Saturday, March 31, 2018

Scrubbing in and suiting up

Early morning from a hospital hallway

I am currently just over halfway through my 12-week surgery clerkship, just five weeks away from the end of the third year of medical school.  It has been an amazing year of learning medicine and learning about myself, and as I have been reflecting on this year and making plans for the next steps, I have begun putting those thoughts in writing.  Below is part of my "brain-dump," which I thought I would share even though it is relatively unpolished.


There is a unique desperation that arises during the medical student surgery clerkship, when the student is confronted with ostensibly simple tasks – such as finding a roll of paper tape, or opening the correct dimension of gauze, or holding a retractor with the right amount of tension – that have suddenly become staggeringly challenging.  Great attention must be paid to the placement of one’s hands when one is doing nothing but standing and observing.  The differentiation between what is light blue (the color of sterility and safety) and not light blue is now the most salient, if one wants to avoid the justified wrath of the scrub technician, to say nothing of keeping alive the chance that one will get asked to hold an instrument or possibly even, if lucky, help close an incision. 

It is safest to keep one’s arms crossed, or forearms folded over one’s stomach, or, ideally, resting on a draped area that is away from the operating field, if the surgeons or a particularly thoughtful scrub tech invite one to step closer.  It is definitely not safe to begin to doze off while sitting on a stool between a patient’s [draped] legs, while watching the surgical proceedings on the screens around the room, to then realize that one has just contaminated one’s gloves by touching the stool.  This may or may not have happened to me in my second week on the inpatient gynecology service, during a six-hour surgery, during part of which I had been told to push in various directions and then isometrically hold an instrument placed in the uterus, while the surgeons used the Da Vinci robot to manipulate parts of the pelvic organs through the abdominal wall.  One of the more surreal moments in my life: being told “Harder!  Push to the right!  No, the patient’s right!,” contorting my shoulder into increasingly uncomfortable angles, seeing on screen the uterus move with my clumsy adjustments, while the surgeons stared into their arcade-like consoles and used carefully calibrated movements of the control knobs to trigger precise adjustments of the articulated robot arms.  For obvious reasons I was extremely alert during that part of the surgery, but all bets were off once my physical and intellectual involvement was over and I was left to watch.

It took well over a week – and if I’m being honest, closer to two weeks – before I felt comfortable scrubbing in, and then just to be a minimally invasive component of the OR milieu.  By the fourth or fifth week, I started appreciating the rhythm and routine around me.  The structure-seeking part of me did find comfort in the repeated ritual of being gowned and gloved by the scrub technician:

After scrubbing for upwards of three minutes, walk into the OR with hands held up in front of you, elbows away from your chest, water dripping downward onto the floor.  Take a sterile towel and, still keeping your elbows up, dry the hands and forearms on one side, then use the other (clean) side to dry the other arm.  Place your arms into the gown which has been held open for you, extending your arms under the arms of the scrub tech with only a slight back bend, and immediately straighten with your hands once again held in front of you, fingers together, so that the arms of the gown can be pulled down just enough.  When the first glove is held open for you, slide one hand down into it, then use those now-sterile fingers to help hold open the second glove that is proffered.  The back of your gown has already been closed by the circulating nurse, but you now ask him or someone else to take the paper card tethering your waist ties, then spin counter-clockwise and pull the other waist tie off with a subtle flourish, so that you can fully close your gown.  You are now enclosed in cleanliness, and you have only to avoid messing it up.  

This sequence of actions, repeated at the start of every surgery, armors the surgeons – and wide-eyed medical students – in a papery, synthetic, fluid-proof, and anonymity-granting suit.  When everyone who has scrubbed is gathered around the draped patient, with only the operating field exposed, they coalesce into a nucleus around which the outside world, the non-sterile and chaotic and hazardous, recede.  Despite interruptions by pages or phone calls, or episodes of chatter regarding weekend plans or how the family is doing, there are always stretches of collective scrutiny on the task at hand.  Sometimes it seems to me that in the OR, the patient’s personhood and humanity are intentionally deemphasized, tucked into the background by the blue drapes.  And yet I also see that in the OR there is a unique dimension of respect for the human body and its natural variations in anatomy and [patho-]physiology, which create the potential for surgical challenges that are not always forseen by imaging studies.  I sensed that the haptic unpredictability of surgery, as well as the monastic focus that must result, is part of what surgeons love about their work.  As an observer and intermittent participant, scrubbing in provides a memorable glimpse into this unique cognitive realm.