Good morning, everybody. So, do we have any residents? One. All right. Yeah, yeah, happens to be my oldest daughter. There we go. So, John Burrus, Bob Bourgeois, Dina Stetson, Doug Martin. If you can't learn something from one of these four, there's something wrong with your brain, right? Now, so, this is a workshop. It's going to be very informal. I'm going to be talking. Bob's going to be talking. We're probably going to disagree on this or that. It's okay. If you have a question, the person next to you probably wants to hear your question and the answer. Okay? It's going to be interactive in addition to the before and after slides that you'll see. I hope you don't mind seeing a little bit of blood this morning. We have video. We have the suture mats. We'll orient ourselves to the suture mats. Let me go through a little bit of didactic, but I promise you I won't talk very long. We have no real disclosures to announce. So, there'll be other people kind of coming in. That's fine. If you're going to suture, you need to come up to the table so you can actually put it on a flat space. So, the question that you might want to ask yourself is what specific skills limit what you do in your office? Can you do a digital block? Yes or no? Everybody can do it? Uh-huh. How you do it, how successful you are, I hope to talk a little bit more about that. Dina's going to man a hand mannequin. I think she's nicknamed it the thing. And this is the first time we've had that, so we hope to use it to good effect. Can you do a layered closure? Okay. If you can't do a layered closure, there's some deeper sutures that you shouldn't probably mess with. But the techniques are not that difficult. That's why you're here. I hope to get through the simple, easier type of suturing so that we can spend more time on layered closures. Okay. Can you deal with nail trauma? Do you have a nail elevator, a specific tool in your office? 20 bucks. You should have four of them sterilized. Okay. Can you do basic plastics techniques? Okay. Bob's going to demonstrate some. I have pictures. Okay. You can't put Humpty Dumpty back together if you need some basic plastic techniques. Okay. Foreign body exploration. We've all been there. Give yourself 20 minutes. If you haven't found it, go home. For God's sake, be able to take cold steel to an abscess. All right. So objectives, refresh and advance. Wherever you are in your journey, let's advance. These suture mats, how many people teach residents, medical students? This is a train-the-trainer course. You're going to take those home and for the rest of your career you can teach whoever comes in your office how to suture. Okay. Additional skills if we can get to it. All right. So treatment goals, minimize pain and repair. Right? We're not there to provide the maximum amount of torture, right? Prevent infection, restore function, optimize cosmesis. Notice I put the cosmesis at the end. I take care of construction workers. Bob takes care of maritime. Doug takes care of, you know, people in the meatpacking industry. Most of these women and men, cosmesis is lower down than preservation and restoration of function. Okay. You'll notice the suture technique I use is industrial strength. Think gladiator medicine. Okay. So it's nice to have some suture technique. So by the way, this case here obviously is a Volsta. See that corner, the proximal corner of that nail? You can't leave that like that. It's outside the eponychial fold. You've got to put that back in. You've got to suture that bed. Most people on a finger would replace that nail for an industrial athlete. That nail serves a purpose. That guy can go to work the next day because the bed's protected. And something's in that fold so it doesn't scar down. The eponychial fold is where the magic happens for the nail. So what you'll see that's a little bit different is, I'll show you pictures of what the hand, how the hand functions. That's, see where he's 14 days out? The guy hasn't missed a day. And see his range of motion on the DIP joint? So this is what you don't want. This is a labor foreman, right? He's not ignorant. He's just scared. A roll-up light, just like a boat trailer, came down and smacked him on the hand. And I'm seeing him, you know, sometime afterwards and he's not used his hand because he thought it might have been fractured. It's a delayed presentation. So I got an x-ray, rolled out a fracture, and I taught him how to do active and passive range of motion. I keep therapy balls in my office. Do you guys have therapy balls? Yeah. So, again, I help with construction workers so they have something called a power tool, right? These things have wide curves. And, for example, this guy, you know, he's a week out and he's got his PIP joint range of motion. If that was taken care of in another place, he'd have a stiff finger for six months and probably would never regain that motion. Okay? You notice how far away from the wound edge the suture material is? You notice I'm using a vertical mattress on a finger. Okay. How many times have you seen a vertical mattress used on a finger? Probably not that many, right? Most people would say, oh, my God, we've got to put it in a splint. No. That's the antithesis of what you are. I would challenge that. Same thing here, bandsaw, wide curve. What's the guy look like 14 days out? I'm keeping the sutures in a little bit longer and I'm telling him when the sutures are in, that's when you move it. Otherwise, you end up with a stiff PIP joint for sure. I'm seeing it a year out for something else. That's what it looks like. He doesn't care about the, you know, the scar. He doesn't care about that. This is what you don't want. And I'm not knocking the EDs. I used to work in them. Bob used to work in them. There's lots of good suturing that happens, but you've seen the ED follow-ups. It's shit care. Urgent care. They don't have the aftercare. You can do a lot better. This is what you don't want. See the number of knots that they use? That was great when my grandfather used silk braided suture material, okay? You don't need as many knots if it's braided. Has anybody here ever used braided? No. Why? More infections. Okay? So we're using monofilament. It needs more knots. Otherwise, it unravels and you end up with this. The guy put it too close to the wound edge in a worker, right? The guy's a plumber. Look at those hands, right? The keratin on that hand, it's leather. It's like an eighth of an inch thick. It's dried out. That's just not what we want, okay? Instead, you know, think of it as a practice builder. You're doing full scope care. Every suture case is a marketing opportunity. Flip it. Think of it like that. People want to talk about their sutures, right? And if it's a cut through a tattoo, even better, okay? These are, I take care of trades people. They know shit work when they see it, okay? As opposed to somebody who's actually taking a moment and trying to put the edges together so that, you know, the tattoo is not lost. The one on the right is a tradeswoman, and she just got this, right? She just invested in this clapper tattoo, and she was so happy that it wasn't, like, more ruined. What do you need in your office? I have a table that goes up and down. I use surgical loops. Bob uses them. Doug, do you have them? Yeah. It's not stupid. Dina uses them, right? Yeah. They're telescopic. My face is, you know, that far away from the wound edge, and I, you know, I didn't bring them this year. Oh, that's right. Anyway, you move your head up and down like a chicken to focus it, okay? And you have to get used to it, but once you do, it's like going from an old Zenith to a flat-screen TV, all right? It's just that much clearer, and I don't know about you, Bob, but I see a lot of tendon injuries, and I take care of a lot of grinder injuries, so they're just, I wouldn't do it without it now. And what you have in your office, I think there's a handout. You can see this picture. You can just mirror this. For an occupational health clinic, you need some tools that you wouldn't normally think you need. I have a nice case of a man with a swollen finger that I needed to take off the wedding ring recently, so you need a ring cutter, and in my opinion, you need needle-nose pliers and wire cutters. Why? I'll show you pictures, but you need to be able to snip the head off a nail so you can pull it through, okay? Do you know what the origin, the etymology of the word physician is? Do you know what it means in Greek? Extractor of arrows. We were tradespeople. We were underneath, in terms of the social, you know, hierarchy, cobblers. We were just the guy you'd go to to pull out the arrow, right? It wasn't until the Romans and the French that we actually had some social standing. John, I would suggest wire cutters might not be good enough. Okay, what do you use? Bolt cutters, and the reason is is because, you know, wire cutters or bolt cutters, there's all different types, right, and, you know, the fulcrum size basically limits, you know, the thickness of whatever it is that you need to cut off. Yeah. So, like, in my world, if somebody puts a meat hook through their hand, the meat hook is fairly stout, and a typical wire cutter, you're not going to be able to do it. So, I'll bring a bolt cutter. Yeah, well, my bolt cutter has got a fulcrum on it like this. They're pretty hefty. They're hard to sterilize, but we can do it. But I guess my message is is know your clientele. Right. That's my bottom line, yeah. Yeah. This curly hue thing here is made of a special metal. What kind of metal was it? That's on blowout preventers on oil rigs. So, that's an alloy that you can't cut, period. I mean, I had these big lineman pliers. I tried that, and the bolt cutters will cut it, but the thing is that's so small, the jaws on them are just so bulky, they can't even grab it. So, that's something you just have to work out. So, here's an example of a couple of needle-nose pliers. That's the thing in the middle over there in the white. That's a bovie. It's got a little heating element. It's great for subocular hematomas. Okay. That's a very quick and easy procedure. All of us should be comfortable with that. The thing on the far left, that's the nail elevator. I'll show you some other pictures of that, but it's like a little bitty baby spoon that you just work underneath that nail. It removes the partially-evolved nail. Okay. So, basic stuff. You know, the goal, I think, at least in my world, is to inspire confidence. Okay. I was talking to some people, I think at breakfast this morning. Evidence-based-wise, you don't have to use sterile saline, and you don't even have to use sterile gloves. But a Jetson sterile saline, the emergency room doc that's covering our clinic this morning, Dina and I work together, he insists on sterile saline. Okay. He's never going to lose that. I go ahead and use sterile gloves and a sterile kit with drapes. It's more for rapport-building in my world. So, it's the assessment. Is the hand stance, finger stance normal? Are you looking at a tendon laceration? Do they have a dropped finger? You would still irrigate it carefully and suture it, because your friendly hand surgeon is going to want to do it elective. Right? Anesthesia, local versus regional, which anesthetic to use, explore the wound, document what you see. Here's where the surgical loops are so helpful. Prep, irrigate, tell the worker, look, I'm spending extra time irrigating. Do people use a splash guard bell? Little bell, keeps it from splashing up in your medical assistant's eyes. It's very nice if you don't have them. It's a cheap little plastic bell. There may or may not be a picture of that in the slides here. Closure, the whole, oh, go ahead. Do you, would you typically do an x-ray after exploring the wound or before to identify additional foreign body, or if you have x-ray on site? Depends. Yes, I often do x-rays. Depends on my flow in the clinic, my concerns. One time we had a shrapnel injury to the belly, and I did an x-ray. Before exploring? Yeah, before. The problem is they didn't do a lateral through the belly. And so I explored it, and there was a hole on the skin and through the perineum. So I got down to the perineum, and I said, OK, off to the Mass General ED where they did a CT scan. And sure enough, they had metal in the liver. So let me just interject. So it really depends on the wound and the flow of the clinic, as he said. Sometimes we'll get the x-ray before we suture, but we have to wrap him really good so he's just not bleeding all the way to x-ray. And then sometimes we just get it after because it doesn't really change what we do with the suture. And we'd rather suture it first, and we have time to do it. You can get a little bit snookered if there's a large metallic foreign body. If there's teeny little sand, sometimes we'd leave that. Depends. Obviously, you'd love to have, especially if it's a grinder, to get as much of the material out as you humanly can. And in terms of plastic techniques, sometimes you actually have to debris, change the shape of the wound. In a lot of my grinders, these are very fast RPMs, and there's a burn on each end, on each edge of the wound. And it's much better heal if you just basically ream out that wound, take away the tissue that you can't really clean. Because, again, it's also burned, and it doesn't heal as well. So the aftercare, I put an asterisk by that because. Can you turn this on? Yeah. We'll get to it in a second. Yeah, yeah, we'll get to it in a second. I'm almost finished talking. So my point is aftercare is critically important. You can do it better than an urgent care and an ED. You can see them the next day, in two days. I don't know, Bob, if you agree, but wound infections often happen day three to six. So it's nice to have them get back in. How you communicate dressing the wound is important. I encourage each worker, look, don't torture this wound with peroxide, alcohol. Less is more. They can actually take a shower the same day unless it's a challenged wound. The evidence base says that it doesn't increase the risk of infection. And for my people, they like to take showers. Their wives won't let them in the house unless they've showered. So that's cool. Just leave the dressing on. Pat it dry. Less is more. I stopped using antibiotic ointments some years ago. Just use simple Vaseline. If you've seen a neomycin allergy, it's not happy. Good? OK. So my nurse practitioner likes to bring them the day after a wound check. Should I just tell her, wait three to six days? Up to the clinical situation. Sometimes when I bring them back, the question is when to do the wound check. And the next day, what are you doing? I mean, what are you going to do different the next day? If it's a real challenged wound, sometime I'll bring them back in two days. Bob, what do you do? Well, we try to bring them back before the weekend, just so we can look at it before they go home. So that might be two days. It might be four days, like we did on Monday. And we'll usually check them on Friday before they go home for the weekend to make sure they take care of it right. And just give them additional instructions if we need to. We should use the mic. It's probably, oh, he's good, yeah. Sometimes I give people my cell phone number and tell them to text me a picture. Oh, yeah, that's a good point. Yeah, go ahead. So if you're lucky like me, and all your major meatpacking locations have on-site occupational health nurses, you train them to do the wound checks, and they call you if there's a problem, and they don't call you if there's not. So again, it's very much dependent upon the situation. There's no question about it. Yeah, so my practice pattern is I have a business card from my cell phone on it, and 24-7, 365. Post-wound care, I had a person call me on Easter Sunday. Okay, now where I'm from in rural Kentucky, a person has to be half-dead to call the doctor on Easter Sunday. But in Northeast, it was like another day. And that was okay. Anyway, so aftercare. So just to close out this part of it here, strengthen the role of occupational medicine clinic by offering this wound care. I think it's a distinguisher. If you have better technique, they can stay at work more. You'll see a lot of these slides I'll have, and the person hasn't really missed any work. So the preceptors, again, we all have our strengths, right? This is what Bob does. Bob was, weren't you general surgery histologist? And then you did the ED? Yeah. And Doug, like myself, did family medicine. You're still boarded in family medicine. I dropped mine after 25 years. I'm ancient. And Dina is, she works with me. This is what we do. This is, the one on the left is my grandfather, Emily's great-grandfather. He was country doc, but he was a really good suturer. And there's a famous hand surgeon at the Houston Clinic that would never have had an opportunity to, you know, help the people that he did if it weren't for my grandfather. And although they looked similar, these are two totally different people. Remarkably similar. But this guy on the right was an orthopedic surgeon during the Iraq-Iran War. And he came to the US and he did internal medicine. And then he shared his suture techniques. And one of the things that you're gonna learn today was from him. But he paid it forward in a remarkable way. And he was loved by the residents at Harvard. So the suture techniques that we're gonna focus on, simple, buried. I'm a big fan of vertical mattress. And in doing the layered closure. The simple plastic techniques, the one we list over there. The kits, let's talk a minute about those kits. The reason why I chose those is if you cut it and bend it, it simulates all the layers. Let's take the mats out of the plastic. Just look at it from the edge. And you'll see it's got these different layers that mimic the tissue. Epidermis, dermis, subcutaneous, fascia, and muscle. And the neat thing about these kits is, when you load it in that plastic contraption there, it can tension it. And the whole thing with wound, once I was covering, I was away, and a nurse practitioner in an office at a medical center said, I can't get the fat back. I can't get the fat back in. She wasn't comfortable handling the tension in the extruded material in a finger wound. But the curve helps to give you an ability to learn how to handle the tension, is what I'm trying to say. Okay? And let's, if we can... Hi, my name is Michael Zenn. I'm gonna be instructing you on 10 different suture techniques, as well as a stapling technique for skin closure. Now, if you're gonna be good at suturing, you need to practice. And here at Duke, we rely on cadaveric material and animal material for practicing, and that's not really very cost-effective and not very practical if you wanna practice anywhere you want. I'm gonna be instructing you on Vata's new suture skill simulator, which is a simulation device I helped to develop. It's incredibly lifelike, and really feels like you're operating and suturing on normal tissue. I certainly would like to thank Vata for supporting this video. I think this suture product that they have made has been a long time coming. It's incredibly realistic. It's compact, so you can take it wherever you wanna go, and it really is a complete solution for anybody who wants to practice suturing. All right, before we get started with teaching different types of suturing, I wanna teach how to tie the knot. The simplest way to do this is with an instrument tie. You simply pass whatever suture we're doing into the skin, and when you're ready to tie it, what I'd like you to do is pull the suture all the way through, but leave a small, short tail, about a quarter of an inch, half an inch is plenty. So you'll have a short end and a long end. And we're gonna keep this pretty simple. You take your needle driver, and you're just gonna simply place it between the two. Take the long end, and then wrap it, and you wanna wrap it twice, and then grab the short end, and then pull the short end across the wound to the other side, and what that does is it locks the wound down. See how it sits there and doesn't move? For the next throw, I'm gonna wrap the needle driver again, and this time, just wrap it once. I'm gonna grab the short end and pull it across, but don't pull up on it. You just wanna tie it down till it gets down to the knot, and then lock it down, okay? Then simply put your needle driver between the two again, wrap it with the long side, grab the short side, and pull it across. So you're doing the same thing every time. The first time, you're wrapping it twice, and that's called a surgeon's knot, and that'll lock it in place, because what you don't want is you don't want the knot to be loose. You want your skin well-approximated. So we call that an air knot when it's not approximated. So just to review one time, once your suture is placed, leave a short tail, wrap the needle driver twice, pull the short end to the other side, locking it. Now, don't pull up on it. Wrap just once around the needle driver, pull it back to the other side, lock it down. And now, for your next throw, you can go ahead and wrap it once again and pull it to the other side. Now, some absorbable suture, you may need to do it four times, but three times for permanent suture, like the suture that comes in your kit, is fine. So the first suture I want to teach you is a simple suture, simple because there's really only one part to it. You're simply going to put the needle in on one side and then put it through on the other side. So it's important to hold the needle in the middle, enter at 90 degrees, exit, and then try to enter again so you can come into the tissue and come up at 90 degrees. Having it 90 degrees on both sides, when you tie it, will approximate the skin beautifully. So that's why I like to do it in two and not try to just run the needle all the way across. Do the instrument tie, as I've already taught you, and see how nicely the skin is approximated. And you'll see as you start doing this more and more, you'll just get faster and faster. It is an acquired skill. So the key, enter at 90 degrees. Sometimes you can keep it in, but you push the skin just to make sure you're getting through it at 90 degrees. And again, that's going to help you to re-approximate your skin. Now, you'll decide how far apart each stitch needs to be. The closer they are together, the more stitching you're going to be doing and the more scar you may have. Some tissues are already just about approximated, so you don't need that many. Yeah. Okay. All right. So I'm going to walk around just a teeny bit. Yeah, flip it back. Okay, yeah, so everybody just use the scalpel and make an incision. Yep, good, good incision. Yeah. Incision doesn't have to be vertical or perpendicular. It can be anything you want it to be. So everybody's got it clipped in. That's good. Okay. Good, good incision. They're all so cautious, John. It's incredible. Yeah. And when he was saying about holding the needle in the middle, it's real important that you don't hold it all the way in the back end. If you don't follow the curve of the needle, you're going to bend it. And then once you bend it, you can't use it. So always grab it in the middle and follow the curve around. Let the needle do the work. Yeah, just get used to this part. Oh, you got one. That's good. Doesn't matter, just grab. Yeah. Do you have to break it? Dina. Oh, no, just pull it. Just retract it. Yeah, nevermind. The safety thing. Okay, yeah, do it. Doesn't matter. I would use the bigger one first. It's easy to put them in the position that's best for you right now, because you can spin them around. But you know your patient is going to have that laceration on the back of their arm, or right in black places, that you have to spin the patient around, or you have to go around the patient. So just be aware that your body position is just as important as the patient's body position, because you don't want to get tired standing in an awkward position trying to suture this person. And Dina has much easier ability than somebody that's my size. I don't see anybody here that's my size. Congratulations. But ergonomics and suture repair is probably another whole different talk. Just a couple of refinements from what Dr. Zinn. Dr. Zinn is a plastic surgeon, and I think he's used to going fast, you know? And I think our world, we need to be more careful with the placement. And by the way, it matters how it looks to the patient and their family. So a couple of things that Bob and I agree on, I don't know, Doug, if you do, but we alternate when we make the knot, we throw the knot. And when I lock it, I pull things to the side. Yes, yes, that's the way that I was taught. Yeah, yeah. So if I could get everybody's eyeballs up this way, can you do one from start? And watch Bob's hands just a teeny bit. It's worth taking a moment. Dr. Mehrdad Hemadani taught me to lock it by pulling the suture to the side. And later, you'll see Dr. Zinn's do it as well. Okay, so. I'm gonna interject also. As much as you can, keep your hands away from the needle. You wanna avoid a needle stick at all costs. Be very aware of where your needle is as you're putting it on the sterile surface. Let them watch. So wrap it twice. Yeah. I pull. So watch this right here. And you see how he's gone off to the side? It seems like a small thing, but to be able to lock it and control that suture and see the tensioning, it's critically important. Because you wanna actually be aware of the tensioning. Not too tight, not too loose, just right. And I do six on monofilament, because with the workers, they're gonna rub stuff, move stuff, and I don't like them coming undone, because they do that. Sometimes they'll pick at them, and they might be able to get one or two twists undone, so I always do six on monofilament. And the other thing is for ease of removal later, you always leave a little tail, but if you pull every knot to the side of the wound, you're gonna make whoever's job easier to take them out, because if you leave them in the middle, they're gonna be in the scab, and then you gotta pull and drink it out, and you're gonna make it bleed, and everybody's mad at you. So always make sure I have it far enough over that you can get to it. Yeah, yeah, and the freshman mistake is to place the suture too close to the wound edge. It's more difficult to get out. It won't hold as well, okay? These are basic, basic things that hopefully our points reinforce. So again, this is the simple suture, also called the interrupted suture. You need to be able to do this well. Bob, I'm gonna take you off. Because it's a building block. So on that first loop, I usually do three loops to pull through, not two, and that really solidifies that first knot. You do three? I do two. Bob, how many do you do? Yeah. No, I take that back. I do two. I'm sorry. Yeah, that's what it is. I do three to get it close. So when you place the needle driver on the suture, do you place it in the middle of the suture? On the needle? On the scoping. Yeah. Use twice as much distance from the wound edge as you normally would. Just surprise yourself. Go far, far away from the wound edge. I promise you, the suture mat will not hate you for it, okay? The suture mat will not say you're doing something wrong. Yeah, take that way far away from the wound edge. Make yourself get a bigger bite. These are industrial athletes. These guys and gals want to work the next day. They don't want to have their finger in a splint for a week and a half. Yeah. Yeah, too close to the wound edge. This is not baby stuff. I hope you guys are getting something out of this. I wish Oh, do you not have a table? I do not. Are you okay? Look at you guys. Right. Oh, man. Little tip and trick. When there's a break, if you can come up closer so that the preceptors know you have the kiss. Pull the needle out in the same curve as the needle. So don't pull straight out. The needle is curved. So use the curve of the needle to come out. There's one up there. Somebody go up there. Hey, Mark, will you help me for one second? We're going to move a table in here. I didn't realize those guys had suture kits. Yeah. Maybe we can let's go over there, I guess. You're not going to suture a worker with their hand in your lap. That's not how I usually do it. Let's put it right here. Yeah. Yeah. You know what? These guys like space. Let's get one more table, Mark. Can you go up? And over. Man, there's a table there if you want it. Great. All right. Everybody's got a little workstation. Bob, where's your microphone? Yeah. Bob, you should answer her question for everybody. Can I move your purse? So the question was, if you see fat, what do you do? And what I'll do is I'll just go ahead and keep suturing. And in between each suture where the fat comes up, I just poke it back down. All right. So the mattress, the mattress suture takes the tension off the wound, but when you tie it you can have the edges bowed up a little bit. But then once you cut the knot, 10-14 days later, it flattens out, it's pretty. Relationship with the needle driver, okay? You don't have to put your fingers in there. You can manipulate it if it's a good tool without, but you can use the fingers. It's okay. Yeah, just the purpose of having a kit is to practice with the tools, okay? Every painter knows how to hold the brush, right? Yes, and you want to go back in the same depth that you went in. See there, you're a little bit, maybe a little bit thin. Yeah, yeah. Yeah, in fact, yeah, you want to, yeah, and then go back in, yeah, the same depth. No, no, no, you have to load that needle in a way that, yeah, you can actually use it. And see how you're holding that? Yeah, you have to be attentive to how you're holding it, because you want to be able to, yeah, right. Right. Yeah, that's good. That's like that. That's good. Now you're off and running. Yes, and then you just get rid of the needle. Yeah, and then you just get rid of the needle, and then you're done. Yeah, and then you just go around twice, and then grab it on the tip, and then, yeah, and you want to have it flat. So you want to invert your, there you go, and then take it this way. See, and you've got it locked a little bit there. And then you can put your knot. Yeah. Now you're just doing one throw. Isn't that amazing? That's amazing. You got it. Nope, just one after you do the first one. You got it. Yes, ma'am. Right, that's because it's tensioned. It's tensioned. That's the whole thing. If we had it flat, it wouldn't be that way, but this is more real to life. So if there's more tension, we'll interpose a vertical mattress and then a simple, and that's the technique we're going to learn in a minute. Yeah, yeah. Right now, you're just learning the interrupted, just getting the mechanics. Go ahead. Yeah. Yeah, perfect. Yeah. Yeah. Right. That's why we need to lock it. Yeah. See, that's right. You locked it a little better. Yeah. Yeah. It's, the beauty of these mats is so you can practice. And it's just like doing anything else. Yes. Okay. Yes. Great. Needles? We have a sharp container somewhere. Here it is. Yeah. Guys, I'm supposed to announce that there is a break from 9 to 9.30. And the beauty part of this particular scheduling is that we have a break, which you can go to the bathroom, you can go to the exhibit hall, or you could stay and practice a little bit more. Yes, ma'am. If it's too deep, you're locking too much work. Correct. Is it my fault? So that's not locked. I will show you. Yeah, it's really, really, really important to be able to lock it, so that way you can see it. So when you're suturing, you want to get rid of the needle. Just focus, just focus on the suture material. Suturing is all about working with the suture material, okay? Excuse me, I don't have my little hands in there. Okay, so this is the secret sauce right here. Oh, I didn't bring it back over. Yeah, see that? See that? Now you try it. Yeah, yeah. That's the secret sauce. Once you learn that, then you've got something. When you do the anesthetic, do you do it outside the wound edges or within? Very good question. What's your name? Anna Nobis. Anna Nobis has a good question. Anna Nobis asked about when you do the local anesthetic, where do you put the needle tip? So the answer to that is don't go through normal skin. You have a cut. Go through the wound edge. Now, the worker may say, oh, don't put the needle in the cut. But you say, look away. This is my job. You're a plumber, okay? Don't tell me how to do my job. I'm going to put it through the wound edge. It's going to hurt you less. Go ahead. So do you spray something? You mean the cold? Yeah, just take this off before you start. I don't personally do that. And I don't personally use a buffer either. Most of the people I suture, they expect to feel pain. If they're not feeling the pain of the anesthetic, they feel like they're getting cheated. I know that you feel the first one. Yeah. Yes. That's a good question. I'm going to combine those two and talk about that in just a minute. Can I get people's attention for one second? So there was two questions. Can people hear me okay? Yeah. Local anesthetic. Again, you want to not try to torture them any more than you have to. Please put the needle tip into the wound edge. And does anybody know how to make this a laser pointer? Yeah. No. Okay. I don't know what I'm doing. So, you want to put the needle tip into the wound edge, and when I do it, I try to leave. I put it in, and then I try to inject, and then put the needle tip in where I've already partially injected. So they really should feel two sticks, one on each side of the wound, if you're doing it right. Okay? And the gait theory of pain is that if you get your medical assistant to rub on their arm, if you're working on a hand, it'll distract them. If nothing else, you'll be empathetic. It gives the medical assistant something to do, and she feels like she's really helping. Would you show us other things? Thank you for watching. Thank you. No, I can see you. All right. I can see you. Thank you very much. Okay, I'm pretty sure that's all. Yeah. Yeah. Right. So, a couple different scenarios when you'll use a digital block, major, major, major trauma, right? Okay, so you get more than like one area that's lacerated or the so-called mangled finger, right? Where you got, you know, stuff is all over the place. Really good for nail repairs, okay? And then if you have like any exploration that you have to do, foreign body, have to wash stuff out, you know, anything that's complicated that you think is going to take extra time is probably the best way that I can explain it to you. It's a great thing to know how to do. Cross the PIP knuckle? Yeah, that's fine. Yeah, that's fine. No problems with this. But if you've got a big laceration that goes this way or you've got the mangled macerated tip or you've got the nail bed that you're gonna have to repair, digital blocks, great. Patients will love it. Absolutely love it. One other little tidbit. What anesthetic do you use? Well, I use actually a combination of lidocaine and bupivacaine. 50-50? Yes. Now, you can use just plain bupivacaine. Send them an x-ray and when you come back, it looks good. The key is to let it sit. You have to let it sit. You have to let it sizzle, stir, on the pot. 10 minutes, 15 minutes, see how the patient come back. If you do it too soon, you're not gonna get full satisfaction. Right. The other thing is, if it's a tip, you can use local lidocaine without that. That's been debunked. Usually, people say, oh, you can't use a lot of things with epinephrine on a tip, but that's now been debunked. That's right. I use it all the time. Yeah, this whole thing about, you know, the way I was tied ears, nose, knees, toes, genitals, you know, that's all a bunch of BS. That's wives' tales and stuff, so there's no problem with using epinephrine at all. The goal is, you wanna have good visualization, so the epinephrine will augment, actually, I'm good. No, I'm not good, thank you. The epinephrine will augment the anesthetic, have it last longer, and help you with the hemostasis. That's a big one, okay, so you can't under-emphasize how important that is, or over-emphasize. Not only when you're suturing it, but afterwards. So, I have workers, they wanna take their girlfriend out to dinner, they're feeling all macho, they had this huge hand injury, I sutured it, they're feeling great, halfway through dinner, their block wears off, now they're whiny baby. So, I tell them, look, don't be macho, go home, elevate it, keep your heart rate down, it's all about the hydraulics, the first day. We send the worker home. They wanna go back to work the same day? I say, no, it's all about the second day, right? A lost time is second day, it's not the first day. So, they go home, elevate it, let the healing start, let the leaky vessels, and then, the next day, okay, you can go. Man, you're burning with a question, go. Is there ever a time where you wouldn't use wireless epi? Like, is there any? I know it's really rough, but you can use it on the appendages and the nose and stuff like that. I don't. The only answer that I can tell you is yes, is if I'm going to do something, but I also know that a hand surgeon's gonna have to do something, and sometimes, my hand surgeon doesn't want me to do that. That's the only. Interesting. Yeah, I, well. My hand surgeons don't like that. You know, John, how hand surgeons are. So, rare, rare. When I'm doing a digital block, I've tried to use lidocaine with epinephrine before, but there are opportunities to inject it intervationally, and I have had someone get a little shaky. Just so you know. Go ahead. So, I have a question as to which kind of suture I would use in the hand. Ah, good question. What suture to use? Depends. Always there's a depends. You have to read the tissue, right? Just like if you're paddling. If anybody ever done whitewater rafting, you gotta read the river, right? So, part of the secret sauce of doing suturing is you read the tissue. For my sake, using 5-0 on a hand in a construction worker, not gonna work well. I must have at least 4-0, otherwise it pulls apart. So. I agree with John. Meatpacking workers forget 5-0. Forget 4-0, to be honest with you. 3-0. The only time I'll use 4-0 is in somebody that has a laceration that's not going to return to an industrial type of an environment. Interesting. So, I mean, I'm probably more conservative than you are. Jesus, all right. Now, if you want to talk about a face, an eyelid, I don't know where you guys' boundaries are, but I have none. I'll suture anything. And because he sutures anything, I suture anything. Yeah, yeah. So, we do have 6-0. Now, if you've ever sutured with 6-0, it's a pain in the ass. It is a pain. So, I think maybe we had the same clinical instruction history. So, during my family medicine residency, I don't know if you had this experience or not, but I did mine in Davenport. So, we had an ENT rotation, but the ENT doctor was also boarded in plastics. So, basically, he was a big believer in see one, do one, teach one. So, he'd get called to the ER for, you know, complexes, that and the other thing. So, I have no problem with vermilion border stuff. I mean, a lot of times, here's the thing, like in family medicine, a lot of times in the residency, I've heard that there's this mantra, oh, don't ever try to, you know, do a vermilion border, you know, or nose or ear or any of that kind of stuff. Well, it all depends on your experience. Yeah. Yeah. I have four daughters, not Emily, but her second oldest. I took them to the emergency room. She had a cut on her lip. I let the pediatric suture her lip. She did a muff. She muffed it. And I've, to this day, I say, I should have just knocked her out of the way. So, anyway, I was trying not to be that dad, you know. Do you ever just do lidocaine to do the cane? Whatever. Or a digital block, do you have a cane like that? Yeah. Oh, yeah, yeah. That's what we said. We both use a 50-50 mix. How much is a 50-50 mix? And how much do you usually, do you use six? It depends on the size of the hand. Yeah, okay. His hands, 10 cc. So, if you had big offensive lineman hands like mine that have been beat up, you know, for years, a lot. If you have a certain part of the meatpacking line where four foot 11, 85 pound individuals are more attuned to get things done better, not so much. But I would say, I don't know what you think, John, err on the side of more. Yeah. And it also depends on where the wound is. If it's a fingertip, you want more to get to the end and wait a little longer so that it gets to the end. And if it's closer, you don't have to put as much or wait as long, in my experience. Yeah. Not sure, you can just ask it. Does it feel heavy? You know, and you can't really predict how quick it's gonna come on. But does anybody else have other great questions about, what technique do you use? You metacarpal, what kind of, are you a web space guy? What do you do? I'm a web space guy. So what I was demonstrating before. There's different techniques here. Some people use a ring block. Bob has this way of injecting the palm. The anatomy is interesting to remember. So you have a digital nerve that comes down in between the metacarpal rays, right? And when it gets to be about right there, it divides, right? And the weird thing about it is, is that one branch goes this way, the other branch goes this way, all right? So where I go is basically there, right? And yes, aspirate, make sure you're not in a vessel, and then inject whatever it is that you've got. It's that simple. So you go to the web space. By the way, here's the anatomy. You know, you've got your extensor tendon. There's actually, you know, two groupings of digital nerves there. Because you, okay, so the anatomy, again, if we're doing index finger, right? Where does the radial digital and the ulnar digital nerves come from? Okay? The ulnar digital nerve is gonna come off this guy, right? The radial digital nerve is gonna come off this guy. So you gotta, so if you wanna do the whole finger, you gotta make sure that you do both sides. Yes. Yes. It's, yes, okay, so between the thumb and the index finger, it's good to come down a little bit more proximal, but I mean, you don't have to go clear down here, right? Don't go down there, because as this model, you can see, big vein, right? You wanna avoid that stuff. So you're gonna go about right there. Okay? Are you doing a digital, are you doing a metacarpal block? Yes. Okay, so you put it, where do you put it? I go right in interdigenous area. Okay, yeah, same thing. Now, the trick is knowing the needle tip. Yes. And how much resistance. I would, if I were you, each one of you, if you haven't done a digital block, try it with this, and the technique is, I'm sorry, we're on break. We're not really talking right now, okay? But if, you know. If somebody tells the staff that we're invading your break, we will deny it. So go in, aspirate, and then inject. You don't wanna have a lot of force. Right. If your hand is shaking, because you're pushing so hard, you're not in the right space. You're probably in the cartilaginous space or something. So you wanna re, so I just touched something hard in there. So you wanna adjust the needle tip. So take a second. This is why we brought this mannequin. We get out of the way so you can try it. Everybody try it, okay? Yeah, but digital blocks, everyone should be able to do this. It's very important. It's worth your time to think about it. And the technique, again, is needle tip in between, empty, in more of the space where there's not a, about like this. Yeah, about like this. And I've heba-cleansed, yes, in between knuckles. It's called a metacarpal block. I think it's a lot more forgiving than a web space. And you can, but other people have different technique. Where's, is Bob? Oh, there's Bob. I would go right through here and right in here. That's what I do. Right in here, right in here. Yeah, yeah. Yeah, I'll get something. I go in here. And I'm putting like five, six CCs in there, guys. And then I'm going over here. And this is painful. This hurts. And you go on this side. But you aspirate first, right? Yes. Make sure there's no blood. Yes, yes, yes, yes. And put it in. If you're feeling pressure, then you readjust the needle tip. More like five. And if it's a hand his size, if it's this hand, maybe four and four. But a good amount of quantity. And afterwards, I do this. I massage a little bit. And then the secret sauce is to wait long enough. 10 minutes, at least. This might be a heresy, but I had a nurse practitioner who taught me the one where you inject right there. Right where the flexor tendon is. Nail the hand down. And it usually takes about six. And where do you put it? Right in the crease. Put it right there? Right in the middle of the crease. Through the flexor tendon? Yeah. Nice. 23 days. Yikes. Yeah, 23, 24, 25. Bob has a different technique. Bob, can you show us your technique again? Which one, which one? For digital. I do it a couple different ways. One of them, I actually go down under 45 here. And then while it's numb, I come across, if I have a bad crush. Yeah. And so I can do all four that way. And once that's numb, you can take the end of that finger off. You gotta put it back. But you can take it off. And so we do it different ways. So that's one of the ways we do it. It's really funky. Uh-huh, okay. When I was taught, I was always taught to go, hit the bone, then back away, aspirate, and go back. Hit the web. There's nothing really wrong with that. It's okay. I mean, I gave good results with it. And usually it's like six. Yeah. So three to each side. It's amazing how infrequent the digital nerves are involved. They're actually quite deep. And I'll feel where I come to the other side, but not go through the skin. What's that? I go where I can feel the tip of the needle on the other side, and then back away. Yeah. I've seen that. I've seen that before. I have a relative that's a surgeon, and he does it that way. He trusts his hands. I wouldn't teach a resident to put their, to poke towards their finger. Yeah, I wouldn't teach a resident to literally go towards their finger. You know, that's. Would you do a turn kit to decrease the bleeding while you're doing this? There's some pictures of a little turnicot on the finger, but I wouldn't do this. I'd be a little concerned about the superficial radio sensory nerve. I wouldn't do that. Okay, what about hot air? No. I wouldn't do it. Just don't do it. I wouldn't do it. I wouldn't do it. Nobody bleeds to death from a digital wound, by the way. And it's all about your being able to see what you're doing. And you can achieve that via, you know, if you need to, you can take a gauze with a curved hemostat and do a little turnicot down here. But if you're using good anesthetic, lidocaine with epinephrine, you don't need any of that. You can do a block and then augment, and the augmentation is both for anesthetic and for hemostasis. Epi, that's a digit? Absolutely. That's archaic. That's being debunked. The evidence now is that you can use epinephrine on the fingers. Now, if the- Can you use it on the other ones that you learned? Yes, I do it all the time. Now, if the person's got Raynaud's, is on five hypertension meds, I'm not sure. I would go there. But normal person, if they're healthy enough to swing a hammer, you can probably use it, okay? So that's where I am with it. These are really good questions, by the way. Do you splint them or just dressing? Do you splint? For the fingers. If I cut it? If they have a laceration repair? Okay. So. If there is no fracture. Yeah, so I'm anti-sling unless you absolutely need it because the shoulder's dislocated, and I'm emphatically against splinting fingers when they don't need to be splinted. Why? Because the skin is the skin. It's this wonderful largest organ in our body. It's wonderfully elastic. It will heal. If you just get the wounds close enough together, it's gonna be fine. I'm way more concerned about the hand function in my tradespeople so that they end up not having that, and they can do this. See that? You don't want that. So when do you start them with the exercises? Day one. Day one, okay. I say if the sutures, maybe I give them, okay, maybe not today, maybe tomorrow. But if the suture's in place, I say, look, you're not gonna pull the sutures out using your hand. I've sutured it in a way that you're not gonna pull the stitches out by moving your hand. I've sutured it in a way to allow you to get early mobilization. That's the purpose. That's why you came here. That's why your company's paying twice as much as they would if you went somewhere else, okay? This is what your company's money is getting you. Don't be stupid. Use your hands, et cetera, et cetera. Whatever I have to do to get them to use it. So once you suture, do you keep them open or do you dress it? Oh, yeah, yeah. I have this thing where I say, when I was growing up, I thought band-aids were for sissies and babies. Actually, it used to be keep it dry, but now you wanna keep a little glistening ointment on it and keep it covered, even at night. We can talk about that more. Again, the main thing about this is we wanna get people using their hands, getting more comfortable with the suture. And again, this is the start. If you go home and use that suture mat, then you'll get more comfortable. And by the way, that video that we're showing you, he's a little loose with some of his technique and it's not quite appropriate for occupational medicine, but he's showing you the technique and he's giving you some good pearls and insights. So if you take it home and you watch the video and you practice, you will get more proficient. Oh, thank you. Do you put steri-strips in between? Don't have to if I suture, right? I've just seen that used. How many people have seen tissue glue on a hand from an ED? Yeah, I've seen it. Yes. And what do we think about that? What do we think about that? Doesn't work in my world. It doesn't work in my world either. If it's on the face, I'm good with it. But not on a hand in a trades person, no. There's no way it can hold a tension long enough. Okay, think about if you actually study wound recovery, it's only a certain percentage strong, even after two weeks. That thing's still healing. Okay. If you pull 100%, it takes almost a year. I don't know about a year, but when we take these stitches out, it's still not completely healed. Yeah, yeah. So I'm sorry. So that's why I tell them, look, use the therapy ball, use the hand, bend it. Sometime we'll even buddy tape it while the stitches are in place. After the stitches come out, that's when you want to baby it just a teeny bit. You know? Go ahead. So when do you use Dairy Strip and Dermabond and how do you, what's the post care for Dermabond to keep the wound open? Because we use a lot in our clinic. Dermabond? Yeah. How do you use it? On what part of the body? I mean, if somebody has a scrape in the hand. Scrape? Or even like in the forearm, you know? Uh-huh. What's your patient population? Well, so, it's like a lot of labor. Labor? Yeah, okay. Yeah. Yeah. So, again, a darkened my experience. Where's Bob? Hey, Bob? Do you use tissue glue in the hand? Where we are, with the humidity and the grease and everything else. Not gonna work. Yeah. They laugh at me at the meat packing facilities if I use Dermabond. Yeah. It just does not work in that environment. No. You got people that are, you know, grease, guts, animal hides, tannins, just doesn't work. There's green fluid of some sort. I don't think it's from somebody's body. Yeah, so we're not, so, you know, if you have a cut right here and it's not gaping, there's no muscle involved, Dermabond's great. Okay? But, we'll actually talk about staples. Hi, how are you? Um, yeah, staples are great if you're doing a scalp. A lot of people will say, oh, you're not going to put staples in me, are you? But actually, the cosmesis is not bad. If for some reason you have to leave it in for two or three weeks, staples are better, less likely to get a stitch reaction. Staples are fast, but you can't customize it, and you can't be quite as picky with the wound edge management. It's all about preventing submarining. Submarining is one edge over another. You know what? Let's pick back up. Everybody should come back up at their leisure and try this. Yeah. When you guys talk about staples, I don't know. Yes. So your kits have a stapler in them. They have a stapler in them. OK, but I don't use it. Well, you don't not use it. Well, we're going to talk about that. So let's push on if we can. So the goal of the class, by the way, in terms of a digital block, because we had this nice tutorial from Dr. Martin, we won't say exactly when we had it, but there was some discussion. So digital block, must have skill. Can everybody hear me? So here's some examples of when I personally would use a digital block. The tip of a finger is very, very sensitive. And so I would do a digital block plus I would augment. There's the anatomy. We talked about that. So here's Dina doing a digital block. Dina, you're on camera. Now, notice this next worker here. Now, how's that for a good? Isn't that great? Yes. Isn't that great anatomy? Notice how I've repaired the tip of that finger there. I've left some of it to heal by secondary intention, OK? Because the edges were sharply beveled, non-viable, OK? And here's an example of a great toe. You notice the date on that. Bob, do you replace the nail on a toe? If I don't have to do a nail bed repair, I'll replace it. Oh, OK. If you're not doing a nail bed repair, I'll put it back in place just to keep the cuticle from sticking down. If you do a nail bed repair, I'll take it off. Interesting. Yeah, I've done numerous of these. And the most recent one, podiatrists don't put the nail back. They're worried about infection. And I had one recently that got infected. And I polled a number of podiatrists that I know. And they don't put the nail back on, frankly. And somehow it works. Doug, do you have an opinion? My experience is just like yours. I have podiatrists that practice in my CNOS office. So I kind of follow what they do. And so you don't put the nail back? I don't. Yeah, yeah. I think we grew up when everybody was worried about the eponychial fold. Here, I've sutured the bed. I put the nail back on. This fellow did fine. But like I said, once you have one that gets infected, you're a little turned off by it. So I'll leave it at that. Another nail bed laceration. Go. If you have, or if you have a bulge, the nail off, I've always read that supposedly then there's a fracture underneath that. Because actually the nail is attached to the bone. Yeah. Well, a lot of times there is. But are you really going to do that much different, other than put them on an antibiotic? Yeah. So you still have to repair it. A lot of these fingers are fractured. I typically always get an X-ray if there's a subalveolar hematoma. There's an example of a subalveolar hematoma. OK. Now, let's swoop back. And I want to make sure we've gotten through a bunch of the different suture techniques. So what we're going to do. By the way, you ask about stapling? OK. Staples are great. There's a way that you can practice from your kit. Why don't you take your staple out for a second? This is very simple. And just try it. We're usually talking about a scalp wound. It's so funny. Stapling is fun. Yeah. So there's some technique you push down, and then you just click it. And you try to center it on the wound edge. If you get a little bit off center, it's OK. If it's a scalp, nobody cares. I'm not going to show you the video on it. OK. Everybody got the staples? That's just a small, small thing. You should already be almost done with that. Go ahead. Use that seam in the middle. Use that seam as a guide. And put the middle of your operation at that seam, and you'll always be good. OK. All right. Everybody, I'm going to push this along. I'm going to put the stapler down. Put the gun down. Let's agree to move on to the priority. What we're trying to do is build you up so you can do a layered closure. So for those of you who are fairly novices, you probably have to go back and practice the simple a little bit more. We thought about having an experienced suture course, but we're still kind of got them combined. So we want to make sure everybody gets something out of this. So if we can, let's move on to the simple buried suture. OK. What is that? These kits are capable of teaching you how to suture down underneath the more superficial layers. And what we want to do is think about a buried suture where the knot is lower, OK, so that you don't end up with spitting where the, yeah. And those would be absorbable sutures. Absorbable sutures, yes. We have some examples over here. If you've never used absorbable sutures, it's worth looking at. The purpose is to close that potential space so you don't have a seroma. OK. So you can see from the pictures here the techniques. You're basically making a circle underneath, and you're going far, far, near, near, OK. So I mentioned about the spitting. That's why you put the knot deep. You can still lock it. It's a little trickier. And we talked about the utility of it. Sorry. Excuse me. Can you go back to that? You said you're making a circle. How are you going to get shallow deep or far? You should start deep. OK. OK. So you're making it deep. Let's go. Now I'm going to show you a simple buried suture. These are the sutures that we use when we're trying to re-approximate the skin, usually with absorbable suture, and then either gluing or sterile stripping, where we're not doing a skin layer. So the key here is you want to get some of the deeper tissues. And here you see in the model, we can get some of the deeper dermis. There's actually a little piece of mesh in that deep dermis. We want to grab that deeper stuff, come out superficially. So we're starting deep, and then we enter superficially and end deep. So both threads of the suture are now deep. And what that's going to do when we tie this now is it's going to pull everything together, but the knot itself is actually going to be underneath. And this is important because we want to take all the tension off the skin, whether we're sterile stripping it or whether we're just closing it with another suture. And we don't want these little ends of the suture to poke up through the skin. We call that spitting. So you need to get deep, grab some of that deep dermis, which in this case is that little piece of mesh, and make sure you're entering the same place where you exited on the other side. So just as superficial as you are on one side, you must be superficial on the other side, or else your skin edges will be uneven. Notice also when I'm pulling, oftentimes I'll pull it along the wound. It allows you to get the tie all the way into the wound, and it's not being prevented by the skin edges. So this is a simple, buried suture. This is something that we use all the time in plastic surgery. Next, I'm going to show you a little more complex suture, the vertical mattress suture. Again, we're going to go ahead and open up the device that comes with your suture pad that helps to put tension on the skin. And when we go ahead and make a cut here, what happens is the skin gapes open. In order to take tension off this, sometimes a simple suture will just pull through. And we'll do a vertical mattress, which some people call the far, far, near, near. So notice I've gone into the skin, along the bottom of the skin, and gone far away. And now I turn the needle around, and come back, and do nearer and nearer to the incision. And what this does is it's going to pull the tissue between each of those throws together, as opposed to just pulling the edges of the skin together. And again, you do your instrument tie. And generally, I'll pull it tight just so I see the skin kissing. And this is a more secure closure, because now what you're doing is you're actually grabbing a bunch of tissue and a bunch of tissue, and it's pulling the skin edges together. But there's no actual stitch in the actual edge of the skin. So again, deep, run along the bottom of the dermis, run along the bottom of the dermis, and come out about the same distance on both sides. Turn the needle around. And now you want to get pretty close to the edge of the skin, because it's the distance between those two bites that gives you your strength. Do the same on both sides. And then again, go ahead and do your instrument tie. So this is important when we are doing different types of deeper closures and certainly wounds that are traumatic and maybe have edema and are swollen and under a lot of tension. There's some other things that he's doing there that's not perfect for me. But you can see the combination of the buried and the vertical mattress is very powerful, closing wounds with high tension. So let's try to practice both. And while you're doing that, I'll flip back. There's a few slides, and then we'll do the demonstration. If people are interested, there's a couple of slides where I did some buried suturing. You notice the gaping in that wound far to the left? I'm using Monocryl, which is a very nice absorbable suture. Plastic surgeons use it all the time. You can see the middle slide there. The wound edges are close together. And then you can see me interposing simple and vertical over to the right. Here's another example. You can see the different layers involved. If you can't do that buried suture, you cannot close these deep wounds like this. I think it's not appropriate to close it with just a superficial suture. It's not going to go well, OK? So that's why it's, I think, really important for us to learn this. And then the vertical mattress. I think, for me, I like to see a longer amount of suture material outside on the top and closer to the wound edge. And the utility of it is you're everting the wound edge, so you're preventing one edge from submarining or getting underneath the other, which is critically important to have the healing wound edges in opposition. Bob, I think this is your... I think you did this suture. Yeah. So you want it to evert a little bit? Oh, absolutely. You want it to evert, and then it heals flat. OK. Yeah. Because if it doesn't look like that, when you pull the stitches, you have a crater of a line. There is a thought. I don't know, Doug, if this is how you do it, but I try not to suture through compromised tissue. I like to put my suture material where the skin is healthy. And, I don't know, Bob, was this yours, or is that...? I think that's one of them, too. I was just looking in here. Anyway, if this was yours, you pulled it away from the wound edge. Yeah. It was a grinder. OK, the grinder. Oh, yeah. Oh, I see, yeah. And here it is. Here's one on a thumb. If it's in a web space, it's a high chance of submarining one edge underneath the other. That's why either a horizontal or a vertical mattress makes sense. Here's a couple examples. I want to get those edges, the healing edges, to oppose any way I can. I do not want it to submarine. Now, let's... This is the part of the workshop where we want to take our time and everybody get really comfortable. And so the preceptors are going to walk around, and Bob can... Uh-oh. Oh, there you go. Bob's got a nice demonstration he can do. But this is kind of where the rubber meets the road. I would make a bigger decision. If you haven't already, I would recommend that you get yourself something really good to work with. Yeah, that's a good cut. Don't be shy. You're supposed to see the fashion underneath, so you can work with it. So when you're doing one of the burials, if you start out... You're going to start out deep. So what he's saying is trying to grab some of the connective tissue. If you reverse the wound edge like that, you can see down here is where they have a little bit of connective tissue. Go in and come out. You're going to start out deep. You're going to start out deep. You're going to start out deep. There's a little bit of connective tissue. Go in and come out. You're still under the skin. Re-grab the needle. Come back out again. Go in at the same spot. Come out at the same spot underneath. So what that does, it makes this big loop on top. But your knot's going to be buried all the way underneath both loops. So that's going to close the inside up. See, it closes down deep. So when you cut that, you put your ties in there. If you use an absorbable suture, you don't have to put six. You can put three or four is enough usually. That's going to take the tension off the wound. Let me cut this one out. It's a little difficult to define. Somebody asked me, did you ever put in a suture and not like what it looks like? I said, yeah, it happens. They said, what do you do with it? I said, you cut it out and put another one. If you don't like it, it's real easy just to put a better one. If you don't like what it looks like, do a new one. Wait, yeah, yeah. So if you were closing like a fat layer, you want to try and get something you can grab. See, like when I did that first one just now? Before, it pulled through because it didn't have anything but that yellow fatty layer in here, which has nothing, which is similar to regular tissue. But see, when you close it with the connective tissue below it, it cinches up pretty nice. On these, on a person, you really may not have to go that deep, because the fat holds better on a person than this does. Yeah, so if you're putting monocryl or chromic or something like that, you just don't pull it too tight. You're trying to, well, yeah, you can, just don't yank it out. You can still tie it down tight, but you don't pull up on it too hard. How do you like the mat so far? Those are cool. The mat's cool, isn't it? Yeah. Yeah, I wouldn't do this without that mat. This is pretty cool, actually. Yeah. I did my burying. Oh, you did a burying. Okay. And then I'm adding a vertical mattress. I would get way the heck away from that wound edge and give yourself... For the nears? These are the nears. Okay, fine. For educational purposes, I would just, you know, come way out here. Okay. And if you see some of the pictures of what I'm doing in real life, I'm going quite a bit away. Okay. Wow. Yeah, everybody wants to be too close to the wound edge. Can you use a visual block versus just injecting around the wound site? When? When I think I need it. Okay. You would never inject around the wound site? Yes, I would actually. We talked about it over there, and we're happy to go over there with you, but I would do a digital block with a metacarpal technique, and then I would augment locally with epinephrine for hemostasis. And it will stay numb longer. Oh, do you also do the other side too? I don't usually. That's more sensitive down there. I would put enough medicine here and here and give a little massage. You want to cover the whole thing? Sure. Okay. Yeah. Yes, ma'am? Are you still going to be doing this in Austin, Texas next year? Yes. Well, yes, if I'm asked to. You have to put a note in there and say what you wanted to do. Okay, good. I'll do that because I messed up and didn't get my act together. Yes, yes. I definitely want to do this. Good, good. We try not to do too, too many, so we limit it to like 30 or so. That's why. Yeah. Because it really is a hands-on thing. Yes, ma'am? Basically just an eyeball. Oh, yeah. Like I said. That's a good cut, by the way. You're getting a good start. Oh, thank you. But like I said, it's the – So remember, the goal is to start the re-approximation. Okay. So you want to actually – I just wanted to get one in there. Oh, I see. So we'll talk about it, but a multilayer closure, sometimes I'll use three layers. I'll close the fascia first and then this whole subcuticular area. Okay. For now, I would practice a buried suture in the subcuticular and then the vertical mattress. And I'm kind of watching the clock a little bit. Reloading the needle? Yeah. Yeah. You must. Yeah. You must. So has everybody had a chance to practice a buried and a vertical? What's that? Okay. No. What you want to do is you want to start deep so that knot ends up deep. So, yeah, I would start on the other side. Go deep. Even deeper. Yeah. Yeah. And you want to come out and grab maybe a little bit of this dermis. Yeah, just a little bit. Yeah. Where's the needle tip? Let's see. Maybe your needle is bent or something. Yeah. So if I may, you want to come in there, out here, in here, out there. Okay. Okay. So, guys, the challenge with a workshop like this is to get through the content. Okay? We definitely want to spend a good amount of time on the vertical mattress, because I think that's the workhorse for an industrial athlete. But if I can get your attention and push on, we can come back. I just want to introduce to you that haven't seen a horizontal mattress. There are some advantages to this. Each of the different sutures is like a tool. It's a technique. And different wounds require these different techniques. So, for example, here I was – oh, shoot, one second. Thank you, Bob. Okay. So, again, we're talking about a horizontal mattress. You can see roughly the configuration here. You're making a loop under the skin, and it does evert. Okay? Like here, I didn't like one of the interruptants kind of in the mid-portion of this wound, so I ended up putting one horizontal mattress. I've lost the laser pointer. The laser pointer? Oh, I have some. Thank you. Thank you so much. So right there, I put a horizontal in, okay? It just happened to work nicely with that wound. Bring it closer and avoid submarine-ing is the reason I did it. So if you want to practice a horizontal mattress, that would be great. Yeah, like that. Yeah. I believe the answer is yes. Ideally, you'd show me what you're referring to. No, no, not at all. That's a buried, a simple buried suture, yeah. When you take the, you want the knot to be deep. Yes, ma'am? Okay, yeah. Did I make that clear? The vertical mattress is on the superficial. On the outside, I don't see a vertical there. That's an interrupted. Sorry. I don't want to do that. You said you use an eye tool that helps you see better. Yeah, I use surgical loops, yeah. You don't have to have them, but. I have really bad near vision so far. So are you doing a vertical mattress? Yeah. Okay, do me a favor and start way the heck out here. Like here? Even further. Like start way out there, just for the sake of education. Okay, and how am I going to come under the wound here? Like this? Yeah. Actually, that needle might not be long enough. Yeah. Maybe start here. That'd be good, yeah. Yeah, that'd be good. Okay, yeah. And then, right, you got it, right? You're going to go in. So far, far, near, near. Yep. Awesome. You can't wear those surgical loops on your glasses or without the glasses? Like the ones that you wear. Ah. Do you wear these? No. These look like near vision glasses. These are just cheaters. Yeah, that's what this is, just cheaters. Yeah. With the surgical loops, you should try them because you go like this and you get your own focal point. Without glasses. And there are vendors. They cost like $2,000, and the vendors will help you with that. Excuse me, John. Yes. I can't seem to get the right tension. Vertical? Yeah. So that's a really good question. Your far, far is not far enough, and your near, near is not close enough to the wound edge. Oh. Yeah. Thank you. What is your name? Karen. Karen asks a very good question. She says, I can't seem to get the right tension. She can't get the wound edge close enough. And the problem was, her far, far wasn't far enough, and her near, near wasn't near to the wound edge enough. So, is this too open for? That's great. Okay. For this practice session. It's going to be difficult to close that. Yeah. You're buried is more of a fascial, and you didn't close this. This tissue here. Okay. So I should have. Hey, Bob. Yeah. Can you demonstrate? See on this? Can you go up there and show them where you're going to close a fascia versus the subcuticular? Okay. No, no. We can do it on this one. Yeah, yeah. Okay. You want to? Yeah. Look at it. It's worth taking a moment to look at this. Yeah, look at it. It's worth taking a moment to think about. Right in here. Yeah. Okay. I would actually make a bigger cut and really get a chance to show them. Would not you? What's that? Would not you? I would show them a multilayered closure. I would put either simple in that fascia and then show them the buried. I want to get them thinking about the layers. Gotcha. Could we have your attention to the front? Bob is going to kind of demonstrate a multilayered closure. Okay. I want you to think about with this suture mat, it's actually lifelike. That thicker, you have the muscle down deep, right? If your cut on your suture mat is not deep enough to see the muscle, make it deeper. You want to see that fascia? The muscle is red. The muscle is red. Thank you, Bob. That's so insightful. Now we know. Now we're talking. You want to close the fascia first. Then what people seem to be having trouble with is closing that subcutaneous layer where the fat is. You want to use something called Scarpi's ligament. You wouldn't think you could suture fat, but there is something called Scarpi's ligament, Bob? Scarpa. Scarpa? Scarpa's ligament. There's actually something you can get a bite on. This is part of the experience is to get a bite of that Scarpa ligament. If you're closing the fascia, this white on this model, this is skin. Yellow is fat. The fat on this does not hold suture very well. If you're closing the fascia, you would be going just getting a decent enough bite to hang on to it because you're closing all of this back. You don't want a muscle belly to come through because it's like a hernia. You could do simple sutures on the fascia if it's deep enough. If it's not very deep, you would do buried sutures to keep the tail from spinning. On this, this is just a simple suture. Remember, we're introducing. If you take this home and you go on your computer and you use that same video, the URL is embedded in the lecture if you have the notes. Dr. Zenz shows you this. You can go through step by step as you're practicing. What Bob is doing there, he's closing the fascia. That's probably layer one of three to get this wound closed. This one is just closing the fascia. When you're using absorbable sutures, they're way easier to tie. It doesn't have to be slippery and that sort of thing. They tie down better. We would close this, tie this, and tie that off. That way your fascia is closed. You don't want to do the whole length of it. Just demonstrate. I want to make sure that they see you trying to close the subcuticular. A lot of them are putting these sutures low. They're not getting close to taking off the tension. If it's too difficult, you can try it without the tensioning device first and then put the tensioning device, the blue thing. The innovation of this suture mat is that tensioning device. That's purposely making... This is this blue thing. Without that, it's not as lifelike. Now, are you going to do the subcutaneous? You can do the fat, but then the whole wound... Just sneak up into the dermis on this. If I did a vertical mattress... First try to put a stitch like you would in a real person. Guys, watch where he's putting the needle. Just for a second, if you can see. This is just going to be in the fat. See how he's going into the fat? What I would do differently... Bob, let me show one little thing here. Let me show... It pulled through last time. It pulled through? Just show them what they would do. If you're going to do this... Watch this, guys. Watch it. See him placing the needle? Can you see it? In the fat there? You can, if you need to, sneak up and get the bottom side of that dermis. Now, see how he's going to the other side and he's trying to grab it again? What you're always trying to do is the same depth in the same line. And by doing that, it comes out the same place every time. So you have similar tension, similar forces. Yeah. So this is trying to close some of the fat. The thing on this, it seems to pull through a lot on the yellow fat part of this. Yeah, but I did want people to see that. In a real person, you'll get a better bite with that scarper's ligament. And you'll know if you take your needle and you pull on it. You hook that tissue and you pull on it and see if that needle is a good bite, is a good hole. Right, Doug? Is that the way you do it? You test it? So if you're an experienced suturer, you have these techniques where you're testing the tissue. You're reading the tissue just like you would read the rapids if you're on a kayak. So you see what Bob's doing there? Yeah. And so for me to talk about it now is just the start. You have to take this home, go through the video with Dr. Zins, and then practice it. Because you've got to get your hands used to what you're doing. And then all you do have to do is suture on a real person. Right? That's the easy part. Or we can make a little cut and practice. No, no. The whole thing is it's hard to get experience. And you have to be ready to try. Dina is basically fearless. Where's Dina? There she is. She came to my office and you had some basic skills, right? Dina, you had sutured before. Yeah. Little teeny, straight sutures on an arm. Yeah. Right. And then now what? The first day I was there, I think you sutured three people. Yeah. It was like crushing injuries and shaggy edges and fractures. Yeah. So this was supposed to be a horizontal and this was the vertical. I would come closer to the wound edge. Okay. But that's a start. That's a good start. What about this horizontal one? Wider, wider. Oh, okay. And remember, we're tensioning it. We're making it very difficult. Okay. But that's great. Okay. So the depth here is okay? Like of this one? That's actually pretty good, yeah. But just closer to the wound edge. Closer to the wound edge. Yeah. Now remember, you're going to put it interrupted between. It's going to pinch it together a little bit more. Oh, okay. But the combination is what's important. So if you guys are having despair and you say, Oh, I'm never going to be able to close this thing. Just remember that it's the combination of the different techniques. If I had a vertical mattress holding this together about like to that march, then I could put a simple on each side and bring it together even further. Okay? It's the simple paired with the vertical mattress or the horizontal that really helps. And I'm going to show you a couple examples real quick, okay? Let's see. But. Okay. Oh. I also want to introduce you to something called a half buried mattress. Has anybody seen this technique before? What's that? Yeah. So what if you have a triangle, a corner? How would you deal with that? This is called a half buried mattress, okay? And Bob's going to demonstrate one. But here's an example. This gentleman, a caulking tube fell quite a distance and struck him in the face. And it cut him just below his safety glasses. Okay? Now, I suspect that other than Doug and Bob and I, nobody in this room would tackle this. Okay? Because if you look at what I'm doing here, I've got the infra-orbital nerve right there. It's on his face, right? And I'm doing a half buried suture. Okay. You see some of that tissue is devitalized, so I have to debride that off. I've examined the base of the wound, and so I pull it from left to right, and then finish the suturing, okay? Now this is one where I'm using a half buried, and you see I'm going to pull that corner down so that I can suture the rest of it. You know, I'm reading the tissue, and I have to get it to travel. You have to put tension on that apex of that corner, and that's what that half buried is for. In just a second, Bob will demonstrate that, okay? I'll switch over. So do you kind of get a sense of using these different techniques? Yeah, and again, the video will show you and remind you, and if you just take some time and go through that video and use the mat, that's where the secret sauce comes from. But how is this going so far? Is it good to have it in your hands, give it a little visual aid, a little verbal? You know, some of us learn by hearing, some of us learn by seeing. So on a half buried, what you're doing is you're going to go in on this side of this. Can you see the cut right here? So what you're going to do is you're going to go in here, come out underneath, go across on this tip, go back in deep, come out here and tie across it. So what it does, it's going to pull that right in. If you try to suture, like if it's a stellate laceration with a bunch of, like something just tore a bunch of them, you try to suture across that, you'll kill some of that tissue. So what you would do with this one is you'd go in, you'd come out at, and you want to come out at whatever depth you're coming out, that's what you're going to go in across this little flap. But it takes this many preceptors to go through that whole enclosure. So I'll look at where it is there, come back and go across at that depth, and then I got to look at where this is coming out. So when it comes out, I want to make sure that's where my knee was going back in on the other side, because you're trying to make all of this nice and even. So when I go back in, look at that, come back, so now I'm about even on the other side. So when I tie across, so when I pull up, it pulls it right back in. Does that make sense? And then you just tie this normally. It is, it's fairly superficial. It depends on how much meat you have left on this flap, but you see how it makes it all go nice and flat, and it tucks it right in without putting any tension on the tissue, so you don't lose that tip, so it doesn't die. So are you guys getting a sense of that there's these different suture techniques, and the question is how to deploy them and when to deploy them? And you, you know, you just, so it's, in a workshop like this, it's, we have to introduce, and then if you can follow through and, you know, look at those videos, and it goes step by step for the different techniques, that's the key. You know, the good news is, is what we're doing here, that's not it. Are you good, Bob? Did you show them? This is just that vertical mattress to finish this off, if you want to see it. Yeah. Bob is going to show a vertical mattress a little bit more. He's done his one far, he's going across, he's going to do the near-near, and again, we have this wonderful tensioning device, and if you took the device out and just had it flat, you'll see you'll be able to close it much more easily. Yeah, I know. So, you see that far, far, okay. Bob, I'm going to cut you off here. There's a few more, like, items that we'd kind of like to introduce to you a little bit, but we did talk about digital blocks, and I'm happy about that. Did everybody have a chance to poke that hand over there, to stick a needle in it? You should. Now, in the video, they'll talk about a figure of eight. That's a strong way to close a fascia. Also talk about running and running locked. I'll show you a couple pictures. Like, this gentleman sliced his wrist, okay. You can see I did a few vertical mattress, and then I did a locked running on top of it. Okay, here's another wrist laceration. The guy tried to give himself a carpal tunnel release. That's actually the transverse carpal ligament right there, and so I sutured that. Now, we've spent most of the time on a complex, multilayered, deep closure, and Dr. Zinn, I guess it's Zinn, goes over that. Here's an example of a grinder injury. You see how that's darkened? I don't know if you guys can see that. You can see the sequence of how I closed. It's a nice ellipse. I probably debrided the wound edges, and then I closed it with that monocryl first, and then I interposed vertical and interrupted, okay, to get that to close. It's on a leg. Here's another one on an elbow. Same thing. Can you see what I'm doing there? Okay, and here's another one, a grinder, where I'm doing a multilayered closure. It looks like I had to close the fascia there, right, Bob? And I used that monocryl on that as well, and then you can see the end, what the patient sees at the end, okay? We talked about staples. We're good. Stitch reaction, have you guys ever seen that? Oftentimes you want to leave the stitches in for 14 days, and some people will have a stitch reaction. I actually warn each of the workers that this might happen. Anybody ever done a delayed closure, like somebody comes the next day or even the next day? If it's a child with a dog bite on the face, that's good. The military has studied this. Delayed closures, like on this hand, for example. We talked about the digital block. Hope everybody gets a chance to use that. We talked a little bit about nails. We talked a little bit about subalgal hematoma. Can everybody relieve a subalgal hematoma? If you don't do it, the nail will evolve from the bed and fall off, whereas if you drain the nail, I'd say if it's more than 20% or 30% in advancing, like if you look at it, send them to x-ray and come back, and if there's a greater amount of the subalgal hematoma, I would do it, okay? Even the next day. So basic plastic skills. Bob, can I bother you to help with this a little bit? So I'll give you some examples. Here's one, for example, where I just trimmed off that thin beveled edge and allowed that to heal by secondary intention. You see this worker here. He fell on a stud, and he's got a nice triangle-shaped wound that you cannot close. So you have to debride that flap off, create an ellipse, okay, and then close it multilayered, okay? Now, how many days off of work do you think this guy had? This guy here. He's a barber. He runs about four barber shops, and he's a carpenter. He had zero days off of work, okay? And the same thing with this guy. Same exact mechanism, all right? This is what you can do. By the way, this is that bell, splash guard bell. If you don't have those, there's the safety feature, okay? Oh, shit. So anyway, now let's talk for a minute, Bob, about how to close a circular wound. You see this guy right here? Okay, you can't close that. There's no way you can close that. Now, this guy's a tradesman. He wants to work the next day. What will you do? You going to refer that out? No, he wants you to fix it, okay? So what I did there, Bob, I don't know if you do this, is I made an ellipse. I extended that wound over here, and I closed it primarily. And he was happy. He worked the next day, right? This is skin. It's elastic, okay? Same thing here in a painter. He was trying to help a coworker. You see how I've got the suture, the scissors flat? I'm undermining, okay? Bob's going to demonstrate this in just a second. But I'm freeing up some tissue so that I can close it easier, okay? I'm also going to extend that wound. If you see the tip of it, see that's kind of blunt looking versus that's more of an ellipse? So I'm going to change the shape, elongate the wound, and then close it. So this is what I'm looking for. See that? It's longer, okay? Don't be afraid to take your suture scissors and change the shape of a wound. Yes, it's bigger, but you can close it, okay? Bob, is this something you would do? Yeah, it's typical. It's easy. Same thing here. I elongate so I can close it. Otherwise, you have big dog ears, okay? So there I'm undermining a little bit and I'm elongating. Sometimes you have to use a scalpel. What do you use, a lemon blade or a tin blade? What do you use? Sometimes I just use the hemostats. Just use those and just bluntly dissect. Sometimes I'll use the scissors. All you're doing is you're undermining the skin, the sub-Q around it. It loosens it up so you can adjust what's there and take the tension off of it. What some people are uncomfortable with is being in the right layer. I think there was a question there. Go ahead. In a circular wound, could you have done it with a simple suture around the circle? Unfortunately, the flap wasn't viable. It was filleted too thin at its base. If you've ever cleaned a fish, if you're filleting it, you're cutting it off the carcass there and you're flipping it over. If you cut it too close, Bob, they may not do that. That may not be a good thing to talk about there. I haven't cleaned a fish since last week. All right. Anyway, here I'm reinforcing about the PIP joint stiffness. We have just a few minutes remaining. Let's talk a little bit about foreign body removal. Here's a nail. You've got to snip off the head. You've got to think about how you're going to take it out. Here's another one through a shoe. How would you take that out? First off, is there a fracture, yes or no? It's hard to tell. It's hard to tell. But the guy can't go home like that. Now, you know what his father asked. These are brand new Chippewas. $300 a shoe. How's the boot? How's the boot? He asked about his boot. They're both carpenters. This is a nail gun through the shoe. What did I do? I snipped off the head there. He did end up having a little bit of a fracture. The guy worked the next day, by the way. We did not save the shoe. This is the tissue glue and the EED. No, that doesn't work. This is a foreign body removal. Someone in urgent care put him on antibiotics. Great. But they did not take care of the problem. The guy knew it. He came to me and he said, I've got a big thing in my hand. Antibiotics is not going to take care of this. This is pus. Good old-fashioned pus. You've got to take a steel, cold blade to that and remove that. Where I'm from, you call it fester. If it's festered, you can take the foreign body out. Sometimes you can put him on antibiotics, have him come back in a couple of days, let it fester, and it'll come out easier. Specific tissues, nail bed lacerations, we did talk about that. Eyebrow, often deeper from blunt force. Lip, I'll show you a picture of that in a minute. See, that's through his lip. The first suture I'm going to do is from here to there and then suture that. This is my first patient when I started my company. This guy, you notice this scar over here? Okay. That was from the year before. Okay. I recognize him from his scar. All right. And, you know, an ear. This is the cutting of the ring. Some references. And we may have a few more minutes for any lingering questions, but, again, in my opinion, to be able to suture strengthens the role of the occupational medicine clinic. There's a huge change afoot in terms of the urgent care. What do we do? What do they do? I've actually gotten new clients because these big, huge construction workers would show up at Urgent Care X and they wouldn't know what to do with them. So if you have better technique, you can have them stay at work, and that's really where we should be, guys. Now, does anybody have any lingering questions? I want to make sure each of us know that you've spent the money, you've purchased this kit, it's been some utility now, but it can be even better utility for not only yourselves, but the people that you teach. Keep it in your office and you can use it. The video from that plastic surgeon is no joke. He'll walk you through it. You didn't get to see all the different segments. The one on multilayered closure I really like a lot. He gives you some of the rationale for it, and I think if you don't look at anything else, go to that YouTube video. Is the URL right here? Yeah, it's on the little card. Go to that and listen to him talk about multilayered closure. Doug and Bob, and Dina, do you have any parting comments? I guess the thing that I'd leave with you is practice, practice, practice. I don't know how long it took me to get proficient in this, but longer than most, probably, because I'm just, you know... We really haven't talked about... You know, I'm very right-hand dominant. My left hand is useless for the most part in doing these things. So if you're like me, it does take a lot of practice to get good at it. Well, yeah, so the thing about the kits is they allow you to practice, to get used to holding the needle driver. You don't have to put your fingers through the hole, you can get better with it. If you have any needles, there is a needle box here. The kits? Yes, yes, yes, yes. You know what? Andrew is the owner of this company. It's kind of a family company out in Oregon, and he will be more than happy to work with you. Just tell him that I referred you, and he'll say, Oh, yeah, okay, yeah. What do you need? He'll go to his... I don't know if he's got a warehouse or not. Who's got a question? We do have a sharps container up here. Go ahead, sir. Put your needles in if you'd like. From time to time, a lot of companies come in for hemostasis, a lot of this powdered hemostasis kind of solution. I don't know what your thoughts were. I mean, it does the job by stopping the bleeding, but do you feel that you need to suture that or just let them contain the gum? That's interesting. So does anybody, Doug or Bob, do you have experience with that powdered hemostasis? Question. A lot of companies, like their safety guy and gals will put it in, and then they'll send them over to me, and, like, hey, it did the job and stopped the bleeding, but do you have any... That's only a part of it. That's only a part of it, though. It's also infection control. You know, what are the indications for suturing? Hemostasis? You know, repair? The question is, does it need to be sutured so the guy can use his hand or his arm the next day? You know? For the hemostasis? It depends on the wound, the depth. If I need to explore the wound to look at the tendons, I would numb it up and look at it. Does your company care about osha recordability? Yeah. A job with a hemostasis, but again, that's only one of the indications. Yeah, and they do okay? Yeah. I have not seen it used, but I can say that it's a judgment call about when you can allow something to heal by secondary intention. If it's more of a puncture than a laceration, I have a greater likelihood of allowing it to heal by secondary intention. I'm trying not to be that suture Nazi. I'm trying to let things heal. If it's a small wound, the worker's okay with watching it. They don't have diabetes. You know, it's a reasonable choice to allow it to heal by secondary intention. If they don't have other indications. Thank you. No problem. Oh, you're welcome. I hope that was useful.

suturing techniques

digital blocks

layered closures

nail trauma care

foreign body exploration

anesthetic administration

suture selection

post-wound care

personal experiences

instructors' tips

administering digital blocks

preferred suturing techniques

epinephrine

tourniquets

wound closure