If You Dont Know What to Do,

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  • 8/14/2019 If You Dont Know What to Do,

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    IF YOU DONT KNOW WHAT TO DO, DON'T CLOSE A WOUND.

    Closing a wound by just sewing the skin together is a very bad idea if you don't know whatyou're doing. The skills involved are not terribly complex - Physician Assistant / Nurse

    Practitioner / Special Forces Medic level skills; but require knowledge of anatomy that most

    people (including paramedic/EMT skilled people) lack.

    There are several problems with closing a wound wrong. If the wound isn't clean and bleeding

    controlled, all you do is create a pocket for infection. How do you treat an infection like that?With more surgery, fixing it the right way, PLUS a lot of antibiotics and pain meds. If the

    patient is lucky, you might be successful the second time around but the odds are against it:

    Gangrene is everywhere and can easily get started, with very bad outcomes.

    Wounds will normally heal on their own, more slowly and with a bad scar, but it's better to leave

    them open than to close them incorrectly or prematurely. And even with that bad scar, it can be

    repaired by a plastic surgeon in 6 months or so.

    Despite people thinking that it's like sewing on a button, the skill required to suture is much more

    complex than just sewing. Do it wrong and the person stands a pretty good chance of killing thepatient. One person even told me that its easy as pie, that I was being unnecessarily cautious.

    Easy as pie?

    OK, great! Easy as pie! Lets see: You have a very simple puncture wound of the abdomen (not a

    gunshot, say a little stabbing). You will have to do the following:

    Secure the airway and maintain breathing

    Control bleedingmaintain circulation and prevent shockinduce and maintain anesthesia

    open the wound and explore - vessels, the gut, and other structures may well have been cut, and

    need to be repaired.How do you repair them?

    Tie a bleeder?

    Repair a hole in the gut?

    Clean out everything that doesn't belong there? If the gut is penetrated, then fecalmaterial is in the abdomen and it will cause a life-threatening infection.

    Close the omentum - what size/shape needle and type/size of suture?

    Which suture, technique, and knots?

    close the deep fascia - ditto?

    close the (possibly 3 or 4 different) muscle groups - ditto?close the superficial fasica - ditto?

    close the skin - ditto?

    Bring the patient out of anesthesia

    Dress the wound, monitor for infection, control pain

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    develop a plan for exercise, monitor the bowel for activity, specify a diet, follow up on patient

    care.

    Even a simple skin laceration may involve 3 layers of tissue, each of which has to be closed

    separately, using different types of sutures and (frequently) different suturing techniques. Screw

    up the anatomy and you can damage a nerve too - want to save a limb with an 'easy as pie' suturejob but leave it non-functional because you accidentally severed a major nerve? Or worse, leave

    the person in incredible pain (without lots of pain meds) because you stuck a suture THROUGH

    a nerve?

    I used to be an EMT (basic, and paramedic), and have been the course director more recently for

    pre-hospital care courses including EMT and paramedic. The training you get (especially these

    days) as an EMT doesn't begin to cover the anatomical structures in a body, much less how to fixthem.

    Please note: I am not saying that only physicians can suture. However, before you think that you

    can, you better get the right training in real life, from a qualified instructor, not from yourinterpretations of the orange book and watching westerns on TV. Buying a knock-off M3 bag

    filled with junk, a tube of crazy glue, or a skin stapler, doesnt make one qualified to closeanything.

    Like many things in medicine, doing the wrong thing, even with good intent, is a very, very badthing to do. Being close usually doesnt count.