“Could you please hand Eric the needle driver?”
As the scrub tech loaded up that blessed golden tool, I knew that I had just ascended within the realm of surgery. Last week, I had been nothing more than an unusually talkative pair of retractors. Now I had become Eric, the one who can close skin incisions of “very short” to “moderately short” length.
I took the tool in my hand with great pride and thanked the scrub tech in my most confident tone. She peered out at me from over her mask, congratulating me with her eyes. She understood what had just taken place.
The incision was approximately two centimeters long, and it was up to me to bring the edges of skin back together as God intended them to be. I felt the weight of the responsibility weighing on my shoulders, which were already sore from standing completely still with my arms fearfully tensed for the past four hours. I ran through the arsenal of stitches I’d been taught and realized that there was really only one with which I could claim any degree of proficiency: the subcuticular stitch. This sacred technique was passed down to generations of medical students around the globe to help them survive their surgery rotations. Today, it would be my saving grace.
I looked back down at the incision and began planning my approach. It had been used as an entry for one of the ports in the laparoscopic surgery that we (they) had just completed. Approximately three-or-so centimeters below the costal margin in the patient’s left upper quadrant, I visualized all of the adjacent structures in my mind’s eye. The spleen and its associated vasculature, the left hemidiaphragm, and the gastric fundus were all the vital structures I knew I would need to keep in mind as I attempted to stitch the patient’s subcuticular tissue back together. There can be no mistakes and no overabundance of caution in the operating room (OR).
After I completed my analysis, I realized that the resident opposite me was suturing some of the last few port sites on his side. I clenched my hand on the needle driver in frustration: time was running out. The eyes of the OR would soon be upon me.
I began my approach, firmly but carefully lifting one side of the wound as I had practiced tons of times before on pigskin in my training leading up to that moment. I set the anchoring stitch in place and pushed along.
The first dip of the needle into the skin was perfection. Its sleek metal body slid gracefully through that delicate line between the dermis and epidermis like an Olympian diving into the water without a splash. I let out a sigh of relief. Unfortunately, my reprieve proved to be short-lived as I heard the familiar crack of Dermabond, a medical adhesive, being prepared for application. My resident had finished closing the other sites. If I didn’t complete the stitch now, I would have to face the scrutiny of six pairs of eyes all trained on my hands. I would be the last obstacle keeping everyone from the few precious minutes of break time we had between cases.
I reloaded the needle and took a bite on the opposite side, making sure to roll my wrist as was my tendency to forget. As easily as the first, the needle slid through the dermal-epidermal junction and exited inside of the wound. I could hardly contain my excitement. Everything was going according to plan.
“Looks good, Eric,” my resident said to me, who had taken to observing my work. “Now tie it up, and let’s get out of here.”
My heart sank. The blood in my arteries ran cold. My hands floated impotently in the air. The accursed tie! I thought back to those days in the simulation lab when I would look down at my horribly disfigured ties and assure myself that it would all come together soon enough. How could I have been filled with such hubris? Now it was too late. Fate was to claim my good fortune as it does for all prideful men.
“You can do a hand tie or an instrument tie, whichever you know how to do,” my resident stated. Alas, I pleaded with my eyes, therein lies the issue. What little I had known about either technique had flown from my mind. My brain had been wiped with mental chlorhexidine, killing 99.9% of intelligent brain activity. I stood frozen with either side of the suture in my double-gloved hands. Before I could formally give up, panic set in and my hands began pantomiming the motions for tying a knot, like a toddler who had just been handed a pair of shoestrings. Witnessing my struggle, the resident took pity on me.
“Here, let me help you with this one,” he said. “We can talk it over afterward, and you can try again in the next case.”
I nodded. My composure was cool on the outside, but on the inside, I was devastated. I had disgraced myself, my family, my medical school, and the human race all at once. There was no way I was going to recover from such a B-team performance, I thought to myself. I was beginning to spiral into despair when I heard a voice call my name. It was our scrub tech. She was smiling at me.
“It’s okay,” she said. “Everyone has trouble with their first few. It’s no big deal. You’ll get the next one.” I smiled back at her and laughed weakly.
Those were the exact words that I needed to hear at that moment. Thank God for her. I knew she was right. As we began wheeling the patient out of the room, my body began to unclench, and the onslaught of anxious thoughts slowed. I immediately began planning the approach to my next port closure with my newly freed mental space. As we went down the hallway, I imagined my hands positioned over that damn two-centimeter incision like a trained athlete visualizing his next in-game performance.
Next time, I would be ready.
Image credit: 2014_02_04_Banaadir_Hospital-3 (Public Domain) by AMISOM Public Information