Tell me if this is the norm in your er! - page 2

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... Read More

  1. by   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?
  2. by   GilaRRT
    Quote from r0b0tafflicti0n
    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.
  3. by   sharpeimom
    Quote from 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?
    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.

  4. by   I_LOVE_TRAUMA
    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.
  5. by   Medic09
    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.
  6. by   canoehead
    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.
  7. by   GilaRRT
    Quote from Medic09
    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?
  8. by   twinmommy+2
    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.
  9. by   Medic09
    Quote from GilaRN
    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.
  10. by   CraigB-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.
  11. by   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.
  12. by   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...............
  13. by   GilaRRT
    Quote from catshowlady

    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.