Day 16 - more suturing
I went for the afternoon shift today. It was real fun. My very first job was to suture up a laceration on the pretibial surface. This occured on a 20 year old motorcyclist who fell down from his bike, after not wearing protective arm/leg gear. The laceration was located on the pretibial surface measuring approx 7cm long, and about 3 cm wide. The main problem with the tibial surface area is its poor blood supply, high tension, and bony prominence. The wound itself went as deep as the bone, but did not involve the bone and its fascia. The muscle layer was torn, but this did not require any suturing.
There was considerable tension between the suture ends, so careful suturing was required so that wound breakdown, and ischaemia will not occur. I gave it some local anaesthetic (7.5ml of 2% lignocaine without adrenaline) around the wound edges, and rinsed the wound thoroughly with NS, and bethidine. I did not use chlorhexidine because it can burn. I used simple interrupted sutures to appose the wound edges.
The principles of suturing any wound is to clean the wound thoroughly, and make sure the wound edges are brought together nicely. One must begin the sutures in the central part of the wound, and then extend equally on other side. You should not begin at one end and work your way to the other end, because this can lead to inappropriate suturing, and also not equalise the distance between sutures. I was lucky to get the wound edges to oppose without much tension, and the wound required about 7 stitches in all. I used melonin to dress it, and used a combine to absorb the discharge. I bandaged up the wound. Before all this of course, I asked my boss to inspect the wound to see if it looked alright - and I got the A okay.
My second job for the day was a urinary catheter on a very old lady who fell over and hit herself on the head. There were obvious bruises. She was confused. I had great difficulty in inserting the urinary catheter, and in the end failed as I kept catherising the vagina. This can be noticed if the catheter does not advance very much. I tried a few times to no avail. The urethra was very difficult to distinguish. I got one of the nurses to attempt it, and she also found it extremely difficult and failed with 3 attempts. It was then decided that catherisation was not the best option.
My third job for the day was to consult a patient who had unknown metastatic malignancy (on radiotherapy), and now presented with 3 week history of pleuritic chest pain, haemopytsis, SOB, and one episde of fevers. He finds it very difficult to sleep at night due to his SOB, and his chest pain was not like his usual angina episodes. On examination he had bilateral mid / lower zone crepts and wheezes. This led me to believe he had an infective component to his current presentation. He was also tachycardic, and tachypnoea. I ordered FBC, UEC, troponin I, and CXR.
So when you hear that a patient has:
pleuritic chest pain
SOB
haemoptysis
mets malignancy
fever
The following DDx should spring to mind:
- chest infection (pneumonia, bronchitis etc)
- TB (unlikely but he ethnicity was Indian - although there was no recent travel history)
- PE (must rule this out)
- angina / AMI / LVF (pulmonary oedema)
I spoke to the consultant who suspected a PE, for which a D-dimer would be a reasonable investigation. However, he is high risk - therefore a D-dimer is not that useful. He is high risk because of his malignancy. I needed to order a CTPA - but tough luck was ahead as it was 7.30pm. I spoke to the radio registrar - who suggested we clexane him until the morning, and then a CTPA would be done if warranted. I spoke to the ED registrar and passed on the information. Thus concluded my day.
The suturing was great experience, is not as hard as previously imagined. In fact I like doing such practical things, and it was great experience - and it was even better when I did it myself without consultants watching over my shoulder every inch of the way - which is less pressure all around.
Merry Christmas and Happy New Year to all of you.