[pct-l] stitches-don't do it

[Gerry Zamora]

Ok doc how about crazy clue? Stop the bleeding clean the wound and glue it
shut.  I have done this on myself so far so good.  No problems of course im
talking cuts not almost took the finger off or I can see bone.  I guess im
asking if I had no choice stiches or crazy glue what would u do?
Fyi crazy glue is a part of my first aid kit
Gerry0625
On Feb 23, 2011 11:48 AM, "Ken Murray" <kmurray at pol.net> wrote:
> In medical practice, there is a saying: "First, do no harm"
>
> There is a lot of chatter about applying stitches, by folks who have never
done it, and don't know the problems involved. So, as a physician and
surgeon, who has sewn up thousands of people, and teaches the skills at a
medical school, lets go over the issues, and see if you REALLY want to get
involved.
>
> When the skin is disrupted, there are several problems: we usually have
bleeding, and we have lost the defense against infection of the skin.
Applying stitches to stop bleeding is not the correct action, nor even
probably possible, in the field.
>
> So the issue is the re-establishment of the skin protective barrier. When
one *correctly* stitches a wound, one re-established the barrier
immediately. But there are assumptions contained within this action!
>
> It's the assumptions that always get you.
>
> -We never apply stitches to a dirty wound. When we say dirty, we mean
non-sterile. GENERALLY, we prefer a wound that has been CREATED in a sterile
environment, such as an operation room. It is a phenominally important part,
perhaps THE most important part of applying stitches, the wound preparation.

>
> -Bleeding must be completely stopped. Otherwise, a pool of blood will
accumulate under the skin which is a perfect "petri dish" for an infection.
A slow "ooze" can really mess this up.
>
> -The wound must be lavishly flushed with fluid. This would be measured in
gallons, not quarts. You would want some pressure behind it. In the ER, we
use a pressure device, in the field, holding a container several feet above
the wound would work. The tiniest bit of foreign matter left in a wound
increases the rate of infection 1000-fold.
>
> -It is CRITICAL to remove any devitalized (dead) tissue from the wound. If
a wound is closed with this inside, it is a perfect growth medium for
infection. This means that you have to be able to recognize what is
devitalized, and what is not, and CUT AWAY the bad stuff. (Hard to do
without good instruments, BTW). You also need to get the edges of the wound
smooth and lined up. Trying to sew something that is 3 inches on one side to
5 inches on the other side is not simple.
>
> -You want to maintain the sterility of the wound that you have so
carefully prepared. The problem is, as soon as you take that sterile suture
pack out of the package, it is contaminated. Sewing needles are not sterile,
dental floss is not sterile, my hands are DEFINITELY not sterile, no matter
how much I wash them. So we KNOW that we will have a contaminated wound.
>
> -Now we come to the sewing itself. There are a lot of stitches one can
use, but this is not like sewing a shirt. From the top of the wound, the
line needs to run to the bottom of the wound, so that when the line is
tightened, there is no space left, or else it fills up with blood/fluid,
once again a perfect place for infection to get started, particularly in a
contaminated wound.
>
> -Assuming repetitive single interrupted stitches (by FAR the best for
anyone but experts at this to use), it is CRITICAL to tighten the stitches
PRECISELY and CORRECTLY. If you tie them too loosely, you have not
re-established the protective barrier of the skin, and the whole thing has
been a waste of time. But if you tie it too TIGHTLY, you will reduce the
circulation into the wound, which carries the healing elements, including
the components of the immune system that fights off infection, and HUGELY
increases the risk of infection.
>
> -If there is a lot of abrasion, which is common in traumatic wounds, you
want to be careful where you place the stitches. It the stitch runs through
the abrasion field, it will inhibit healing and promote infection. There is
a certain amount of technique involved.
>
> -Here we run into the problem of swelling. When the skin has been injured
by a severe enough traumatic wound to consider stitches, it has sustained a
lot of secondary injury (this is where an injury wound is very different
than a created wound in the operating theater). As a result, the area of the
wound WILL swell during the next 24 hours. That means that the stitches that
were placed at the correct tightness at the time of repair, will gradually
over the course of hours become TOO TIGHT, and STRANGULATE the wound,
cutting off the circulation. Yikes!
>
> -Surgeons have special techniques of tying knots that have the effect of
being like "shock absorbers", so that they gradually expand to accomodate
swelling of a sewn wound, and eliminate the above effect. However, this
would be difficult to do with non-medical grade materials, and without
instruments, as one would have in the field.
>
> The bottom line is that MOST of the time, sewing a wound in the field WILL
result in an infected wound, and you have converted a relatively simple
problem into a relatively complex problem. Management of a sewn, infected
wound, is a real problem. You MUST remove the stitches to manage the
infection.
>
> So, what do do? We teach never to close (by stitching or gluing(I'm not a
glue fan, BTW)) a wound in the field. I never would. Leave the wound open,
but covered. Clean it with plain soap and water (alcohol, bad, iodine, bad)
multiple times a day. Slap some neosporin on it, cover. They will ALMOST
NEVER become infected. They will heal beautifully. You can do a whole lot
wrong with this technique, and things will still turn out perfectly ok.
>
> If one cannot manage with the open wound, then you have to leave the
trail, and have the wound taken care of.
>
> Concepts in first aid management of wounds has evolved a lot in the last
few decades, based upon increasingly good information and research. It is
probably a good idea for anyone embarking on the PCT to avail themselves of
a current WFA or better course, but even taking one of the free online first
aid courses would be better than nothing.
>
> Of course, your mileage may vary. :)
>
>
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