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!

[GilaRRT]

Paramedics are allowed to suture in the field, and in many ERs the techs are Paramedics (Children's in Chicago only hires EMT-Ps as techs, for example), so I don't see why they couldn't suture there.

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.

[r0b0tafflicti0n]

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?

[GilaRRT]

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?

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.

[sharpeimom]

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?

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:paw::paw:

[I_LOVE_TRAUMA, RN]

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.

[Medic09, BSN, RN, EMT-P]

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.

[canoehead, BSN, RN]

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.

[GilaRRT]

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.

I think they still do at Presbyterian?

[twinmommy+2, ADN, BSN, MSN]

I have a few techs where I work that I would let suture a family member, but that is because they are Army medics and do that kind of thing. Any of the others, no thanks.

Now that is not policy where I work that they let techs suture or RN's give lido. Both are done by mid level providers or higher.

[Medic09, BSN, RN, EMT-P]

I think they still do at Presbyterian?

Dunno. I'm not that up to date on what happens down at Pres. UNM stopped only because Centers for Medicare wouldn't reimburse for it under the existing billing categories, and they wouldn't (of course) add a code to allow for billing it accurately. It became a legal issue then, because the present billing codes assume that a mid-level or MD/DO did the sutures. So technically it was a fraud to bill it when the suturing had been done by a tech. Or some such. I wasn't directly involved, so I may have some details wrong.

[CraigB-RN, MSN, RN]

I learned to suture as a military medic 30+ years ago. It's mechanical skill, easily tought, learned, and performed. I lost count of the number of sutures I've put in over the years. There are some locations that due to apearence should have someoen who is will to take on the liabilty do no matter what the skill level. Lips, eyebrows, and things like that. During later years as an RN, I've close after many a surgery. Now like has been stated here, it's a billing issue.

As to the wouldn't cleaning, the betadine that we used to use was shown to possibly cause tissue damage, Not only is it common practice to use only saline now, but there is also limits to "pressure washing" also. In some of the remote environments I still work in just using clean "not sterile" tap or filtered water to wash the dirt away is all I get, and my wound infection rate is the same as in the city with big bottles of saline. It's def an improvment over teh duct tape ane bag balm the farmers and ranchers used.

[catshowlady]

CraigB - My husband also learned to do sutures when he was an Air Force medic years ago! He also said that he, like you, would never do sutures on a face either.

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.