The first of the two new patients were a surfer who had been hit in the head with a board, leaving a two-inch cut over his left eye. He was oriented and alert, with normal vision. In fact, he was fine except for the laceration. I called his private doctor, who, predictably, told me to go ahead and sew it up. That was the way it worked. The patients came in, and I saw them and then called the private physician. If they had no doctor, we picked one of them, provided, of course, they had the means to pay. Otherwise they were considered staff patients, and I or one of the residents would take responsibility for treating them. "Suture it up" was the invariable reply from private doctors on these laceration cases. During the first few days I often speculated as to whether the private doctors then billed their patients for the suture, although we weren't encouraged to investigate that.
Actually, I was now rather good at knot tying and suturing, by virtue of having forced my way into several operations, including three hernias, a couple of hemorrhoids, an appendectomy, and a vein stripping. Mostly, though, I had gone on holding those damn retractors and, occasionally, cutting off warts.
Cutting off warts is an intern's reward for behaving himself; if s about on a par with hemorrhoid removal, although hemorrhoids are rather higher on the ladder. We had taken off dozens of warts in medical school, during dermatology, since the procedure was essentially without risk and well beneath a surgeon's dignity. My first Hawaiian wart had come with the Supercharger, a surgeon nicknamed for his matchless slow-motion incompetence. We scrubbed together on a simple breast biopsy, which is normally a thirty-minute job, unless you find a malignancy.
Not so with the Supercharger. He rooted around for an hour or so before sending off a little wedge of mangled tissue to pathology. I stood by hoping that the tissue was benign — luckily it was — and then the Supercharger closed the wound. Being an assistant on a breast biopsy is not a thrilling procedure under any circumstances; this one was made worse for me because I hadn't done anything, not even retract. When the Supercharger finished tying the last knot, he had stepped back, snapped off his gloves, and magnanimously informed me that I could now remove the wart from the wrist, which I dutifully did — to the accompaniment of a lot of bad advice from the Supercharger, who couldn't understand why I wasn't more grateful.
My next operation, however, had been more involved; in fact, it had almost wiped me out. It was a vein stripping, and the surgeon was a private M.D. I had never scrubbed with before. As we washed our hands he told me that he expected me to do a careful job on my side. I blinked a little, knowing he had mistaken me for a resident, but I let the misconception stand. When I answered that I would try to do a good job, he told me trying wasn't enough, and that I'd either do it right or not at all. I didn't have the guts to tell him that I had never done a vein stripping before. I had seen several of them, but only from behind retractor handles; besides, I wanted to try it.
Needing to follow the surgeon's lead, I delayed beginning until he was well under way. The patient was a woman of about forty-five, with bad varicose veins. Having been assigned to the case only a few minutes before it started, I hadn't seen the patient beforehand, so I had to guess what her veins looked like when she was standing. Although I knew the theory, I wasn't quite up to the practice. It was like having read all about swimming, knowing the names of the strokes and the movements, having watched other people swim, and then getting thrown into deep water. My job was to make an incision in the groin, find the superficial vein called the saphenous vein, and tie off all the little tributaries. Then I was to move down to the ankle, make another incision, isolate the same saphenous vein there, and prepare it for the stripper. The stripper was simply a piece of wire, which I would thread up through the vein to the groin; after tying the end of the stripper to the vein, I would pull both stripper and vein out through the incision in the groin. That was what I was supposed to do, and I knew it by heart; I'd read about it, watched it, and thought about it.
Almost without pressure, the supersharp scalpel cut smoothly through the skin in the groin region. I began to dissect with the scissors, but I couldn't control them very well. I changed and used a hemostat clamp, not to clamp a vessel, but to bluntly separate the tissues by opening the clamp after I pushed it into the fat. That method caused less bleeding, and I began to make some headway, going deeper into the thick layers of fat. Down there, deep in the groin, I saw nothing I recognized, nothing; it was like feeling around in the dark — until I stumbled on to a vein. I had no idea which vein it was, but, by slowly cleaning around it, I was able to follow along it to a larger one, which I hoped was the femoral vein. If I was right about that, then the first vein I had encountered was the coveted saphenous vein, but I wasn't sure. I was all thumbs, dropping the instruments once or twice, altogether nervous about my role. After all, what would the surgeon say if I told him I hadn't operated before except to put in cutdowns for IV's and remove warts? I thought about asking him if I had the right vein, but such a confession of ignorance would only have gotten me removed from further participation.
At any rate, I plunged on, hoping I'd found the saphenous vein and not a nerve. The job grew progressively more difficult. In fact, it was a mess. I pushed and pulled on the vein, trying to strip it out, bluntly spreading the hemostat, dabbing blood with a gauze sponge to keep the field clear. Several times the vein broke and blood spread, but I somehow managed to stop it with a hemostat after a few wild stabs in the dark. There was some consolation in this bleeding, because it proved that the structure I had isolated was indeed a blood vessel.
Perhaps the hardest part was trying to get a tie around the hemostats that I had placed deep in the wound to stop the bleeding. Putting the silk around the tip of the hemostat was easy enough, but trying to maintain tension on the first throw seemed all but impossible. Then, when I released the hemostat, the tie I had just made would pop off and the bleeding would start again. All in all, from a technical standpoint I might as well have been butchering a hog. I glanced self-consciously over at the surgeon from time to time, but he seemed oblivious to my trials and intent on his side, where all was under control.
What a way to learn, I had thought. But it seemed the only way. If he had known I was a novice at vein stripping, he wouldn't have let me do it. It was as simple as that. So I pushed on, finally freeing up all the tributaries to the saphenous vein. Even with the tributaries isolated, I was nervous about cutting the vein in two, an irrevocable act. So I went to the ankle and made a cut, locating the saphenous vein easily there because it was the same one I had used doing IV cutdowns. I threaded a stripper up inside the vein and pushed it out through the inguinal incision. After tying the vein to the stripper at the ankle, and using a bit of force, I pulled the whole thing up through the leg, ripping out the vein. A spurt of blood, a sharp crunchy sound, and the vein came out, all shriveled up at the end of the stripper. The surgeon had long since finished the other side and disappeared for coffee, leaving me to sew up the whole job. I never heard anything dire about the day's results, so I assume that the lady was none the worse for my debut.
Despite my having sewed hundreds of incisions in the OR, the first few emergency-room lacerations had been major affairs for me. For one thing, in the ER almost every patient is awake and sharply observant. On my first ER day, when the nurse asked me what kind of suture I wanted, she might as well have asked me for the population of Madagascar. In the OR, the surgeon stipulates what kind of suture material he wants for the skin before the case starts; you merely take what the nurse gives you, even if the surgeon has already departed, the room. But in the ER I was faced with a variety of choices — nylon, silk, Mersilene, catgut — which came in all sorts of thicknesses. The nurse wasn't trying to put me down; she just wanted to be told. "What sutures will you be using, Doctor?" I had no idea. "I'll take the usual, Nurse." "The usual, Doctor?" Obviously, there was no usual. "Uh, nylon," I tried.