One of my favorite things about working in a small hospital is the community. While in the ER last night, the tech was monitoring the scanner to get a heads up for patients that might be sent our way, and upon hearing 911 responders giving instructions to EMTs in the field, he would be like "Oh, that's George Jones, he's gonna need such and such when he gets in." Haha.

Last night was pretty busy in the ER. I got to help remove a foreign body from the eye (piece of steel) which was new. We had one guy come in after nicking his ankle with a chainsaw in the morning, ducttaping it up, finishing the day of work, then swinging by the emergency room later to get it checked out (kinda stupid since lacerations need to be closed within a certain time period, but still funny nonetheless).

We had a guy come in who had had a run-in with his pinky finger and a dado blade on a table saw. Since the ER was filled to capacity and there was only one doctor working, he got me all the tools and said "have at it!" It was definitely a great challenge and the hardest suturing I have done to date. In the OR, all the cuts are in clean lines on soft skin/tissue in a sterile environment and have controlled bleeding. This guy's skin was leathery, shredded, and had chunks missing. Suturing is actually a lot harder than I thought initially, there's a lot of theory that goes into it. You have to be very good with wound healing physiology. For example, and this I was taught from the very beginning, you don't want to ever bring the skin edges together, you want over compensate a little but make sure you have even amounts of "bites" on both sides. The skin will stretch back out once it heals, and if you don't suture with that in mind, the skin will stretch out after healing and be weak and produce a big scar.You also have to consider the many different types of stitches there are (I know of at least ten), the types of suture you want to use (asorbable vs nonabsorbable, as well as the type of material), and placement of the sutures. Whenever you put in a stitch, you are cutting off the blood supply to that part of the skin, so you need to keep that in mind when you suture. Last night I had to spend some time thinking about how I wanted to lay the skin back, and where I could put stitches in without compromising blood supply to shreds of skin where it was already severely diminished to begin with. I ended up putting in some subcutaneous sutures to anchor down some random flaps of skin that had nothing to be sutured too, then piecing everything back together. It was approved by the ER doc, but too bad I won't be able to check it out in a month to see how well it healed. There wasn't much we could do cosmetically to begin with, the doctor wanted me to do more of a functional closure, but I decided to challenge myself to see what I could do.

Speaking of suturing, today I watched a wide excision of a melanoma in a 93 yo woman. We had to move a 3 inch chunk of skin from the back of her neck, and I was thinking "How is he going to compensate for the fact that we now have this huge gaping hole in her neck?" He ended up doing something like this and it's incredible, you can't even tell we took all that skin out!!

Last night one of the docs I was working with brought up a great point. Most of our patients are laborers: woodsman, carpenters, plumbers, fisherman, etc. Almost every single one could care less about their ailment as much as how long it is going to keep them out of commission. He was saying "You know, winter is coming in about three weeks and most of us are trying to scramble to get as much done as possible before the snow hits. Otherwise it makes for a very rough winter." It's true! I had never thought about that before, in terms of it being an extra sort of stress on the patient and how it should affect our treatment plans.

PS-snow in the forecast two days from now!!!