Learning Sticks:

L to R: Malleable, or Ribbon; Deaver; Kelly; Richardson; Army-Navy; and rake. From Alexander's Care of the Patient in Surgery, 11th edition. 1999. (To make things more confusing, names can be switched--i.e. I've always known the Richardson to be the one that's labelled as Kelly in this textbook. )

Many surgeries require more than two hands for success.  That’s not counting all of the other hands in the OR–the scrub tech, the circulating nurse, the anesthesiologist–nor all of the people who make the process an oiled machine from the time you arrive for check-in, pre-op, labs, IV starts, to the recovery room where the PACU nurses bring you generic Sprite and Lorna Doones, if you’re lucky.  I’m talking about in the operating room, at the table, where your surgeon works her ordinary (to her) miracles (to you).

Abdominal surgeries in particular require retractors–people and instruments who hold vital organs out of the way so that we can see what we came to fix or remove.  Skin, fat, fascia, muscle all need to be held aside to peer into the pelvis.  As a medical student, when you get the nerve to approach the table, you get handed a retractor, aka learning stick.  

Retractor is a verb, potentially passive or active.  It is also the person doing the thing, and the instrument used for it.  The handheld versions are of all kinds of shapes and sizes, with names that may be related to who invented or used this one (Richardson, Deaver, Army/Navy)  rather than the function or shape–until they are not (S-hook, curved, skin hooks, right angle, bladder blade).  

It’s not fair, those first attempts at retracting.  You have no idea what you’re trying to expose, what steps come next, how to do this job better; you can’t see, all you want to do is sit or pee or sleep, your hands get cramped, nobody looks at you until you do it wrong (again).  At teaching institutions, the medical student is the least vital part of the surgical team.  You are trying to see and learn around a junior resident, a senior resident, maybe a fellow, and the attending running the procedure.  You can’t really harm anything with your blunt instrument, but if you are not sure what you’re holding and why, it’s easy to lose that tissue.  Then you get readjusted, sometimes with a sigh.  The procedure has to stop for a moment, you may get a quick anatomy lesson or view of the procedure, but you’re impairing the efficiency so it doesn’t last long.  Besides, didn’t you read about the steps of a hysterectomy before today’s case?  Never mind that you didn’t know until this morning that today you would be assisting on one.

It’s not your fault.  If you’re doing the job well, the surgeons can forget that you’re there.  Your task isn’t to cut or clamp or sew, but to use your tool so that they can see to do those things.  

It’s not until you get more experience, closer to the field, that you realize how much a skilled retractor can make a difference.  The best retractors are the surgeons who know what comes next in the procedure, and are exposing here while anticipating that next you’ll need to see there.  It dawns on you that the reason you look like an amazing surgeon as the senior resident is because the attending is now retracting for you, and making your job easier.  One of the gyn-oncology surgeons had a reputation for being able to do almost all of the procedure with the retractor that she was holding, and a pick-ups (like a long tweezers) in her other hand.  The residents would joke that if you weren’t looking, the procedure would be over before you actually did anything other than incise the skin.

One of my first experiences with mindfulness in the OR was as a medical student, holding a retractor for what felt like hours on end.  I had one of those moments of microscopic movement, where everything has to be repositioned.  The attending looked me in the eyes: this was usually my cue to peer into the abdomen for a teaching moment.  Yes, he showed me something anatomical–but next he took the retractor from me.  “Flex your hands, and spread out your fingers.”  This was new.  “Push them gently on the sterile field for a few seconds.”  (Nobody had to tell me to stay on the blue sterile field, nor that I had to be gentle, since the field in front of me covered the patient’s legs).  “Take a couple deep breaths.”  He retracted for a minute or two, then asked “Better?”  Yes.  Better.  Turns out this also works when you are the one in charge, or aren’t in the OR, or can’t sleep.   Even if you're not in surgery.