you for one minute before starting work. As simple as this sounds it's surprisingly difficult to do.

Try and see for yourself. See if your eyes want to look somewhere else and pay attention to the willpower needed to overcome that temptation. Once you're done, inspect the texture of your mind to see if you feel more focused on the task at hand.

The second is to keep your work environment free of distractions. It's why old-school writers only had a writing desk with a typewriter, some paper and a wastebasket nearby. No distractions at all.

To get into deep focus and flow, visual attention is key.

To recap how to tackle an impossible task:

• Make a plan to get you started and be ready to revise it as you go.
• Set micro-goals within each step of your plan to stay motivated.
• Remove distractions to use your vision to focus.

To help with your next big hairy goal, here's a ChatGPT prompt you can copy-paste to create a step-by-step plan to get started:

"Assist me in dissecting a large, overwhelming task into smaller, manageable components. I will describe the task in detail, and your role is to help me identify and outline the incremental steps required to complete it. First, ask me questions to understand the scope and complexity of the task, then guide me in establishing a sequence of actionable, bite-sized tasks. Each mini-task should be simple enough to tackle without significant effort, yet collectively, they lead to the completion of the main objective. The goal is to create a structured plan that allows for steady progress in small, manageable increments, making the process less daunting and more achievable.”

Good luck eating that elephant.

It's not as big as you think.

See you next week.

P.S.

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