As far as “first day in surgery” stories go, mine is pretty pedestrian. I have no grand memory of the chest being opened or a ten blade making a first incision. (I don’t even remember what the procedure was.)
But I do remember the suture scissors.
My resident was “throwing” (i.e. tying) surgical knots on a stitch. It was what you would expect — quick, elegant, confident — each knot perfectly stacking up on the other in alternating succession. In the middle of her third throw, the command “suture scissors” dropped out from under her mask with an almost audible thud of expectation.
I became acutely aware that my hands were palm-up on the sterile field. Our surgical tech must have noticed too, because I felt the firm thump of metal in my right palm. I looked down to find a pair of suture scissors, and then looked up to catch my resident finish her final knot, lift the tails of the stitch with her needle driver, and immediately command, “Cut.” Eager with having a first-day role, I moved with confidence. These are scissors — how hard can it be?
Of course, I stuck my fingers through the scissor loops like a five-year old making a paper snowflake and “bit” the suture — fraying it like the end of a shoelace without an aglet. Our tech snatched the scissors from me and cleanly snipped the stitch tails like they were hair. Without lifting her eyes from the surgical field, my resident offered me a few lessons.
I like to think these lessons were all ontological — because we medical students are a bit like suture scissors. We’re potentially awkward, low on the totem pole (perhaps even “dull”). But we’re also foundational, fastidious — frequently used. Teachable.
First of all, operating fingers don’t go all the way through the finger loops like in kindergarten arts and crafts. The instrument will get stuck on the knuckles, impeding both control and the freedom to move quickly to another instrument if needed. Instead, the thumb barely hugs one loop while the end of the ring finger (not the middle finger) holds the other.
As students, we too struggle to find our “right fit” in medicine, clumsily sticking ourselves through the loops of healthcare’s possibilities before finding that strange vocational grip between what we want to do, can do, and perhaps should do.
Second, suture scissors are not a passive instrument. Push with the thumb and pull with the ring finger. These simultaneous actions bring the blade edges into closer proximity, increasing shear stress for maximum cutting force rather than tearing, fraying, or “biting” the suture. Biting often yields blame on the scissors being “dull.” Rarely are the blades truly dull. It’s usually user error.
Being a medical student is also not a passive experience. But it is all too easy to slip from active engagement around our medical formation into the passive daydreams of escapism or the doldrums of endurance. Medical training, for all its stunning difficulty, flourishes under the sheer stress formed by the twin blades of attention and reflection. These blades of contemplation are rarely dull, so much as unused. As we push against the temptation to check out and pull on ourselves and our communities to reflect on just what it is we are doing in this wild world of medicine, we increase our force.
Third, don’t open the scissors all the way to the pivot point to cut with the full length of the blades. Instead, cut with the tips. This emphasizes both precision and safety. Precision, because it demands cutting with a relatively small part of the instrument. Safety, because cutting with the tips guards against damaging tissue around the suture or injuring structures outside the field of view.
Wittgenstein wrote, “Whereof one cannot speak, one must be silent.” We learn as students that whereof one cannot see, one must not cut. Wisdom is in using only that cutting edge of clinical practice that is necessary — even while having access to the endlessly wide blade of medical knowledge. Like a samurai slicing with only one perfected portion of his nihont_ sword, we learn to intentionally and conscientiously utilize that part of medical knowledge that is fitting for the moment — for the sake of protecting patients and habituating precision. We cut with the tips.
Finally, the lengths of the suture knot tails matter. Too short, and the knot might come undone. Too long, and the tails might stimulate excess scar tissue, present an opportunity for infection, irritate the patient, or just appear lazy or unsightly. The surgeon might ask for suture tails at 5 mm, then 7 mm, and then 6 mm to ensure such practical accuracy (something I happily suffered through in my surgical clerkship, earning the affectionate nickname “Cutter”).
The lengths within our lives also matter. “Ars longa, vita brevis: Art is long, life is short,” say the elders of medicine. We learn just how many years the medical art demands — just how much time we should devote between our patients, our colleagues, and our loved ones. Cut the study too short, and our art might come undone. Study too long, and our lives might irritate, sicken, or scar.
Perhaps before controlling the suction or holding a retractor, medical students are handed the suture scissors. To the neurosurgeon or ophthalmologist using instruments that look like something out of Star Wars, these humble instruments are nothing riveting. But I’ve grown rather fond of them. They help me to see the beauty in the quotidian — the lessons in the everyday — how those first moments in the operating room, biting at a suture, offer a reflection of who I am as a student and who I am becoming as a physician.
My first stab was not on a patient on the cusp of death. It wasn’t in a stat C-Section or a DIEP flap. My first cut was not with a scalpel blade, but with a pair of humble, teachable, boring, beautiful suture scissors.
John Brewer Eberly, Jr. is a fourth-year medical student at the University of South Carolina School of Medicine and a fellow of the Theology, Medicine, & Culture Fellowship at Duke Divinity School. His writing has appeared in JAMA, First Things, Mere Orthodoxy, and Hektoen International, with forthcoming articles in the AMA Journal of Ethics and Academic Medicine.