Dermabond

[squire]

Does anyone know of any EMS systems that has used Dermabond in the field? I think it is used more in the ER or clinic environment than anywhere else. I just curious if anyone has ever used this or is there specific requirements as to who can use it. My understanding is that trained healthcare personnel can use it. Let me know what you think.

[HERBIE1]

We don't use it, nor am I aware of anyone who does prehospitally. Seems like it could be useful- if you verify current tetanus status, properly irrigate and clean the wound, etc. I would be concerned about the possibility of infections and liabilities since we would not have the ability to prescribe prophylactic antibiotics. Seems to me most companies/municipalities would not want the added head ache of liability but in some situations, I see it being useful. Rural settings, limited access to care, advanced scope of practice providers, etc.

I know folks who have "acquired" Dermabond and used it for themselves and had no problems, but to me it's a risky proposition to put into our treatment arsenal.

[Just Plain Ruff]

We don't use it, nor am I aware of anyone who does prehospitally. Seems like it could be useful- if you verify current tetanus status, properly irrigate and clean the wound, etc. I would be concerned about the possibility of infections and liabilities since we would not have the ability to prescribe prophylactic antibiotics. Seems to me most companies/municipalities would not want the added head ache of liability but in some situations, I see it being useful. Rural settings, limited access to care, advanced scope of practice providers, etc.

I know folks who have "acquired" Dermabond and used it for themselves and had no problems, but to me it's a risky proposition to put into our treatment arsenal.

The main question with using dermabond is this. Are paramedics currently educated well enough to know what kind of laceration would be a candidate for Dermabond? Have they been trained to correctly irrigate a wound? Are medical directors going to go for a paramedic or an EMT dermabonding a laceration that may need to be sutured yet didn't get a physician exam to determine depth, tissue damage and type of wound.

In every ER I've ever worked in the physician was the one to dermabond the laceration. Sure I could have done it but the physician was the one who actually applied the dermabond.

I think that this is beyond the current purveyance of the EMS systems in this country.

[Chief1C]

I've purchased it online, and used it on myself, friends, etc.. I have like a field surgical kit type deal, solely for personal use. I avoid seeking higher care at all costs. It burns. Badly. Apply ice, and it comes apart, so in a rural setting if you're lacking a doctor... Go to the Vet, they can usually do a good job. Never had a problem, yet. Antibiotics? Call up and ask for oral liquids for a cat, usually get that bubblegum flavored pink stuff. Totally serious. Being a technical rescuer, wilderness rescue, I would never seal a wound. There is nothing sterile in the middle of the woods, I carry stuff to irrigate; and benzoin tincture, steri-strips, etc.. That Band-Aid stuff in the tube, with the foam applicator does just as good of job. But I'd never seal a patients laceration. Irrigate it well, perhaps mixing betadine w/ water, dress it, and wrap it w/ coban. Never seal it, any more than you have to, if it's big... Slap a QuikClot on it and hope for the best.

I can say, that dermabond, when allowed to dry and not move the area, does heal quite well. I was hanging a light fixture in the EMS supply room, sat the drill down, and my hand ever so gently rubbed the bit. Nice, kinda deep, 1.5" lac from my back of my thumb, across the side of my wrist. There's a vein there. Bloody fricken mess, but you can only tell where the lac was, b/c my wrist, yanno, bends. Just like a 1/4" spot where there is an obvious scar. As nice as that is to have on the spot, and not take 4 hours to go to the ER... However.

I don't think that it has a place in EMS. We're not even allowed to carry first aid cream. At least if it gets sealed up, then turns into an abscess, they won't be suing EMS. We don't get a lot of BS calls in the minor injury department, ppl out here tend to be able to take care of themselves a little better. First Aid Kit rant... Honestly, have any of you bought a first aid kit recently? We have one in the kitchen, from Target. It looked neat, that's the only reason, it looks cool in our 1940's looking kitchen. There's nothing in it to treat anything larger than a paper-cut, or a hangover. Maybe a broken finger. Sorry to go off topic, Oxycontin on board, I have 45min CPR cramps.

[Bieber]

I think this would be a great addition to our arsenal, and represents one of those areas where EMS could truly provide definitive care (or at least a greater component thereof) if two conditions were met: the first, and always foremost, is education. Like I've been ranting about in another thread, we need to expand our understanding not only of emergency medicine, but all fields of medicine in general. I hear a lot of people in this thread questioning whether or not paramedics could safely determine what wounds are candidates for dermabonding, and the answer is YES! We CAN do that, with the proper education and training. Wound sealing and referral to the patient's primary care physician for antibiotics (I think five days of Keflex is the commonly prescribed antibiotic for prophylaxis of open wounds? Someone correct me if I'm mistaken.) or even (potentially, and understand that I realize how long the road is before we reach this point) actual prescription writing privileges for those patients who don't have a primary care physician.

The second component is money. Just like medicare won't pay for the IV supplies and the amp of sugar we use when we wake up diabetics and send them on their way, they're not going to pay for wound care treat and release practices either. Until we can bill for service, no EMS service is going to waste the money on supplies and training to make this a reality.

This is one of those niches where EMS could really step up and prove its worth. There are plenty of minor wounds that don't require an ER visit, and by paramedics becoming educated and capable to handle simple wounds on a treat and release basis, we can not only help to bring down the cost of unnecessary ER visits, but also tack on another treatment to the currently small list of things we do that have actually been shown to be cost effective and beneficial to our patients.

We've got to stop thinking about pure emergencies and start thinking about minor injuries and illnesses, because, like I've said, we're really not as good as we think we are or as effective as we think we are. The healthcare environment is becoming more and more about "prove to me you're worth your cost", and this is something we really ought to consider capitalizing on if we don't want to go the way of the dinosaurs.

[HERBIE1]

Ruff makes an excellent point. Like anything, proper training is essential. Is it a clean lac, or does it have jagged edges. Is the wound macerated? I would say that something like this should require training under a doctor's supervision for awhile to ensure proficiency. I was taught to suture by an ER doc years ago. Is it hard to do? Not really. Requires a bit of manual dexterity to tie the knots, etc. Is it difficult to do WELL. Yes. Poor technique yields a nasty scar.

Same with using Dermabond.

[Just Plain Ruff]

I am not saying that we cannot do the dermabond thing, I'm saying that we really shouldn't.

I'm also not saying we are not educated well enough or we can't get educated on this but previously in the past this has been a physician/NP/PA thing and I don't see that changing any time soon.

I see a time issue here also. With our utilization being watched so closely by the bean counters, the time it takes to irrigate a wound and then dermabond it is not going to set well with the management of many services.

Plus, many services will not want the liability for laceration repair. The added expense of the education on how to use dermabond will be a big issue with the services.

I think that rules need to be in place to clearly define what lacerations can be repaired with Dermabond and I think that the first exclusion group would be children. Any child under 12 should not get dermabond until evaulated by an ER physician. Many times in the ER a physician will elect to send the child to a plastic surgeon due to the cosmetic issues of a laceration especially to the face.

Dermabond does not work well on joints. Can a medic determine whether there is other damage underneath? I do not believe that they can. I used to work full time in an ER and was taught by some of the physicians to suture but I would never take it upon myself in the ambulance to dermabond a laceration as that is WAY beyond my scope of practice.

If we are going to go down this road to put dermabond on lacerations we need training, education and hands on practice in the ER.

I for one would not allow a medic to put dermabond on my child or on me to that matter. Others here might but not me. I don't have that much faith in the education levels of many of my co-workers. I'd rather spend the money on an ER visit.

[Richard B the EMT]

Is Dermabond a kind of "superglue" for the skin? Just asking for a clarification.

[Bieber]

Ruff, in our current incarnation, as EMS is today, I agree with you one hundred percent. I am in no way advocating this practice start being adopted by EMS services or paramedics first thing tomorrow, what I mean to do is get the creative juices flowing and get rid of this defeatist attitude we've held for so long and try to shake people out of this "I can't" philosophy. Yes, we can, but it's going to take people who have a thirst for education and knowledge and improvement to look at things like dermabond and say, "Well, damn, we ought to be doing that someday!" and to get those same people to say, "I'm determined to bring our educational standards up to that level where we ARE educated enough and capable enough to make that desire to be able to benefit our patients in such a way a reality.

Is Dermabond a kind of "superglue" for the skin? Just asking for a clarification.

It's a liquid skin adhesive for wound closure, yes.

http://www.dermabond...duct/index.html

Edited April 9, 2011 by Bieber

[HERBIE1]

To me this falls under the advanced scope of practice umbrella. In some areas it makes sense- fiscal and practical, in others it does not. In a busy urban system for example, clearly this idea would be a non-starter. Think about the idea of intubation and other advanced procedures we perform. It was not that long ago when there was a huge backlash- no way should someone without an MD be able to do surgical crics, intubations, needle decompressions, etc.

With PROPER training and oversight, I see no reason why EMS providers cannot use something like Dermabond- given the right circumstances.