What better way to begin the surgery part of my surgical blog than with a love note to a scrub nurse? A scrub nurse is one who participates directly in the operation, setting things up, passing instruments, and, with luck, adding her (usually its a "her") thoughts to the proceedings. She can make a huge difference in the flow of things, raising it to an art-form. So here's an excerpt from my book, in which I try to make that point very clear. It begins as I find myself on the neurosurgery rotation, early in my training:
Esoteric and tedious, neurosurgery impressed but didn’t attract me. Charlie Wilson, however, amazed me. Chairman of the department, he radiated enough energy to power the place had the lights gone out. A marathon runner before it became widespread, he spent the rest of his time at the hospital, all hours, day and night. He was a superb operator, tackling brain tumors others refused, getting results far better than expected. He looked you right in the eye, drilling the truth in deep, exuding understated confidence. Patients came from all over the world, handing him their brains.
One of the neurosurgeons looked like an alien, come to Earth to help us, if allowed to breathe methane. He did all his cases with a self-designed, fully enclosed mask, dangling two exhaust hoses over his shoulders and down his back. As he meticulously
attended to bleeding, one corpuscle at a time, his operations took hours longer than anyone else’s. But they said he’d never had a post-op hematoma (blood collection), never an infection. Of course not: any bacterium that wandered into the wound would
have died of boredom or starved to death.
In a world where looks matter, kids with craniofacial abnormalities are screwed. When their facial bones and sections of skull fuse prematurely, or grow in the wrong direction, some are so disfigured you want to look away. A French surgeon, Paul Tessier, had developed a spectacular and wondrous approach to such problems, doing operations that lasted twelve hours and longer— unroofing the entire top of the skull, cutting out cubes of bone containing the eyeballs, moving them outward, rearranging entire sections of facial aberration that formerly had been set in stone. One of the neurosurgeons at UC had gone to Paris to study with Tessier and brought him back to San Francisco to put on a clinic. I didn’t have the time to watch an entire operation, but what I saw has stayed with me.
Dr. Tessier brought his team with him: an anesthetist, a tech, and a scrub nurse. It was the pas de deux performed by Tessier and his nurse that opened my eyes and dropped my jaw. As he sat, focused like a cat on his work, he’d raise a hand wordlessly and his nurse would give him an instrument, which he’d bring to the field, work for a moment, then pass it back and receive another one. Never a hesitation, never a wrong move, it flowed like a ballet, musically, the noblest art humans can create among themselves. Still clumsy, I could nevertheless recognize perfection. That, I thought, is what it can be, what it must be to do surgery. It’s a rarity. Few surgeons get to do the same thing over and over, in the same place, with the same team. Instead, it’s night shift, day shift, one hospital, two or three. You try to find the rhythm, to get a flow going, with you, your assistant, your scrub nurse all knowing what’s coming, facilitating, cooperating. In a tough spot, you want to maintain focus, not moving your head, keeping the area you’ve just exposed perfectly in view. Hand out, wanting the right tool slapped in smartly, you don’t want to fumble for it, nor lose sight, nor have to reposition the instrument; boring in, you try to keep it going, saying, “I’ll be using a long Allis next.” But instead of getting it you hear, “Sue, can you get me a long Allis from central supply?” “Geez! This is a low pelvic case. I always use a long Allis.” “Sorry doctor. I usually scrub ortho.” Screech. Nureyev drops Fonteyn on her ass.
I’ll divert to the present long enough to say that in my practice I got close. My clinic hired away the hospital’s best scrub nurse, Joanie Thompson, and I worked with her on most of my cases. When I did, we were a hell of a team. She knew. She always had what I needed. When I’d want an instrument different from what I typically used, Joanie had it before I asked. “I’ll need a longer needle holder, and mount it backwards.” Whack, into my hand, the suture perfectly placed in the jaws. “And make it snappy,” I’d say, after the fact. The pleasure from an operation allowed to flow, where every step follows logically from the last, where each move is fluid without stops and diversions, is transcendent. It restores the soul. It makes you want to sing, which I often did. Joanie told me the best thing I ever heard as a surgeon: “You make this look so easy,” she said. She became an RNFA (Registered Nurse First Assistant)—in fact, she’s a national force in making that occupation a reality; she’s just as good an assistant as she was a scrub. But I always missed having Joanie pop an instrument into my hand, the right one, at the right time, making music.