It is an unwritten rule in our emergency department (ED) that we do not let medical students stitch lacerations that occur on a patient’s face. In fact, most EDs would call in a plastic surgeon to repair these wounds, especially if they are anything but minor. Unfortunately, we work in an inner-city hospital that lost its plastic surgery fellowship many years ago so the burden falls upon the emergency physician (EP) to fix all but the most complicated suturing jobs. We can call ear-nose-throat or oral-maxillofacial surgeons for larger injuries, but they will usually only repair a laceration if there is another injury such as a fracture or cut duct below the wound or if it is going to the operating room for closure. However, the injury we were faced with this evening occurred at the hairline on the forehead, and it was not that large. Besides, it was not that busy today so I, as the attending, probably had enough time to directly supervise our medical student while she tackled this 4-cm stellate defect.

Our visiting student was named Jamie and she informed me that she had “a lot of experience suturing.” She said that she had closed many lacerations and that she was confident that she could do a perfectly fine job on our patient. We set out to reapproximate this sleeping drunk man’s forehead. After Jamie had blocked, irrigated, and prepped the wound, we began to discuss how to best repair the individual segments of this defect. I began to point out curves and edges that I believed went together in the patient’s initial state. I saw a dark hair follicle that had been cut and was visible on both sides of the wound. I pointed this out to Jamie and told her that would be a good place to put the first stitch to get the wound to go back together correctly. She had to squint to see the cut hair, and exclaimed, “Wow, you really pick up the smallest detail.” I began to explain to her that it was important to pay attention to the small details since that was how you got a “perfect result.”

As she methodically closed the wound, bringing pieces into place where I thought they belonged, I began to think about the conversation we had just had. I realized that what I had said about the laceration actually applied to all of emergency medicine. Good EPs see every single detail of the wound and make sure that each little jagged corner fits into the place where it came from and every hair lines up in the end. Similarly, we must recognize every single aspect of each case and train our residents to do so as well. It would be easy to just “call a consult to take care of the problem” for the patients we see. However, I am a proud academic EP. I believe that every single case should be treated as if we were the consulting service and this is what we need to teach our future generation of EPs. We need to do the “perfect job” and make sure we achieve the best possible outcome for our patients. This is important because one day, some of our graduates will take jobs in hospitals that do not have any in-house consultants. They may actually be the only doctor in the hospital during off-hours. It should be assumed that every single resident will be that one graduate who ends up in that hospital. Otherwise, how can you assure that the one that does end up there knows what he or she is doing in each and every possible situation that they could face?

In the end, the wound went back together “perfectly.” We only had to cut out and redo one suture, but the forehead ended up totally flat and well opposed. Every single hair and edge lined up correctly, and most importantly, it looked great. The patient looked in the mirror and was happy with the results and so was I, which made Jamie the most happy of all.