Keep Your Hands Up

The day before I left for my six-week solo backpacking trip across Europe, my beloved, 80 year old German piano teacher invited me over for tea.

Between stuffing me intermittently with lemon cake or chocolate ice cream–all of my muffled pleas of being full fell mysteriously on deaf ears–she fired rule after rule of European etiquette at me, often with an impromptu grab of my wrists to illustrate her meaning precisely.

Scrutinizing me with piercing eyes, she handed me another piece of cake (at this point I had resigned myself to my sugary fate) and told me to slice it.

Her instructions had barely processed before she snatched up my wrists yet again and squawked, “Nein, nein! Keep your hands on the table! Elbows at your sides! Wrists where I can see them!”

This was, I later learned, the hallmark of proper German table decorum. It took me four or five more pieces of cake before she was satisfied with my progress, and it was with decided relief that I waddled out to my car idly wondering if I would be able to fit in my seat on the plane.

Little did I know just how important a lesson I had been taught.

Fast forward a month or so later. After a whirlwind tour of the cheapest hostels Europe has to offer, I had made it to my internship in Homburg, Germany, in which I would basically be sprinting around the hospital with various surgeons while valiantly attempting to understand and respond to their rapid German explanations.

As a wide-eyed naïve MS1, I was about to join the head of pediatric surgery on the operating table while he performed a duodenal anastomosis (an anastomosis is a joining together of two ends of a tube–in this case the small bowel) on a newborn that tipped the scales at just over 700g (roughly 1.5 pounds).

My experiences with shadowing in surgery thus far had basely consisted of being confined to the far corners of large American operating rooms, cursing my short stature and craning to see whatever was being broadcast on the laparoscopic video feed.

I was therefore politely incredulous when the chief pediatric surgery resident told me to “einwaschen,” German for “scrub in.” I must confess, I thought I had misunderstood her, and she had to repeat the word four times, motion energetically to the sink, and finally drag my disbelieving self to the scrub station before I realized she was serious.

Thus began my trial-by-fire initiation into the world of surgery. Despite scrubbing every square millimeter of my hands and forearms until I felt the skin would soon come off, I would inevitably make some movement (e.g. letting my hands fall below my waist) that resulted in a stern “Das geht nicht” (German for “That won’t work”) from the circulating nurse, at which point I would begin the whole process over again.

When I had finally been deemed sterile, the nurses chuckled openly when I approached the operating table and discovered that the patient was basically at eye level for me. A stepstool was requested for the “small Amy.” When I was finally tall enough to see the patient, the surgeon announced “Schnitt!” (“Incision!”) to the anesthesiologists, and I was handed two tiny metal forks.

“Keep your hands up,” the surgeon intoned. “Wrists where I can see them.”

“Elbows tucked in,” the chief resident directed. “Keep your hands on the table.”

Under any other circumstances, I would have happily described the irony of the situation to the room at large, but there were a few things that rendered that rather difficult, such as the limit of my German vocabulary to “I can’t speak German” and various fruit and vegetable names, my utter terror at being asked to hold the incision open with the retractors perfectly still for two hours, and the fact that the room was heated to roughly 85 degrees Fahrenheit so that sweat was probably soaking through the back of my gown.

And yet, somehow, I made it through. Wielding forks of a very different nature than the ones I had been holding only four weeks prior, I stood courtside over the next month through PSARP procedures (the posterior sagittal anorectoplasty, or pull-through procedure), hernia repairs, and catheter implantations, gradually making sense of the previously unintelligible German and learning to “dance” with the surgeons, predicting their next movements so as to position the retractors appropriately.

“Das geht nicht,” the circulating nurse sighed. “Hands up. Keep your wrists on the table.”

I may have been scolded at least three times a day for the lactic acid buildup in my forearms from holding the hooks that caused them to drift dangerously below the table. Memories of eating cake with my wrists planted firmly on the table by my tough-as-nails piano teacher came to mind every time, especially when it was four o’clock in the afternoon and all I had eaten that day was a slice of toast. (Most of the German surgeons seemed to survive happily on coffee and cigarettes alone). Despite all that, I fell in love with surgery in Germany. The blindingly bright lights consigned the rest of the world to oblivion, and human beings became a wonderful jumble of organs and life, of problems to be excised or solutions to be connected.

Each time, once the surgeons declared themselves “fertig” (“finished”), I emerged from the table a sorer but happier student. A clean white bandage covering a neat line of sutures was often the only evidence that anything had happened to the patients at all. Massaging my aching wrists and ripping off the suffocating gloves with enthusiasm, I watched the anesthesiologists cradle the babies as they returned to consciousness and wondered what percentage of surgical residents develop carpal tunnel every year.

When I went with the surgeons to reassure the anxious mothers and fathers sitting in the waiting room to tell the parents that everything had gone beautifully, their eyes always followed the surgeons’ hands. They watched as the doctors described the procedures, undoubtedly imagining them artistically and gracefully maneuverng scalpels and forceps.

My final day in the OR rolled around three weeks later. I scarcely noticed anything strange until after the final patient had been wheeled out of surgery: I realized I had not been reminded even once. I had kept my hands up.

Two months alone in Europe taught me plenty, but it is this final lesson that I will never forget. To keep one’s hands on the table is not simply an exercise in operating room sterility. It is also more than merely a nod to the differences between European and American standards of etiquette. The hands of doctors (and analysts, math teachers, and beekeepers, to name a few) are capable of doing equal amounts of harm or good. In every profession, it is our hands that bring the product of our thoughts and training to fruition. Analysts, math teachers, and beekeepers use their hands to cultivate their corners of the universe, and trust their own lives to our hands.

By keeping our hands on the table, we concede readily to the transparency of medicine that benefits both caregiver and patient. We subject the tools of our trade to the careful scrutiny of the others around the table, rising to their and our own expectations of excellence and detail. Nothing can be hidden, and nothing should be. Lives have been delivered into our hands, and they deserve to be in the best ones.

Keep your hands on the table. They will do great things.