No stitches for dogbites?

SkyHog

SkyHog

Touchdown! Greaser!
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Everything Offends Me
So after Brianna was attacked by Piper, we went to the hospital to get her wounds checked out. She has a really nasty gash, about 1/2inch long, on her right arm, and it was split wide open good (apparently, he bit and pulled). At the first hospital, the Triage person told her "I would have just put superglue on it" and then told us that Presbyterian does not stitch dogbites due to liability.

So, I showed up, raised serious hell (I think I scared them), and got the copay refunded. We then went to a second hospital and decided to tell them that she was washing dishes and a glass broke and slashed her up. They stitched her up without a problem.

Is it common to not get stitches for dogbites? I wanted desperately, after the stitches were in, to say "oh, btw, that was a dogbite," but decided against it, since we were at the hospital until about 1230 this morning.
 
?????

Liability? For what? that sounds pretty weird. I think you made the right call on the "washing dishes" thing, but I have never heard of a hospital not suturing due to "liability."
 
Closing a contaminated wound is a good way to get some serious infection, even if you get antibiotics. It is usually best to leave small wounds open(1/2 inch is small). You can always deal with the scar later.

Barb
 
The reason they consider a dog bite wound and a glass wound differently is due to the risk of infection. It's probably not a good idea to try to game the system by lying to your doctor.
-harry
 
Sounds like the first hospital failed to explain the reason for not closing the wound. Perhaps they need an inservice on patient relations.
 
I don't suture too many humans but do a lot of animal to animal bites and when I look at such bite wounds, I assess how contaminated it is.
If it is full of bacteria (ie a dog's mouth) I might make a laceration smaller but probably won't always close it because you might end up trapping those bacteria in, resulting in a wonderful cellulitis or abscess 5 days down the road.
If it is clean (and recent) I will probably irrigate well and then primary closure.
By not revealing that the wound was contaminated, you could inadvertently cause a problem for the patient.......and it really helps the docs if you tell them the truth up front so they can respond appropriately.
With my limited knowledge of human medicine, I could't fault the first docs for not suturing as long as they gave antibiotics and did local therapy (flushing/soaking). Of course hard to say anything defiinite without having been there and having seen the wounds.
 
I should have taken a picture for reference. They irrigated the holy crap outta her wound, so I think infection issues are ok. I would actually think that slicing a hand open in dirty dish water would be more infectous, no?
 
My kid had a run-in with a dog and got a gash on her nose, about 6 years ago. They numbed it up, then irrigated it and put 8 stitches in about a 1/2" tear. The scar isn't noticable, they did a good job. But first I had to get past that 'look' they gave me that meant they thought I did it to her.
 
Nick

I have practiced for 23 years and treated conservatively in excess of a hundred severe bites to the face, scalp, ears, nose, and periorbital areas subsequent to dog bites. The "record" involved placing 285 skin sutures (did not count the sutures placed for layered closure) in a 23 month old. These wounds need to be carefully irrigated and debrided. Emergency room Docs may not have had adequate experience, necessary specialized training, or simply the time to provide the necessary care required for care of these wounds (as they relate to maxillofacial region; unlike Brianna's wound). I have always closed the wounds primarily in the cases wherein the wound was a fresh one. Perhaps, I have been fortunate with regard to the risk of infection. As to the Hospital's concern regarding liability; I can only speak to my own medical liability issues. in my 23 years, I have not seen any risk as to scarring or infection.

I am sorry for you and your mate's bad experience and wish you both well.

Scott
 
redcloud said:
Nick

I have practiced for 23 years and treated conservatively in excess of a hundred severe bites to the face, scalp, ears, nose, and periorbital areas subsequent to dog bites. The "record" involved placing 285 skin sutures (did not count the sutures placed for layered closure) in a 23 month old. These wounds need to be carefully irrigated and debrided. Emergency room Docs may not have had adequate experience, necessary specialized training, or simply the time to provide the necessary care required for care of these wounds (as they relate to maxillofacial region; unlike Brianna's wound). I have always closed the wounds primarily in the cases wherein the wound was a fresh one. Perhaps, I have been fortunate with regard to the risk of infection. As to the Hospital's concern regarding liability; I can only speak to my own medical liability issues. in my 23 years, I have not seen any risk as to scarring or infection.

I am sorry for you and your mate's bad experience and wish you both well.

Scott
Click to expand...


I wouldn't say you were fortunate. It sounds more like you are just meticulous. I'm more inclined to close facial wounds, the blood supply is good and it seems like the wounds are much more "resistent" to infection. The "farther from the heart" that the wound is, the less likely I am to close a contaminated wound especially small ones. Cosmetics isn't as much of an issue and the risk for infection is greater.

Barb
 
SkyHog said:
So after Brianna was attacked by Piper, we went to the hospital to get her wounds checked out. She has a really nasty gash, about 1/2inch long, on her right arm, and it was split wide open good (apparently, he bit and pulled). At the first hospital, the Triage person told her "I would have just put superglue on it" and then told us that Presbyterian does not stitch dogbites due to liability.

So, I showed up, raised serious hell (I think I scared them), and got the copay refunded. We then went to a second hospital and decided to tell them that she was washing dishes and a glass broke and slashed her up. They stitched her up without a problem.

Is it common to not get stitches for dogbites? I wanted desperately, after the stitches were in, to say "oh, btw, that was a dogbite," but decided against it, since we were at the hospital until about 1230 this morning.
Click to expand...

Congrats..

YOU ARE AN (insert insulting word of choice here). FOR LYING. :mad2:

Animal bites are dirty. They drain. They get infected. They need to heal from the inside out. And that means you DONT CLOSE THEM UP completely :nono:. Best compromise would have been closing it, putting a drain into the suture line then you following up in a few days at another doc's office for drain removal and wound check.

I hope you are proud of yourself for LYING :nono:to a medical healthcare practitioner to get what you ignorantly thought was best. Are you going to SUE them when the wound gets infected because you tricked them into closing it?

And the nurse at triage at the first place was an idiot for telling you she would have closed it as well (with glue or otherwise).. Its not the superglue thats the problem.. we use it medically.. its the act of closing the wound.

I hope your loved one doesn't suffer any harm as a result of your bad decision making.

If you were worried about a scar, you let it heal, then go see a plastic surgeon to get a revision on a HEALTHY, CLEAN wound bed.
 
SkyHog said:
I should have taken a picture for reference. They irrigated the holy crap outta her wound, so I think infection issues are ok. I would actually think that slicing a hand open in dirty dish water would be more infectous, no?
Click to expand...

No. an animal (or human) mouth is much dirtier. Unless you are washing muddy boots and fresh turds in your dishwater..
 
Doggtyred said:
Congrats..

YOU ARE AN (insert insulting word of choice here). FOR LYING. :mad2:

Animal bites are dirty. They drain. They get infected. They need to heal from the inside out. And that means you DONT CLOSE THEM UP completely :nono:. Best compromise would have been closing it, putting a drain into the suture line then you following up in a few days at another doc's office for drain removal and wound check.

I hope you are proud of yourself for LYING :nono:to a medical healthcare practitioner to get what you ignorantly thought was best. Are you going to SUE them when the wound gets infected because you tricked them into closing it?

And the nurse at triage at the first place was an idiot for telling you she would have closed it as well (with glue or otherwise).. Its not the superglue thats the problem.. we use it medically.. its the act of closing the wound.

I hope your loved one doesn't suffer any harm as a result of your bad decision making.

If you were worried about a scar, you let it heal, then go see a plastic surgeon to get a revision on a HEALTHY, CLEAN wound bed.
Click to expand...

3 days later, its fine.

edit: BTW, if I inserted my insulting word of choice, it wouldn't fit in your sentence because it doesn't start with a vowel. Are you sure you want me to pick my own word?
 
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redcloud said:
Nick

I have practiced for 23 years and treated conservatively in excess of a hundred severe bites to the face, scalp, ears, nose, and periorbital areas subsequent to dog bites. The "record" involved placing 285 skin sutures (did not count the sutures placed for layered closure) in a 23 month old. These wounds need to be carefully irrigated and debrided. Emergency room Docs may not have had adequate experience, necessary specialized training, or simply the time to provide the necessary care required for care of these wounds (as they relate to maxillofacial region; unlike Brianna's wound). I have always closed the wounds primarily in the cases wherein the wound was a fresh one. Perhaps, I have been fortunate with regard to the risk of infection. As to the Hospital's concern regarding liability; I can only speak to my own medical liability issues. in my 23 years, I have not seen any risk as to scarring or infection.

I am sorry for you and your mate's bad experience and wish you both well.

Scott
Click to expand...

Scott, I had a bad experience with an infected wound a long time ago. The wound was from a broken bottle in a lake which went all the way through the fleshy part of my foot between ankle and toes. I first went to the local ER where a doc cleaned it out and sewed it up. Two days later I was admitted to the hospital for a severe infection that was traveling up my leg. They put me on some antibiotics, reopened the wound and cleaned it out several times before sending me home (sans stitches) three days later. Obviously, the wound wasn't properly cleaned at the ER but I do recall my doctor saying that they never should have stitched it closed. I certainly wouldn't have been concerned about a scar on the sole of my foot.

BTW, there's something at the wound site that's still producing an annoying callus that I have to cut off every couple weeks or so. One doc I had look at it said it was a wart (there's nothing I can see but dead skin building up) and he attempted to kill the wart by freezing with liquid N2 after removing most of the callus but that (and subsequent more recent attempts by me to treat with an OTC freeze tool) but nothing has ever had an effect. Do you suppose this really is a wart or is it possible that something from the original infection is causing the callusing?
 
Warning, don't look at my next post, it has some pictures of bite wounds. Avert your eyes if squeamish!
 
As if on cue, tonight we had 4 dogs come in - all had contaminated bite wounds about the face from scuffling with feral hogs.
Some warranted primary closure. Some were large with dead space and filthy enough to do partial closure with drain tubes and lavage. These are tough dogs, all the wounds had good vascularity so I bet they heal rapidly. A couple had inverted V flaps on limbs (which means trouble...the V will die because the blood supply comes from the top and the flap is detached from the vessels...No problem - lots of skin at these sites - excise flap and plastic surgery to fill in defects as needed. 6-Dr. hrs later, all parts are in roughly correct general location!
 

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I do recall my doctor saying that they never should have stitched it closed..
Click to expand...

ah, that retrospectoscope is always 20:20!

BTW, there's something at the wound site that's still producing an annoying callus
Click to expand...

sounds like a keloid to me (non-MD response)
google it.
 
redcloud said:
Nick

Emergency room Docs may not have had adequate experience, necessary specialized training, or simply the time to provide the necessary care required for care of these wounds....

Scott
Click to expand...


Let's propagate a few more false stereotypes, shall we?

Jon
 
WAAAAY back when I was a CG medic (trained as a physician assistant) the standard of care for ER/clinic treatment of any bite (or otherwise "dirty" wound) was cleaning and debridement under local anaesthesia, followed by closure with drain in large wounds, to partial closure with medium wounds, to no closure at all for small/shallow wounds. Goal was to prevent infection.

Even FARTHER back, when I was bitten on the face by a sheepdog as a teenager, the treatment was daily cleansing with peroxide and a q-tip, letting the punctures heal from the inside out.

Disclaimer: I let my PA license lapse over a decade ago, so I know very little about current standards of care unless my daughter received it recently. But the fundamentals don't change much - that's why they're fundamental.
 
Nick,

Seriously - dog bites are a serious risk of infection. SERIOUSLY.

My wife got bit by a pit bull. It wasn't intentional - she was roughing him up and he was young and trying to be playful - but it punctured her arm. A small puncture - 1/4" diameter maybe.

We didn't get it treated professionally - we cleaned it out and put neosporin on it.

Two days later she had red streaks on her arms down to her hand and up to her shoulder. She was put on IV antibiotics and heavy doses of take home meds. She was nearly hospitalized.

You do not want to take chances with these kinds of injuries. It may be that two days later, she's ok - but that's a case of luck only.
 
Let'sgoflying! said:
I don't suture too many humans but do a lot of animal to animal bites and when I look at such bite wounds, I assess how contaminated it is.
If it is full of bacteria (ie a dog's mouth) I might make a laceration smaller but probably won't always close it because you might end up trapping those bacteria in, resulting in a wonderful cellulitis or abscess 5 days down the road.
If it is clean (and recent) I will probably irrigate well and then primary closure.
By not revealing that the wound was contaminated, you could inadvertently cause a problem for the patient.......and it really helps the docs if you tell them the truth up front so they can respond appropriately.
With my limited knowledge of human medicine, I could't fault the first docs for not suturing as long as they gave antibiotics and did local therapy (flushing/soaking). Of course hard to say anything defiinite without having been there and having seen the wounds.
Click to expand...

See, now that's the kind of info you need in order to make an informed decision. IF all they told me was "we don't suture dog bites due to liability," then I would have done exactly what Nick did -- call BS and go get it fixed. If they told me "we leave them open because the risk of a dangerous, potentially deadly infection from dog bites is very high, and it is better not to seal the wound in that case" then I'd say, okey dokey.

Seems like a failure to communicate.
 
Let'sgoflying! said:
I agree; we can never talk enough.
It is also true that studies have shown patients only retain 10% of what they are told verbally!
Emotionally charged situations, less.
Click to expand...
Yup.. Should have said
"It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites.
It's not good for the patient to seal animal bites."

Since it's repeated 10 times, they'll remember
"seal animal bites."

and will forever after have an irrational fear of seals.

Nick, hope Brianna's OK.
 
Let'sgoflying! said:
I agree; we can never talk enough.
It is also true that studies have shown patients only retain 10% of what they are told verbally!
Emotionally charged situations, less.
Click to expand...

I believe that.

Communication consists of sending AND receiving. :D
 
flyersfan31 said:
I believe that.

Communication consists of sending AND receiving. :D
Click to expand...

And the obligation is on the sender to ensure that his message was received and understood. No confusion of symbols or any other barriers to communication. Quizzing's a good way to ensure this, e.g. "So, you understand that Brianna's going to have an open wound for a few days to care for. Do you remember why we leave the wound open"?

FOI has been useful - I'm not doing anything very different when I teach, but I'm more aware of WHY the techniques I use are effective, and I'm more alert to when they may not be.

It's too bad, FOI says nothing about teaching the mentally ill - which would be useful with my current client. Maybe I can get approval for some special ed classes.
 
TMetzinger said:
And the obligation is on the sender to ensure that his message was received and understood.
Click to expand...

I think we are going to see more audio/vid taping of visits. Mainly from a cya standpoint. I hear quite a few are already doing it. Just like every big company you call tapes everything. What will be interesting is to see if the law will allow patients to access the tapes when they think they have been wronged.
 
Let'sgoflying! said:
I think we are going to see more audio/vid taping of visits. Mainly from a cya standpoint. I hear quite a few are already doing it. Just like every big company you call tapes everything. What will be interesting is to see if the law will allow patients to access the tapes when they think they have been wronged.
Click to expand...

Not a bad idea for doctors. I'd do it.
 
Please believe me, I am not being derisive of ER docs; I see an occasional facial wound that had been closed and healed with significant scarring and/or a history of post treatment infection. Invariably, there is evidence of inadequate debridment and a foreign body/debris is found. Often, the treating Doc did not revise the wound margins to remove compromised tissue. From what you related in your post, it is certainly possible that a foreign body may have been left behind.

Scott





gismo said:
Scott, I had a bad experience with an infected wound a long time ago. The wound was from a broken bottle in a lake which went all the way through the fleshy part of my foot between ankle and toes. I first went to the local ER where a doc cleaned it out and sewed it up. Two days later I was admitted to the hospital for a severe infection that was traveling up my leg. They put me on some antibiotics, reopened the wound and cleaned it out several times before sending me home (sans stitches) three days later. Obviously, the wound wasn't properly cleaned at the ER but I do recall my doctor saying that they never should have stitched it closed. I certainly wouldn't have been concerned about a scar on the sole of my foot.

BTW, there's something at the wound site that's still producing an annoying callus that I have to cut off every couple weeks or so. One doc I had look at it said it was a wart (there's nothing I can see but dead skin building up) and he attempted to kill the wart by freezing with liquid N2 after removing most of the callus but that (and subsequent more recent attempts by me to treat with an OTC freeze tool) but nothing has ever had an effect. Do you suppose this really is a wart or is it possible that something from the original infection is causing the callusing?
Click to expand...
 
redcloud said:
I wasn't being derisive of ER docs. But, it is pretty difficult to be expert at everything that they come across.

Scott
Click to expand...

Hey at least you guys got er docs. Years and years ago, I gashed my foot on a rock in a stream. Deep enough to sever the flexor tendon, but we didn't find that for a few months. Anyway - who "cleaned" me up and stitched it up -- the ME! I guess nobody else was available. I use 'cleaned' in quotes because of the raging infection that ensued. The stitch job is pretty nasty looking too, but that was almost 35yrs ago, and the toe-to-heel scar from the surgery to reattach the tendon attracts most of the attention.
 
flyersfan31 said:
Hey at least you guys got er docs. Years and years ago, I gashed my foot on a rock in a stream. Deep enough to sever the flexor tendon, but we didn't find that for a few months. Anyway - who "cleaned" me up and stitched it up -- the ME! I guess nobody else was available. I use 'cleaned' in quotes because of the raging infection that ensued. The stitch job is pretty nasty looking too, but that was almost 35yrs ago, and the toe-to-heel scar from the surgery to reattach the tendon attracts most of the attention.
Click to expand...

The reason why you didn't get an ER doc back then -- they didn't exist.

As far as I understand, my dad was one of the first trained ER docs in existence. About 36 years ago he finished med school and went to do a residency in a brand new specialty -- emergency medicine -- which he did in Lansing Michigan. From what I hear, ER residency programs were established in both Lansing and in LA around the same time.

Prior to that the folks who worked in emergency rooms were either GPs or specialists in other fields (such as the ME you saw). Presumably experiences like yours were why folks decided there was a need for an emergency specialty.

Chris
 
That is true, EM is one of the youngest specialties in the house of medicine. My residency is one of the older ones and is only 33 years old, and the specialty is still growing, we established our residency here only 2.5 years ago, and that was a big deal...

Generally speaking, one has to think twice and weigh the options with regards to closing animal (especially dog, cat and human) bites. It's not prohibited, one just has to use sound medical judgement with regards to it's location, size, depth, time since injury, etc. There is no one right or wrong answer...

Ryan in Madison
 
Closing one of these is completely in the area of "Doctor's judgement". Animal bites are SOOoooo loaded with AWFUL types of bacteria that it may result in a better cosmetic outcome if they are left OPEN (amazing, no?), and then closed after a week.

You can really get bacterially deadly ill from not letting one of these drain. It'll drain allright, even if sealed-->into your bloodstream and lymph system.
 
Many doctors advise not closing other small cuts as well, especially in areas that are prone to infection due to low blood flow or other reasons.

From personal experiance, my dad knicked his knee with a grinder a few years back, cleaned it well and pulled it shut with band-aids and kept it covered with gauze, also used neosporin in the wound. A week or so later it was infected and he went to the doctor. The doc cleaned it, and left it open with just a light gauze covering. He told my dad if he had done that to start with, it would have been nearly healed.

Basiclly most deep wounds need to heal from the inside out, and should be left open to promote drainage. Keep them clean and lightly covered to prevent irritation.
 
Lying to medical professionals is a bad idea. No, they aren't all-knowing, but it's entirely probable they know things you don't, which was the case here.

1/2"? That's tiny. I had an inch gash in my hand (still have the scar, but it's pretty hard to see) from when I wasn't taking proper precautions while using a drill press. Oops. My own stupid fault. Nurse cleaned it out, put some steri strips on it, and left it. Stitches don't always make sense.
 
Ted DuPuis said:
Lying to medical professionals is a bad idea. No, they aren't all-knowing, but it's entirely probable they know things you don't, which was the case here.

1/2"? That's tiny. I had an inch gash in my hand (still have the scar, but it's pretty hard to see) from when I wasn't taking proper precautions while using a drill press. Oops. My own stupid fault. Nurse cleaned it out, put some steri strips on it, and left it. Stitches don't always make sense.
Click to expand...

True - but I still find it amazing that a sink full of dirty dishes, bacteria, and disease is less harmful than a dog bite.

FWIW, she removed her own stitches 3 days ago, and all is almost healed now.

Perhaps the difference is that it was a gash and not a puncture?
 
FWIW, when my son got a bit by a dog he got stitches and staples... about 100 or so.

Ruckin
 
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