Back to the Suture

I'm fond of scars. They impart a sense of history with pain and suffering, then regeneration and recovery. They mark a person as different and the scar-bearer is changed forever. I've talked about a few of my scars in a previous entry. There are many more which are equally apparent and their stories are equally clumsily ridiculous. Enough about me, though...

Let's say that you get a nasty gash and you go to the ER or your neighborhood friendly family physician to get patched up. What goes into this process? What should you know? I will split this up into two parts, general instructions for patients and tips to keep in mind for doctors.

For Patients:

• You stumble into the office seeking help and you've just been told to take a number and sit down?!? Relax, you're not going to die of exsanguination. Unless you have a scalp wound. Those buggers keep on bleeding until they are stapled or sewed shut.
• It's a good thing you came in early. Even a short delay of three hours can greatly increase your risk of infection.
• You've had your tetanus shot in the past 5-10 years, right? Good. If not, expect to get a needle in your shoulder to make sure that you don't get lockjaw and die of tetani spasms as your whole body locks down and you stop breathing.
• Have you ever had an allergic reaction to iodine or iodine dye or anything like that? Then why is the doctor giving you BETADINE?!? Well... betadine doesn't cause an allergic reaction because of its chemical makeup.
• Have you ever been told that you have an allergy to lidocaine? Then why is the doctor giving you LIDOCAINE?!? Well, you're actually allergic to the preservative in the bottle and chances are high that you're getting the preservative-free version.

YEOWCH! The topical anaesthetic takes away most of the pain, but you still feel like wincing a bit from the uncomfortable feeling of someone tugging on your flesh to knit it back together. You're a brave trooper! :) What do you do now that you have spiky threads and a tender wound?

Here's what you need to know about your wound care:

• Keep it dry for ONLY 24-48 hours.
  It is okay to wash the wound carefully after that with soap or shampoo. Keep it clean.
• Daily washing can be supplemented with a little hydrogen peroxide to bubble off sticky bits of scabs (coagulum.)
• You don't need any antibacterial ointment. It's important that it is exposed to air; it helps with the healing. KEEP IT CLEAN, though.
• Go back and get your sutures removed as directed.
  Face: 3 days (cosmetic); 4-5 days (less cosmetic)
  Scalp, trunk, extremities: 7 days
  Joints: 10-14 days max
  Palm, soles: 14 days
• Steri-strips with may be placed in a "ladder" formation (rungs going across & the legs securing it on)
  
• Initially, your wound will look... okay. Nothing too bad.
• Then in about 2-3 weeks, it will get thick and red and tender and lumpy... some might even say ugly. Don't worry, this is normal.
• In 6-12 months, the scar you see is the scar you get. The affected area will never regain its original strength back, but it is important to stretch it so you don't lose its flexibility.
  

For Doctors:

1. The "Golden Period" is 6 hours. This is a period of time in which a wound can be sutured up safely with few complications like infection or scarring.The general vasculature of certain areas extends this period for some areas, 10 hours for the hand and 24 for the face; extra perfusion means better healing.
2. High Pressure Irrigation
   Use a 19 gauge needle on a 35 ml syringe to apply the needed 15 PSI of saline to reduce infection.
3. Antibiotics
   Dog/Cat/Human bite wounds require extra attention and Augmentin (875 mg BID) should be good. Most physicians feel it is necessary to prescribe a full weeks worth, but the majority of the bacteria is taken out in the first 24 hours.
4. Prep the wound with betadine solution, but keep it out of the wound itself.
5. NEVER shave eyebrows. They might not grow back. Avoid shaving hair at all, if you can. Gloss up hair with antibacterial ointment to move it out of the way for suturing scalp wounds.
6. Anaesthetics:
   NEVER use Lidocaine with Epinephrine on "fingers, nose, toes, hose and lobes" because Epi's vasoconstriction effects can cut off blood flow.
   The toxic dose of lidocaine is 50 cc of 1%.
   Bupivicaine is a great alternative to lidocaine. It has a slower onset, but the fact that it wears of slowly also has HUGE effects on patient comfort.
   Avoid injecting anaesthetic directly into the pads of the fingers; use digital blocks instead to numb up the entire finger instead. You're not using lido w/ epi on the fingers, right? Good! :)
7. Count the stitches you put in or have the patient keep track of them. Many people want to know the exact number for comparison's sake. Be prepared to give them an answer.
8. If you have nurses provide wound care instructions, make sure they don't say "keep the wound dry." This will make it very difficult to remove the stitches later on because of the extra tacky coagulum.

Source: the wonderful Dr. Waters
Thanks for a thorough and excellent suturing workshop!