Scalpel

by David Schneider

08/27/2015

Almost every patient mentions how it’s cold in the operating room. We keep the room around 60 degrees, in part to keep comfortable in our layers of clothes and gowns, and in recognition that keeping a chillier room helps keep infection rates lower. Lisa is no exception. As she’s being wheeled in on the gurney, she’s groggily awake and mutters something about the cold.

Before rolling her into the operating room, Dr. Cohen, my anesthesia guide today, performed a nerve block injection on Lisa. He used an ultrasound wand to guide the trajectory of the needle via computer screen as it delicately plunged through the skin and explored the depths of tissues around the neck. Once the shadow of the needle tip approached the brachial plexus (the bundle of nerves that connects brain and limb), he injected a syringe-full of numbing medicine around the nerves. The procedure rendered her arm simultaneously numb and paralyzed. On cue, our little team trekked toward the operative theater.

Underneath her translucent blue surgical bonnet, Lisa’s bright auburn hair is visible, tucked safely away in our clean environment. She’s another East Coast transplant who moved west to Colorado in middle age. In the last several years her left shoulder has become unbearably painful, and after failing injections and physical therapy she has opted to undergo shoulder replacement surgery. In the pre-operative staging area, Lisa nervously asked about how much pain she’d be in tonight, but that’s a faraway concern now. Her sedative medicine has rendered her punch-drunk and unaware. Her sister confided that they watched a shoulder replacement on YouTube last night, only barely enduring the odious cinema.

While in high school, I saw a television special about Dr. Frank Jobe, the longtime team physician for the Los Angles Dodgers, who pioneered so many shoulder and elbow operations. That day, I decided to be an orthopedic surgeon and never wavered in that pursuit. Following medical school in the Midwest and surgical residency in Pennsylvania, I was accepted at the sports medicine fellowship overseen by Dr. Jobe, the same man who had inspired me almost 20 years before. I have traveled with the Lakers, ran onto the field of the LA Coliseum with the USC Trojans, lived in a bungalow on Jackie Robinson Way during spring training, and listened to the plaintive cries (bad back, bad feet) of a now middle-aged Mike Eruzione in the dressing room of the US Olympic ice hockey team in their only reunion since the 1980 Lake Placid gold. Those experiences, teamed with guidance from world-class joint doctors, turned me into the surgeon I am today.

All of us in the operating room wear scrubs, caps, and masks, but only the surgical tech dresses in her sterile gown as she prepares the instrument table. My physician’s assistant, Ashley, and I help Lisa scoot over onto the narrow surgical table.

Dr. Cohen administers more anesthesia through a combination of intravenous sedatives and inhaled gases. Our main goal is pain-free surgery, but we also want the patient motionless so we don’t have to worry about injuring a nerve or vessel with a sudden jolt. Cohen renders Lisa unconscious. As the gas mask is held firmly over her mouth, milky white Propofol pushes into the IV. In the few seconds it takes to travel to the heart and circulate into the brain, Lisa plunges into the marvel of senselessness.

Now that Lisa is completely anesthetized, we position her body carefully on the table. Great care is required: while her body is completely alive, it is incapable of self-protection and as vulnerable as a newborn.

We position her to minimize bed sores or nerve injury, and then I adjust the height of the table so that the surgical area matches the height of my elbows. This minimizes shoulder strain and allows for up-close visualization. During shoulder replacement surgery, I stand. Once we’re all positioned, the circulating nurse paints the surgical area with skin-prep chemicals, including alcohol and other bactericides.

While the nurse paints the patient’s shoulder, and after scrubbing our hands, I perform an intricate dance with the scrub tech, who already has her gown and gloves on. While facing her, she slides my gown over my outstretched arms without touching the unsterile parts of my body or clothes. She snaps latex gloves over my freshly doused hands. From behind me a nurse ties my gown and I twist 360 degrees to cocoon myself in a sterile microenvironment.

After all the busyness of collecting Lisa from the preoperative holding area, dealing with her sister’s anxiety, hustling to finish a basketball player’s physical so he can play this weekend, phoning my office assistant to hear the results of a rugby player’s MRI, and readying the patient for surgery, it’s time to cut. Dr. Cohen and I catch each other’s gaze, connecting in a deep sense of trust over the dominion of life. His somber eyes and a gentle nod of ascent confirm that we are ready to journey on.

The scalpel is made of two parts, the handle and the blade. The scalpel handle is flat and made of stainless steel, which allows for repeated washing, sterilizing and packaging. A scalpel handle can last for years, even decades. The scalpel blade, however, only lasts one case. Instead of stainless steel, the blade is made of carbon steel, which is much sharper. In many operations, a blade loses its requisite sharpness in the middle of surgery and must be discarded.

As a surgeon, you always ask for instruments without turning toward the scrub tech or without taking your eyes away from the surgical field. An experienced tech knows, within a few tools, the instrument the surgeon will ask for next, along with the proper orientation to place the tool into the surgeon’s hand. To the close observer, surgery looks as well choreographed as ocean-going sailors maneuvering their craft with minimal conversation and maximal coordination.

My gaze is now firmly fixed on the purple line I’ve drawn over the front of Lisa’s shoulder. All the acts of positioning, scrubbing, gowning, prepping, and draping have come down to this. It is time to make an incision. It is the moment of truth beyond which there is no turning back.

“Scalpel.”

There are two ways of holding a scalpel. In one position, you hold the stainless-steel handle like a pencil; in the other, you hold it like a conductor holds a baton. The former technique makes the majority of incisions, while the latter is employed during larger incisions. When I perform the incision on Lisa, I steady my hand and wrist, and use the muscles around my elbow and shoulder to direct the blade across the skin.

With the scalpel in my right hand, I hold my gloved left thumb and index finger on either side of the incision site, stretching the skin tight. Nothing else in the world exists, no other thoughts, no realities, no controversies. Nothing funny, nothing sad, nothing interesting. I’m in a vacuum where everything further than 10 inches away vanishes.

My father was a Marine Corps sniper in Korea before becoming a veterinarian. Curious about his military days, I watched a documentary on sniper training, wherein elite marksmen like him were taught to deeply inhale and exhale before squeezing the trigger. This same technique helps me steady my hand during precise movements; I use it every day in the operative theater.

After my brief breathing exercise I move the scalpel blade to the uppermost part of my planned incision. The razor-sharp blade is touching the skin and yet no penetration of the metal edge has occurred until I downwardly angle the instrument towards the elbow. New surgeons notoriously misjudge the correct pressure required to properly cut through the skin. Typically, rookie cutters barely scrape the skin, and their supervisors joke about paperclips inflicting greater damage. However, too great a pressure will plunge the knife deeply into the wound, causing potentially catastrophic damage to deep nerves or arteries.

Cutting skin feels like slicing into a fresh peach. As I draw the knife along the skin, yellow fat billows up from the wound. As we age our skin becomes thinner, so I account for this as my scalpel blade progresses across Lisa’s shoulder. The tiny vessels along her skin’s edge emit droplets of bright red blood where they have been transected; these must be cauterized, or heat-sealed, with an electrothermal device called a Bovie.

A perfectly executed cut penetrates only the dermis, leaving further dissection to scissors and electrocautery. Having made the initial surgical incision, I hand over the scalpel and retire the blade. The skin layers contain dangerous bacteria (even after the most fastidious surgical prep), which contaminate the “skin knife.” After mere seconds of use, that scalpel blade is done forever.

Lisa doesn’t move and doesn’t recognize the violation of her body’s boundaries.

The remainder of the shoulder replacement operation involves exploring deeper and deeper layers of tissue. This kind of deep investigation of the corpus was unimaginable at the time that photography, the telegram, the steam engine, and perforated toilet paper were being invented. Every great surgeon requires an innate sense of three-dimensional space buttressed by years of anatomic learning. The location of every muscle and minute blood vessel and nerve is surprisingly predictable; a gifted surgeon comprehends these laminations with rapid, precise dissection. An aging joint, like an ancient tree tentacled onto a rocky cliff, develops thickened stratums of bony spurs, loose cartilage bodies, and overgrown, inelastic ligaments. As I delve deeper toward the diseased shoulder joint, I have to abandon the scalpel for stouter instruments.

Other specialists deal with soft tissues like brains and bowels. Orthopedic surgeons deal with bones, ligaments, muscles, and joints. Our toolkit includes hardware: metal saws, chisels, drills, and hammers. After dissecting deeply through the soft tissue layers around the humeral head, I expose the arthritic joint, cut off the top of the bone with a metal battery-powered saw, and place successively larger metal stems down the hollow humeral canal. Once prepared, I can insert the final total shoulder implants. At some stages, every operation is like a project, and requires the use of brute force to pound, shape, smooth, and extract tissues and body parts.

After implanting the new shoulder replacement components, I reverse course and backtrack my way out of the shoulder joint. The last step is always skin closure. Back in the days before antibiotics, early surgical pioneers used silk or catgut sutures to bring tissue edges together. Those materials were dissolvable, which created an immune reaction that opened the door to infection and, commonly, death. We now use “inert” or low-inflammatory suture materials or metal staples that hold skin together.

As my surgical team applies the final dressings, Dr. Cohen also reverses his steps. He stops the short-acting inhalant anesthetics that were vaporized into the breathing tube and discontinues the intravenous drugs that kept Lisa sedated. Gone are the days where drugs, such as ether, took days to wear off: today’s designer molecules wear off in minutes. Lisa begins to move her body and fight against the tube in her mouth. When it is safe, we remove the breathing tube and shuttle her back onto the gurney.

Our little contingent rolls Lisa down the hallway, now progressing towards the recovery room. Patients often fear saying something stupid or embarrassing in the operating room. Most do not. There tends to be only incomprehensible mumbling in the moments surrounding the induction and reversal of anesthesia. However, there is a disarming sentiment most patients have in the first minutes of wakefulness: loss of awareness in the passage of time. With me at Lisa’s side helping to guide the gurney, Dr. Cohen asks her if she’s doing alright.

“Are we almost ready to go?” she asks.


Originally published in This Land: Summer 2015.