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 square knot, not a slippery granny.