Tell me if this is the norm in your er!

perhaps the bottom line is....is the patient getting what they are paying for? are they entitled to a mid level or higher, and can they refuse anyone else? providing that they are informed.....have they really consented to the treatment if they havent been informed

Perhaps? I'd be pretty comfortable with simple suturing from a paramedic, myself. They're a highly skilled group; they're even allowed to intubate. Suturing isn't really rocket science, imo.

In fact, why can't RNs do simple suturing?

Not typically the case. Laceration repair is not even part of the DOT PM NSC. In fact, laceration repair is not an applicable skill for the typical pre-hospital provider. True, some tactical support or remote medical/wilderness providers may have additional wound care provision; however, this is not the case for the typical PM.

Even among flight medics, the only "suturing" skill utilized is placing a purse string with a chest tube or securing an invasive line. It is simply not a technique that is needed in the pre-hospital environment.

Now that you mention it, though, I'm sure they can refuse a medic if they want a longer wait. I'm sure people refuse PAs and NPs and residents in place of a "real doctor" all the time and that's their prerogative, right?

Some places allow RN's to "suture." However, I will tell you that with all the other things I have do do when working ER, taking time to close a wound is the last thing I want to think about doing.

Unfortunately, even simple laceration repair with the generic "interrupted" technique is in fact a complex procedure. First, you need to identify structures, neurovascular integrity, and the overall condition of the tissue and wound bed. Additionally, you need to know how to properly debrid the wound and even determine if a wound should or should not be closed. You also need to identify what type of wound will require what type of technique. In addition, what about multi layer closure or the identification of compromised deeper structures requiring sub-specialty resources, not to mention local anesthesia techniques.

This is where the slippery slope applies IHMO, the identification of a "simple" laceration/wound versus a serious wound.

No one has ever sutured me except a plastic surgeon since I was a little kid. I keloid despite the fact that I have typical very fair Swedish skin and have been told I shouldn't keloid. No way will a tech, PA or NP ever suture me. I've had to have three scars treated after the injuries healed.

sharpeimom

I would only let an NP, PA, or MD suture up my kid. Even though I have closely watched 1000s of people get sutured and could probably do it , (I guess I'll see how good I am soon enough since I'm doing the ACNP now). I even once gave my husband 6 stiches across his eyebrow-there's hardly any scar at all. But when it comes to my kid, I would always want the most highly qualified and experienced person available. I agree that it is probably very varied by state.

UNM Hospital in Albuquerque used to have techs suture as a regular thing. It was quite successful. The only reason they stopped is because it wreaked havoc with billing.

As for cleaning wounds, if you do a literature search you will find several studies whose results pretty clearly show that irrigating wounds with sterile water or plain saline is as effective in preventing infection as all that other stuff we used to use. And it doesn't have any of the risks. It is good, evidence based practice. I first learned this at a wilderness medicine conference about 6 years ago, and it was pretty well accepted by then. About the same time, I talked it over with our vet while assisting in wound care for my (then) search dog. She said the same thing.

If a wound was well irrigated by someone trained to do so, and it looks right to the doc, why should the doc do it again? There is no evidence to support such a practice.

In our ER the techs or nurses do all the wound prep. The docs inject and suture.

BTW, I can tell you honestly that some of our techs are far better at skills like splinting or wound prep than nearly all of the nurses.

Irrigation here is just saline or water.

I believe the wound should be assessed by a physician, and then delegated to the appropriate person. I have heard of techs and RN s suturing, but have never worked with any. I would not want to forgo the MD assessment though.

I think they still do at Presbyterian?