Take a look at these hands.

These aren't so manly, are they?

I wear a size eight glove. Only a few of the male surgeons I work with wear gloves as large as mine, and I'm not aware of any other females who do. Often times, when I finish scrubbing first and enter the room before the surgeon, the scrub tech will try to give me the smaller pair of gloves, assuming that a female must wear the smaller size. This stereotypical division of size according to gender also occurs in restaurants. If I am out with a male friend and we both order the same item, whether it be steak or dessert, the larger portion will always be given to the man. This recently happened with a dessert and when I pointed out to the server that my friends portion was bigger than mine, she suggested I trade him. Since the plate had already been set down in front of him, my food compulsions (oh yeah, they go way beyond simply not allowing certain foods to touch each other!) would not allow this.
A good friend of mine recently began calling me "Man Hands." Anytime we give each other a ration of shit he says "O.K. M.H." While I was out of the room, one of the surgeons finally asked him what M.H. stood for. My friend informed him that it meant Man Hands and suggested the surgeon call me that also. Well, as you can imagine, size eight hands don't belong to a demure, petite, fawn-like Barbie. I'm a full six-foot-zero and while I'm not heavy, I'm big enough to take care of myself. When he told the surgeon to call me Man Hands, the surgeon replied, " I guess it's O.K. to call her that, as long as she doesn't mind!"
The funny side of the nickname is that famous Seinfeld episode, Bizarro Jerry where Jerry dates the woman with Man Hands.



The practical side of the nickname is the fact that large hands are often a blessing in surgery. In ortho I assisted on a proximal humerus fracture just last week and I was able to hold two hohmanns under tension by spanning the wound with my left hand, thumb on the right hohmann, pinkie and ring finger on the left hohmann, while providing suction with my right hand. In a difficult trauma splenectomy earlier this month on an overweight male with guts that insisted on getting in the surgeons visual field, I was able to use my left hand backhanded to sweep guts out of the way while temporarily holding the tail of a suture placed on a stubborn bleeder between my left thumb and forefinger. Meanwhile, my right hand was occupied with maintaining traction on a large rich. I think the surgeon (my F.T.S.*) even made a comment about my hand span(?) though I don't remember it now.
There are occasions where size eights are a hindrance. In vascular surgery where 6-0 and 7-0 suture is often used and one must follow suture (maintain slight tension on the suture as the surgeon sews) with just the right amount of tension so as not to tear through the vessel, I feel like the proverbial bull in the china shop. When trying to provide traction on tissues deep in a narrow male pelvic cavity, my size eights are sometimes in the way of the surgeons field of view. If anyone has been wondering if I like the nickname or not, I do. All in all, I think my Man Hands are pretty handy.

*Favorite Trauma Surgeon

Path to SFA 6 Ortho rules!

five here
Training in the "real O.R." was much more stressful, but the cool factor was significantly elevated. In the beginning, you do a lot of work on opening supplies for the case, setting up the back table and mayo stand, and then observe as the primary scrub passes instruments. It is sort of like grunt work with no glory but a valuable lesson none the less. You may be surprised at how easy it can be to contaminate the field if you aren't careful. Do it once or twice and have to explain to the surgeon why you have delayed the case, and explain to the OR manager why you have wasted supplies and you become more vigilant.
Scrubbed in as the observer during those early cases, I would use an empty glove wrapper and a sterile marking pen and take notes of the procedure in sequence. After the case, I would transfer my notes to a sheet of paper and use it for reference the next time the same procedure came along.
After observing as second scrub for about a week, you begin to first scrub and your preceptor gets to sit back and observe. With the pressure of knowing that I would have to take call in about four months I became anxious to scrub everything. The crew was more than happy to oblige me. If there was only one line that day, I scrubbed it all. If anything got added on during a slow day, I scrubbed it.
The influx of information was often overwhelming and I thought that I would never be able to retain it all. Ortho cases, particularly total joints, have a high volume of instruments. You may have as many as six instrument trays in addition to your basic setup. In fact, you need to use two back tables to accommodate them all. Being slightly (yes, just slightly) obsessive compulsive, the clutter from total joints was frustrating for me. It was also hard to retain the sequence of surgical steps and instruments during the case. I would take whatever notes I had been able to gather and tape them to the wall behind my back table so I could "cheat" during the case. It was too difficult to turn away from the procedure long enough to squint at my notes trying to find my place again in the sequence. I longed for a better way since I didn't have a better memory.
Then my hero came along. The girl from central sterile processing, that I had spent a week with back in the beginning, had discovered that if you use a permanent marking pen on a 4x6 index card, put it in a peel pack and run it through the autoclave, it comes out sterile and still readable. Hallelujah! I soon had a collection big enough to require it's own space in the supply cabinet. Total knees went from my most frustrating case (I am a perfectionist), to the most satisfying and fun. And, bonus! The orthopaedic surgeon was the most fun to scrub for.
The general surgeon was very high strung, and the Gyn doc was a bit of an ass, but in a clever sort of way. More on that later.
prelude here
one here
two here
three
SFA four here

What I learned Today

Today I learned that when the trauma surgeon recounts his last trauma call shift and says, "Trauma was dead last night." He doesn't mean that it was slow.

The "Arte Y Pico" My First Award!

Oh my gosh! My first blog award! Thank you Oystein of The Sterile Eye for choosing me to be honored with this award. And thank you for your compliment,

The blog of the Surgical First Assistant that calls herself makeminetrauma. To her “surgery junkie” is a compliment. Her love for anything surgical shines through in all of her posts. I envy her hands-on access to the human anatomy, and I love her blog.

Now I pass the award on to five other blogs. The rules are as follows:

1.You have to pick five blogs that you consider deserve this award in terms of creativity, design, interesting material, and general contributions to the blogger community, no matter what language.

2. Each award has to have the name of the author and also a link to his or her blog to be visited by everyone.

3. Each winner has to show the award and give the name and link to the blog that has given him or her the award itself.

4. Each winner and each giver of the prize has to show the link of “Arte y pico” blog, so everyone will know the origin of this award.

5. To show these rules.

Buckeye Surgeon. His posts are well written and always interesting with some great case presentations. He is very representative of the human side of medicine and his compassion for his patients is obvious.

Mother Jones, R.N. at Nurse Ratched's Place . I love her writing style and the nostalgic pictures she finds. Her captions and interpretations of the pictures are as entertaining as the posts themselves. She has a very clever sense of humor.

Bongi author of Other Things Amanzi. He is my hero of the blogosphere. His posts are an insight into another world that most of us will never experience. From the "sink or swim" style of surgical training to the roadblocks of dealing with the Government, his dedication to his country and his patients is unwavering. He truly loves his craft.

Addicted to Medblogs. Here is a loyal medblog addict. She is very creative. From her monthly (pretty close to monthly, as time allows) series Calander Doc, to all of the goofy cool stuff she finds to incorporate into her posts.

Someonetc at Orthopaedic Residency. He cleverly incorporates everyday challenges and situations as a mirror into the challenges of training ortho residents as their attending . He is constantly striving for more creative, motivating and successful methods of teaching.

Path to SFA five. Training begins

SFA four here
After placing ads and interviewing candidates, of which, if I remember correctly, there were only a few, none qualified as certified or experienced. Surgical techs were still a scarce commodity at the time. The fact that the town was so small and basically in the middle of nowhere was also to my advantage. With no local employee base to draw from and relocation an issue for anyone else, it was announced just two weeks after the search began, that I would start my on the job training as their new surgical technologist. I had made it at last! My patience and perseverance (harassment ?) finally paid off.

My training began by spending the first week in central sterile processing. This is where the instruments are brought after they are disinfected with enzymes that remove gross contamination.The sets are brought here to be reassembled and placed in their containers or peel packs or wrapped in blue wrap and autoclaved for sterilization. Central sterile is a great place to begin learning the names of the instruments, a vital bit of knowledge for a surg tech. You also learn proper sterilization techniques and how to identify something that has not passed sterilization parameters. There are checks and triple checks performed to insure sterility of instruments.
Before you can begin doing the fun stuff, you must first know the proper way to scrub, gown and glove, and learn sterile technique. With the help of a timer, scrubbing was easy enough. Gowning yourself if fairly simple, but learning how to closed glove yourself takes a little more practice. You must keep your hands safely within the end of the sleeve of the gown and not extend beyond the cuff. Then you pick up a folded sticky glove with your mittened hands and lay it on one gowned wrist, usually right hand first, upside down and backwards with thumb to thumb. The long cuff of the glove is folded over about halfway. With certain brands of gloves, the cuff is often quite sticky and hard to separate. With your other mittened hand you peel the folded cuff of the sticky glove forward around your fingers while holding the other cuff end of the glove with the enclosed hand you are currently gloving. Then, as you wrap the glove around, you are able to slide your hand forward through the gown sleeve and it should end up enclosed in the glove. Sounds easy enough! The good news is that after you perfect this move, you get to smirk under your mask at residents, PAs, med students and even some assistant surgeons who have no clue how to glove themselves.
Sterile technique is something tangible that can be taught. Sterile conscience is a little bit different. Part of sterile conscience involves recognizing a break in the sterile field, reporting it, and taking steps to reestablish sterile field. It is about being the patients advocate. As a tech, one very important part of my job is to protect the sterile field. It also became my pet peeve. If anyone non-sterile gets too close to my sterile field, I let them know. And they don't forget.

When it was finally time to start learning procedures, the girls who were precepting me decided that I should begin my training in the Procedure Core. The worst duty one could have was in the Procedure Core, which was their title for the Endoscopy Suite, aka GI Lab, aka any other title that makes what goes on there seem more glamorous. Well, let me tell ya' there is nothing glam about EGD's and colonoscopy's . Especially if it is your own. For the first week , they stood right there with me, instructing me on the proper way to handle a polyp specimen, how to give proper sigmoid pressure to help the surgeon maneuver the colonoscope through this redundant section of colon, care and cleaning of the endoscopes, etc., etc. By the third week, they would sit just outside the room at the nurse's station, within a shout's reach should I need help. Week four, I was on my own. Not a problem, I felt pretty confidant. However, I began to wonder just when I was going to be allowed in the OR to learn "real" procedures. Two more weeks had passed and I realized that they were very content just to leave me up there because that meant less poop and drool for them. I had to throw a little hissy to finally let them know I was on to them!
prelude here
one here
two here
three

Hey, I finally wrote a post for "My First Time" What? You mean there was a deadline?!

Last weeks' SurgeXperiences theme, hosted by Jeffrey MD, (excellent job, Jeffrey!) was "My First Time". As usual, I missed the deadline, partly because deadlines make me anxious, but mostly because I could not think of a single "first" that I thought was memorable enough to blog about.

Having been away on vacation for 9 days, I have been refueling my obsession and passion for the OR by reading "Top Knife" The Art and Craft of Trauma Surgery, by Dr.s Asher Hirshberg and Kenneth Mattox, actually/finally studying for my Sept. First Assist certification test, spent a few hours one afternoon hanging out in the ER near the ambulance bay and the trauma rooms while under the guise of waiting for one of the Orthopods I work with to come and examine a patient, (Discovered an ER doc I wouldn't mind knowing better!) and catching up on "Hopkins". If you have not seen "Hopkins" it is about the Johns Hopkins hospital in Baltimore. It isn't fiction, the stories and patients are real. They focus on both the ER and OR but it seems to me that they favor the OR which is awesome for me. I missed the network airing of the series(?) but all episodes in full can be found on the ABC website.
Every episode that I watch causes me to swell with pride and tear up. How can anyone not love a surgeon!? Heart transplants, brain tumors, dissecting aortas from arch to abdomen! My adrenaline starts pumping and I get all jacked up for the OR! I sit here at home, on call, and will the phone to ring with a surgeon on the other end.

My point is.....while watching the opening credits on "Hopkins" one surgeon reaches across the operating table at the end of a case and shakes the hand of his assistant. And then, suddenly I realized what "My First Time" should be about.

I used to scrub exclusively on the swing shift for the gynecology oncologist whenever he had a line. His operations were not typical gynecology procedures. While he did some simple hysterectomies and oopherectomies, they were for cancer or suspicious tumors. His big cases were modified posterior pelvic exenterations, often with node sampling, and on occasion, urinary diversions and ileal conduits if the exenteration was anterior as well. All of his cases are by referral only and so very often, the referring surgeon is there to assist. As I have mentioned before, the almost psychic rhythm between a surgeon and an assistant is magical. As a scrub, I often shared this same magic with this particular surgeon. You hand him the right instrument, at the right time, in the right manner without a word passing from either ones lips. This interpretation/anticipation becomes second nature, yet I always recognized the thrill of it.
So, on with the story. At the end of a particularly long case, the Gyn/Onc surgeon reaches across the OR table and shakes the hand of his assistant surgeon. "Wow, that was pretty cool." I think to myself. That was the first time I had ever seen anybody do that. I began to observe the actions of other surgeons and noticed that the hand shake doesn't come that often. It is reserved, it seems, for long or difficult cases, or long and difficult surgeries perhaps. A surgery where the primary surgeon is very thankful for an assistant.
As I made the transition from scrub to first assist, I never forgot about the rare handshake. I fumbled along through my provisional cases required by the hospital before I would be granted assist privileges. Just when I would think that I was getting the feel of things and feeling fairly confident, I would make a rookie mistake, or freeze when asked to hand tie a suture. I took a lot of ribbing and criticism from my main preceptor but I paid attention to everything he said. Active privileges granted at four hospitals and about 15 months under my belt later, I was assisting my F.T.S. (favorite trauma surgeon), on a somewhat difficult bowel resection. Extensive adhesions make dissection on somewhat distorted anatomy very tedious. The patient was also obese which means a lot of tissue that is tougher to retract (and keep it there) and a deep abdomen in which visualization isn't always easy. To top it off, the patient was male which translates to a narrow pelvis, making mobilization and resection of the sigmoid colon more challenging. I think I did all of the right things that day. I had finally found my rhythm. Providing traction and counter-traction was intuitive. Clamps were effortlessly being released with my non-dominant left hand. Suction was right where my F.T.S. needed it, when he needed it. Manual traction with a lap under my outstretched, slightly fanned out fingers protecting healthy bowel from electrocautery was unwavering until it was safe to move. And as we were finally closing, it felt good.
As I sometimes do, while mindlessly following the looped PDS suture as the surgeon closes the abdomen, I rehearse the procedure that has just been completed, looking for weak spots in my technique so that I may improve them next time. I am a bit in my own world as the dressings are called for, and I am brought back to reality as my Favorite Trauma Surgeon extends his hand across the table. To me! I look at his hand for an ever so brief second and it registers that he wants to shake my hand. Suddenly afraid that the moment will pass and he will withdraw the gesture, I slap my hand into his palm, perhaps a bit to eagerly, and accept the rare handshake that I have long awaited. As I blushed behind my mask and he broke scrub, I could barely contain the exhilaration of that first time handshake.

Filler and Fluff

Got distracted with this test.....hope the assassination victim doesn't pan out.

What Famous Leader Are You?
personality tests by similarminds.com

Home again.

Made it back in one piece. I drive everywhere. The highways were noticeably uncrowded this trip. It was me, truckers, giant expensive bus conversion RV's, a few u-haulers (the most dangerous species on the road), motorcycles and a spattering of mostly fuel saving cars with license plates from the state we were in or one state away. There are some advantages to the fuel prices.

I only had one OR related dream. I was on my way to the hospital. I wasn't sure what I was going there for, but I knew I was late. My cell rang and I answered it with, "I'm on my way!" It was the vascular surgeon that I was apparently on my way to assist. He ignored my salutation and proceeded to tell me all of the special equipment, thrombectomy catheters, shunts, grafts,etc. that he would need for this case. I was still driving, didn't recognize half of the stuff he was rattling off and had no way to write it down! I felt a little panicked but there wasn't much I could do but say OK and hope for the best.
Next scene I am in the OR and the patient is a male friend of mine. Not too bad except we seem to be doing a bilateral inguinal hernia repair, or so I think. I don't really want to see my friends "junk" so my dreaming psyche resolves that by having his testicles selectively draped into the field but I don't recognize them as such because they are neatly butterfly filleted! To top it off, he is awake, propped up on both elbows and conversing with me about ?? I don't remember.
Well, at least I didn't contaminate everything.

Vacation! Well sort of, away from my business of assisting for a week or so anyway. It actually stresses me out to be leaving. I'm packing about four Trauma/Surgery/Review books with me for some bedtime stories. About four days out, I'll be craving some O.R. action. On about the sixth day, I will be in actual physical withdrawals. Maybe another glass of wine on the back deck at sunset will help them go away.
I will probably dream of being scrubbed. That usually happens when I don't work for a while. I just hope it's not that horrible recurring dream where no matter what I do, I can't keep from contaminating the sterile field. That one really wears me out.
Call schedules won't come out until after I leave so at least I won't be squirming over who's trauma call I'm missing. There are several surgeons gone all or some of the same time frame that I am, so I probably won't be missing much. Still.....
When I get back, I'll work on finishing my long winded novel that "Path to SFA" has become. See y'all soon.

Meanwhile, back at the ranch...

My ortho docs are off passing their boards. The state of the economy has slowed my business. No, the surgical assisting business is NOT recession proof. Resistant perhaps, because traumas and emergencies still happen, but elective surgeries decrease and partners assist partners and my services become unnecessary. But the gods smiled upon me these past several days and I had the ultimate pleasure of working with my favorite trauma surgeon. Truth be told, he is my favorite surgeon, period. (Please don't tell my ortho docs!)
It started Sunday afternoon while he was on ER call, which means general surgical cases from the ER are referred to him. First case, a perfed (perforated) viscus at the jejunum. Fairly straightforward repair with a patch of omentum thrown over the top for added strength and healing power. He complimented me on having quiet hands. I was flattered.
Early Monday morning, 0500 early, another perfed viscus, this time of the duodenum. Another repair incorporating an omental, or graham patch. That same afternoon we had a previously scheduled case together, splenectomy. We were finished around 1700. It was an excellent case and I was honored that he had chosen me to assist. Somewhere in the middle of the case one of his partners who had been operating at the same hospital came in to announce that they were done and asked how it was going.
"Got some bleeding right now."
"Do you need a hand?"
I was concentrating on providing him with exposure but I was still aware of the conversation. I usually dread hearing that particular question because most often the surgeon will say, sure, if you want to. After all, they are peers, colleagues and there is a professional courtesy or protocol of sorts, and I sometimes feel like an accessory. Of course, I will always defer to another surgeon, especially a partner in the same group, but he has never traded me in.
He simply did not answer because he was concentrating and I was aware that his partner had left the room. When we were in recovery, he complimented me for being attentive during surgery and made a point about what a difference it makes when the assist actually cares about the surgery at hand. I knew that he was referring to not losing concentration when we had encountered bleeding. Coming from this surgeon, whom I respect so much, I was honored.
He was on trauma call Tuesday, and he asked me if I wanted to assist him on Wednesday. He had two cases, a lap chole and a small bowel resection. He forewarned me that he thought they were both Medicare patients (that means I don't get paid), but I jumped at the chance. After all, I had nothing better to do and I don't often have the opportunity to assist him so many days in one week.
The Trauma Gods brought us together again Tuesday afternoon. A fall from what and how high, I don't know, but it was enough to tear the patients mesentery, fill the abdomen with blood, and necrose a portion of the small bowel. The resection of the dead bowel would have taken less time had the patient had not been on long term steroids and blood thinners. That combination causes the tissue to become very friable and therefore more susceptible to bleeding and the bleeding more of a challenge to control. In fact, who's to say that the injury would have resulted from the fall at all, had those two factors been absent. With skill, gentle handling and the blessing of hemostatic agents, a very stable patient was delivered to ICU two hours later.
There were no more surgical traumas that night so we met again on Wednesday. Our lap chole was not so easy, a large, stone filled, edematous gallbladder and some variant anatomy made dissection tedious. Even after decompressing the gallbladder, pulling out some 45ml of dirty brown fluid resembling 30wt motor oil, it was still taut and difficult to grasp, but in the end, the gallbladder always loses.
Our final case of the week together was a small bowel obstruction. Often an obstruction is caused by an adhesion wrapping around the bowel narrowing the lumen and stopping flow. Or, the bowel may adhere to itself and cause such an acute angle that obstruction occurs. This patient had a combination of both. The bowel had adhered in the pelvis and had turned itself around so that it was twisted shut, sort of like the beginnings of a balloon animal. A short distance from that adhesion was another side to side adhesion that, despite blunt dissection attempts, refused to let go of itself. A small bit of bowel had to be resected and reanastomosed and before I knew it, my four days with my favorite surgeon were over.
There is a certain harmony between two people who work closely together for an extended period of time. As an assistant, you don't have to be told what to expect, what to do next, or what the surgeons next move will be, you already know and you act and react without thinking about it. In the operating room, it is a dance of sorts, and when you click, when you work well together, you begin to know each others moves by instinct. The choreography is perfect, flawless and smooth as silk. It is a high unlike any other.