Lip and facial lacerations are common injuries presenting to Urgent Care. Unfounded fears may be leading Urgent Care clinicians to turn these patients away. I recently co-authored a study (1) with two physician colleagues where we called 100 Urgent Care centers across the country posing as a patient with a lip laceration. An unbelievable 45% of the centers we called said they could not manage this type of laceration in their facility. The reasons cited for refusal are listed in Table 1.
Patrick O’Malley, MD
Section Editor, Lacerations and Wounds
Table 1. Free-Text Responses from “No” Respondents |
• Have to ask the physician, concerned about how deep it was • Not on the face • We do cuts on the hands, arms, and legs, but not the face • Center policy that we do not do sutures on the face • Had to go ask the provider. Says they would look at it but that “they can’t do it if it goes onto the lip inside the mouth because those always come undone” • Will need a plastic surgeon, we don’t touch the face • Can do stitches but not “cosmetic” • It’s a sensitive area. Go to the ER where they have surgeons. We have a lot of new providers, PAs and NPs who aren’t comfortable with suturing • Don’t feel comfortable doing the lip line or the eyebrow • Not with it going all the way through, “go to the ER to get a good stitch job” • Nothing on the face, will repair lacs elsewhere • Nothing that will “leave a scar on the face” • Aren’t doing stitches right now “due to COVID” • Can’t do stitches on the neck and up • Do not repair lacs on the face • Won’t do it if it touches the lip • Would have to see it. Probably not, may need plastics because it “needs to come out perfect” • Nothing on face; needs plastic surgery From: Ford DT, O’Malley PM, Dick B. Assessing Urgent Care Clinics’ Readiness to manage a lip laceration. J Urgent Care Med. 2023;17(8):39-41., with permission. |
Let’s discuss the reasons these centers chose to send away these lacerations, as many are based on opinion and untruths. Addressing these reasons may help you feel more comfortable in managing facial lacerations.
Many centers simply stated they do not repair facial lacerations. That is just their policy. This trend is concerning and should be addressed. Like any procedure or skill, suturing in general, and especially on the face, takes practice. No one wants to have a bad cosmetic outcome- — not the clinician, not the patient. Guess what? All wounds leave a scar no matter who repairs them. They just do. It is part of the physiology of wound healing. Knowing and accepting this is a big part of being able to manage these injuries. The trick is knowing the techniques to mitigate this and make the scar less obtrusive.
Myth #1: Plastic surgeons are readily available in the ER. Just telling a patient to go to the ER and see a plastic surgeon does not mean this will happen. In fact, there is a 99% chance that the wound will be repaired by an emergency physician, PA, or NP. If they do see a plastic surgeon, it will likely be a surgery resident on a plastic surgery rotation or a first-year fellow. Most ER providers have more experience than the on-call resident for plastic surgery. Giving the patient the expectation that they will see a specialist puts the emergency clinician in a tight spot. Please don’t promise the patient what services they will receive in the ER. It’s OK to say the emergency team will evaluate the patient and determine the next steps. If you really want them to see a plastic surgeon, call one yourself and discuss the case and arrange for them to see the surgeon in the office. You cannot guarantee the patient will see a plastic surgeon in the ER (2).
Myth #2: Plastic surgeon’s repairs do not leave scars. ALL wounds scar. It is a physiologic process, and a fact. But you can take steps to help reduce the scarring. These include carefully removing foreign bodies, debriding devitalized tissues, copious irrigation to reduce chance of infection, selecting the appropriate suture for the wound, prescribing antibiotics for high-risk wounds, providing concise discharge instructions for wound care and when to return for recheck or problems, use of sunscreen when the scab has fallen off, and follow-up with plastic surgeon later if the outcome is not as desired. (3)
Myth #3: Patients will sue if there is a bad cosmetic outcome. Patients sue for many reasons, but usually not because of a scar, unless you missed something. They sue because you missed a foreign body that required further care. They sue because you overlooked significant risk of infection or a tendon injury. They sue because you were not a nice person. (4) Seriously.
They came to you, expecting it to be repaired. They didn’t go to the ER and didn’t call a plastic surgeon. They expect that this is something you can do. I’ve had people tell me, “No, I don’t want a plastic surgeon to do this, that’s why I came here.” It may be a one- to two-hour drive to the closest hospital with a plastic surgeon in many communities. This is just not feasible in many areas, not to mention the extra cost and hassle.
If the fear of litigation is your driving force here, consider saying something like this: “I have repaired many wounds on the face, and I feel very comfortable doing this. All wounds leave a scar. I can take steps to minimize this and share with you some things you can do to minimize scarring. You can always follow up with a plastic surgeon later for scar revision in the unlikely event of a poor cosmetic result.” You will be surprised at how much a simple statement like this can put your patient at ease and reduce any medicolegal risk.
If you are not comfortable suturing the face, that is another whole discussion, but it’s OK — you must start somewhere. Skin on the face is the same as skin elsewhere. It has layers, it bleeds, and you can put stitches in it. I encourage you to see every single laceration you can. Shadow a co-worker when they are suturing, take a day in the local ER to observe some more complicated suturing, or take an in-person or online class. Get a practice suture pad and fill it up. If you are a medical director, the suture pad can make for a great homework assignment for your newer or less experienced providers. Challenge them to do 100 sutures in a month. This can be done at home or work, can serve as a check off assignment, and can help give your new clinicians experience in the technical aspect of laceration management.
It should also be stated that staff answering the phones need to be careful with the phrasing they use when patients call in asking if they can be managed in your center. Secret shopper calling using a mock patient is a great way to test this. Have a family member, co-worker, or friend call asking if your center can see XYZ. You’d be surprised at the answers they get. Use a script to ensure a uniform experience. An example of this: “Question: Do you do lacerations on the face? Answer: We would be happy to evaluate you for this injury. In most cases we are capable of this service, but the provider will evaluate you and give you advice and options for your wound care.” If in doubt, have the front desk ask the clinician working if they can do a procedure before telling the patient to go elsewhere. Remember this is revenue going out your door.
As the Urgent Care workforce shifts to newer, potentially less experienced providers who may not have had the needed suturing experience, we must increase education and training in procedures like suturing. These procedures were once considered the “bread and butter” of Urgent Care medicine and were one of the defining services of Urgent Care practice. Urgent Care clinicians who are less skilled in these procedures should take the initiative to improve their skills. To help support and foster this, medical directors should provide them with the tools and training they need so that they can practice at the highest of Urgent Care standards.
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