I was doing a case with one of my attendings the other day. She asked for her next stitch. A specific stitch, 4-0 Vicryl, which unfortunately the scrub tech did not have open and on the field. But she did have a 3-0 Vicryl, which was offered to my Attending. The entire room was then strongly reprimanded for not having the correct stitch open and ready. The scrub tech and circulator offered up their defense and counter argument. But in the end, heels were dug in, and everything stopped until the correct stitch was collected, opened and handed over.
I watched the all too familiar scene in silence. Why did it have to be like this? The 3-0 Vicryl would have sufficed for our present need just fine, why couldn’t we have just accepted the 3-0 Vicryl and moved on? There are a few reasons I have pondered, not in any particular order...
1) A surgeon’s OCD personality. Like a check-list, the steps of a procedure are completed routine, sure and safe. Deviation or flexibility allows for unsure steps, mistakes, complications and then death.
2) Responsibility. A patient has put their life in the surgeon’s hands. Taking that trust to heart, the surgeon owes the patient their absolute best in every cut and in every stitch. There is no minor surgery. There is no minor stitch.
Taking it a step further, a wrong stitch placed in a surgeon’s hand in a time of emergency is enough to waste 4-5 seconds of that patient’s life. Take a transplant surgeon, handed the wrong stitch during the venous anastomosis, watches his patient hemorrhage for those 5 seconds while the mistake is corrected. By the second or third time it happens, it has now been 10-15 seconds of their patient hemorrhaging, well past their 20th, 30th, on their 40th unit of pRBCs. They throw the instrument, and in so doing emptying their hand 3seconds sooner and receiving the correct stitch that much sooner in the race to save their patient’s life.
Perhaps is can be argued that by allowing argument in a case of nonemergency like our example, would then make it acceptable in a case of emergency when time and life are in the balance.
3) Hanging onto a time past. The era of the Physician. Their word was golden and followed without argument. That was an era past. We can trace how medicine has evolved from that time, through an era of the Patient into what today could be called an era of the Payor. Greatest evolution noticeable outside of the operating room, but it has now greatly altered the environment within as well. Did you notice how the tech and circulator not only defended themselves by argued back? I personally do not know a time when the nurses did not argue back, but my attendings do. Was this simply the right to be heard and followed?
I did not ask my Attending why we couldn't use the 3-0 Vicryl. I know if it had been me in that situation I would have. But then I think of the possible reasons (as mentioned above) for holding out for the correct stitch, the one that I actually asked for and I feel chastised. Is it just my inexperience and lack of understanding that makes me want to use the 3-0 Vicryl instead of the one I asked for. And then I come to myself again and remember, God may send me to a jungle some day, a desert, a mountain village...wherever I am needed. Where a plethora of sutures and needles (as we are blessed with here) will not be available.
If it’s routine, flexibility will be my routine. If it’s responsibility, I owe it to my patient to use what is at my disposal to make it work. If it’s about time, times change. And I pray God grants me the grace to Love through it all and despite it all.
Much Love.
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