Wednesday, October 31, 2007

Cool

image from damnitimvixen.com

To the essential questions of modern life -- paper or plastic; boxers or briefs; regular or decaf -- add this: fingers or palm? In what way, with which appendages of the hand, should one grasp a needle holder? I was chastised, during my formative years, for transgressions of either type; now, I feel strongly both ways.

Huey Lewis said it: "Cool is a rule." I doubt any student of surgery, from earliest medical school forward, failed to practice the technique of palming a surgical instrument. It is cool. Rather than putting fingers through the rings, the whole handle is placed in the palm, one side on the thenar eminence. The ring finger and/or the little one, when pressed onto the part of the handle that's not resting at the thumb, can be made to unlock the ratchet, and widening the palm makes the jaws separate. The index finger is laid along the shaft of the instrument, with the tip near the very end.

The index finger is really the most important thing, and it must be there no matter how the handle is held. The following picture, which amazingly enough is from the website of a university surgery program purporting to describe suturing techniques, demonstrates the worst of all possibilities (I suppose I shouldn't be surprised since in another section it refers to a pictured set of forceps by the name "Addison" instead of the correct "Adson." I'd bet my soul [a low-ball wager if ever there was one] that the piece was NOT written by a surgeon):

Here, the index finger looks bent and is not nearly close enough to the tip of the instrument. And no matter what the chosen method, no surgeon would ever stick his/her ring finger so far into the grip-ring. The object of the game is to achieve precise control, with the ability to make fine movements exactly the way your brain is suggesting. "Awkward" is the word that comes to mind when looking at that picture.

"God gave you fingers, so why not use them," said "Chatham Knell" (a pseudonymed teacher of mine), arguing for keeping the fingertips in the handle-holes. In my book I also referred to him as "Death" Knell.

In placing a suture, most of the action is in the supination of the wrist and hand. But fine adjustments can be made when the fingertips are in play; less so when the holder is palmed. On the other hand, when using a long instrument in a deep hole, one usually braces the hand in some way or another, taking fingertip control out of play. So here's what I think:

When placing fine sutures with a delicate instrument, hold the needle-holder with fingers in the handle-holes -- the TIPS of the fingers. When taking big bites or when necessarily using a large instrument, grip it with the palm, which confers strength.

And when you're using hairy-thin suture on fairy-fine needles, repairing nerves or patching small arteries, you use these beauties, the coolest of the cool, and it's fingertips all the way, baby:

14 comments:

lights n steel said...

Awesome post. Thanks for the tips. ;-)

rlbates said...

Or "flipping" the scissors back into your palm when not cutting. It always reminded me of the gun play in the old movies. Way cool.

Sid Schwab said...

Yeah. Somewhere in the dusty corners of this blog I mentioned that flipping maneuver and how cool it is. The gunslinger analogy is very apt. Wish I'd used it.

Sid Schwab said...

Found that description, here. We really are cool, aren't we?

rlbates said...

Yes, we really are. (though my nieces and nephews wouldn't agree)

Bongi said...

super cool. i routinely use the flip back to palm technique. to flip it out as fast as possible really does impress (often me more than the casual observer).

but seriously, the finer points of how to use the instruments is an important part of surgery.

Assrot said...

You know I'm a lurker here that does not comment much but I do learn a lot. I once had a terribly ingrown toe nail and decided to perform my own surgery to save myself a few bucks. To make a long story short, two days after my self applied surgery, my toe was the size of a tennis ball, red hot, infected and oozing pus and about to explode.

I went to the doc and paid his rather fair fees (considering I had no insurance at the time) and he fixed me up right nice. He told me if I ever wanted to operate on myself again to call him on the phone and he would guide me through it although he could not be held responsible and would not be able to supply anything to kill the pain during surgery. He was joking I'm sure and we both got a good chuckle.

Getting to the point, I'm thinking that if I keep reading this blog I might acquire enough knowledge to perform some minor surgeries on myself as I grow older. I see now from your impeccable teachings that my technique has for the most part always been wrong. Now I can correct that.

Would you be willing to provide some telephone guidance to remove a very annoying hang nail that has split and grown in several different directions on my right middle finger? No? I thought not but I had to ask.

Interesting blog doc. I do have very good insurance and I am going to a an orthopedic surgeon that specializes on hand surgery so don't worry about that.

Keep up the good writing.

Sid Schwab said...

assrot: you've inspired me. I'm going to look into publishing a sort of "Surgery for Dummies" thing; "Take out your own gallbladder and save." Something like that.

jb said...

FWIW, I was taught by a master surgeon and artist to use the palm technique. He himself had been taught the fingers in the hole style, and operated that way, but he said that he always regretted not using the palm technique from the start. I usually use the palm but fingers come in handy when extra precision is needed.

The really fine needle drivers pictured are Castroviejos, always abbreviated as "Castros." Do you know who Dr. Castroviejo was? I can't find a reference.

Sid Schwab said...

jb: he was an opthamologist.

Lynn Price said...

Yet another post that's gone into my file of "Sid's Tomes," to be pulled out when I need info for writing certain scenes. I would love to see a pic of how you hold the needle holders since I have a hard time visualizing it.

Anne said...

Re "Surgery for Dummies", it could be a companion volume to "Survival Techniques in the Wild". Here in the UK we have a wonderful chap called Ray Mears who teaches bushcraft. He has presented TV programmes and written books about how to survive in the wild. He's the type who can knock up a canoe in minutes or light a fire with a couple of sticks. You and he would make a great team....

Phil7 said...

Good 'surgical hand' has often impressed me, particularly when coupled with suture and neat tying off, and slide knots etc.

As a sales rep, i have the rare priviledge and opportunity to evaluate good technique.

Rob said...

Well, as a student about to start his third year rotation in surgery (who is also very interested in it)this was a timely post. Thanks!