Essential Medical Skills to Acquire: Suturing, Part 1, by Cynthia J. Koelker, MD

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In the introduction to this series of article I gave a brief outline of the medical skills that a layman should acquire when preparing for TEOTWAWKI.  One of the most needed skills is suturing and other forms of wound closure. 

Lacerations are frightening, especially to young children.  One’s sense of wholeness is violated, often out of proportion to the actual injury.  Even adults view minor cuts as emergencies, when the truth is, most would heal (though perhaps with more scarring) with little intervention beyond cleansing and bandaging.  Pain and fear may cause as much discomfort as the actual wound.
The primary goal of intervention is to speed healing with a good cosmetic outcome.  Healing is accelerated when the wound edges are in contact with each other and infection is prevented.  That’s just about all that suturing does.  The God-given wound repair mechanism is what really heals the body.  The secondary goal of treatment, which is often equally important, is instilling confidence in the patient that he or she will be fine.  The ability to provide gentle, professional wound closure earns the skilled caregiver a great deal of respect in the injured party’s eyes.

The most common lacerations patients experience are relatively superficial.  In my work in urgent care I rarely encountered an injury that required complex closure techniques, though deep lacerations certainly do occur.  The incidence of minor to major lacerations is at least 100:1, likely much higher.  By minor, I mean no deeper than through the skin and subcutaneous tissue, not penetrating to muscle, tendon, or internal organs, and not involving the eyes or other special organs.  Therefore, learning how to suture a standard laceration is the place to start. 

Before discussing suturing I’d like to stress that other wound closure techniques are often quicker and may give equally good results.  When the edges of the wound are practically touching each other, with no tension to stretch them apart, taping is an excellent choice.  When speed is of the essence, taping or stapling is often the best option.  Several staples can be placed in the time it takes to numb a wound – and hurt little if any more than an injection of anesthetic.  Anyone who doubts this should purchase a surgical stapler and try it out personally (I have). 

Both surgical staplers and suture material are available online without a prescription, though the quality is often not equal to professional equipment.  Don’t bother with the super-cheap stuff except perhaps to practice – it will certainly be inferior for human use.  Outdated veterinary sutures are fine for knot-tying or practice on a chicken breast, but at least the ones I’ve purchased have dull needles.  (More on this in the next article.)  If you are going to practice suturing, needle choice is paramount.  Sewing needles have tapering points, which actually do not penetrate the skin well.  Surgical needles have tiny knife points, labeled cutting or reverse cutting.  A tapered point is fine for practice on foam, fabric, or perhaps a chicken breast, but requires too much pressure for penetration when used on actual skin.  Practicing on a pig’s foot will yield a simulation more comparable to suturing human skin than does chicken skin or foam.  They don’t stay fresh long, though, so be sure to refrigerate your practice pig’s feet and use them within a few days of purchase. They also freeze well, and after practice you can cook them up for your dogs if desired (but beware of the distinctive smell). 

To date the best sutures I find online available to the layman are the brand Unify.  The 4-0 size is appropriate for most lacerations; 3-0 works well for larger or deeper injuries, whereas the 5-0 is good for facial lacerations or the tender skin of children.  A suture length of 18” is generally sufficient, and easier to work with than the 30” material.  The silk suture is easier to tie so that knots slip less easily, but nylon slides through the skin easier, causing less trauma when positioning knots or removing stitches.  As a single filament, nylon also produces less wicking action and therefore less likelihood of infection.
If you do not or cannot obtain surgical suture, purchase nylon or silk thread from your local sewing supply store.  Prior to use you can dip it in alcohol to sterilize. 
Before suturing a wound you must make sure it is clean.  Clean is a relative term – no wound is completely clean, and some are assumed contaminated whether they look clean or not, especially human and animal bites.  Human bites and cat bites will get infected nearly 100% of the time and so should not be sutured.  Dog bites generally should not be sutured, either.  Closing a dirty wound provides a cesspool for bacterial growth – i.e., a warm, moist, dark environment with foreign bodies (sutures) that bacteria can cling to.  Cuts inflicted by sharp objects (knives, razors, wire) can usually be rinsed clean with soapy water and sutured (as long as no rust is present).  Any wound where infection is suspected should not be sutured.

After the wound is cleaned, establish a sterile field for your sterile instruments, or at least a clean field so your suture is not dragging over dirty clothes or adjacent skin.  If you don’t have a sterile field, at least use a clean towel to cover any contaminated areas.  I’ve never used aluminum foil, but I think it would be a good option, or possibly plastic wrap or even wax paper.  Paper that tears when moistened would be less than ideal. 
The topic of anesthesia for suturing will be covered in a separate article, but for now I’ll just mention that it certainly is possible to suture without numbing, especially an adult patient.
Once the patient is prepared, establish a work area so that you can work in a relaxed, comfortable position at a comfortable angle.  You may need to move your chair or the patient’s orientation.  If you try to suture while leaning over the patient you will certainly regret it part-way through as your neck or back begin to ache or your hands begin to tremble (as most doctors know from experience.  Please learn from our mistakes.)
The goal of suturing is to bring the edges of the wound together clear down to the depth of the wound, with no gaps in between where the wound can separate.  The depth of the wound determines proper needle size as well as suture width and spacing.  Specifically, the radius (R) of the curved needle should equal the depth of the wound, which is also the distance the suture should be placed from each edge, as well as how far apart the sutures should be spaced.  Half this distance (R/2) is a good spacing to place the first stitch from the end of the laceration.  As you’ve cleaned the wound you’ve estimated the depth and decided on the proper size needle and suture.

When suturing, it is best to use a needle holder with smooth edges rather than a hemostat with small teeth or ridges.  The flat edge holds the needle more securely.  When inserting the needle into the skin, grasp the needle holder in your palm (not with your fingers in the finger holes), making sure the needle is directly perpendicular to the skin to enable it to reach the full depth of the wound.  (Beginners usually direct the needle in at an angle rather than directly perpendicular.  Palming the needle holder assures much better control.) 
Each suture should be placed half at a time, that is, start from the right side and have the needle come up in the middle of the wound; then reposition the needle and insert inside the laceration, directing your needle up and out to the opposite side of the wound.  (Left-hand dominant individuals often sew from the opposite direction.)  Proceed from one end of the laceration to the other; usually it is best to start at the point furthest away from the operator and work toward the operator for best visibility.  When the laceration lies well-closed, make sure the knots are positioned all on one side for easier removal and less crusting.  Apply Bacitracin antibiotic ointment (optional) to a sterile (or clean) dressing and cover the wound (as opposed to applying the Bacitracin directly to the wound, which risks contamination of your tube of medication and also may cause discomfort for the patient). 
 
As I write this I realize that a picture is worth a thousand words, and not everyone learns well from text alone.  Doctors don’t suture their first laceration without an experienced physician supervising their work, and preferably neither would you.  If at all possible it would be ideal to receive hands-on training from a medical professional in your area.  Alternatively, I offer this at my own SURVIVAL MEDICINE workshops, as mentioned previously (see www.ArmageddonMedicine.net for upcoming classes). 

In the next article I will expand on the above with SUTURING, PART 2

About the Author: Cynthia J. Koelker, MD is SurvivalBlog's Medical Editor, the author of the book Armageddon Medicine, and the editor of www.ArmageddonMedicine.net   

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About this Entry

This page contains a single entry by Jim Rawles published on July 16, 2012 12:13 AM.

Guest Article: Effective Small Team Tactics for the Coming Collapse, by Max Velocity was the previous entry in this blog.

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