The Unknown Unknowns

When he made this statement at a press briefing in 2002, Mr. Rumsfeld was trying to paraphrase a quote by Confucius that was recorded by Henry David Thoreau in Walden. What he is trying to say is accurate if you think about it—there are things we know we know, things that we know we don’t know, and there are things that we don’t know we don’t know. There are many facts and “things” all of us know as the result of our education and life experiences. Most of us are smart enough to admit that there are things we don’t know. That is why we keep struggling each and every day to improve our knowledge about many subjects. I think this would fall under the heading of “getting smarter.” It is the last group that can cause problems for all of us—what is it that we don’t know that we don’t know? Is it some scientific fact or theory we should know but don’t? Is it some treatment that could help others that we don’t know we don’t know? Is it some life experience that has somehow eluded us?   I was recently made aware that all the reading you can do does not necessarily let you know what you don’t know. Many times it takes real life experiences to lead you to those discoveries.   I recently had both of my knees replaced. As a surgeon, I was well aware of the drill—do the preop, go to the hospital, talk to anesthesia, take a nap, wake up with new knees, go home, and return to work—right? I thought I knew all the ins and outs of having an operative procedure, even though I had never had one.   Boy, was I wrong. I learned very quickly that there are others who don’t know what they don’t know. Among the first things I had to do was educate the anesthesia resident about how long it takes local anesthesia to take effect before you start the IV! After that mini educational course, he promised he would do better for the next patient. That bit of unsolicited education may be the reason I have absolutely no recollection of the insertion of my epidural catheter by the same resident.   I can truthfully and thankfully say I had no direct knowledge of how it feels to be paraplegic. It is not pleasant, but fortunately my “paraplegia” wore off the next day. My only concern while I was paraplegic was lifting myself off the bed so I would not get a pressure ulcer. I could just imagine how it would look if I came home with a presacral pressure ulcer!   Another perioperative fact with which I was well aware was the Foley catheter. Like many of you, I have ordered them, put them in, adjusted them, and taken them out. No matter how many hundreds of times you have done this, it is no substitute for personal experience. All I shall say about the Foley catheter is that it was one bit of information I knew I did not know and had no interest in knowing.   There are other things I discovered that I did not know about actually having an operative procedure. Many of those I shall leave to your imagination. Fortunately, all went well with my procedures. My new knees are essentially pain free and work very well. I could not have had better care. The only thing I hope for in the future is the opportunity to do the physical therapy for a physical therapist who just had a knee replacement!