by Robin Cook
"Oh, I don't know," George retorted. "Back then the patients not only attacked with their hands; they kicked, too. Have you noticed how quiet his feet have been? We're making a lot of progress in anesthesia."
As such sallies went, this was a pretty heavy barrage, and the surgeon decided not to return fire. Instead, he directed his attention toward salvaging what he could of the operative field. While he kept a precautionary hold on the patient's troublesome hand, I covered the incision with a sterile towel soaked in saline. Straus and the scrub nurse and I were still sterile, as the OR terminology put it.
Breaking the sterility of the operative field was a serious problem, because it greatly increased the probability of post-operative infection with something like a staph. Some surgeons are quite maniacal about sterility—but never, it seems, in a consistently rational way. For instance, one professor in medical school required interns, residents, and students to scrub for exactly ten minutes by the clock. Anyone trying to get into the OR after a scrub of less than ten minutes had to start over from the beginning. These strictures did not extend, however, to his own scrub, which lasted, by generous estimate, no more than three or four minutes. Apparently the others' were more contaminated, or his bacteria less tenacious.
His fastidiousness about sterility had been responsible for one memorable episode. The case was an interesting one, involving a bullet wound of the right lung, and residents and interns were three deep around the OR table. One resourceful medical student a rather short fellow, was intent on seeing every detail. He piled several footstools on top of each other, stood on them, and by holding on to the overhead light for support, could lean over and gaze directly down into the operative field. This ingenious vantage point worked well until his glasses slid off and fell with an innocent plop directly into the incision. This had so unnerved the professor that he directed the resident to continue the case.
Luckily, Gallagher, the surgeon for the appendectomy, had a firmer grip on his emotions than the medical-school professor had. Though obviously upset, he was still functioning.
"George, see if you can pull this arm out from under the drapes and hold it securely," Gallagher said, looking over at me and rolling his eyes at the absurdity of it all as the anesthesiologist burrowed headfirst under the sheets.
"And, Straus, you just back away from the table," I said. Poor Straus was obviously confused. His eyes moved back and forth from the surgeon, still grasping the patient's hand, to the trembling mass of drapes that indicated the anesthesiologist's progress, or lack of it." "Just fold your hands, Straus, and keep them about chest level." Straus backed away, grateful for the instruction.
With some difficulty, the anesthesiologist worked the patient's hand back into its proper position and attempted to secure it flat on the operating table. Then the surgeon stepped back and allowed the circulating nurse to remove his gown and gloves, while the scrub nurse descended from her footstool with a new, and sterile, replacement set.
What a way to end my internship, I thought. This was my last scheduled scrub as an intern—perhaps my last time in the OR as an intern, although I was scheduled to be on call that night and could get some after-hours surgery. Anyway, this case had been a circus right from the start. For one thing, the patient had been given breakfast because I had forgotten to write "nothing by mouth" in the chart, and the nurses, who should have known better, what with all his other preoperative orders, had missed it, too.
"Straus, help me with the sterile drapes." I leaned across the patient and held one end of a fresh sterile drape toward the new intern. We were overlapping by one day—his first and my last. I was still officially an intern, although I suppose I had been acting more like a resident since all the new interns arrived. They seemed a good group, as eager and green as we had been. Strauss and I had been scheduled together so I could help him get acquainted. In fact, we were on joint call that night.
"Hold it up high," I directed, raising my end of the drape to about eye level and letting the edge cover the old drape. "Good. Now let the upper portion fall over the ether screen." He seemed to catch on easily, and I gave him the lower drape. But the surgeon, now freshly gowned and gloved, was impatient, and he took the drape from Straus, helping me to complete the redraping rapidly and without another word.
It was two-fifteen by the large clock with its familiar institutional face. I could not comprehend that within twenty-four hours I would be leaving my internship behind. How rapidly the year had passed. Yet some memories seemed older than a year. Roso, for instance. Hadn't he always been a part of me? And ...
"How about a little help, Peters?" Gallagher was already brandishing a needle holder that trailed a fine filament of thread from the tip. But he couldn't begin because the sterile towel I had draped over the incision was still in place.
"Large clamp and a basin." I reached toward the scrub nurse, and she crashed a clamp into the palm of my hand. She was a demon when it came to OR procedure. Apparently she had been watching a lot of television, because she cracked the instruments into your hand almost to the point of pain, and when she gloved you it was as though she was attempting to stretch the glove all the way to your armpit. Using the clamp, I removed the sterile towel without otherwise touching it and plopped it into the basin. The concept of OR sterility baffled me to the point that I always erred on the safe side. I didn't know if Gallagher thought the towel was contaminated, but, to be sure, I didn't touch it. Of course, with the patient rummaging around in the wound with his bare hand, all this procedure was nonsense.
The towel out of the way, Gallagher returned to the appendix stump. Luckily, the patient had chosen a good time for his antics; not only had the appendix been removed, but the stump had also been inverted. Gallagher had been nearly ready to put in his second-layer closure over the area when the mysterious hand appeared.
George, the anesthesiologist, had made a fantastic recovery. Things were already back to normal over his way—the sound level of his portable Panasonic was competing with the automatic breather that had been brought in after the succinylcholine. This was not a mere precaution. Succinylcholine is so powerful that the patient was totally paralyzed now, and the machine was breathing for him. As Gallagher took the first stitch after his arm wrestle, the general atmosphere returned to precrisis level. We even paused to listen when the surf report drifted out of George's radio over the ether screen—"Ala Moana three-four and smooth." But my board had already been sold. Gallagher was one of a couple of the younger attending surgeons who occasionally surfed. I had seen him a few times at "number 3's" off Waikiki, and he was definitely a better surgeon than surfer, being rather dainty at heart. He had a telltale habit of picking up surgical instruments with his little finger stuck out, the way a flower-club lady holds a teacup.
That was the way he took the next stitch— extending his pinky as far as possible from the rest of his fingers and deftly trailing the silk out of the needle holder into my waiting hand. Since I was the first assisting, it was up to me to tie. Straus was holding the retractors. The first throw was formed and run down extremely rapidly, as happens when an act has become reflexive. The opposing walls of the large intestine came together over the inverted appendiceal stump. As I tightened the suture, Gallagher pretended not to watch, but I was sure he had an eye cocked. Since he didn't say anything, I guess he approved the degree of tightness I placed on the first throw. Then he took the freshly loaded needle holder from the scrub nurse as I started the second throw.
"Hey, Straus, how about lifting up a little on those retractors so I can see my knot?" It bugged me that Straus was staring off into space just then. I held up running down the second throw while he looked into the wound and lifted with his right hand, opening the wound wider. That made it possible for my right index finger to carry the fold of thread down until it matted with the first throw, where I tightened it with a precision that seemed to me exactly right. Another throw, but with my other hand leading, so the knot was sure to be a squ
are knot, not a slippery granny.
Five such sutures completely covered the appendicial-stump area, and we were ready to close.
"Straus, you did a fantastic job," said Gallagher, winking at me, as he took the retractors from the new intern. "Couldn't have done without you." Not really knowing if Gallagher was putting him on, Straus wisely elected to remain silent. "Where'd you learn to retract like that, Straus?"
"I scrubbed a few times in medical school," he said quietly.
"I was sure of it," returned Gallagher, a supercilious smile creeping from the sides of his mask.
"Peter, can you and our young surgeon here close the wound?"
"Yes, I think so, Dr. Gallagher."
Gallagher hesitated, looking at the incision. "On second thought, maybe I'd better stay. If the patient gets a postop infection, I want as few people to blame as possible—just George. George, you hear that?"
"What’s that?" George looked up from his anesthesia record, but Gallagher ignored him and stepped back to rinse his hands in the basin.
"Straus, how are you at tying knots?"
"Not too good, I'm afraid."
"Well, ready to try a few?"
"I think so."
"Okay, when we get to the skin, you tie."
The fascial sutures went in quickly. My tying now was nearly as rapid as the surgeon's suturing, and the scrub nurse had to hustle to keep up with us. The smiling wound came together as the subcutaneous sutures were placed and tied.
"Okay, Straus, let's see what you can do," said Gallagher, after placing the first skin suture in the center of the wound and trailing the silk thread out over the patient's abdomen. The first skin suture, in the center of a wound, is the hardest, because until the adjacent sutures are placed it bears a lot of stress, and the stress makes it hard to tie with the correct tension. Gallagher winked at me again as Straus picked up the two ends of the thread. Straus didn't even have his gloves on tightly, and there were wrinkled bunches of rubber at the tips of his fingers. He didn't look up, though—which was a good thing, because I knew what was coming and my face was contorted in a broad smile of anticipation.
Poor Straus. By the time he got the second throw down, he was perspiring, and the skin edges were still almost half an inch apart. Moreover, he had gotten his fingers all bunched up in the suture in a fashion that suggested he was going through a comic routine. But he still didn't look up, a good sign. He would be all right.
"Straus, you've got the theory right. Skin sutures should not be too tight." Gallagher chuckled. "But half an inch is pushing a good thing too far."
"You guys can take all the time you want. The patient is going to be paralyzed for quite a while with that succinylcholine," added George.
I cut the gaping suture, pulled it out, and dropped it on the floor. Gallagher flipped in another in its place, detaching the thread from the needle with an almost imperceptible twist of his hand. Straus silently picked up the ends and started fumbling again.
"This isn't the first time I've seen a bare hand in a stomach wound," I said, looking over at Gallagher. "Once in medical school about eight of us students were in the OR trying to see a case, and the surgeon said, 'Feel this mass. Tell me what you think.' The residents all took a feel, nodding in agreement, and then an ungloved hand sneaked between two residents and felt around, too."
"Was it one of the medical students?" asked the anesthesiologist.
"Probably. We never knew for a fact, because we were all thrown out by the chief resident, who was trying to calm the surgeon."
Straus was still fussing with the second suture, dropping the ends, getting his fingers caught, and leaning this way and that in a kind of hopeful body English. I'm not sure how he expected body English to help, but I recognized the same tendency in myself.
"Did the patient get a postop infection?" asked Gallagher.
"Nope. Sailed through without a complication," I said.
"Let’s hope we're traveling the same path."
Without saying anything, I untangled the silk from Straus's hands and rapidly placed a knot, pulling it over to the side so that it was away from the incision. Straus doggedly kept his head down while Gallagher whipped in another suture.
"How about that one, promising surgeon?" said Gallagher, stretching his arms out with his hands inverted and his fingers intertwined. One or two knuckles cracked.
This Straus certainly was a silent fellow; not a sound came out of him as he concentrated on the skin suture. Actually, I was already tired of the game, of watching him fumble around. It was getting pretty close to three, and I had a lot to do, last-minute packing and other details. After a reassuring glance at Gallagher, I again untangled the suture from Straus and laid a rapid square knot, bringing the skin edges together without any tension.
"Well, I think you two can finish this up. Remember, I want only a piece of paper tape for a dressing." With that, Gallagher swaggered over to the door, snapped off his gloves, and disappeared. Straus looked up for the first time since starting the skin sutures.
"Do you want to tie or stitch?" I asked, looking at his drawn, sweating face. Actually, I couldn't decide which would be worse, his tying or his stitching. I wanted to get out of there.
"I'll stitch," he returned, reaching toward the nurse, who, true to form, slammed the needle holder into his palm. The sharp sound of metal on tense rubber glove surged and echoed around the blank walls of the OR. Straus literally jumped, startled by the impact. Then he winced and, after pulling himself together with another quick glance at me, bent over the wound and tried to dig the needle into the skin on the upper side of the incision.
"Straus."
"Yeah?" His face tilted up from his hunched position.
"Hold the needle so that the point is perpendicular to the skin, and then roll your wrist—in other words, follow the curve of the needle."
He tried, but when he rolled his wrist he pivoted the needle holder without taking account of the distance from the end of the needle holder to the tip of the curved needle. The result was a faint metallic snap as the needle broke off right at the skin. His hand froze, while his eyes, filled with disbelief and anxiety, darted from the broken needle point back to me.
Screw, I thought. "Okay, Straus, don't touch anything." "Big Ben" said five after three. Needle points—in fact, whole needles—were almost impossible to find once you lost them. Luckily, I could see the upper part of this one flush with the surface of the skin. "Mosquito clamp." Without taking my eyes off the almost invisible needle point, I reached toward the scrub nurse. Wham. The force of the delicate instrument sent a shock wave up my arm, vibrating my field of vision. The broken needle vanished. I scowled at the scrub nurse. She was a hulk, practically spherical, who surely outweighed me by a good twenty pounds, and her glare at that moment held such unexpected malice that I declined the opportunity of saying anything.
Instead, I concentrated on the delicate mosquito clamp, which was, at any rate, still in one piece in my tingling hand. By placing my left index finger in the incision and pulling up slightly under the broken needle, I was able to get some resistance before I attempted to grasp the embedded piece of steel. Still, the first attempt only succeeded in pushing the damn thing a little farther in. That was when I decided to finish both the suturing and the tying myself. The second attempt was more successful; withdrawing the clamp, I was relieved to see the gleaming needle point firmly caught on the end of it, and with a watchmaker's care I deposited the broken point on the corner of the instrument tray, matching the piece with its base to be absolutely sure there were no missing segments. Satisfied, I asked for a suture, avoiding a look at Straus.
The skin indented under the perpendicular needle as I raised the pressure until, with a pop, the needle broke through the skin. Rolling my wrist in an arc whose center shifted to eliminate torque on the needle point—the force Straus had ignored—I brought the needle point to the undersurface of the skin on the opposite side of the incision. Against t
he counterpressure exerted by the index and middle fingers of my left hand, I gave a decisive, crisp final twist of my right hand, and the needle point burst forth. Plucking the needle out with the needle holder completed the stitch. I detached the thread by lifting the needle holder so that the eye of the needle pointed upward; the drag on the end of the thread looping through the skin pulled the thread from the instrument.
Following the accepted routine, I dropped the empty needle holder into the draped area between the patient's legs. The scrub nurse would automatically retrieve the instrument and rethread it. Meanwhile, I snatched up the end of the thread, laid four throws of a square knot, and finished with the two ends on a stretch. Only then did I look at Straus.
"How about cutting, Straus?" I said.
He moved without answering, cut the thread, and continued looking at the incision. Ten more sutures were placed in like manner, rapidly and without conversation. After cutting a piece of paper tape and placing it over the closed incision, I turned to Straus. "Why don't you write the postoperative orders? You've got to start sometime. I'll look them over after I change. Then I'll introduce you to your patients. Okay?"