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Leaving Them in Stitches, No Laughing Matter

(A Stitch in Time)

by Glenn Cockwell

This article first appeared in the Scouts Canada, Leader Magazine, (March 1992)

You have all experienced it, the high pitched summons, bordering on panic, "Scouter come quick, John has cut himself." Why do they always send the youngest for help? They never knows what happened or how bad the cut is. Well, better prepare for the worst.

Off you go, first aid kit in hand, hurrying but trying to maintain an image of calmness. And there is the victim, blood over everything. Move quickly now, calm the victim, find the wound, apply direct pressure, and elevate. Thank goodness the bleeding has stopped. You know the drill now. Clean up the blood, wash out the cut if it is a minor one, apply a dressing, secure it, and now--

And now the first aid book goes on to the next chapter. But wait a minute! The cut wasn't that minor, it was kind of deep. Should you take the youth to the emergency clinic, will they end up with stitches?

There is no pat answer of course. There are many circumstances that will influence your decision and not all of them are directly related to the wound. How far are you from medical attention? Are you 15 minutes from the local hospital, or is it a 2 hour drive, or maybe you are 6 hours into a weekend canoe trip. What about support? Are you on your own with a patrol of six youth?  Do you leave them unsupervised? When are the parent coming to pick them up?

I guess if we look at the situation, we must really make two basic decisions. Does the cut need stitches and if the answer is yes, how long can we wait before the stitches are applied?

Being fortunate enough to have a doctor in the family who also specializes in emergency medicine, I sat with him one evening and posed these questions.

How deep must a cut be before it must be stitched?

Before we talk about the depth of a cut I think we should make clear why stitches are used. There are two basic reasons for stitching. The first is to bring the wound together and keep it together. This will let the body mend the wound as quickly as possible. It will also reduce the possibility of infection. The second reason for stitching is to reduce scarring. The body will grow new flesh between two edges of a cut but it will not have the same look and feel as the surrounding skin. If the edges, at rest, are more than .5cm apart then stitches are essential. Stitches hold the edges of the cut together as tightly as possible and the new skin will be less visible.

Now with that in mind lets talk about how deep. General any cut that that goes beyond the dermis (the skin) and into the subcutaneous fat below should be stitched. That means any cut more than about 1/8 inch or .3 cm deep. However that is not the whole story. The location and shape of the cut must also be considered. If the cut is located such that the edges are pulled apart either at rest or through normal activity then stitches are needed. A shallow cut on the forearm that can be immobilized might heal quite nicely with proper bandaging. The same cut on a patient's calf will be continuously pulled open while he is walking and will need stitches. Always consider cuts on the face candidates for stitches. A cut that might be considered too shallow to stitch if it is on the patient's thigh will more likely require stitches if it occurs on the face. We want to reduce scaring in areas that are visible.

Up to this time I have been talking about, what I would like to call tidy cuts. These are straight cuts, usually caused by knives and other sharp edges. There is another type of cut, the untidy one that has ragged edges, bruised edges, or flaps if skin associated with them. These cuts need immediate attention and careful stitching to enhance healing and to minimize scar formation.

How long after the cut has happened will stitching not have an affect?

The primary consideration here is contamination. Contamination will occur if the wound happened in association with swamps, bogs, marshes, clays or subsoil. Bites, both human and animal are also associated with high infection rates. If the wound happened in a situation where there was a high possibility of contamination then medical treatment should be obtained as soon as possible, with anything over 6 hours considered too long. In other situations such as stubbed toes on a clean sandy beach, a delay of 6 to 8 hours will not have an adverse affect. You can even delay up to 18 hours if you are very careful cleaning and bandaging the cut. For facial wound scarring can be minimized with stitches even if treatment is delayed up to 24 hours. If the wound is deep enough to possibly damage nerves, arteries, or tendons then immediate specialized treatment is needed. If you can get to medical attention right away then do it.

What can I do in a long-term delay situation such as an extended canoe trip?

Any action here must try to duplicate what the stitches themselves would do. That is you must try to immobilise the edges of the wound so that they are not being pulled apart and you must ensure cleanliness to prevent infection.

Particular attention must be paid to the cleansing of the wound. Where normal first aid procedures call for the use of clean water to rinse the wound, ideally in this situation you should use a .9% saline solution. Since most first aid kits do not normally contain a supply of this, your best alternative is water that has been boiled for a minimum of 5 minutes. During the cleansing process wash the area around the wound as well, making sure that you wash the dirt away from the wound and not into it. Once the wound is clean it should be bandaged to ensure the edges of the wound are held together as closely as possible.

Sterilized tape that can be used to hold the wound closed, is available in drugstores. It can be used in areas where the skin can be kept dry. Degrease the skin close to the wound with alcohol, being careful not to get the alcohol in the wound, and then apply the tape perpendicular to the cut. Do not use this tape as an alternative to stitching if you can get your patient to medical help. It is only to be used if it is impossible to get to a doctor within 24 hours.

If the cut is in an arm, or leg, then immobilise that limb to the extent that the area of the cut is not stretched or flexed. In warm weather you should ensure sweat does not wash contamination into the wound. The dressing should also be changed every 12 hours.

Is there anything else that you would like to add?

Yes, in general, if there is any doubt then take the patient to medical help and let them decide whether a stitch is needed. Unless the wound continues to bleed, there is no need to panic. You can take the time to ensure the safety and security of the rest of the youth, once you have applied the initial first aid. The person that does take the patient to the emergency clinic should know when the wound happened and under what circumstances.