Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Thursday, February 19, 2009

First Time for Everything

I did something the other day that I had never done before: I sutured a laceration without anesthetizing it first.

It was a 17-year-old boy messing around in the weight room who had been hit in the middle of the forehead, right at the hairline, with a barbell. There was no loss of consciousness, just a tiny little five millimeter laceration that was bleeding freely after being thoroughly cleaned out.

It only needed one stitch to close, and it occurred to me that the injections of lidocaine to numb it up would probably be at least as, if not more, painful than the single stitch with its two needle pokes. I explained this to the patient and his mother and he agreed to try. Of course I told him that if he changed his mind as I was doing it (ie, if it hurt too much) that I would stop and numb it up before continuing.

So I did it. The kid didn't blink; indeed, he said it didn't hurt nearly as much as he thought it would. Nothing to it. It was the first time I've ever documented in a chart,
After informed consent obtained, local anesthesia was deferred.
I know there are tons of you ER types who routinely do this for tiny lacerations, but bear in mind I only sew up about a couple a year instead of dozens a month. For me, it was a first.


At Thu Feb 19, 10:40:00 AM, Blogger Unknown said...

I could be wrong, but I seem to recall having a stitch or two once where the doctor used a topical anesthetic (not to be confused with a tropical anesthetic, which is generally administered in a big glass with a little umbrella in it...)

I may be misremembering, but it certainly seemed like a good idea at the time.

At Thu Feb 19, 03:22:00 PM, Anonymous Anonymous said...

I do that quite often when I am sure only one or two stitches are needed. A few weeks ago I did a 8cm wound that way in an alcohol intoxicated patient who was a completely paranoid about the syringe with the needle for the anesthethic but didn't feel any pain at all from the stitch needle.

At Thu Feb 19, 05:30:00 PM, Blogger Dreaming again said...

At age 8, my son needed 10 stitches in his knee after a bad fall in a parking lot.
He REFUSED the local anesthetic ... telling the doctor that there was a HUGE needle involved in the local and a TINY needle used for the stitches.

"I'm not stupid!"

He proceeded to tell the doctor knock knock jokes during the procedure.
Mom (me) proceeded to faint during the procedure.

word verification is mulastich

At Thu Feb 19, 06:07:00 PM, Blogger Jennifer said...

I had to get the ball of my ring finger stitched up once. The doctor gave me two shots at either side of the base of my finger to numb the pain. I about came out of the chair with the first one and the second one hurt even more. I still think the three stitches wouldn't have hurt as much as those shots did!

At Thu Feb 19, 07:00:00 PM, Anonymous Anonymous said...

Are you kidding me? I would require full on anesthesia. Out like a light kind. Wake me up when it's over kind. And I want a frigging tequila-laced lolli when it's over.

At Thu Feb 19, 09:18:00 PM, Anonymous Anonymous said...

I fell at 55 and had stitches in my lip and my nose. And there wouldn't have been any stitches without lidocaine, I promise you.

At Thu Feb 19, 11:05:00 PM, Blogger The Hatchling said...

I actually did two sets of sutures today in the ER. First time I've done them on awake patients (yay practice during surgery).

One was a LOMFDGB (little old man fall down and go boom) with a nasty 4cm nonlinear laceration on his sphenoid. The other was a DIP laceration for a 'crush' injury. Both were bleeding and especially the head laceration was swollen so i actually sprayed some of my lidocaine into the wounds before i injected local to try to help with the injection pain. Both of the men were a little bit.... well dramatic when the needles came out.

I really wanted to try to do a triangular flap closure on the two odd edges I had by my attending just had me do perpendicular simple interrupted. I think I still made him look good. Give him 2 weeks and he'll be popping his little blue pills again.

At Fri Feb 20, 08:05:00 AM, Anonymous Anonymous said...

Wow, I'm impressed! I was one of those kids who could read at the age of four but couldn't tie his shoes until the 5th grade, so I pretty much had to go into internal medicine. The thought of having to tie a square knot terrifies me so I try not to do any suturing at all, ever. I'll stick to my stethoscope, my prescription pad, and to calculating transtubular potassium gradients and fractional excretion of sodium.

At Fri Feb 20, 12:57:00 PM, Blogger Elizabeth A. said...

Yeah, if I had known how much those numbing injections could hurt, I might've passed for the three stitches. Good thinking, glad the mom was cool.

At Fri Feb 20, 01:35:00 PM, Blogger Margaret Polaneczky, MD (aka TBTAM) said...

I've heard of folks who buffer the bicarb so it doesn't sting. I don't know the recipe, though, and have always wanted to try it. Anyone doing this?

At Fri Feb 20, 04:33:00 PM, Blogger Unknown said...

Sometimes we hold ice on the cut for a few minutes and that numbs up the skin enough to put in stitches without the lidocaine.
I've had stitches both with and without lidocaine. Trust me, the shots hurt more than the stitches.

At Mon Feb 23, 04:52:00 PM, Blogger Fred Smilek said...

I say congrats on the success, great call and concern for the patient. Realizing the shot would hurt more than the stitch did prove wise.

Fred Smilek is the acting president of the Society to Save Endangered Species. It was founded two years ago by Fred Smilek along with his two best friends Charles and Jonathan.

At Wed Feb 25, 10:20:00 AM, Anonymous Anonymous said...

Nine parts lido to one part bicarb...but you do have to mix put the lido in the syringe first then the bicarb....sometimes the doc is in a hurry and the first part of the injection is only bicarb...

At Wed Feb 25, 09:46:00 PM, Blogger Sarah said...

There are ten mL in a normal lidocaine bottle. I usually inject 2-3 mL of bicarb into a fresh lido bottle and then use that. If you use 25 gauge or smaller to infiltrate the mixture, a lot of pts have minimal discomfort. This is especially helpful with abscesses requiring I&D. Also makes the digital blocks more bearable, but only if you s-l-o-w-l-y inject the mixture into the interweb space.


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