So we sew

Wednesday, July 25, 2007

Sewing is one of the fun things that we do in the emergency department. Repairing a laceration provides immediate gratification of a job well done, seeing the skin edges come together to provide a nice scar, and it’s one of the few times that the emergency doctor can sit down and spend time visiting with a patient.

While providing a nice scar is important, the two reasons we truly care for wounds is to make certain that the structures that run underneath the skin are not damaged and are functioning appropriately and that we can minimize the risk of infection. So it’s with regret that I have to disagree with a quote in the USA Today by dermatologist Ranella Hirsch. She says that “many doctors use a medical superglue to close minor wounds. There’s no painful stitching, and the wounds heal just as well. It’s a win-win for everybody.”

The implication made in Dr. Hirsch’s take on stitching, is that stitches hurt and that the skin is the most important thing in wound repair. But beauty is only skin deep and while wounds may appear minor, they all need to be explored to make certain that things like tendons, nerves and joints haven’t been damaged. And cleaning out the wound to remove debris is also a task that needs to happen before the skin gets sutured.

How and when the wound occurred gives the doctor some idea as to what to expect for potential complications and plan what to do. Animal bites have a high risk of infection, with the human bites almost always getting infected. The infection rate is so high, that unless the cosmetic benefit overrides that infection risk, most animal bites are anesthetized, explored, washed out and not sutured. The closed skin would act like a potential abscess, dark and warm and inviting bacteria to thrive in that situation. The balancing act between good scar and good outcome, is one that the doctor decides before a laceration is repaired. Usually, it’s only the face where cosmetics wins out and shifts the balance.

Whether dermabond (the skin glue) or sutures are used for skin closure, the wound still needs to be explored and cleaned. This may require anesthetic to accomplish regardless of the method of skin closure. The local anesthetic used (usually lidocaine) can be warmed and buffered so that its injection causes minimal discomfort and with skill, suturing a wound should not be painful. The expectation of pain and the fear of stitches is no longer reality. Wound repair should not be the painful experience it may have been a generation ago.

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