Tell me if this is the norm in your er!

[missnurse01]

Hi everyone...we had an er visit last night, and I don't work ER full time anymore (moved on to another specialty) although I do work agency in the ER now and then. I am a trav nurse, currently in NM, and havent worked in an ER here yet.

So here goes! My son had to have a nice lac on a toe sutured....the Er we went to did things a bit differently than I am used to, and I am wondering if it is the norm? Have worked many states in the Er and many different types of ERs...

1. only irrigate wound with saline, no betadine, no chlorhex, no doc cleaning it with anything before suturing. I was told that this is normal practice now, as they feel that all the cleaning agents are just too caustic to the tissues.

2. an RN came in to inject the lido (before they decided to do a digital block), and she also said that that was the norm there.

3. as I was further talking shop with the ER tech, she told me that normally the techs suture nearly everyone up...that it was just since none of them had experience with the type/loc of the lac on my son's foot that we got the doc. She said that they get some special training, then are allowed to suture.

I am all for streamlining throughput in the ER, but I was taken by surprise. Are these items the norm in your ERs? Curious! I just kept saying, I have never heard of such a thing before...

?

thanks!

[nigerianmalenurse]

do you seriously want to know the norm in my er?

lets go back to when you got to the er (my er), first you would have to come with a referral leta since it is a "teaching hospital' according to them,if you dont have that you would be advised to go seek help from somewhere else,even if u do hav a referral leta, you would hav to wait in line and mark my words "wait in line in your car in the parking lot" till theres a bed space since we have only 36 beds in our er,so it doesnt matter that you got to the hospital,u still may not get help. lets assume u beat all these hurdles,every lac, no mater how small are sutured in the "theatre" by the doctors,we dont have techs here (who eva they),u dont wana know the payment protocol. the is no prefence for dead,living,partially living or dying patients. compare this to what you have over there...............

[GilaRRT]

As a side note, he said at that time, that the military medics were allowed to do more than the civilian RN's working the base hospital.

Well, yes and no. The core medical training is highly skill and protocol based. If this, then that kind of mentality. Remember, you typically have less than six months to pump out an entry level military medic. In addition, many medics have what are called ASI's or additional skill identifiers. This typically requires an advanced school. For example, the ASI M6 is for an LPN. They attend an intense year long course to obtain the M6 ASI. However, they are still considered medics first, with an ASI as a practical nurse. So, it is a bit misleading saying medics can do more, simply because you have providers with little to extensive education and experience, who all considered "medics."

Also remember that military medics do not typically share the nursing philosophy. They have more in common with with a physician. See a problem fix the problem. This physician extension like concept was one of the elements that went into the development of PA education in the 1960's. Military medics were the prototype students for many of these new programs. Therefore, the military medics scope of practice if you will is not dictated by a nurse. (Such as the case where you have a tech and delegated skills to the tech) Typically, a physician or midlevel provider in the case of medics working with a PA at a BAS will be responsible for allowing the medic to perform skills and training the medic.

In addition, not every medic sutures. The medics role in the military is highly dependent on the unit, and the unit's mission. When I was assigned to a combat arms company, I spent more time shooting and doing MOUNT exercises than providing direct medical care. However, when I worked for a field artillery unit BAS, I was able to provide more advanced care.

Finally, remember the legal implications, billing implication, and liability in the military is significantly different from the civilian world.

[GilaRRT]

do you seriously want to know the norm in my er?

lets go back to when you got to the er (my er), first you would have to come with a referral leta since it is a "teaching hospital' according to them,if you dont have that you would be advised to go seek help from somewhere else,even if u do hav a referral leta, you would hav to wait in line and mark my words "wait in line in your car in the parking lot" till theres a bed space since we have only 36 beds in our er,so it doesnt matter that you got to the hospital,u still may not get help. lets assume u beat all these hurdles,every lac, no mater how small are sutured in the "theatre" by the doctors,we dont have techs here (who eva they),u dont wana know the payment protocol. the is no prefence for dead,living,partially living or dying patients. compare this to what you have over there...............

True; however, we cannot hold you to the same standard as the USA. You most certainly are attempting to improve the healthcare environment; however, comparing this suture situation to your situation is difficult if not impossible given the profound differences between the health care environment of our two countries.

[catshowlady]

GilaRN - Thanks, that was interesting. When hubby wakes up, I'll have to ask him about the training levels. This was 30+ years ago, during the Viet Nam war. He worked on a base hospital in the ER at night.

[missnurse01, MSN, RN]

wow thanks everyone for the replies-and i see that i wasn't off in thinking that techs suturing wasn't the norm. yes it was at pres hosp. they said they were the only ones in the area that still did it.

so everyone is only cleaning with saline now? not even hibiclens or something? i thought the doc would at least swab the wound with something, but nope, just the ns irrigation the tech did. i haven't seen this in practice yet, everywhere i have been has been betadine or hibiclens at least after the ns irrigation.

i think in my head like so many other items in the medical field, that we becoming task masters, and like a new grad or whatever, don't really realize the full scope of our actions...i understand that suturing is generally a tactile skill, but i worry about the assessment portion of it, as well as the running into problems. yes i have seen tons of suturing occur without incident, but i was fairly confident that when problems arouse the docs knew what to do. does this make sense?

once again, thanks to all!!!

anyone doing dermabond over dissolvable sutures? i am starting to think that might have been a good fit for my son's toe, as a portion did not take the suture (read it tore through and couldnt be resutured in that spot) and i have had a time trying to get the wound edges decently together for him to not lose a wound edge. i know, it's only the underside of a tiny toe really...

[nolabarkeep]

We have a tech in our ED who does all of the splinting of limbs. He actually knows as much, if not more than the physicians regarding orthopedics. I guess its possible to thoroughly train staff to suture wounds. I can't imagine a hospital spending that amount of time and money to do this. I also have never known a physician that would trust a tech to suture a patient. I believe this person(s) were making this up. What if there is a lac to the lip? This is a delicate procedure that needs a professional trained hand.

[navvet]

So what's the problem. One can buy a suture kit on the internet, and then watch how to do it on Youtube. Simple sutures are not that complex. If the doc assesed the pt and then gave the go ahead for the tech/RN to suture, well there you go. I beleive that RN's should learn how to suture in school. I believe that all RN's should be trained as field medics as well. Why not? If in any small town or big city where a catastrophic situation arises, and hundreds or thousands have to be triaged and treated, then we as a society with the medical knowledge should be ready and capable to handle those situations. Where would one get the practice to be prepared? When one is handling everyday problems.

[navvet]

Why do RN's sell themselves so short? One needs a professional hand, Bull Malarky !!! If a Doctor can be trained to suture a lip, hip, or hand so can an RN.

My Father used to say " I can't, never could." It is the skill they don't want RN's to have so the RN can't bill fo the skill !!!

[GilaRRT]

So what's the problem. One can buy a suture kit on the internet, and then watch how to do it on Youtube. Simple sutures are not that complex. If the doc assesed the pt and then gave the go ahead for the tech/RN to suture, well there you go. I beleive that RN's should learn how to suture in school. I believe that all RN's should be trained as field medics as well. Why not? If in any small town or big city where a catastrophic situation arises, and hundreds or thousands have to be triaged and treated, then we as a society with the medical knowledge should be ready and capable to handle those situations. Where would one get the practice to be prepared? When one is handling everyday problems.

I think you are missing the point. "Field medic" is not really the role of a nurse. Hence, the fact that nurses spend a significant portion of their education learning to work in "backbone" areas of medicine. You must understand, nursing is a highly diversified field. Therefore, entry level education is focused on the common jobs and tasks required of a nurse.

Additionally, we can train every RN as a field medic, and these RN's will promptly forget all of this knowledge within a few years of practice because only a few would actually work in such a role. Would you expect an emergency room nurse to perform a comprehensive in-patient psychological assessment and interpret GAS scores on a patient with schitzoaffective disorder?

In addition, I guarantee you that if such a scenario occurred (doomsday/field medic), our ability to do any meaningful care to critically injured patients would be minimal at best. This is from somebody who has worked in urban and remote areas of the world where the health care system is all but non-existent. If a nurse wishes to learn "remote medicine" there are a multitude of ways to obtain such knowledge after they master the fundamental concepts of nursing.

You see, we need to focus on the commonly encountered scenarios and do the most good for the most amount of people, not train for a doomsday scenario. In the big picture, suturing is not an important part of our overall job. I simply cannot see wasting precious time teaching nurses to do this when that time could be spent working in the clinical environment as a floor nurse. In my final note, I would like to point out one fact. RN's do learn laceration repair. Most nurse practitioners are taught wound repair techniques as part of their advanced education.

[ernursen]

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.

Funny.....the people most qualified and most experienced to suture in my ER are the medics. I would trust them with my life.

[ayla2004, ASN, RN]

anyone doing dermabond over dissolvable sutures? i am starting to think that might have been a good fit for my son's toe, as a portion did not take the suture (read it tore through and couldnt be resutured in that spot) and i have had a time trying to get the wound edges decently together for him to not lose a wound edge. i know, it's only the underside of a tiny toe really...

In ther uk np can suture. whilst a nursing student in the er

i ahve seen simple lac on a patients finger not sutured but secrued by sterstrips and dermabond and worked really well. the pt was an older adult with tissure papter skin and the lac was skin deep only to suture it would not have held. The rn was ex army nursing services and really knew what he was doing.

[mmutk, BSN, RN, EMT-I]

I would also assume laws vary by state, In TN it is the norm for the MD to do the cleaning and closure, although at busy times I have seen an RN or two do it all. I do believe this is out of their scope of practice though.

Not sure about your state.