A short, thin slice of metal with an endless tail of string dives in and out, up and down, methodically through layers of fabric. Despite the sharpness of the needle, an overwhelming softness permeates the act. There is something so very sensual about sewing, and I am reminded strangely of the weekend quilting bees that filled the apartment of my childhood. My mother, aunts and grandmothers would gather together, align themselves along our plush davenport, then, in one supreme act of unity, they would march forth their blankets at a prodigious hourly rate.
We, too, speak idly as we stitch, often joking and interjecting, always working in unison toward a common goal. I am a fourth-year medical student, six months from being called doctor, and tonight my co-workers are a nurse, an attending doctor watching over me, and a first-year medical student. I look down at our hands. We have no calluses, no thimbles; just gloves to cover our palms and blood to coat our fingers.
We four are the urgent-care team of an Emergency Department, and tonight we are holding the hands, while also holding down the hands, of an injured young girl. I sew and sew, as have the many matriarchs before me, except my quilt is not cotton, but a girl's skin, and the stuffing is not fleece, but a girl's flesh.
Earlier this evening, a drunk driver swerved off the road and showered role, and my reward, is to practice suturing upon as many "simple" wounds as possible. Luckily for me, if not also for this young lady, each of her three larger wounds is defined as only "simple," and so will heal well, needing only "simple interrupted stitches." I have sewn many such sutures before, yet each stitch into actual human flesh represents an invaluable opportunity for me to practice my doctorly craft.
We manage to communicate despite the fact that her English is terrible, and my knowledge of her own language even worse. I have paged a translator and a social worker, but doubt that either will arrive soon on such a busy Friday night. She tells me that she is an immigrant. She has no insurance, no documentation of any kind, and perhaps, most sinful of all in today's world, no money.
Four years of medical school has long since numbed me to hardships such as hers. It's not that I've stopped caring for each patient's welfare, or that I care any less--it's just that finally I can do something more for them--finally I can care for their wounds as well. As a senior medical student, I can suture. And so I tell this patient as best I can that "I care" with a touch, a smile and most certainly with this intimate deed.
As I place a last stitch into the girl's right arm, the first-year medical student comes forward to begin dressing the wound. I move on to prepare the second large wound above her left eye--local anesthesia, irrigation, exploration, sterilization--and finally I begin my suturing. Throughout all this, our "sewing" group continues in conversation. The weather, our hometowns, the stock market, gossip, movies. The endless banter breaks only when the attending's pager beeps. "I've gotta head up front for a trauma. I think you guys have got everything under control." The attending circles the perimeter of the table and stares approvingly above my shoulder, then quizzes me, "Tell me what you've done so far on her eyebrow?"
A sterile white drape covers the girl's face, with a small opening cut to expose only the wound above her eye. I clench the forceps from the instrument stand and point up and down along this wound. "I present to you a 3-centimeter superficial linear laceration to the left eyebrow. The wound has so far been anesthetized with 5 cc of 1 percent lidocaine with epinephrine and irrigated via an 18-gauge angio-catheter syringe with 300 cc of sterile saline. Exploration has revealed no foreign bodies and no debridement is deemed necessary. I am now completing in a sterile fashion the placement of nine simple interrupted sutures of 6-0 nylon, experiencing excellent wound edge apposition and eversion, with no complications. As the wound edge is parallel to the static tension lines of the skin, I predict a cosmetic closure with negligible scarring and vigorous healing."
"Strong work." The attending smiles at what I've done, then backs toward the door. He leans against the handle, pushes, then stops--"Oh, and by the way, I think you're ready to teach one. Have the first-year sew up her leg wound." The door closes behind him. The nurse has long since been buzzed away, and so suddenly we are alone, a fourth-year medical student, a first-year and a young girl with a dressed arm wound, a finished eyebrow suture, but an as-yet-unattended gash in her leg.
I place a last stitch above her left eyebrow, and the first-year student comes forward as before to dress the wound. I observe his work, then ask, "So, have you taken the 'Pizza' class yet?"
I learned almost everything I know about suturing from our annual "Pizza" class. The company that supplies much of the suturing material for our hospital also supplies an annual "sewing" party for our preclinical medical students. Over pizza and soda, a plastic surgeon teaches the various knots, and every student is able to practice these techniques with specialized materials at their very own knot-tying workstation. Then, after the soda and pizza are thoroughly digested, a dessert plate of fresh pigs' feet is passed to each student.
Humans and pigs share from 80 to 90 percent of their nucleotide sequences identically, a genetic resemblance that is much more than skin deep; but for our purposes, it's the similarity of skin that matters. A cutlery of scalpels, forceps, needles and sutures is dispensed, and for the remainder of the night, students are encouraged to make different gashes into their pigs' feet and then practice the many techniques for sewing up these various wounds--the simple interrupted suture, the running stitch, the vertical mattress, the horizontal mattress, the subcuticular, the diagonal flap.
It was the first time I had ever sutured flesh, although over the course of that first year of medical school, from anatomy through pathology, I soon became a master of stitching dead flesh--pig, human and other. So many incisions and so many sutures, but living flesh remained a mystery. Soft and warm, it jiggles to the touch, nothing at all like the stolid bogginess of dead skin. Living flesh is just that, "lively," with an entirely different look and feel. But into whose living flesh does a student's first suture get stitched?
All the dead are equal--equally dead, equally powerless--but the living are quite another matter entirely. Equally alive, but perhaps some less "lively" than others, and certainly some less powerful. And so one night, in our E.R., when a homeless old man arrived in a drunken stupor with a cut to his scalp, the first-year medical student was me and I stitched my first sutures into living flesh. It all happened so fast, as first times often do. I answered the questions obediently--"So, have you taken the 'Pizza' class yet?" "Great, ever sewn anyone up?" "Come over here and watch and help, and then I'll have you throw a few stitches."
I remember how holding the curved needle at the end of the needle holder first felt so awkward, like trying to balance a pin between two metal chopsticks. The trick is not to force your hands from their shaking, but simply to let any vibrations to the needle holder get absorbed by the index finger of your free hand, then both hands can glide the needle along the wound edge and guide it directly into an insertion position. At which point, with just a single rotation of the wrist, the stitching can begin and end. There are moments in your life that change you forever, and, for me, this was just such a moment. I closed my eyes, twisted my hand, then heard a noise. It was a weird sort of scratching sound, the short staccato of a metal tip, first puckering, then puncturing into human skin, and it all took place in one short inhuman moment. The needle was in, then out.
I opened my eyes and saw the curved needle on the other edge of the wound, with a trail of suture material connecting it to the first side. A white drape covered the man's face and head; and although I was looking down into a laceration in a living man's scalp, the image was remarkably similar to the lacerations I'd sewn up in dead pigs' feet. We were of course not in class, but in the E.R., and this was not a pig's foot, but a man's scalp, yet suddenly I realized that a wound will always be a wound, a stitch a stitch, and a knot a knot. I placed each stitch more vigorously and forcefully than the one before, and noticed gradually that my mind--and my mouth--were left free to wander. I talked first with my teacher about suturing, but then inevitably the conversation drifted to gossip and movies. Finally, one of us said something funny, and both of us began to laugh.
But then my laughter stopped. Beneath the white drape surrounding our sewing, I noticed a trickle of water. Suddenly I remembered that there was a human face beneath this drape, and that these were human tears, which coalesced with the blood droplets on the patient's cheeks to form a steady stream of pink fluid. The scalp is weakly enervated at best, and so between this patient's alcohol ingestion and our own local anesthesia injections, how could he be feeling any pain at all? The attending physician stopped laughing as well, then injected more lidocaine solution into the remaining edges of the wound. But the man continued to cry, and his crying began to tie a knot in my stomach. My hands started trembling. I wanted to drop my tools and excuse myself--but, instead, I took a deep breath, blinked my eyes and continued to place the remaining four sutures. I had won, but I had also lost, and an innocence left me that day that I can never regain.
"Virginity" comes in many forms, and each time it's lost, it represents a moment that changes you for a lifetime, pleasurably, maybe painfully, but always quickly. And so I begin to guide my own first-year medical student through these same experiences. I know it will be quick but I refuse to let it be meaningless. I begin with the same litany of questions that were used on me, "So, have you taken the 'Pizza' class yet?" "Great, ever sewn anyone up?" "Come over here and watch and help, and I'll have you throw a few stitches." But I add a new sewing lesson, my sewing lesson, to the student's curriculum, "Before you throw the stitch, I want you to do something for me, and for yourself, I want you to look into her face, really look hard, and remember that you're sewing up a person, not just a wound."
Medical schools boast of serving the poor, but too often it is the poor who truly serve them. The "free" health care offered by us medical students is an invaluable act of compassion, but it is inherently offered in exchange for our own "free" training as student doctors. On whom else would it be better for a clumsy, inexperienced student doctor to first practice stitching than an indigent, elderly or homeless person, or maybe even a drunk? Best of all, like tonight, use a poor person who speaks little English, then student and teacher can talk freely of suturing tactics and techniques without unduly alarming the patient.
And tonight I share in just such a discussion, as the first-year student and I debate the best strategy for placing a needle into the edges of the wound. The word doctor comes from the Latin docere--to teach. Teaching these skills, at the moment, makes me feel more like a doctor than ever before. And I am indeed just months away from attaining this title. I've noticed lately that my white coat does seem to fit much better, and my scrub shirts certainly wear well. And, after four years of medical school, I think the nurses on occasion actually remember my glove size. I'm holding a pair of these gloves right now, folding them between my fingertips, as I push myself back behind the first-year student, guiding him with my words as he places his first stitch. I watch as it goes in and out, wraps around, and finally closes. And perhaps too, at that moment, another sort of stitch closes, one circling around my own life, and threading into the future.
Adam Strassberg, a fourth-year medical student, is a frequent contributor to Stanford magazine.
