Chapter 18: An Introduction to Surgery

April 29, 1986, McKinley, Ohio

"Michael Loucks," I said to the clerk at the surgical coördinator's desk. "I'm here for my surgical Preceptorship with Doctor Roth. I checked in with the admin office and have my ID."

"Good afternoon! Have you scrubbed into a surgery before?"

"Once."

"Then you know the basics. I'm assuming you have on appropriate undergarments under your robes?"

"Yes."

"Doctor Roth will be in OR 2 for an open repair of an inguinal hernia. Do you know where OR 2 is?"

I didn't, but given the lines on the floor, I couldn't miss it.

"Yes," I said.

"Then go see the scrub nurse, and she'll assist you."

"Thanks."

I left the Clerk's desk and followed the blue line on the floor marked '2', which led me to the doors of the OR. I walked past them to the surgical scrub room and went in.

"Mike Loucks," I said to the scrub nurse, whose name tag read Marla. "I'm a First Year here for my surgical Preceptorship."

"Ellie's 'Mike'?" she asked with a smirk.

I suppressed a groan. I had to put a stop to it, and I had to stop it right away. The last thing I needed was for rumors to continue to spread through the hospital.

"Mike, who is married and was when he met Nurse Ellie," I said. "There is nothing between Nurse Ellie and me; there never was, and there never will be. And if she is saying there is, or was, it needs to stop immediately because it will ruin my reputation, harm my marriage, and likely lead to discipline from my bishop. Do I need to go to the hospital administrator?"

"No," Nurse Marla replied quickly. "Please don't do that. It's harmless."

"It may seem that way," I replied. "But it's not, really, for the reasons I gave."

"Let me speak to her, please. But now, I need to help you scrub. Have you scrubbed before?"

"One time."

"OK. You'll need to change into scrubs first. The locker room is out and to your left."

"I'll be right back."

"Remember, undershorts, T-shirt, socks, and shoes only besides the scrubs."

"Got it."

I left the scrub room and went to the locker room. I quickly changed into scrubs, leaving my watch, wedding ring, and baptismal cross in the locker as well. I returned to the scrub room and put on booties to cover my street shoes. Nurse Marla handed me a surgical cap to put on, and she tied it for me. I stepped over to the sink, opened one of the brush packs, and began scrubbing.

"Twelve times," I said. "As per the standard."

"You pay attention; that's good."

"Thanks."

I scrubbed as I had been taught the first time — fingers, nails, palms, backs of my hands, and forearms. When I finished scrubbing, I tossed the brush in the disposal bin, rinsed off the remaining soap, then followed Nurse Marla into the OR, holding my arms up in front of my chest and bumping the door with my hip.

"Glove size?"

"7.5," I replied.

"Big hands ... uh, sorry."

I chuckled, "It's OK. I'm not an uptight prude. I just simply cannot have anyone thinking I'm cheating on my wife."

"I understand. What denomination are you?"

"Russian Orthodox," I replied, though technically, we weren't a 'denomination'.

"Pastor?"

"No. I'm a deacon."

Marla took a folded surgical gown from a shelf and helped me put it on, tying it around my waist, and then helped me put on the surgical gloves.

"Large mask, please," I said. "With a beard pocket."

"Very good. Is that a style thing or a religious thing? I've seen pictures of Russian clergy with huge beards."

"Religious. But I keep it neatly trimmed because my wife prefers that, not to mention not wanting to have problems with masks."

She put the mask on me, tying it around my neck and the back of my head.

"Where's my chair?" I asked.

"No chair. Doctor Roth insists that everyone stands. Your position will be at the patient's feet. Do you know the procedure?"

"I only found out what procedure was being done when I arrived, so, no, I don't."

"You'll be permitted to slide this week, but for next week, call on Tuesday morning and ask for the procedure, then review the steps."

"Thanks for the tip."

"When Doctor Roth asks you, don't try to fake it. Just say you didn't know you were supposed to call to find out which procedure was being done and say that you'll be prepared for next week. Do you know the anatomy of the abdomen well enough to answer questions about it?"

"Yes. I aced anatomy lab."

"Good. Just answer the questions succinctly, don't embellish."

"Got it. Thank you."

"You're welcome. I see the team coming to scrub; just stay where you are until Doctor Roth invites you to stand by the surgical table."

"OK."

She went back to the scrub room, and I waited while two nurses made final preparations. A minute later, the patient was wheeled into the room and transferred to the table. Once he was situated, the orderlies left the room, and the nurses began the final preparations, including inserting a pair of IVs. About five minutes later, the surgical team entered.

"You must be Michael," Doctor Roth said.

"Yes, Doctor."

"Be here at noon next Tuesday so you can join us for the pre-surgical visit with the patient."

That would mean leaving class about fifteen minutes early, but perhaps the most important thing I'd learned during my first year was that I should take advantage of every chance for 'hands-on' training, even if I never got my hands on a patient. I was sure he was aware of the class schedule and that this might be a test, so based on my quick analysis of the situation, I readily agreed.

"Yes, Doctor," I said.

"Do you know what procedure we're using today?"

"No, Doctor. I do know you're doing a repair of an inguinal hernia."

"Describe that type of hernia, please."

That I knew.

"It's a weakness in the abdominal wall that abnormally allows abdominal contents to slip into the inguinal canal in the groin."

"Good. Doctor Lindsay, what procedure are we using?" Doctor Roth asked.

"Shouldice," the female Resident replied.

"What are the initial steps, Ms. Williams?" he asked of a female who I assumed was a Fourth Year.

"It's an 'open' procedure. An incision is made from two centimetres inferio-medial to the ASIS to the pubic tubercle and parallel to the inguinal ligament, exposing the inguinal canal and femoral space."

"Good," Doctor Roth replied, then turned to the patient, "Hi, Mr. Bowden. Everything looks good. Doctor Kelsey will administer the local anesthetic if you're ready."

"Whatever they gave me an hour ago was good stuff! Better than the pot I smoked in college in the 60s!"

The doctors and nurses all laughed.

"Start the clock, please," Doctor Roth ordered.

A nurse pressed a button, and a digital clock on the wall began counting up.

"1% procaine hydrochloride," Doctor Kelsey announced as he administered the drug with a syringe, and I saw a nurse write it on a large chart on the wall with a time notation.

The surgery began, and I watched as Doctor Roth guided Doctor Lindsay through the procedure, with additional anesthetic administered at two points during the procedure. Everything went well, at least from my vantage point, and I was able to answer the questions about anatomy I was asked. When the surgery concluded, the patient was taken to recovery while the surgical team went to the locker room to dress.

"What's with the robes?" Doctor Kelsey, the anesthesiologist, asked.

"I'm a deacon in the Russian Orthodox Church," I replied. "We're generally required to wear our cassocks at all times when we're in public. I have «ekonomia», which loosely translates to 'dispensation' to wear slacks, a shirt, and a tie when required, and obviously, for scrubs."

"Shirt and tie for pre-op visits, please," Doctor Roth said. "I don't object, but I don't want to create any emotional responses immediately before surgery."

"Understood," I replied. "That is exactly the reason my bishops have given permission to deviate from the norm for clergy."

"We'll do the post-op review in the lounge," Doctor Roth announced.

We finished dressing, and the doctors and medical students gathered in the lounge.

"Doctor Lindsay?" Doctor Roth prompted after everyone got coffee or a soft drink.

"Routine procedure with no complications. Post-op care is oral narcotics and routine antibiotics. The patient should be ambulatory in the morning and permitted light exercise after one week. No heavy lifting for four weeks after discharge. If there are no postoperative complications, the patient can be released on Thursday morning with a follow-up suture check in seven days."

"Contraindications?"

"Fever, swelling, or any other sign of infection; excessive pain which isn't controlled by standard doses of oral narcotics."

"Good," Doctor Roth replied. "Mike, if it's OK to call you that, tell me what you observed, please."

I had paid extremely close attention to each step, anticipating a question similar to the one Doctor Roth had just asked.

"Mike is fine," I said, then listed the major steps I'd observed.

"Loretta was right," he said when I finished. "I also see from your course evaluations you were handy with the scalpel in anatomy lab. I'd like to see you in at least two surgical rotations during your clinical work."

"I'll do my best with my scheduling," I replied.

"Emergency medicine is changing, so even if you don't want the toughest of all specialties, you're going to need surgery."

I suppressed a laugh at his blatant attempt to convince me that his specialty was the one for me. Clarissa and I had compared notes, and she'd received the same kind of encouragement in each of her Preceptorships, as had Peter. I hadn't discussed it with Sandy, Fran, or Maryam, but given they were making honors in their work, I expected it was the same for them.

"Doctor Gibbs mentioned that," I replied.

"She got her hooks into you first," Doctor Roth observed.

"Actually, I've planned on emergency medicine since I was in fourth grade."

"Fourth grade?" Doctor Kelsey asked.

"A playground incident where a classmate was cut badly on the playground, and I used my shirt to put pressure on the cut to stanch the bleeding. Made the papers and everything."

"And that's when you decided on being a doctor?"

"Yes. And when I decided I wanted emergency medicine."

"You've never wavered?" Doctor Lindsay asked.

"No."

"Your grades and test scores were good enough for Harvard or Stanford," Doctor Kelsey observed. "Why not go to either of those schools?"

"Because this is where I intend to practice, and this is where my church is. Are you suggesting that McKinley Medical School and Moore Memorial Hospital are not good teaching institutions?"

"No, but..." he began, but I interrupted him.

"Or that my patients are going to care which school issued my parchment?"

"No," he replied with a smile. "But if you're that good..."

I interrupted him again.

"You're suggesting the people here don't deserve the best possible medical care?"

"Forget it, John," Doctor Roth said with a soft laugh. "He's obviously been asked about this before."

"By the interview committee at the medical school, among others," I replied. "Do you have another surgery today?"

"No. 1:00pm was the last scheduled surgery for the day. General elective surgery is pretty much 6:00am to 4:00pm. My team is on call until 6:00pm. We use that time to prepare for the morning, as well as complete charts."

"How many surgeries per day?"

"It depends on the procedures. I had two this morning, and we'll go check on them as soon as our hernia repair is moved to his room."

"Do you get many emergency surgeries?"

"We're the second team right now, so if we were to get one, we'd bump a scheduled procedure. The primary team is Doctor Cranston's. We'll be primary in two weeks. That means we do all the surgical consults for the ER and other services, and handle any emergency procedures."

"How many teams are there?"

"Seven total to cover the entire twenty-four-hour a day, seven-day week. Overnight, there's one team on site and one on call."

A nurse came to the door, "Doctor Roth, your patient is being moved to his room."

"Thanks, Ally. Mike, please go change into your shirt and tie. We'll be ready when you get back."

"Yes, Doctor," I replied.

I went to the locker room, took off my medical coat, shed my cassock, and quickly dressed in my slacks, button-down shirt, and tie, put on my medical coat, grabbed my stethoscope, and returned to the lounge. Doctor Roth got up and led all of us to the surgical ward, where we visited a total of six patients, including the one who'd just had his hernia repaired. Doctor Roth wrote one set of discharge orders, and then we returned to the lounge for the rest of the shift.

"I'd prefer you stay until 6:00pm," Doctor Roth said.

Which would mean missing dinner and going right to church, but that was a small price to pay for the extra hour.

"I'll just need to call my wife and let her know I won't be home for dinner and that I'll meet her at church."

"On a Tuesday?"

"This is our Holy Week," I replied. "Our calendar for Pascha, which is what we call Easter, follows a different calculation method than the Roman Catholics and Protestants."

"Will staying make you late?"

"No, but it's irrelevant. My first priority is medicine. My bishop and priest are both aware of that."

"Make your call."

I went to the phone and called home, letting Elizaveta know that I'd be at the hospital until at least 6:00pm, and asked her to please let Father Nicholas know there was a remote chance I'd be late for Bridegroom Matins. She wanted to ask questions, but I felt it was better to discuss it when I was alone with her rather than with the doctors in the room with me. She said she'd ride with her parents so that we could ride home together.

"All set," I said.

"OK," Doctor Roth said. "Actually, first, go with Zoë and check on our two patients for tomorrow morning's surgery."

I nodded and followed the female medical student from the lounge.

"Why just you?" I asked after we left the lounge.

"This is just a final check of their paperwork — I need to ensure the consent forms have been signed and make sure the correct meds are on their charts. I'll also find out if they have any last-minute questions. That way, Doctor Roth is prepared to answer them in the morning."

"What procedures?"

"A partial colectomy due to extreme diverticulitis and a cholecystectomy due to biliary colic symptomatic of gallstones. Both should be routine."

"Did you Match for surgery?"

"At Jackson Memorial in Miami. I'm originally from Fort Lauderdale, so I tried for hospitals in the area."

"How did you end up at McKinley?"

"I met my boyfriend at Ohio State, and he talked me into staying in Ohio. We broke up last Fall when I told him I wanted to Match in Florida and he didn't want to move."

"Had you talked about it?"

"Yes. I thought he was on board, but when it was time to fill out applications, he said he didn't want to move. I filled out the applications, and once I sent them in, without selecting any hospitals in the Columbus area, he broke up with me."

"What does he do for a living, if I may ask?"

"He's a CPA. What does your wife do?"

"She's still in school," I replied.

"Major?"

"High School."

"You married before she graduated?"

"Yes," I replied, deciding to leave it at that to avoid the drama. "In the Orthodox Church, we have to marry before ordination, or we can't get married."

"How long have you been married?"

"Almost a year," I replied.

"Hang on! How old is your wife?"

"Seventeen."

"You married a sixteen-year-old girl?!" Zoë gasped.

"She proposed to me," I replied. "In fact, she insisted I marry her."

"At sixteen?" Zoë asked, sounding skeptical.

"I knew I wanted to be a doctor at age ten. How old were you?"

"Fourteen. But that's WAY different from getting married!"

"Being a doctor is actually more of a commitment when you think about it — eight years of post-secondary education and eight years of Internship, Residency, and a Fellowship before you're a full-fledged surgeon. And your career choice is pretty much locked in for life unless you want to flip burgers. You decided that at fourteen."

"Not even close to the same!"

"Were you wrong to make your decision at fourteen? I certainly wasn't at ten. As for my wife, her parents, our priest, and our bishop, all agreed she was mature enough to make the decision. The State of Ohio concurred."

"But marrying at sixteen? Fifty years ago, sure, but in 1985?"

"Her plan was always to be a wife and a mother, and she's very happy. To be honest, I don't think I could make it through medical school and Residency without someone like Elizaveta."

"She's awfully young," Zoë declared. "But if her parents were OK with it, it's not really for me to say otherwise. I do have to ask one question..."

I chuckled, "I can assure you no shotguns were involved in the forming of this marital bond!"

Zoë laughed, "Nice."

"So, back to the patients; what happens if you find something wrong? You're a Fourth Year."

"I go back and tell Doctor Roth, and Doctor Lindsay gets taken to the woodshed, as she does all the pre-op work. That's pretty common for surgical teams. The surgeon sees the patient for the first consult, describes the proposed procedure, and then it's the Resident's job to take care of everything. The surgeon visits right before the procedure, as that builds confidence. Fourth Years on their surgical rotations, do all the paperwork.

"For example, with Mr. Kingston, who's having the partial colectomy, I did the surgical questionnaire, which is basically a detailed medical history. That usually takes an hour or more, and it's to make sure we're prepared for any eventuality and find any potential risk factors. I also reviewed all the past charts to verify the diagnosis and to look for potential errors or omissions. All of that is part of ensuring a successful surgery."