This rotation is closing with a bang. Today Dr. Mark had a breast reduction case which lasted for eight hours. That was with me doing a fair amount of work: maybe a third of the total suturing. The scrub techs gave each other coffee breaks and lunch breaks, and circulating nurse got reliefs, and the anesthesiologists took breaks; but we didn’t. I offered to take over and let Dr. Mark get lunch, but somehow he wasn’t thrilled with that idea.

At first I thought things would be a little bit difficult, because two scrub techs presented themselves, since the case is so difficult, and usually requires assistance. The second one, a tall young man, decided to stay and scrub in; so I was hoping not to have to get in a contest with a tech about who was doing what. To start with, it was good to have him, because the first step involves holding skin spread out tight while the surgeon uses the scalpel. I have to admit that six-foot-tall men are better at this than I am. (It’s not fair that, in spite of being shorter than me, Dr. Mark has hands two sizes larger than mine. . .)

Then came the de-epithelialization of the sections to be removed: which frankly means skinning it. Dr. Mark started on one side, and after I’d watched for five minutes he said, “Ok, you want get started on the other side?” Only a recent resolution never to back away from anything until someone takes it out of my hands (ie, don’t give up on getting a tube in anywhere as long as the person supervising is willing to let me keep trying; don’t give up on sewing anything until someone announces that it’s too bad, they need to get it right; don’t give up on intubating anyone until the anesthesiologist takes things out of my hands; usually I let go too fast) kept me from saying, “You’re not serious, are you?” Apparently he was. He lifted up the corner on the other side, and then handed it to me. I set off shaving the epithelium off, ideally in one piece, and ideally without serious disruption of the dermis underneath (the blood vessels in the dermis are needed for healing). The tall young man, Josh, came over to my side of the table and held things for me. It quickly became apparent that he knew far more about the procedure than I did, and could probably have done it single-handedly, but amazingly he didn’t say anything to my numerous buttonholes, or all the bleeders I discovered (beyond asking Dr. Mark the first time, “Is she allowed to use cautery?” to which he hardly deigned an answer, and after that Josh just helped me find the bleeders). It also turned out that by “start the other side” Dr. Mark actually meant, finish the other side. I went through three scalpel blades, they got so dull after a while. I couldn’t believe myself. I think I’ve held a scalpel about three times previously. He let me clear off that whole side, and cauterize everything that needed it.

The next step was Dr. Mark cutting away all the extra tissue, going back and forth between the two sides, trying to get them even. I couldn’t refrain from telling him the Aesop’s fable about the monkey who judged between the two cats trying to divide a cheese, and ended up eating the whole thing. He got the two sides within five grams of each other. We were all impressed. Then he started piecing things back together.

Somewhere in here the entire OR staff entered on a discussion of violence in general, and the war in Iraq in particular. I was just about the only supporter (mistakes have been made, but you can’t just run away from a war, and pretend it never happened; that’s irresponsible). Dr. Mark exclaimed, “What are all those people in Iraq dying for, anyhow?” Josh answered dryly, from his great height above the two of us, “Freedom. And liberty.” I couldn’t tell from his tone, so I asked, “Are you serious, or are you being sarcastic?” He said, “Perfectly serious; I was in the army for four years. I volunteered to take another tour and go to Iraq, but I had a health problem, so they turned me down. I’m going to try again in a few months.” Which kind of squashed Dr. Mark’s arguments.

The last three hours were spent suturing the breasts back in shape. I was amazed by how, after all that cutting (and some very dramatic bleeders – I actually managed to use hemostats to some purpose today) Dr. Mark was able to put two sutures in, and pull everything into almost perfect order. He put the major sutures in on both sides, to take the tension and outline how the skin should match up, and then both of us started suturing away. We used up almost the entire supply in the hospital of 4-0 vicryl. At one point the other scrub nurse was heard wondering whether we would need staples. Dr. Mark exclaimed in horror; plastic surgeons should never use staples; staples are ugly; they ruin the skin, and the incision, and the healing, and make scars; better to spend two hours suturing, and get it right.

So we spent two hours suturing the subdermal tissue together. Dr. Mark’s specialty is placing subdermal sutures so close to the surface, and so precisely on both sides, that when the knot is tied, the skin is perfectly approximated, and no further sutures are needed. I tried, and after about an hour I was starting to get the hang of it. Both sides came out very neat, but a good deal of that was due to Dr. Mark going over again and putting a few more stitches in key spots to smooth things out.

Best day ever. I imagine this is what residency is going to be like: they actually let me hold and use the instruments, and I can keep going and keep going – not just one tiny step and then stop. This is wonderful.

Driving in to the hospital early this morning, I was thinking: the reason surgery has such horrible hours is because we have to get up so early to round on patients before starting surgeries, and then stay late to check on the patients after surgery. And surgeries are scheduled early in the morning because it would be miserable for the patients to have stay andxious and NPO any later in the day. So it’s all about the patients. There’s a reason for the hours, and that reason is patient comfort and safety. We have the privilege of using sharp instruments and going inside people – and we pay for that by waking up early. That’s not an unreasonable bargain. I can live with that.