suturing

[chemist157]

So, I've become, in my opinion, pretty proficient at two-handed and one-handed ties, at least for a med student. However, practicing suturing at home with a foam square or whatever just doesn't cut it. I can suture but it takes me a really long time so the attending leaves or takes over, usually. "Good job, I'll finish the rest" kind of thing. I'm still not that great with skin so not only speed but technique could both use improvement. Any suggestions? Buying pig feet?

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[asmallchild]

I've been told bananas are great to practice on. More realistic than pig's feet.

 

[BlondeDocteur]

Why not make like the Grey's Anatomy interns and practice on yourself?

 

[SLUser11]

So, I've become, in my opinion, pretty proficient at two-handed and one-handed ties, at least for a med student. However, practicing suturing at home with a foam square or whatever just doesn't cut it. I can suture but it takes me a really long time so the attending leaves or takes over, usually. "Good job, I'll finish the rest" kind of thing. I'm still not that great with skin so not only speed but technique could both use improvement. Any suggestions? Buying pig feet?

Side note: When I go through two-handed knot tying with the med students, and I ask them "which hand do you tie with?" They almost universally say "either one," as to advertise some ambidexterity. They also mention being good at one-handed tying.

Then, I ask them to demonstrate, and they usually can't do any of the knots correctly. Usually, they've learned the basics, with some huge rope, and not realized how dynamic the process is (based on body and suture positioning), and how much harder it is to tie knots with gloves and small sutures.

To quote Eddie Murphy, quoting Nietzsche: "He who would learn to fly one day must first learn to stand and walk and run and climb and dance; one cannot fly into flying." (great movie, btw)

I think med students should focus on being really good at two-handed tying with their dominant hand as the base, and should hold off on practicing one-handed and opposite-handed techniques. Otherwise, they just become mediocre at several techniques instead of being good at one. Also, most good residents won't allow a student to tie one-handed out of principle.

As for suturing, there isn't a very good synthetic alternative for skin when practicing subcuticular stitches. A banana sounds fine. Still, don't focus so much on being fast. Instead, focus on doing it correctly. Try and find a resident who will go over it with you patiently. The biggest problem is usually lack of good teaching.

 

[SocialistMD]

I've been told bananas are great to practice on. More realistic than pig's feet.

Orange peels work well, too (and I think they taste better than bananas).

 

[SouthernSurgeon]

Side note: When I go through two-handed knot tying with the med students, and I ask them "which hand do you tie with?" They almost universally say "either one," as to advertise some ambidexterity. They also mention being good at one-handed tying.

Then, I ask them to demonstrate, and they usually can't do any of the knots correctly. Usually, they've learned the basics, with some huge rope, and not realized how dynamic the process is (based on body and suture positioning), and how much harder it is to tie knots with gloves and small sutures.

To quote Eddie Murphy, quoting Nietzsche: "He who would learn to fly one day must first learn to stand and walk and run and climb and dance; one cannot fly into flying." (great movie, btw)

I think med students should focus on being really good at two-handed tying with their dominant hand as the base, and should hold off on practicing one-handed and opposite-handed techniques. Otherwise, they just become mediocre at several techniques instead of being good at one. Also, most good residents won't allow a student to tie one-handed out of principle.

As for suturing, there isn't a very good synthetic alternative for skin when practicing subcuticular stitches. A banana sounds fine. Still, don't focus so much on being fast. Instead, focus on doing it correctly. Try and find a resident who will go over it with you patiently. The biggest problem is usually lack of good teaching.

I think this is great advice. I thought I was a pretty fly suture-er for a third year - I was always one of the fastest when we did the little knot-tying tutorials and pig's feet, etc; I'd been on trauma so I'd gotten to fix up a number of lacerations.

Then I get in the OR - double gloved, at the end of a long case, and the attending tells me to tie (and stares me down the whole time of course). I was nervous as crap and kept fumbling with a basic two-handed tie. He was very nice about it - but told me more or less this exact same advice:

He knows I will be slow, but he wants me to do it right; don't worry about one-handeds or how fast you can throw or being ambidextrous at this point. He said yes, at some point the goal is to be able to tie one or two handed with right or left hand, but you don't get there instantly. One thing at a time.

 

[dynx]

I think med students should focus on being really good at two-handed tying with their dominant hand as the base, and should hold off on practicing one-handed and opposite-handed techniques. Otherwise, they just become mediocre at several techniques instead of being good at one. Also, most good residents won't allow a student to tie one-handed out of principle.

I disagree. I find being able to tie a two-handed tie quickly and making it lay square is easier if you can do it with both hands, my initial movement usually depends upon what side of my body the needle is so I don't pull it through. I tell students to practice at different angles so they figure that out.

And i don't care if a student ties one-handed as long as they do it well, otherwise they need to stop and tie two handed. No principle involved, only the outcome.

 

[SLUser11]

I disagree. I find being able to tie a two-handed tie quickly and making it lay square is easier if you can do it with both hands, my initial movement usually depends upon what side of my body the needle is so I don't pull it through. I tell students to practice at different angles so they figure that out.

And i don't care if a student ties one-handed as long as they do it well, otherwise they need to stop and tie two handed. No principle involved, only the outcome.

That's not my point. There are a lot of situations where tying opposite handed or one-handed is easier. There are plenty of other things, like slip knots and half-hitches, that are easier in some situations. Med students should learn to do something correctly, and do it well, then move on to the more complex movement.

 

[chemist157]

I think this is great advice. I thought I was a pretty fly suture-er for a third year - I was always one of the fastest when we did the little knot-tying tutorials and pig's feet, etc; I'd been on trauma so I'd gotten to fix up a number of lacerations.

Then I get in the OR - double gloved, at the end of a long case, and the attending tells me to tie (and stares me down the whole time of course). I was nervous as crap and kept fumbling with a basic two-handed tie. He was very nice about it - but told me more or less this exact same advice:

He knows I will be slow, but he wants me to do it right; don't worry about one-handeds or how fast you can throw or being ambidextrous at this point. He said yes, at some point the goal is to be able to tie one or two handed with right or left hand, but you don't get there instantly. One thing at a time.

The tying isn't the hard part for me, it's the actual suturing. It was a little more difficult with gloves and small suture but I did fine tying. It's just the actual running of the needle, I take a long time b/c I'm trying to make sure I am getting it right (right positiion, angle, not through the skin for subcuticular etc).

So, what I gather is the speed will come eventually and even though the attending takes over or leaves he does not expect me to be speedy gonzales and I probably shouldn't take this as a judgement on my performance...?

If I have little/no trouble actually tying one-handed knots is it still bad form for a third year to do it? I just find it fun I can actually do it.

 

[SocialistMD]

I disagree. I find being able to tie a two-handed tie quickly and making it lay square is easier if you can do it with both hands, my initial movement usually depends upon what side of my body the needle is so I don't pull it through. I tell students to practice at different angles so they figure that out.

You are a resident. You tie daily, you have been tying for a while and you find yourself in situations like you described because you are in the operation at a level beyond that of a med student. Presumably, there was a point in your training (we'll call it "medical school") where you were better with one hand over the other. I don't think SLUser is saying people shouldn't use one-handed ties or shouldn't be able to tie with both hands, but is making the point that med students are at a different level and should learn to do one well with one hand before trying to learn another way or with another hand. Personally, I agree with SLUser and think every physician should know how to tie a two-handed knot because it is much easier to master and much easier to ensure you've thrown a true square knot. As such, I make sure every med student on my service knows how before they rotate away. What they do to hot-dog in front of the attending is up to them, but I try to make sure that if they try to tie a two-handed knot with their dominant hand, they won't look stupid doing it.

 

[ESU_MD]

as an intern, we were only "allowed" to tie 2 handed knots.

luckily, as a med student, I learned to tie one hands with my left hand. this is the key to efficiency- if you tie one hands with your right, then you have to drop your instruments

 

[SOUNDMAN]

as an intern, we were only "allowed" to tie 2 handed knots.

luckily, as a med student, I learned to tie one hands with my left hand. this is the key to efficiency- if you tie one hands with your right, then you have to drop your instruments

That's the whole point of the one handed tie really, that you have a needle in your suturing hand and you tie with the other hand while continuing to hold the needle/needle driver and not drop it. So if you are right handed you tie one handed with your left and if you are left handed you tie one handed with your right.

 

[maxheadroom]

as an intern, we were only "allowed" to tie 2 handed knots.

luckily, as a med student, I learned to tie one hands with my left hand. this is the key to efficiency- if you tie one hands with your right, then you have to drop your instruments

Very true -- I learned the same way as a med student, but it was because I had a scaphoid fracture and my right hand was in a thumb spica! Honestly, I never got as fast at two-hand ties as I am at one-hand ties since I had to start one-handed.

 

[Winged Scapula]

Very true -- I learned the same way as a med student, but it was because I had a scaphoid fracture and my right hand was in a thumb spica! Honestly, I never got as fast at two-hand ties as I am at one-hand ties since I had to start one-handed.

Did you scrub in with a cast? How did that work?

 

[ESU_MD]

in my case- i feel it was shear luck to learn left handed one hand ties

it is better to be lucky than good

 

[SLUser11]

in my case- i feel it was shear luck to learn left handed one hand ties

it is better to be lucky than good

I tie with my left hand predominantly as well. I think it's a combo of my partial left-handedness (bat/throw/kick left, write/operate right) as well as my teaching myself to tie based on books/manuals. In those manuals (ethicon, etc), they teach you with good reason to tie with the left....and with good reason.

Of course, there are always situations where using the other hand is easier or more practical.

Side note: My switch-handing makes me absolutely awful at racket sports (tennis, racquetball) because I want to backhand everything for some reason, and I keep switching the racket between my two hands during play.

 

[maxheadroom]

I learned to tie while I was doing research during my first year. We were doing some rat surgeries looking at osseointegration. I had an orthoplast splint that we just doused with rubbing alcohol before I gloved.

 

[SouthernSurgeon]

I t my partial left-handedness (bath/throw/kick left, write/operate right)

You bathe left handed? TMI...

 

[Anka]

I'm not sure there is a single "right" answer for what medical students should learn. It tends to be institution dependent. Some have rules that medical students are only allowed to tie two handed (and in some places, no one ties one handed), others reward students who are able to tie one handed. Personally, I was taught initially to tie one-handed with my left hand, and I teach students to tie the same way. I learned two handed and right hand one handed primarily for completeness (even when people say you need to tie right handed, what they really mean is that you need to bring it down with the other hand). I agree, however, that for students it is best to be really slick with one thing, whether that be one handed or two handed, left or right, rather than trying to master all four simultaneously.

As far as suturing, the only thing you really can practice at home is instrument handling, i.e. picking up the needle, reloading (correctly with the needle at the tip of the needle driver and at an appropriate angle), using your wrist to turn the needle through whatever you're sewing without undue torque, etc. That said, all of that will help you develop faster in the OR. The particular dynamics of a subcuticular really only work out on skin -- you just need to find someone who is willing to be patient with you while you learn. And the best way to make people patient with you learning is to read about the operation ahead of time, be helpful where you can be helpful both in and out of the OR, etc.

Best,
Anka

 

[Winged Scapula]

I learned to tie while I was doing research during my first year. We were doing some rat surgeries looking at osseointegration. I had an orthoplast splint that we just doused with rubbing alcohol before I gloved.

Ahhh gotcha. Rat surgery.

 

[SLUser11]

You bathe left handed? TMI...

Typo....I meant bat.

Still....

 

[SpineKing]

He said yes, at some point the goal is to be able to tie one or two handed with right or left hand, but you don't get there instantly. One thing at a time.

I agree. When I teach people I teach them to become very good at one level of endeavor before worrying about becoming good at the next level. It's a lot easier than learning eveything at once and ensures that you become adept at various things in stages. One thing at a time. Very sound advice.