Does This Really Need Vascular Surgery?

In light of the recent JUCM article by Dr. Benjamin Barlow, Alan Ayers, and Monte Sandler, I wanted to talk about acuity degradation in urgent care. For me, it always circles back to lacerations. This articles shows that urgent cares are taking care of few lacerations than they did 10 years ago. Why? Is it patient volumes, reimbursement, lack of training/confidence? Likely a combination of these and more. 

I just took care of a patient in the ED with a 1.5cm laceration of the finger. (Image 1) She cut herself with scissors while working as a hairdresser. She went to a local urgent care, was evaluated, and was told that she may have severed an artery and needed to go to the ED. Her tetanus was updated, the wound was bandaged, and she was discharged.  

I acknowledge that I did not see the wound when she presented to urgent care. She described a lot of blood oozing from the wound, but did not describe arterial pulsations or blood shooting from the wound. I understand how this can be intimidating. This is not a condemnation of anything the clinician at urgent care did. I completely understand why it was sent! This is just a teaching moment that I wanted to share with you. 

Think about it from the patient’s perspective. Small wound, sent away from urgent care, then easily managed and repaired in the ED. An extra 2-3 hours of her time and a much larger bill. She wondered why they could not have handled this at urgent care. I made sure to not bash anyone-we are all on the same team here! From an urgent care perspective-what message does this send? Does this type of experience leave a lasting impression? Will this patient come back or will they bypass you for something simple in the future? Do you want to be more than just a cough and cold clinic? 

It comes down to education, knowledge, understanding anatomy, principles of acute wound management, and having the skills to pull from to address a wound. First and foremost, when you see a bad wound, check your own pulse – don’t let the outward appearance overwhelm you. Yes, there is bleeding-that is expected. Knowing the anatomy of a finger (Images 2 and 3) allows you to understand that the location of this wound is nowhere near any major artery that would need surgical repair. The dorsal and volar digital arteries run along the sides of the finger, much deeper in the tissue. This was likely some arteriolar injury. There is significant collateral and redundant circulation in the finger. Even if one of the small dorsal or volar arteries are injured, orthopedic or vascular surgery will not be repairing this. From a physiology standpoint, closing the wound creates a tamponade effect. The tension applied by the sutures, bringing the wound together, will overcome the pressure within that bleeding arteriole and the bleeding stops.  

Urgent care clinicians have to have the right equipment. In this case a finger tourniquet (Image 4) or a glove with the tip of the finger cut off and rolled down to the base of the finger to allow for hemostasis, allowing visualization of the wound and repair it. (Image 5) Also, lidocaine and epinephrine, either directly into the wound or as a digital block will provide vasoconstriction and can help control the bleeding.  

The wound was irrigated with tap water at the sink, a finger tourniquet was applied allowing for inspection and evaluation of the wound. Four simple interrupted nylon sutures were placed. (Image 6) There was a miniscule amount of oozing. Bacitracin ointment and a bandage were applied.  

Maybe you have not seen a wound like this before. Even after doing this for 15+ years, I still see lacerations that I have never encountered. What I can do, however, is take principles from other wounds that I have seen and apply them to the wound in front of me. This is where core knowledge comes in. I frequently talk about how managing lacerations is 90% knowledge and 10% suturing skill. This case is a perfect example of that. The four interrupted sutures was the easy part. The hard part was coming up with a strategy and approach with how to handle the wound. Understanding anatomy, physiology, pharmacology and what tools to use allowed for a simple repair.  

If you have not yet taken a look at The Laceration Course I encourage you to do so. I want you to have the confidence to manage any wound that walks through your door. I know you can do this and want to help in any way I can.

Sincerely,