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Monday, October 18, 2010

Dirty Medicine, Part 2, by J.V. in Tacoma, Washington

atraumatic sutures; atraumatisches Nahtmateria...
Welcome to the second installment of Dirty Medicine.  Today we are going to be discussing something that will be beneficial on a few different levels.  It can help you stop uncontrolled bleeding, prevent infection, and repair skin.  That’s right, we are going to talk about sutures, also called stitches, today.
Starting off we are going to need to define what materials will be needed, both for practice and for real life situations.  The most obvious item needed is going to be some sort of suture material.  Suture materials come in various thread compositions as well as sizes.  Something like Chromic Gut (cat Gut) or Polyglycolic Acid is best used for inside the body or mouth as these dissolve after a week or so.  Polypropylene or Ethicon would be better served for skin closer or for tying off a bleeder.

My preferred site for obtaining suture materials is EmergencyEssentials.com. They have a fairly narrow range of products supply, but their prices are extremely reasonable.  I would recommend getting one or two of their Surgical Kits.  This will have everything you need to get started.  If that is not your cup of tea and you want to just buy your own stuff separately and design your kit(s) for certain scenarios/situations be sure that you get at a minimum some sutures.  I like to use a set of needle drivers, however in a pinch a Gerber or other similar multi-tool could work.  Another thing would be to get some scalpel blades to trim the skin up around the edge of the cut or incision, again a regular knife could work, but I prefer to have all the proper tools.  Some surgical scissors (I prefer the stainless steel variety, but there are some decent ones that are plastic). 
Now for the fun part!  Go to your local butcher (or your hog house) and acquire a pig foot for every member that will be practicing sutures (this number should be everyone in the family/group).  With the pigs foot thawed, i.e. not frozen, and soft like it was just cut off, make a cut anywhere in the foot/ankle region with a knife or scalpel.  Pig’s skin is a pretty close representation of human skin so it will give you a good idea of what it feels like to actually perform sutures.
At this point gather up all of your suturing supplies/suture kit and take a close look at the cut you just made in the foot.  Hopefully you used a sharp knife and the cut has straight edges and is a cut and not a “tear”.  If it does appear to be torn then take your surgical scalpel or whatever type of blade you will be using with your surgical kit and cut some of the skin off along the wound so that the edges of the wound are straight.  Now, opening up your sutures you will notice that the thread will be attached to the needle, just grab the needle away from the point with your needle drivers and lift out.  All of the thread will come out with it.  When holding the needle drivers with the needle in them, you want to use an “under-handed motion” to insert the sutures into the skin.  This means that the needle drivers should be in your dominant hand with the pointed (pliers-like) part pointing towards your non-dominant hand.  The needle should be held so it points away from the body with the pointed needle tip.
Most wounds will look similar to a “V” if looked at from the side, with the tops of the “v” being the sides of the skin and the “trough” of the “v” being the cut itself.  To suture you must place the needle in the skin from the side of the cut a little ways (usually a couple of millimeters will work; you just want to make sure it is far enough back to not tear through the skin when it is tightened).  Place the needle in the skin and angle it so it will cross the “v” about ¾ of the way down towards the point, then come out the other side of the “v”.  Once you see the needle break the skin you will want to let go of the back end of the needle and grab the tip and pull the thread through until there is only an inch to half-inch long tail on the other side of the wound. 
To tie the knot you will need to drop the needle (preferably onto a sterile surface) grab the long end that just came out of the wound with your non-dominant hand and wrap it around the shaft of the needle drivers.  Do this one single wrap for the first time.  Then open the needle drivers slightly and grab the small end of the thread and pull it through the loop you just made in the thread.  Pull this knot tight enough that the skin is aligned and closed, but be careful not to over tighten it to the point that the skin starts to turn up and look like a mountain.  Now do the same thing, this time however wrap the long thread 3 times around the needle drivers. The total amount of times you will want to wrap the thread around and pull it through is 4 times, the first you will do it once, the second will be 3 times, the third will be 2 times, and the last time will be 1 time again.  Now you can cut both the long thread and the tail, as close to the knot as possible.  This completes one suture. 
Congratulations on your first suture, however you are not done yet, now we must continue to do sutures until the entire wound is closed up.  I prefer to start in the middle of the wound and then keep dividing the wound in half, until the skin is completely closed up.  You do not have to put a suture every 2 mm or anything like that, just put sufficient amount that the skin edges are “joined” together and there is no break in the joint.  Just be careful to make sure you do not over tighten the knots.  You want the skin to be lined up, not look like the Rocky Mountains.
The important thing to remember is that sutures must be removed (except for the dissolvable ones that is).  The following is the recommended suture removal time based on what part of the body is sutured.  Face 3-5 days, scalp 7-8 days, chest and extremities 8-10 days, hands and joints 10-14 days, back 12-15 days.

Always make sure prior to wound closure that you debride the area and cleanse it, you wouldn’t want to lock that in the skin forever to cause infection.  Also be sure to check on the closure every day, look for signs that the sutures are ripping the skin, or the wound turning read, any sort of heat coming from the wound, discharges from the wound or bleeding from the wound.  These could all indicate either infection, or improper wound closure.
As always, practice and be prepared.