Have you seen my finger? A guide to wound care.

lacerationLast week, as my wife is finishing dinner, I’m cleaning a couple of glasses for iced tea. I’m not sure what happened, but the glass starts to fall. Unfortunate to be blessed with ninja-like reflexes, I catch it. Sort of. In catching it, I slam it into the granite, and it breaks in my hand. The bottom half falls to the ground while the part I’m still holding cuts into my left pinky finger. Disregarding the germ theory, I grab some paper towels to hold pressure. I’m trying to keep the kids and the dog from walking through the glass as I clean it up and drip blood on the floor. I didn’t really have time for this. I was getting together in 30 minutes for a neighborhood card game. Still had to get the kids in the chairs for dinner. Still had to eat. Long story short, I had some wound glue and fixed it. It bled under the glue and didn’t look very professional, but a Band-Aid took care of that. However, my near-ampuation (not quite) made me think: if I weren’t a doctor, would I have gone to the hospital? Would I have known how to treat it or what infection would look like?

Mostly, wounds need good cleaning. With water. Not with peroxide, not with alcohol, or whatever other home remedy you’ve heard. In the hospital, we use saline (salt water at the normal “salt” level of your body, so it doesn’t burn). But, tap water works just as well. It’s the “irrigation” effect of the water, squirting the bacteria out, so soaking in water won’t do the trick. Once it’s clean and there are no foreign bodies (like glass) in there, you have to make certain nothing bad is injured. If everything is working ok, and nothing is particularly numb, especially if the cut is superficial (not deep), then it’s likely it’s just a simple laceration.

The next step is deciding if it needs sutures (stitches). Stitches help cuts heal faster. They can make the scar smaller. In general, the more cosmetic an area (like the face), the more likely a cut needs some repair. Hand lacerations less than an inch or so tend to do ok without stitches. If bleeding is an ongoing issue, sutures can sometimes help that by bringing those edges together and allowing all the little clotting factors to do their thing. Sutures probably don’t prevent infection, other than the fact that it restores our best bacteria-fighting organ, our skin, back to some integrity. In fact, some really nasty, contaminated wounds we don’t suture initially, we bring you back a couple of days later for something known as delayed primary closure, once we’re certain the laceration is not looking infected.

Most cuts don’t need oral antibiotics, just good wound care, which can include topical antibiotics. I’ll let you discuss that on an individual basis with your doctor. While all cuts scar, there are some things you can do to decrease that. One is prevent infection, or treat it early if it develops. Signs of infection include redness (getting worse), swelling, pus, fever, increasing pain. Once the laceration is healed, rubbing vitamin E oil into the wound helps soften the scar. Another way to minimize scarring is to keep the wound out of the sun for the first year. Scars like to soak up pigment in our skin, which is essentially what a tattoo is: scar the skin with pigment. So, either cover, or really strong sun screen.

  • Clean the cut – usually running tap water is fine
  • Maker certain everything works ok – not tendon or nerve damage
  • Decide if this cosmetically needs to be fixed
  • Apply antibiotic ointment twice a day
  • See a doctor if the cut gets infected
  • Try vitamin E oil and sunscreen to minimize the scar

If I hadn’t been in such a hurry when I got cut, I probably would have just wrapped it with some gauze after I applied some antibiotic ointment. Being a doctor, I got to cheat with the glue.

What wounds have you had that you wish you had treated differently?

MD, PA, NP: sorting the letters of health care providers

These days, there are so many different providers of health care, which one you’re seeing might be a source for confusion.  There are so many different letters involved, sometimes medical business cards are like a tornado of alphabet soup. There are MDs, DOs, FNPs, ACNPs, PA-Cs, and CRNAs. There may be more that I’m forgetting. On top of that, the various training levels doctors go through to become a “real” doctor is also somewhat difficulty for the public to follow. Let’s break it down.

I’ll start with the docs, since that’s the one I’m most familiar with. After 4 years of college and 4 years of medical school, these physicians graduate with a doctorate degree, either Medical Doctor (M.D.) or Doctor of Osteopathy (D.O.). These two types of schools are similar, but the osteopathic school tends to be more holistic, using some manipulative techniques to assist in healing the body.

After medical school, these young doctors go to residency. This is specialty training, and it lasts 3-5 or more years. Yes, even your primary care doctor, or the old term “G.P.” is a specialist these days. While in training, these guys are actually doctors (as soon as they get that M.D. or D.O. degree), but they aren’t ready to take care of patients on their own. Gradually, over the course of their training, they are given more and more responsibility and autonomy. After residency, most of these physicians will go out into practice, and a small number will become subspecialists, which requires a fellowship. During that time, these doctors are no longer called residents. They’re called fellows. Eventually, everyone ends up as an attending physician, the proverbial “real doctor” everyone at teaching hospitals wants to see.

As you engage the health care system, you will also encounter midlevel providers: nurse practitioners (NPs), physician assistants (PAs). In most situations, these people work under the supervision of a physician, but that varies from state to state.  These providers are a great resource, and help make more health care available to more people throughout the country.  Just like doctors, some are great, and some are not so bright, but that’s true everywhere. Most are very intelligent and provide excellent care. I would not hesitate to receive care from a good midlevel provider.

Nurse anesthetists (CRNAs) are nurse practitioners who work in the operating room delivering anesthesia to patients. Again, these folks usually work under the supervision of an anesthesiologist, although this, too, varies by state. The CRNAs are trained in all matters of anesthesia care.

In summary, medicine is a team sport these days. In an attempt to deliver quality but cost-efficient health care, there are an increasingly diverse number of players on that team. Don’t hesitate to ask questions about each person’s role in the care you’re receiving.

What interactions have you had with various or less-traditional providers?