I know we are all anxious, inundated with updates, and feeling way in over our heads with the amount of new information we need to rapidly digest to effectively prepare at our institutions for the COVID-19 pandemic response. Firstly, from one “front line” provider to another, thank you for your courage and all you do.
If you are an urgent care provider, a physician assistant who primarily works in an ED fast track, or even a family practitioner doing mostly telemedicine–even if you are not directly involved in COVID care–you still have a role to play, and I am thankful for you too. This post, in fact, is for you.
I’ve been thinking a lot about how we provide care to the patient with soft tissue injury and acute wounds as our emergency departments begin to fill up with “patients under investigation.” As I see it, the name of the game here to allow us to care for these patients while simultaneously supporting the COVID response is (1) rapid throughput of patients who can be rapidly discharged; (2) reducing total points of contact with the health care system; and (3) resource stewardship of precious supplies of PPE.
Rapid Throughput
If you are of the mentality that non-emergent patients should take a number, and sit in the waiting room for an indefinite amount of time to be seen, dispel that mode of thinking. Given what is currently known about the incubation period of COVID-19, the rate of asymptomatic carrier transmission, and fomite stability of the virus, we need to get patients who can be rapidly evaluated, triaged, and dispositioned out of our care spaces as efficiently as possible without sacrificing safe, quality care. To that end, here are some ideas that may help you.
Skip the repair
Remember, not every laceration needs to be sutured. For the most part, suturing a wound remains mostly a cosmesis issue. If the patient does not require closure for hemostasis, doesn’t have a ruptured tendon you need to repair, and is fine with a slightly larger scar, consider counseling them about the merits of leaving that wound open. Contrary to some commonly held cultural beliefs that closure prevents infection, wound closure generally involves placement of an embedded foreign body that actually increases infection risk.
If you are providing telemedicine care, you may be able to provide this counseling without a face-to-face visit, provided your patient can tolerate tap water irrigation and apply local wound care at home. For selected wounds of the face and scalp you could remind them that irrigation may not even be necessary. Remember that small hand lacerations have equivalent cosmetic and functional outcomes whether or not they are primarily closed, and this likely generalizes to a number of wounds, especially now when time is of the essence.
Quicker Closure
If you decide that a wound does need primary closure, consider some options that speed things up:
Glue and tape are often overlooked as great solutions for low and moderate tension wounds. Remember that a high-tension wound can be easily transformed in to a low tension wound with a layer of deep dermal sutures.
For longer lacerations you plan to suture, running percutaneous sutures or even running horizontal mattress sutures will get that wound closed much faster than simple interrupted sutures.
No Returns
Tissue adhesive glue and tape for closure have the added benefit of obviating the need for a return visit, and thus save your patient an additional health care system interface, at a time when that interface could mean infectious exposure risk.
Absorbable sutures used for epidermal closure may also have a role here. Pediatric facial lacerations can be closed well with fast absorbing plain gut sutures and selected adult wounds can be closed with vicryl rapide. In both situations, the intention is for the patient to manage the wound at home since the sutures dissolve and thus don’t require the need for a return visit (in practice, you might advise the patient to remove the suture strands with a pair of tweezers once the knot breaks).
For the selected patient who can understand the technique for suture removal, you may even consider discharge with a little gift bag of a suture removal kit and a timeline of when to take the sutures out.
PPE Preservation
In normal times, I err on the side of being fairly rigorous with PPE. I use a surgical mask with face shield and sterile gloves (or nitrile for uncomplicated upper extremity lacerations), and sometimes even an impenetrable gown if it looks like the repair is going to be bloody or messy.
But in the weeks ahead, we anticipate shortages of personal protective equipment which will be vital to help us mount a confident response to COVID patient surges.
In light of this, I advocate for skipping the surgical mask entirely during uncomplicated wound repair. Remember, for wound closure the mask is meant to protect the patient from you, not the other way around. Theoretically, your exhalation and saliva while talking during the repair could contaminate the wound but any appreciable increase in infection rates have never borne out in studies. Still, if this unnerves you, just keep your mouth shut.
Eye protection is important, but doesn’t require wasting any one-time usage PPE. Get yourself a pair of construction goggles with side-eye protection. These can be re-used and wiped down between patients with soap and water. And the protective gown is a no-brainer; skip it entirely as long as you yourself have no open wounds exposed that could result in blood-borne pathogen exposure.
Much like the wounds I would sew in the tent in my outdoor festival days, a pair of protective eyewear and gloves is all you really need for PPE.
Thanks for reading, and I hope the ideas generated will help you in your personal or departmental workflows as we prepare for the expected patient surges during the pandemic.
Speaking personally as an Emergency Physician, it’s never been harder for me to climb the hill from the parking lot to the entrance of my ED to work my next shift. But at the same time, my work has never felt so important. So I keep putting one foot in front of the other to walk up that hill, and I hope you will too.
Stay safe.