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: