I know Cuv must have had his failures, but I don’t recall ever seeing one. Even a guy like Thomas Rodnovich, upon whom Cuv had made a mistake, certainly could not be classified as a failure. All his pre-operative pain was gone, and he was delighted with Cuv and his care.
Whit and I had positioned, prepped, and draped Mrs. Bergmann for her total hip operation. We waited at the OR table while Gladys, the nurse who always worked with Dr. Coventry, gowned and gloved him. He approached the table with an air of quiet confidence.
He nodded good morning to Whit and me, then silently held out his hand. Gladys placed the scalpel in it. “Dr. Collins,” Cuv announced in his stern voice, “will make the incision.” He handed the scalpel to me.
I was stunned—thrilled, but stunned. I hadn’t expected it. Tired from being up all night, I was prepared for another routine surgery. I had been working with Dr. Coventry for almost six weeks. I knew the answers to all his pet questions, and was prepared for a nice, relaxing ride watching Whit and Cuv work while I mindlessly assisted. Suddenly I could feel my heart pounding. I had never made an incision before. I had never “cut.”
As residents, even junior residents, we wanted to operate. That’s what surgeons do—they operate. And until we got to pick up a scalpel and cut it was hard to think of ourselves as real surgeons.
Sometimes at the beginning of a case, while we waited for the attending surgeon to scrub in, we would stare at that gleaming steel blade lying on the Mayo stand. We longed to take it in our hands. We craved the power and skill it represented. The scalpel was a symbol of that other world that was waiting for us, the world of operating rooms and surgery, the world of “hot lights and cold steel,” as the older guys called it.
The attendings knew that every resident wanted to do every case. At the beginning of the quarter, the attending would observe his senior resident, assessing his competence and confidence, judging his ability to operate. If the resident seemed to know what he was doing, if he answered anatomical questions correctly, if he was attentive and respectful, the attending would usually turn over more and more cases to him.
As junior residents we dreamed of someday doing our first total hip or rotator cuff repair, but we knew it wasn’t going to happen until we paid our dues working the suction and the cautery, cutting sutures and maybe sewing the skin. Frank and Jack had already done a couple minor procedures. So far Bill and I had never even touched a scalpel.
Frank wasn’t very sympathetic. “They don’t make scalpels with training wheels,” he said. “Why you two dang fools are more likely to cut yourselves than the patient.”
I had sutured many times, had closed many lacerations, and now, finally, I was being given my chance to cut.
Cuv stepped back and motioned for me to assume the head surgeon’s position. Gladys, Cuv, Whit, the two anesthesiologists, and the circulators all stood watching. I could see Whit’s eyes smiling in amusement as he watched my uncertainty.
“Well, Doctor?” Cuv said.
I laid down the scalpel and felt the hip, searching for the landmarks I would use to make the incision.
Is that the greater trochanter? I thought in panic. She was fat, and it was hard to tell. I palpated her skin one more time before I took the skin marker from Gladys and drew a long purple line indicating where I would make my incision.
Cuv felt the hip and nodded his approval. I held out my trembling hand to Gladys who was obviously enjoying my discomfort. “Scalpel, Doctor,” she said.
Holding the scalpel gingerly in my fingertips, I prepared to make the incision.
“Not like that!” Dr. Coventry boomed in irritation. “You don’t hold it like a pencil. Put it in your hand and hold it like a man.” He took the scalpel from me and demonstrated, holding the scalpel deep in his palm.
Intimidated, feeling like I was failing my first big test, I took the scalpel and once again approached the wound. I glanced briefly at Cuv for reassurance, but his eyes peered unwaveringly from above his blue mask and told me nothing. I took a deep breath, brought my hand forward, then drew the scalpel down the long purple mark. I took my hand away and seven pair of eyes looked expectantly at what I had done. A tiny, superficial scratch that was scarcely deep enough to draw blood was etched along the length of the hip.
“What was that?” Cuv grated. I could see Whit laughing from behind Cuv’s shoulder. “At this rate we’ll be here all day. Push on that thing and make a decent incision.”
I grasped the knife, then realized I was holding it like a pencil again. I shifted it back, deeper in my palm. I brought my hand back up to the top of the mark and pushed with what seemed like reckless force. Once again I brought my hand down the length of the purple mark, afraid that at any moment my hand might plunge into the depths of the wound and cut several arteries and nerves.
We all looked again. This time I had at least incised down to the subcutaneous tissue.
“Very nice, Doctor,” Whit murmured in mock approval. Cuv stood straight and still, saying nothing. I leaned forward to proceed.
“Deep knife,” Cuv corrected.
Since the base of hair follicles may still harbor bacteria even after the skin has been scrubbed, the knife that is used to make the skin incision is considered to be contaminated. Once the incision is made, the “skin knife” is discarded in favor of the sterile “deep knife.” I turned to Gladys who was already waiting with the correct knife.
Down through the greasy yellow fat I drew my scalpeled hand. Whit and Cuv held the Israel retractors as I worked my way deeper and deeper. I could tell they were growing impatient. I told myself there were no significant anatomical structures in the area. I wanted to go faster, but I couldn’t. It was all too new. I was terrified that at any moment I might find myself staring in horror at the severed ends of the sciatic nerve (which I knew was nowhere near me).
Cuv restrained himself admirably. What was taking me ten minutes would have taken him thirty seconds, yet he assisted me silently and competently, pulling the wall of yellow fat back from the operative field, and using the suction to point my way.
Finally I reached the fascia overlying the hip. Cuv tapped the fascia with the suction. “Can you identify this structure, Doctor?”
“That is the tensor fascia lata.”
He gently edged me over. “And directly below it is…?”
“The vastus lateralis muscle.”
Cuv nodded, handed me the Israel retractor, and picked up the scalpel. “What is the innervation of the vastus?” he asked as he incised the fascia in one delicate stroke.
I was back to being a junior resident. My time in the spotlight had ended. This dog had had his day. I told Cuv the femoral nerve innervated the vastus. He nodded approvingly and said, “Well done, Doctor.”
Cuv had thrown me a crumb. He let me open. He had done the same for countless junior residents before me. It was a moment he probably forgot within a week, but for me that crumb was a gourmet feast. I had held a scalpel in my hand and I had cut.
I was a surgeon.
Chapter Five
September
The ERSS. Even the name had a dark, sinister resonance.
On September 26 I completed my six weeks with Dr. Coventry and was assigned to the Emergency Room Surgical Service at St. Mary’s Hospital. Every car crash, every farm injury, every gunshot wound—every major trauma in southeast Minnesota was brought to St. Mary’s and cared for by the ERSS.
There were three general surgery junior residents assigned to the ERSS with me: Mac Self, Rollie Whitfield, and Jerry Washburn. The attending surgeon of the ERSS was Dr. Joe Stradlack. Joe was an archetypal, frenetic trauma surgeon who constantly struggled with his inability to speak as rapidly as he thought. When excited, he could hardly finish one word before starting the next.
I had heard one of the other residents at breakfast doing an imitation of Joe: “Trauma big time gotta move on this guy full code type-and-cross cut-down crack his chest get the lines in subclavian large-bore p
ump the fluid where the hell is anesthesia?”
Joe was only a few years out of his residency but was fiercely dedicated to teaching residents and to improving the quality of care provided in the Mayo emergency rooms. The residents loved him. I was sorry to leave Dr. Coventry, but I couldn’t wait to get in the trenches with Joe Stradlack and “go to war.”
On our first morning on ERSS we reported to the tiny conference room next to the ER. Joe Stradlack filled us in on our responsibilities.
“You junior residents will be on call every other night. That means”—he consulted the paper in front of him—“Collins and Whitfield, you are on tonight; and”—another glance at the paper—“Self and Washburn, you are on tomorrow.”
On the nights we weren’t on call, Joe said, we could go home; but if there were emergencies we might be called back in.
Mac, Jerry, Rollie, and I looked at the four junior residents who were just finishing their stint on the ERSS. Three of them were already sprawled asleep in their chairs. The fourth, disheveled and unshaven, was holding a cup of coffee on his lap and staring ahead unseeingly.
“Morituri te salutant,” Mac whispered to me.
“Semper ubi, sub ubi,” I replied.
A week later, when we hadn’t had one good night’s sleep among the four of us, Mac called us together.
“Look,” he said, “this is bullshit. I don’t want to spend the rest of my time on ERSS being here every goddamn day and night.”
Rollie rubbed a hand across the stubble on his chin. “Neither do I,” he said with a loud yawn, “but since when does it matter what we want? We’re slaves, remember?”
“The hell we are,” he said. “I have an idea.” He took the cup of coffee from Rollie’s hand and set it on the table. “Listen to me.” He pointed at Rollie and me. “I swear to you, I swear to God, that from now on, when I am on call and you two are at home, I will not let them call you back in. Whatever it takes, I’ll do it. Even if I have to lock Joe Stradlack in the morgue, I will not let him call you back in.” I could see the determination on his face and I knew what he had in mind.
I nodded. “And we do the same for you.”
“You got it.”
Like little kids forming a secret club, we solemnly shook hands and swore we would never allow the two guys at home to be called back in.
Sure enough, that night when Rollie and I went home, we weren’t called back in. We slept all night and didn’t go back to the hospital until 6:30 the following morning. Later, when Mac and Jerry were going off duty, I looked up from the face I was suturing and waved a sterile hand at them. “Go home,” I said. “I’ll see you tomorrow.”
It worked. We made it work. We did whatever it took to cover for each other. We made up stories. We worked twice as hard. But our best resource was the shameless commandeering of medical students.
Joe Stradlack was rushing a lady with a hot gallbladder up to the OR for an emergency cholecystectomy.
“Mike,” he called, “come on. I’m going to need you to assist.”
I held up my gloved hands. “I can’t. I’m sewing up a guy’s leg.”
“Then call Mac or Jerry from home.”
No way, I thought.
I stripped off my gloves and sprinted into the hall. A kid with an armful of books was walking by. “Are you a medical student?” I asked.
“Um, yes,” came the startled response.
“Thank God,” I said. “We have an emergency in the ER and we need your help.” I grabbed his arm in a way that would dispel any doubts he had about his ability to refuse my “request.”
“Do you know how to scrub?” I asked.
“Well, I—”
“Good.”
I took his books from him and tossed them on a chair. “Get into the locker room and change, then get up to OR 4. They need you right away. Emergency.”
He stood there befuddled. “But I’ve got a biochem quiz in ten minutes.”
I pointed to the locker room. “Get going. Do you want her to die?”
He looked at his books, looked at me, and then sprinted for the locker room.
I pitied the poor kid. I knew he would be stuck with a big old Deaver retractor in both hands trying to pull the liver and several inches of fat out of the way while Joe dug around, trying to take out the gallbladder.
“The Right Upper Quadrant Man,” we called the guy holding the Deaver. He was always the guy with the lowest seniority. His retractor would be positioned by the head surgeon. The student would be told to grasp the retractor with two hands and then step back slightly. The surgeon and his first assistant would then wedge themselves in front of him to perform the surgery. The poor student couldn’t see a thing except the back of the surgeons’ gowns. During the operation, one of the surgeons might amuse himself by firing a question over his shoulder: “Can you identify this structure?”
The student wouldn’t know what to say. “I, uh—”
“No, not that one, this one.”
“I can’t really—”
“Try paying a little more attention.”
“Yes, sir,” he would mumble. Asshole, he would think.
I pulled in the driveway at home, shut off the engine, and slumped back, too tired to get out of the car. Even though I was no longer getting called back into the hospital on my night off, I was still working thirty to thirty-six hours in a row, followed by twelve to eighteen hours off. When I wasn’t working, all I wanted to do was sleep.
I sat in the car, head back, eyes closed for several minutes. Finally I sighed, picked up my shaving kit, heaved myself out of the front seat, and went in the back door.
Eileen, as usual, was penned in the kitchen. “Daddy!” she called as she trotted to me with her arms outstretched. I picked her up and nuzzled my face into her neck. She gurgled in delight. I carried her over to the sink where Patti was standing.
“Hey, hon,” I said. I shifted Eileen to the other hip and leaned forward to give Patti a kiss. She was pregnant with our second child, and must have found it difficult caring for Eileen and taking care of the house without any help from me. But I didn’t know. Most of the time I was too tired to even ask.
“Hi, you.” She looked me up and down and smiled sympathetically. “How was your day, er, night?”
“Ah, okay, I guess.” Eileen began squirming so I put her down. “We got another hunting accident in last night—a kid shot in the belly by his brother who thought he was a deer.”
“Let me guess. The brother had a few brewskis.”
“Nope. Schnapps. He just wanted to ward off the chill.”
“So is the kid going to make it?”
“Well, it’s a miracle he didn’t bleed out before they got him to us. His brother wadded up a flannel shirt and jammed it into the hole in his belly. That probably saved his life.” I tried to remember what happened next. “We took him to the OR. Joe was going to take out part of his liver or bowel or something,” I said slowly, “but then I had to do a cut-down on some guy in the ER, so I don’t know if the kid made it or not.” I reached over and took a carrot from the cutting board. “I’ll have to ask Jerry about it tomorrow.”
I didn’t even know if he lived or died. What was the matter with me? Was I becoming so calloused I didn’t care about my patients?
I took some silverware from the drawer and began setting the table.
“So, how are you feeling?” I asked Patti.
“Tired, but fine. And,” she said, turning to me, “I saw the doctor today. He says the baby is doing great.”
I smiled at her. “That’s awesome. Did you get a nap?”
“Yes, thank God. When I put Eileen down for her nap I laid down for an hour, too.”
“Speaking of lying down for an hour, I thought I’d—”
“Oh, Mike, don’t. Dinner’ll be ready in twenty minutes. If you lay down I’ll never get you up. Just sit here with me until dinner’s ready. Please?”
She pushed me into a chair, then opened the
refrigerator. “Here,” she said, “have a beer and engage me in some scintillating conversation.”
I took a sip of beer. It felt good just to sit there…
“Mike!”
My head snapped up. “Huh? Sorry.”
“Come on, hon. Talk to me. I’m desperate. I have no one to talk to all day except Eileen.” She came over and started massaging my shoulders. “Tell me about that drunk guy from Friday, the one who drove his golf cart off the bridge. Has he gone home yet?”
I didn’t want to talk about the drunk guy. I didn’t want to talk about anything. I didn’t want to drink beer or eat or watch TV either. I just wanted to sleep.
The next thing I knew Patti was jabbing me in the ribs. “Here’s your dinner,” she said, slamming a plate in front of me.
What I should have said at that moment was, “Patti, although I am terribly tired, you are the most important thing in my life. I apologize for seeming so disinterested, but in a few weeks I will be off ERSS and our life will get back to normal.”
What I actually said was, “Patti, I…uh…just…” I couldn’t remember what I wanted to say next. I ate my dinner and went to bed.
The next day at morning report, I looked for Jerry. I wanted to ask him about the kid who got shot. I couldn’t even remember his name. Jeff something.
In front of the room, one of the senior residents was giving report on a couple that had been brought in from a car crash on I-90. “Joe’s up in surgery with the husband. He’s got a ruptured spleen and a flail chest,” he said. “The wife’s in CT. She’s stable, but she’s got a femoral shaft fracture and a big scalp laceration. Her belly tap was negative.”
I was half listening. I wanted to talk to Jerry about the kid. Unfortunately, Jerry was on the floor, propped up against the crash cart, sound asleep.
Hot Lights, Cold Steel Page 5