From HIIT Workout to Hair Apposition

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This story is from the Anamnesis episode called Is There a Doctor in the House? at 2:22 in the podcast. It’s from Ted Handler, MD, a primary care pediatrician at East Bay Pediatrics in Berkeley, California, and the founding pediatrician at Oath Care, a startup for parents.

This is a story about a recent workout class that I went to that had a bit of a surprise opening.

I always go to a local, cardio-focused, high-intensity workout class in my neighborhood. And I usually go at 6 a.m. every day. But what was so crazy about this day is that my friend texted me asking if I wanted to go at a later time so that we could go together. And I moved my class to that time period, and then my friend canceled on me. And so, I decided to go anyway, but there’s no reason I should have been in that class — I never go at that time. And I show up, and we typically sign up for which workout machine we want to work out on first. So I do that at the front of the little waiting area.

The previous class had led out, and there was a lot of pandemonium — well, it’s sort of expected pandemonium that occurs in the locker area, every day between classes. The old class is coming out, the new class is going in, and everybody is gathered at the lockers trying to either take things out or put things in.

So everybody is at the lockers, and I just decided I’m not going to go into the crowd in front of the lockers, I’m going to sit somewhere else, and, you know, tie my shoes and put my little wrist strap on. And while I’m doing that, all of a sudden I hear like a crash, and then a scream come from the locker area. And my initial reaction to that was, who’s being dramatic at the lockers? Nobody needs to be screaming. It’s really early. Somebody’s overreacted.

Blood Just Dripping Down the Face

I look back down at my shoes, and I go back to what I was doing. And then look back up again to see a woman on the ground with her head in her hands and blood just dripping down the face decently aggressively. And so, I realized, ah, no, that is not an overreaction. This is a very appropriate reaction.

I go over and — what had happened was a woman had been putting a very large and heavy water bottle into a locker that was up high at the same time that this other woman was working to put her things into a locker that was very low, and that water bottle had fallen directly onto her head.

So, I said, “Hi, I’m a doctor, is it okay if I take a look?”

And the woman was crying but nodded her head, yes. And so, I took her hair out of a ponytail that it was in and some extra hair bands, and then pulled the hair apart and saw that there was a scalp laceration. Scalp lacerations bleed like absolute stink, there’s a ton of capillaries in them. There’s just a lot of tension and her hair was already under tension. And so when I got the hair separated, noticed that there was like a full thickness laceration, you know, like there is — if I had looked it would have gone all the way down to the skull, but it was also very small.

I was gathered there with the woman, and then the person who had dropped the water bottle and that person’s friend were also gathered, feeling absolutely terrible, apologizing profusely, and wanting to help. The staff at the fitness place were also sort of gathering around and helping. And so I had them get a lot of water and a lot of paper towels and got to work just sort of cleaning the area, and realized that it was in a place on the scalp where I could do my absolute favorite technique in urgent care medicine, which is the hair apposition technique.

Hair apposition is when you have a scalp laceration, and the reason it’s my favorite is because historically people have always needed metal staples to close scalp lacerations. They’re very high tension, they don’t hold well with stitches, and so, you need to staple it unless you do this other technique. And I just love anything that gets to keep people from having like very invasive or painful or, you know, sometimes expensive interventions, and this is one of them.

So you take a very small number of strands of hair that are on either side of the laceration — usually like three or four — and you take those strands of hair and you just start to twist them until they become a little thread. And you do that on each side of the scalp. And then you take those little strands of hair that you’ve now turned into threads, and then you simply tie a knot on top of the laceration.

Pulled It Together Perfectly

I was kneeling there next to this woman and, you know, the person who dropped the water bottle. I had her hold one thread, and then her friend hold the other thread. [I] finished cleaning off the laceration, and then used the threads to tie a little knot, and it pulled it together perfectly. There was just like one tiny little knot there. And it just like approximated — the bleeding stopped immediately. It was fantastic. The problem was that you actually need a little bit of glue then to put on top of the hair knot. And so you know, typically people will have to cut those hairs out, but it’s only like eight strands of hair on a full head of hair, so it’s fine.

But I was in the middle of a gym class, and so I did not have any glue available to me.

I do carry skin glue with me in my backpack or in my little gym bag. I just like have little medical supplies that live all over all of my belongings in case that I ever should need them. And because I had gone to a different timed class, I didn’t have my typical stuff with me. And so, I did not have the bag — the very bag that contains the very skin glue that I would have needed for this exact hair apposition technique.

We dried the knot, I relaxed the tension just a little bit to allow a small amount of blood to come out into the knot itself, and then held that knot tight again and allowed it to dry. And so then the blood became some makeshift glue. But then just to be totally safe I did a double knot, which is not — you don’t typically wind up doing that, but [I] really wanted it to hold.

The best part was at the very end of tying her head together, the woman goes, “So can I go work out now?”

This is somebody that had just had, you know, their scalp cracked open.

And the person who dropped the water ball was like, “Are you serious?”

The patient said, “Well, yeah, I have to be in a bikini in 2 weeks on the beach. So, no time to waste.”

And she did, she went to the class. I checked on it again in the middle of class. We switch devices that you’re on during the class, and so about 15 minutes in I checked on it, and then I checked on it again at the very end and you know, bled like a tiny bit extra. But otherwise the knot had held tight.

Then I said, if you’re going to be here in 5 days, I would love to take this knot out for you if the scalp laceration has healed.

So as a pediatrician, I think it was absolutely amazing to have everybody as calm and collected as they were, my patient was sitting perfectly still, and cooperating with everything I asked of them. I had people nearby that were not worried parents, and were able to actually help out and hold things tight for me even though there was a scalp that was open in front of us.

It was just really, really cool and surprising to have such levels of cooperation. But I think at the same time, it was very similar to any urgent care setting I’ve worked in. There were people that were involved, and a lot of other people that were making loud noise and doing things around us that were not involved.

And then I think having absolutely no responsible supplies available — I think typically, I would have liked to wash a scalp laceration a little bit deeper than with just gym sink water. And having the glue would have been really nice. Having absolutely no supplies except for my hands, that was different.

Check out the other stories from the Is There a Doctor in the House? episode , including “A Crisis Curveball at the Cubs Game” and “A Code Blue While Dressed in Red.”

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