'stop if you see brain'

Probably you saw the photo before you started reading. Probably the correct response, if there is one, is 'dear Lord', or an expression of your choice to that effect.

That's about right. That's what I say to myself too. A couple shifts ago I spent five hours on scalp lacerations, including history, eval, and then repair.

The first one was a bit silly; poor anxious girl had banged her head on the visor of her car after running into a post at 5 miles an hour and was more upset about what dad was going to say than the lac in her forehead. Aside from poor anesthesia, probably secondary to her anxiety, it was a quick repair.

The second was a stoic swiss farmer who had fallen off an ATV and hit god knows what; he had four inches of a jagged tear. The ED was busy. I went in to clean and evaluate it.

"Any pain here?" I asked, tapping on his exposed skull. His exposed skull. When I went in, the attending said, go ahead and clean it out well. Stop if you see a fracture or exposed brain. Always good advice, stopping when you see exposed brain.

The ED was still busy. Attending came in, looked, and said, 'OK, well I'd close with a couple sub-Q for approximation and then staple it. Let me know when you're done.' Twenty-three staples and five sub-Q dissolveable stitches later, it was a nice Frankenstein scar down the right side of his forehead. But it wasn't bleeding. And the bits of hay and dirt were gone.

Despite myself, it was an amazingly satisfying complaint. The guy needed help, but there was no way he was going to surgery. The perfect wound care challenge for the ED. And now, when I walk into a room with a lac and they say, 'have you done this before?', I have a lot more confidence in saying, 'yup'.

Wow. I can actually deliver care, instead of just going in and talking to someone. Gotta love this job. A small part of me still whistles internally as one would witnessing any dramatic incident from afar; the part that drives me at work steps up and sees what needs to be done. So much still beyond my experience, obviously. But there's getting to be more and more I can handle.

BTW, please don't ride your ATV without a helmet. Thanks. Remember how lucky the patient in this story was. His CT was normal.