ER: The First Day Back

Lauren, Fourth Year Medical Student

It has been over 2 months since I have set foot in the LLU medical center, as I have been traveling back and forth across the US. Which means it has been over 2 months since I have spoken to and examined a patient. So what better way to start off the new year than an ER rotation? Here is an excellent teaching moment that occurred during my first shift of the new year:

Near the end of the shift, the resident I had been assisting that night ran into the work room and asked me to follow him.  Next door, the attending was evaluating a patient who had fallen and had suffered a laceration to the back of the scalp. The attending saw me coming, smiled, and said “Great! Our future surgeon is here. I’m going to let you stitch this patient up.” A jolt of horror punched me right in the stomach (or maybe it was hunger pains after skipping dinner), as it had been over 2 months since I’ve sutured (and I am definitely a bit rusty with my skills). I slapped on my biggest grin and let the attending know I would be delighted to assist. I went to gather the supplies, while the resident took care of some other tasks. When he came back, he wanted me to walk him through just what I was going to do. I explained I was going to inject the area with Lidocaine (for numbing), clean it up, then use a running subcuticular stitch to close (basically one long zig-zagging stitch – looks prettier). He agreed, and while running away out of the room backwards, told me to get him if something went wrong.

And now I am left standing by the patient’s bed, all by my lonesome, with a table full of supplies, wondering how exactly I got into this situation. I was quite a bit nervous, but I knew I had to try before bailing and getting the resident. I introduced myself to the patient, letting him know I was going to be taking care of him and asked if he needed anything before starting. Water! He desperately wanted a drink of water. I could use this to buy me some time to calm my nerves (and hopefully calm the patient). I fetched him a cup, helped him finish it, then set to work.

I have seen this done multitudes of time in the ER on various surgery rotations. I just hadn’t done it myself, especially all by myself. First time for everything, right? I injected the lidocaine, which calmed the patient down as now his head wasn’t hurting. So far off to a good start. I washed it out with some saline, and cleaned it the best I could. I loaded the needle driver, and then just froze. The only wounds I had sutured up to this point had been clean cut incisions in the OR, not a jagged/crushed wound. I also quickly realized that suturing on the scalp is a bit tricky because of all that hair getting in the way. Regardless, I started to sew. I knew the steps, but I just wasn’t able to get the edges together. The skin had become a bit squished by the fall, and the suture kept slipping out. It just wasn’t working.

As I took a step back to consider fetching the resident for a bail out, in comes the attending physician to check my progress. I explained that this method just wasn’t working, and I needed to start over. He leaned over my shoulder, and stated that the wound was deeper and worse than he initially thought. He asked me what my next step would be. I suggested that perhaps a simple interrupted stitch (a row of separate knots used to pull skin together – less pretty) would be a better choice. He asked me what supplies I would need and went to collect them while I set to work removing my failed stitches.

A few moments later I was finally successfully suturing this scalp back together, and what shocked me the most was that the attending was assisting me! The attending physician is the “big boss”, “head honcho”, “le big cheese.” Yet here he was helping me, dabbing the wound so I could see, pulling the hair out of the way, handing me instruments,  and encouraging me each and every step. 5 stitches was all it took. I asked him if I was keeping him from another patient, and he replied that his shift was over and he wanted to stay behind. As I was cleaning up, he patted me on the shoulder, and told me I had done good work. I was absolutely stunned.

I hope that as I move forward in my career, I will not forget the importance of patience and humility. At any point the attending could have told me to move over and let him suture, but he knew if he had done so, I would have lost the opportunity to learn a new technique. At any time he could have left, as his shift was over, yet he stayed to teach a struggling student how to get the job done, even if it meant him being the assistant. Medical students often take rotations for granted, especially rotations in fields we aren’t planning on going into. That night, I was excited just for the opportunity to practice suturing, however when I left, I realized that I had learned so much more.

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