[pct-l] Read this post - on stiches

Fri Feb 25 17:53:30 CST 2011

i don't disagree with Ken on the stitches, though I admit I never thought it
through beyond the idea of closing a gaping wound. Never thought of the
details he mentioned. Good info over all

That said... regarding sterility, well, no wound can ever really be sterile.
Washing generously is about reducing contaminants, not eliminating them,
right? That's why we have immune systems, or else every cut would get
infected and kill us.

I agree, of course, that stitching oneself with a sewing needle and floss
will be much more likely to result in infection, but I guess I'm not as big
a germaphobe as a surgeon is (but thank god they are, as it's a huge advance
in saving lives!)

For myself, I doubt I'd ever sew myself up, but won't worry too much about a
cut, beyond keeping it clean and with new bandages. I trust my white blood
cells on my body's natural capacity for healing to do the rest.

I guess the only point of this message is to give a little shout out to the
immune system....

On Fri, Feb 25, 2011 at 11:52 AM, Edward Anderson <mendoridered at yahoo.com>wrote:

> 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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-- 
~ Moccasin