ER CARE

BAD SUTURING/ BAD SCARS

BAD EMERGENCY ROOM CARE IS THE NORM

Bad Emergency Room care is the norm in this managed care world. This child is a perfect example of everything that is wrong with the system.


The child was hit in the face with a golf club by another boy. This resulted in a burst injury, not a laceration. That means the tissue broke open by a concentration of impact energy that explodes the tissue apart. Thus the margins of the wound are damaged. If this is simply sutured together, the body will have to remove the dead cells and replace them with scar tissue. There will be prolonged swelling which will isolate the area from the immune system and result in a higher infection rate. Wound healing 101.

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    The mother asked if they could repair the “inside first” or get a plastic surgeon.  “No plastic surgeons, and we don’t need to sew the inside first.”   The mother had an incomplete understanding of what was needed (understandable) and the technician repairing the wound was ignorant of the pathology and high quality care of such injuries.


    So the Burst injury was repaired with ABSORBABLE sutures without cutting away the zone of injury. Followup was to be in a week.   Bad, Bad, Bad.


    Cutting away the zone of injury back to normal tissue is critical to minimal scarring.  Absorbable sutures resolve by an inflammatory reaction called hydrolysis which only occurs within tissue.  It is not prudent to use absorbables in the skin closure.  The inflammatory response results in more scar formation.  Making the sutures too tight, not allowing for the swelling to come, and leaving sutures over 5 days results in railroad tracts (Frankenstein scars).  I always try to check my patients the following day to avoid disasters such as this allergic reaction to the bandaid that would not have been picked up for a week.  


    I saw him Monday, the injury was repaired Saturday.  Note how the sutures are buried in the swelling, cutting through the tissue.  I removed the sutures immediately and put the boy on steroids for the allergic reaction and antibiotics.   The plan was to control the allergic reaction, then cut out the entire wound and zone of injury and do some fancy suturing without cross sutures.

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    • HB (House Bill) 221, another well intentioned bill passed 7/1/2016, has resulted in a constant flow of patients deprived of state of the art quality care. It made it a criminal offense to bill a patient for services delivered in the Emergency Room punishable by loss of license, $10,000 fine, and/ or criminal charges. The result? Try to get a Plastic Surgeon in the E.R.


    The good news? If you get to me or your personal plastic surgeon, the next day, we can usually reverse the damage before it is too late by excising the wound, bad sutures and all, and using state of the art techniques.


    Best practice requires removal of the injury zone to normal tissue, reorientation to favorable direction, delicate tissue handling, and layered closure. Absorbable sutures deep and monofilament nylon or polypropylene externally.

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