If You Dont Know What to Do,
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8/14/2019 If You Dont Know What to Do,
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
8/14/2019 If You Dont Know What to Do,
develop a plan for exercise, monitor the bowel for activity, specify a diet, follow up on patient
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
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.