On Suturing

1.

“Looks like it’s your job to fix this – don’t screw it up.”

I was watching the finish of a pediatric surgery case with an upper level resident – I can’t remember whether it was a port placement or a port removal, but either way it signified an unfortunate and difficult path that no child should ever have to undergo.

The resident was placing deep dermal sutures, which are sutures that are usually placed as the second to last step before the skin closure. It’s a layer of suture that can make or break the appearance of a closure – it can either bring the skin edges together flawlessly for an easy skin closure or it can make the skin edges lopsided and bunched, a poor reflection of what a closure should be.

She placed one. It was fine. She placed another. It, too, was fine. And then she placed the third. It resulted in an uneven approximation, bunching the child’s skin, leaving it noticeably distorted and uneven. She stared at it a moment, shrugged, and then asked the nurse to hand me the suture to close the skin on top of her sloppy, lazy, poor job.

“Looks like it’s your job to fix this – don’t screw it up,” she said to me.

I was furious.

One of the many reasons I want to be a pediatric surgeon is the tedious perfection and care that is needed in every aspect of care with a child, and that includes skin closures in surgeries. Where adult skin is more forgiving, tough, and already marked with life’s scars, the skin of children is not. It’s delicate, easily scarred, and any poorly thrown stitch is noticeably visible.

Learning to suture children closed was an entirely different ballgame from adults…absolute perfection was the demand. And it was all under the umbrella of an intensely protective culture of the miniature patient on the table. It is that part of the pediatric surgery culture, amongst many many other things that has made it such a draw to me.

In examples of the one above, I’ve seen pediatric surgeons take out inadequate deep dermal sutures to redo them over and over and over until they’re perfect. It’s simply the norm.

I remember holding the needle driver in one hand, unsure of what to do or say. The shock and anger had rendered me relatively speechless. Regardless, she didn’t care either way and walked away, leaving me alone to try to close the skin and make it look as flawless as possible despite her poor job. I wished that the attending had been in the room.

What made it worse is that she had just made the decision to pursue pediatric surgery, and I was also incensed at that. If she was going to be lazy about this, what other, more serious things, would she be lazy about?

All of this was passing through my mind as I started to close the rest of the skin. Thankfully my skills were advanced enough at that point that I was able to work around and minimize her mess. It was still visibly distorted from what it could be though.

(Side note: I usually try to maintain some semblance of anonymity in my writings, but I will outright say that this was not a resident at my home institution…and that she was awful to work with throughout the entire rotation).

The entire scenario with her blasé attitude, despite the anger it caused, brought up other thoughts and sentiments. Was this just her personality? Did she start residency like this? Or was she a product of the long hours, jaded attitude, and burnout that goes hand in hand with a surgical residency?

Also going through my mind was the power differential that inevitably exists within medicine between students, residents, and attendings…how it prevents people from speaking up and expressing concerns. One of the things I am looking forward to most is to creating an atmosphere where the situation in which that resident put me in never exists.

Throughout medical school, we each come across role models that inspire us to be just like them. However, I’ve also found immense value in the unfortunate role models that inspire me to never be like them.

So what can I strive for?

Right now – to be the type of resident and attending that always cuts out and redoes even the simplest of sutures for the sake of the patient, while simultaneously never putting anyone around me in a position where their morals become compromised.

2.

Well over a year ago in October 2016 I texted one of my best friends a picture of a suture board with a loaded needle driver. I had been extremely uneasy in the OR that day, so nervous that my hands had shaken uncontrollably under the watchful eye of my attending and resident as I sutured a patient close. It was not one of my finer moments as a medical student.

I had been so embarrassed that I took a suture board home with me that day to practice, stubbornly determined for the episode not to be repeated.

“Practicing suturing as if I had any idea of what I was doing,” I texted jokingly and simply, not relaying the true nervousness and insecurity that had plagued me through the first half of my surgery rotation.

“You can do it,” she responded. “Looks like cool practice. I know you have shaky hands though. Mind over matter.”

I remember thinking something along the lines of “Busted!” at her very casual yet very correct comment. Her adeptness at reading and stating the unsaid has always been an intriguing, yet comforting and much appreciated, skill of hers.

I’ve never been good at expressing how I truly feel, something I have been incessantly trying to work on throughout medical school. This is one of the friendships that has brought out the vulnerability in me, and the underlying strength that ultimately lies within that concept. I owe a lot of my inner growth over the past few years to her and our friendship.

“Thanks,” I replied. “I’ll have to remember that. I get nervous when people watch and when it’s on a live body.”

“You’re supposed to be nervous. You’re a person,” she stated. “We all get nervous…Maybe when you’re doing it you can think of me and how I get really nervous every time for karaoke even though I do it all the time. But once you’re doing it and you see it’s going fine it’s easier to relax. Everyone watching you has their own nervousness too. It’s ok.”

As I remember this in depth now and reflect on it, good conversations and the blessed irony of an unlikely friendship fills my head. But aren’t those supposed to be the best connections? Her words struck me as profound (they usually are though, more than she probably realizes) and the insight stuck out to me in a way that obviously has remained (always with a smile, too, when I think of the karaoke inclusion).

“You’re right,” I responded. “It’ll probably be better anyways if I just relax. I think these weeks of surgery are good for me…I just gotta embrace it more and get over the hump.”

I am a combination of the people in my life…the deep friendships that push me to want to be my best even in the moments where I want to stop and give upright before the proverbial hump. They always carry me over.

This was one of those moments. A permanent handprint on my life that lingered and will no doubt continue to linger.

Over a year later and my hands don’t shake nearly as much anymore. I embraced and conquered the hump and it ultimately led to my decision to pursue surgery. The stark contrast between this conversation and my thoughts at the time compared to now don’t escape me. Life is funny sometimes….okay….maybe a lot of the time.

I’m grinning as I type this despite the fact that I’m also tearing up…sentimentalism at its finest.

There are moments where I definitely still get nervous while suturing – situations where an attending, chief resident, and nurses are all silently looking at me and critiquing me in a quiet room save for the steady beep, beep, beep of the patient’s heart rate on the monitor.

I still think of this conversation in those moments. And also in moments that have nothing to do with suturing.

I simply pause, take a deep breath - Everyone watching you has their own nervousness too. It’s ok.  – and continue. It always helps.

You’re never alone.

Mind over matter.

3.

As a third and fourth year medical student, suturing skin closed seems to be the one thing that we can reliably be able to do. I’ve always thought it to be a bit ironic considering that it’s the one thing that patients look down and see, and yet it’s often one of the first surgical techniques we learn how to do.

“You better do this well because it’s the one thing they’ll be able to visually judge you for” is the general statement that I’ve heard repeated to me ad nauseum by a multitude of attendings and residents at a few different institutions.

The first few times I did it was rough. Shaky hands, not knowing how to maneuver the needle driver and my forceps let alone knowing that there’s so many other details that go into it – how to grip the skin edge, what angle to place the needle, how far on the needle to clamp, and a multitude of other minute particulars that all lead to an efficient, beautiful skin closure.

“Dermabond fixes everything” is another phrase that a medical student often hears from residents and attendings.

Dermabond is basically surgical superglue. It’s usually smeared on an incision site after being closed with sutures to protect the incision and further pull skin edges together in a desired fashion. It’s the fix-all to any less-than-perfect incision closure and it truly does work (if only it could be used on children per the first story).

However, I cringe every time a resident says that phrase to me.

Because when a resident says that about my incision, it implies that it wasn’t done as perfectly as it should have been the first time. Each time I want to ask if I can redo it….if I can work on learning the technique so perfectly that I just use the Dermabond as an extra layer of protection rather than a corrective measure. Realistically though, Dermabond could probably make my incision look better regardless of how perfect my skin closure is.

I remember reflecting on this a few weeks ago as I was hanging up clothes in my closet. In the moment, I was slightly perturbed by the fact that the hangars weren’t the same and that some of my clothes weren’t facing in the same direction. At one point I stopped and shook my head at how ridiculous I was being, and I wondered in the same moment if lamenting over Dermabond should evoke the same response of silliness.

My obsessive-compulsive traits have been a strength. It’s never reached a pathologic level, but instead has fostered a perfectionism in me that has helped me be successful in both my professional and academic life. I double and triple check everything I submit with my name on it. Organization and completing tasks in an orderly fashion genuinely makes me feel satisfied. It’s what will make me – hopefully – an excellent surgeon.

But these same traits can also be a weakness.

I hate it when objects are partially hanging off the edge of a counter. I check to make sure both my alarms are on in a ritualistic fashion at least three times each night. I used to often go back after heading outside to make sure my oven was off and my door was locked, but I’ve thankfully made myself let that slide over time to a less neurotic level. And those are just the ones on the top of my head as I type this.

I’ve learned over the past few years that there’s something to be said for easily being able to let go of a situation or certain things. It’s also healthy.

And it’s a balance I’m always struggling to maintain.

Surgery residency is going to be a struggle of discovering how to work efficiently while not sacrificing that perfection where it matters, and I wonder if I’ll be able to conquer that struggle. Will my need to dot every ‘I’ and cross every ‘T’ eventually overwhelm me? Will I even still be able to do that? Should I?

I feel that finding that balance is just one of the many keys that goes into unlocking how to navigate through residency successfully…how to be both effective and efficient without being overwhelmed.

Right now, I have my jeans hanging up in my closet with different hangers. It makes me internally twitch a bit sometimes whenever I go to that section of my closet, but I’ve learned to shrug and let it go.

I haven’t had to force adaptations such as that in my professional life yet – I’ve always had the time to devote in order to maintain my strict work tendencies. However, I know that’s about to change in a few short months, where my equilibrium will have to be shifted to maintain my sanity, and ultimately, maintain good patient care.

And perhaps learning when and where to let the proverbial superglue in life take over is simply the first step to ultimately conquering that hurdle.