Thinking About Wound Repair & Minor Surgery - Part 1

[RESQDOC]

Not giving up on the lab medicine thread, far from it, but this is always an area with a lot of interest and questions, one that has generated a few e-mails in the last week or two. In fact, it is the most requested of any topic that I have taught. One could argue that there are far more important things to learn first, such as ABC’s, trauma management, disease prevention and public health - and you’d be right, too. But fortunately most people recognize that and already have some training, with plans to gain more, so that this becomes another tool in their capability kit, rather than a substitute for the basics. Don’t fall prey to “shiny steel syndrome” and persue this in preference to learning the full spectrum of medical care - basics first, always!

Wound repair is both an art and a science, about 50/50 I think. It is not as hard as it
sounds but not as easy as it sounds either. I know that does not make sense, this is what I mean: the mechanics of manipulating the instruments is easier than most people think, but the judgment of what to do, how to do it, when to do it, and perhaps most important what NOT to do are much more complex than most realize. It takes study, practice, and experience to develop the skills and judgment needed, particularly for the more challenging/difficult problems. Add that into the difficulties associated with operations in the remote/disaster environment and you can find yourself ass-deep in alligators before you know it. In short, don’t think that you can stick a few tools in the box and a book on the shelf and get by without prior instruction and practice. Wound repair is fun. No question. Neat tools, blood, injections - how can you not like that? But it is not easy.

Nationally about 12% of all ER visits are due to wounds. 50% are on the face/scalp, 35%
on upper extremities, 13% lower, 2% elsewhere. Interesting distribution, huh? About 13% of the wounds have significant contamination, about 5% become infected.

When evaluating wounds there are several steps that need to be done. First, you need
some patient and injury history. Determine the mechanism of injury, age of the wound,
tetanus vaccination status, and any medication allergies. Then examine the injured area. Look at it’s location, contamination or foreign bodies, missing tissue, underlying structures, joint involvement, tendon/ligament involvement, motor & sensory function, circulation, and skeletal integrity. With this information you can then (and only then) decide if, when, and how to repair the injury. As you can see, this evaluation is enhanced by a good understanding of the anatomy and function of the area involved as well as the
techniques of examination and assessment.

The definitive textbook on wound repair is Wounds and Lacerations: Emergency Care and Closure by Alexander Trott. Pricy at $62.00 and WORTH EVERY PENNY. It has been reviewed elsewhere so I won’t go into details. Unless you have been trained to the level of an advanced practice medic or better you are a FOOL if you plan to repair wounds and don’t buy and learn this book cover to cover. Then find a mentor, learn first hand, and practice, practice, practice. If possible do, do, do.

Later,

Keith

[tangent]

I've allways gone by the saying: Know your limitations and do not excede them. (well, not too much... if there is no alternative, stretch what you know into service) As far as suturing goes, my limitations are the dermis. What do you do if muscle or tendon is involved? That seems like an art form, reserved for someone that really knows what they are doing (at least if you want to regain function). How do you practice something like that? Oranges aren't going to cut it...
You mention assessment. We were taught to do it, document it, and transport, but allmost nothing about what to do about it, especially in an extended care situation. (granted, some of it is obvious...) Care to key us in abit on diagnostic thought processes and resulting Tx implications?

I know about "S" cuts arround joints and things like that, though others may not - be good to cover too.

hmm.. other things: what size suture where? believe 5-0 is generally good for trunk and arms and 4-0 for face and hands (could be wrong, though), different types of suture, diff types of needles and needle holders, aseptic technique, irrigation, delayed closure, anesthesia (including epi and what that does) and of cource, what to do if there is vascular, ortho or neuro involvement - don't think this can be handled in the field - maybe vascular and some ortho, if you're REALLY good! Debridment and using a probe - never seen a good writeup on that. And of cource, no discussion of survival wound management would be complete without mentioning urine, dental floss and MAGGOTS! :smile:

have at it doc!

[tangent]

found a used copy of Trott's Wounds and Lacerations, 2e, and it came today. The difference between the first and second edition, aside from updating, is the addition of 2 chapters, one on pediatric wound care, the other on abscesses.

I don't know what it is about medical books, but with each new addition it seems that there are improvements but at the same time, parts are worse. In Trott's case, it's his coverage of anesthesia and nerve blocks. I had been reading an earlier version of his book, from the library, that one titled: Principles and techniques of minor wound care and it had beutifull, clear illustrations that let you know exactly where the nerves were and were/how far to insert the needle. In the new book, he's done away with most of these and replaced them with photographs that have lines painted over them representing where the nerves are. Makes things about as clear as mud!

Otherwise, it's an excellent book! The focus is on disease and healing processes as well as the mastery of a handfull of surgical skills. It is this latter area, that while perfectly adequate, is abit lean. For that reason, I'd suggest getting a companion volume: "Pocket Manual of Basic Surgical Skills", by Van Way and Buerk as this latter volume gives a more complete treatment of scrubbing in, identification and handling basic instraments and teaches more knots. OTOH: it's treatment of wounds and the healing process is superficial at best. If you could have only one book, get Trott.

OK - one thing neithor of these books taught me was making practice pieces. I've practiced suturing on oranges, but that doesn't give you a feel for deeper wounds. I've heard of pigs feet being used... could someone elaborate on these or other ways to make/use practice models?

[Buffalomary]

We used pig's feet in a class I took at the hospital I work at.