time to sew

Monday, May 7, 2012

Wound care starts with history, learning what happened to damage the skin and whether other issues need to be addressed. A laceration that was caked with mud is more likely to get infected than one that happened slicing a tomato. A laceration that is 18 hours old is more likely to be infected than a wound that just occurred before walking into the doctor’s office. Where the cut is located on the body also matters. Some parts of the body have better blood supply than others and will heal faster. Scalps and face bleed a lot when they are cut but also heal faster. Shins have poorer blood supply and not only will take longer to heal and are also prone. Diabetic patients have poorer blood supply to their feet and it may take longer for foot lacerations to heal, if at all.

When the skin is violated, anything located underneath the wound is in danger of being damaged, including tendons, arteries and nerves. Knowing what’s underneath is important in knowing what injuries to look for. It isn’t god enough to sew up the skin and call it a day. The physical exam will make certain things work the way they are supposed to but examining needs to be confirmed by looking.

For the doctor, the fun stuff starts next. Armed with good tools, lots of light and a working knowledge of anatomy, the wound needs to be explored to the full extent of the wound and the process of wound repair begins.

Step One: It all starts with making the wound numb; it’s cruel to hurt people, even if it’s for their own good. Local anesthetic can be injected into the area and depending upon the type of drug, its effects can last for many hours.
• Step Two: A light cleaning come next, usually with saline or salt water, to wash out the big particles of dirt and grime if they exist.
• Step Three: It’s important to look inside the laceration for potential bad things. If visual inspection confirms the physical exam and nothing bad is cut, then
• Step Four: more aggressive cleaning is needed. Perhaps the most important reason to care for wounds is to prevent infection and there is nothing better than washing. No soap is needed, plain irrigation or rinsing with saline is best. Soap damages cells and can prevent healing.
• Step Five: Time to suture. What type of suture that is used depends upon the situation and doctor preference but the purpose is to hold the skin edges together.

In fairness, once the wound is examined, explored and cleansed, sewing isn’t mandatory. Bringing the skin edges together will allow healing to occur more quickly and leave a better scar but if left alone most wounds will heal on their own. Sometimes, with dirty or old wounds it is best not to sew up the skin and lock in the potential for infection, but again, it’s the situation and the doctor’s experience that will make that decision, one patient at a time. Once the wound is repaired, the healing process starts and doesn’t stop when the stitches are removed. It takes months for the skin to finally repair itself and the final scar depends upon the type of injury, the doctor’s skill and the patient’s ability to heal.

In the operating room, planning where to cut and using a sharp thin scalpel, the plastic surgeon can make an incision almost undetectable. In the real world, people don’t plan their injuries, most places aren’t clean and the lacerations are jagged and uneven. It’s important to know that all cuts leave a scar, but it’s the doctor’s job to make it look good, not invisible but cosmetically appealing.

In the midst of the playoffs, when a hockey player gets cut, he only cares about getting back to the game. A quick trip to the locker room for temporary repairs can do the job, but those stitches can be removed and the real work done after the game. For the rest of us, one time getting fixed is enough.

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