“Surg-Path promised me we’ll have the results ASAP,” Juana called out to the team as she breezed into the OR from the sterilizer room, heading directly over to Marianna. Brandishing a package, she then added for Marianna’s benefit: “Here’s the three-zero Vicryl suture you asked for before I ran down to Pathology.” Being scrupulously careful to use sterile technique, she tore open the package and made certain the contained suture packet dropped untouched into Marianna’s open hand.
“What’s the matter, young fellow?” Dr. Smith prodded when Mitt didn’t immediately respond. The surgeon had not taken his eyes off Mitt.
“I don’t know,” Mitt stammered, trying to mentally orient himself after the shock. His mind was in a momentary jumble, questioning what he had truly seen. Once again, the question loomed: Was the fleeting and disturbing visual a product of his tired, overstimulated mind or had he briefly fallen asleep and experienced some kind of an instantaneous nightmare, all while standing up and otherwise functioning? He had no answers, nor did he have the time for any internal debate. Dr. Smith was expectantly staring directly at him, waiting for an answer.
“I’m sorry,” Mitt said, believing an apology was the way to start. He stuttered a bit, then pulled himself together, shaking his head. “I don’t know what came over me. Maybe I fell asleep for a second. I apologize. I’ve been under a bit of stress these first few days.”
“I know exactly what you mean,” Dr. Smith said in a fatherly tone. “I think all of us can relate to what you are saying about just starting out as a resident. Am I right, Dr. Singleton?”
“No doubt,” Dr. Singleton responded.
“Have you already been on call?”
“Yes,” Mitt said. “Monday night. It was my first night.”
“Well, there you go,” Dr. Smith said knowingly. “Did you get much rest?”
“Not a lot,” Mitt admitted.
“I can remember falling asleep in surgery my first week,” Dr. Smith said with a self-deprecating chuckle. “The night before I had gotten called in the wee hours of the morning to help with an emergency surgery where the surgeons were trying to save this guy’s leg that had been crushed by a garbage truck. My job was to stand down at the end of the operating table and hold the foot aloft while they tried to connect the vessels behind the knee. It went on for God knows how long, and I fell asleep standing up. I remember that incident to this day, especially because the two attending surgeons got really pissed.”
“Something similar happened to me,” Dr. Singleton said with a chuckle. He went on to describe his experience, but Mitt tuned him out. He’d gone back to agonizing about the hallucination he’d just experienced. Since he’d seen the girl before, she was at least familiar, even if scary. But that wasn’t the case with the others, which begged the question of why on earth his mind had conjured up such a horrid, disgusting ragtag group. It was as though patients who had been surgerized at Bellevue sometime in the distant past were returning en masse to exact revenge for what they had experienced and suffered.
Mitt inwardly shuddered when he recalled the image, some men and women holding amputated limbs while others held even more disgusting bloody organs. Could the whole idea have somehow originated from his skim-reading Pendleton’s unpublished article the night before? After all, it had been a shock to learn that his own medical forebearers had inexplicably eschewed anesthesia and antisepsis when the benefits were so glaringly obvious.
“Good news, everyone,” Juana called out, putting down her phone and interrupting Dr. Smith and Dr. Singleton, who had continued trading war stories, with each trying to outdo the other in how much they’d been overworked as a point of pride when they had been first-year surgical residents. “Frozen sections are all clean. No malignancy.”
“Perfect,” Dr. Smith said. He straightened up, pulling himself together. “Okay, let’s close up. But before we do, I want you to notice, Dr. Fuller, that our operative field is completely bloodless. I can’t emphasize enough that hemostasis is vitally important in thyroid surgery. That said, how would you rank yourself with suturing ability?”
“Amateur,” Mitt admitted.
“Well, I guess we’ll see,” Dr. Smith said. “Marianna, hand Dr. Fuller the three-oh Vicryl so he can close the strap muscles for us.”
To Mitt’s surprise, Marianna did hand him the loaded needle holder along with a pair of forceps while Dr. Smith removed all the retractors before approximating the strap muscles to the midline with a pair of forceps.
“Try to grab just the connective tissue of the two sides of the median raphe,” Dr. Smith instructed. He used the point of another pair of forceps to indicate exactly where he meant.
Mitt tried to concentrate, pushing the shock of the hallucination out of his mind with some difficulty. He was able to handle the needle holder as Dr. Wu had suggested, rolling his wrist to follow the curve of the needle point. He did the same on the opposite side of the median raphe.
“Not bad,” Dr. Smith said. “Now tie it so the tissue edges just touch.”
Mitt felt like all thumbs as he tried to tie the suture, and by the time he’d placed the second knot, the suture itself was loose. In a flash, a pair of scissors appeared and the mis-tied suture was gone.
“Try it again, but this time maintain adequate tension on the ends of the suture to maintain the position of the tissue edges, particularly as you run down the second knot.”
“I’ve advised him to spend some time in the simulation lab,” Dr. Singleton said.
“Very good advice,” Dr. Smith agreed. “Suturing is the bedrock of surgery.”
Mitt tried again, and the result was better. Then, after having placed three sutures, he began to feel a progressive confidence. Not long after, the strap muscles were back to the same position they had been in at the beginning of the case.
The skin closure took Mitt a bit longer, as he found the fine silk that was used more difficult to handle. Also, following the advice of Dr. Wu, he took the time to make sure that the skin edges didn’t roll in or pucker out. While that was being done, Dr. Smith gave a mini-lecture on why he didn’t use a drain with his thyroidectomies despite a number of surgeons doing so. Mitt listened with half an ear, concentrating on his suturing.
When the case was finished, Mitt thanked Dr. Smith with great sincerity. Except for the brief but disturbing hallucination episode, it had been the most positive experience he’d had in the operating room so far. There had been real teaching, the atmosphere had remained cordial and cooperative, and the instruments didn’t do any gymnastics. Mitt gave full credit to the attending, who seemed to take Mitt’s compliments to heart, and thanked him in return. He then made sure Dr. Singleton would see to the postoperative orders and the dictation, and left the OR.
Mitt and Dr. Singleton helped move Diego Ortiz from the operating table onto the gurney and then angle the gurney out into the hallway. With the anesthesiologist, Dr. Lenora Carpenter, at the head of the gurney and Mitt and Dr. Singleton at the foot, they began heading toward the PACU. “Thanks for the help, guys,” Dr. Carpenter said. “This gives me a chance to give you a heads-up when you write up the post-op orders. I did something a little out of the ordinary on this case. As a bit of background, I’d learned that this patient had been severely hypothyroid for some time and was taking a rather large daily dose of thyroxine. Since I’ve personally had a couple of bad anesthesia experiences with cases of severe hypothyroidism that resulted in a cardiac arrest made even worse by being difficult to resuscitate, I’ve hung a micro drip with a specific concentration of levothyroxine to piggyback his IV at ten drops a minute to avoid such a situation.” While she was pulling the gurney with one hand, she used the other to gesture toward the smaller IV setup next to the normal-sized one that hung from the IV pole at the head of the gurney. “My point is that the levothyroxine should be maintained at the rate I set until he can take it orally. To be doubly sure, I did check the TSH level, and it was normal. If you have a problem with this strategy, you could get a medical consult. But let me warn you: During the case he did throw a few extra heartbeats to keep my attention, so all this is not a hypothetical concern.”