[pct-l] Read this post - on stiches

[Edward Anderson]

Ken,  
This is an excellent post - INFORMATION THAT EVERYONE SHOULD READ - at least 
once!
MendoRider




________________________________
From: Ken Murray <kmurray at pol.net>
To: . <pct-l at backcountry.net>
Sent: Wed, February 23, 2011 11:47:40 AM
Subject: [pct-l] stitches-don't do it

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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