Dermabond

[Eydawn]

Come on, Bieber... do you really have to ask? Why would you monitor for infection- same reason you'd monitor any other sutured wound. High risk for anaerobic bacterial growth and tissue damage. Doesn't matter if you stitched it together with surgical sutures or sealed it over with dermabond/medical superglue, you've still got the same risk.

I think the risk in the field would actually be higher, as you might not have irrigated or disinfected properly... less access to topical anesthetics to improve pt. compliance with irrigation, etc. Hence, why I watched the two lacs I superglued like a hawk. My terms were actually that I would only do it for him if he agreed to go to the ER at any signs of infection, which he readily agreed to.

Which brings me back to my original point... if we're going to start treating minor things in the field and releasing, we need to develop a community health interface with protocols for assessment by home health nurses or specially trained paramedics for a prescribed period of days post-treatment. It would be also great if we could field stabilize and then refer to a community based in-home care for things like asthma exacerbations, flu/cold, etc...

Wishful thinking, I know...

Wendy

CO EMT-B

[Bieber]

Come on, Bieber... do you really have to ask? Why would you monitor for infection- same reason you'd monitor any other sutured wound. High risk for anaerobic bacterial growth and tissue damage. Doesn't matter if you stitched it together with surgical sutures or sealed it over with dermabond/medical superglue, you've still got the same risk.

And? Patients or their caretakers are perfectly capable of monitoring for signs of infection on their own with proper instruction. The hospital doesn't have patients regularly return for daily wound care checkups for minor injuries--why would we?

I think the risk in the field would actually be higher, as you might not have irrigated or disinfected properly... less access to topical anesthetics to improve pt. compliance with irrigation, etc. Hence, why I watched the two lacs I superglued like a hawk. My terms were actually that I would only do it for him if he agreed to go to the ER at any signs of infection, which he readily agreed to.

Why would the risk of improper irrigation be any greater in the back of the ambulance versus the hospital? That's not a problem of location, that's a problem of technique. Also, I have to question, if you think it's such a bad idea to be done in the field on the basis of it's done in the field--as opposed to a problem with the providers--why would you ever consider doing it yourself? Are your neighbors less important than any of your other patients? Those same terms would apply to any prehospital provider doing wound care: if signs of infection appear, you need to seek higher care.

Which brings me back to my original point... if we're going to start treating minor things in the field and releasing, we need to develop a community health interface with protocols for assessment by home health nurses or specially trained paramedics for a prescribed period of days post-treatment. It would be also great if we could field stabilize and then refer to a community based in-home care for things like asthma exacerbations, flu/cold, etc...

Wishful thinking, I know...

The future belongs to those who dream, and those who are willing to work for those dreams. I've said it before and I'll keep saying it, there is a growing movement of folks out there who are demanding that we show that we're worth the pretty penny that funds us, and to be honest, as we currently are, we just might not be. There's a growing body of evidence that most patients don't benefit from ALS, or at least that they don't benefit from as early ALS care as EMS provides (rural EMS being the exception). If we don't find additional services to provide for our patients, we could return to the early days of really being "just ambulance drivers". There's even some service in Ohio (Cincinnati, maybe?) that's talking about switching to an all BLS service. What's going to happen if they do that, and it ends up that there's really no statistical difference in end care results? Paramedics go bye-bye. And if all we can provide is emergency care that ends up being maybe not necessarily unnecessary, but statistically neutral when it comes to end patient results, then people all over this country are going to seriously begin to question why in the hell they're paying 15 bucks an hour for a paramedic when a 10 buck an hour EMT will do just as good.

Like I've said, I think paramedics are vital. But I'm not perfect and I'm not always right. I do know, however, that most of my patients don't end up requiring anything more than my observation. And policy makers aren't as concerned with the fact that we all know patients deserve a proper assessment from a highly educated provider, they just care about the numbers. Is ALS making a statistical difference? Is that statistical difference correlating to an efficient cost-benefit ratio? People are no longer willing or able to pay for medical treatments that haven't proven their worth, and that includes much of emergency medicine. It could simply be that we haven't yet reached a point in our development where we can save the most serious of conditions, or that they're simply incurable. And outside of those most critical patients, most of our patients need palliative measures and monitoring alone--which the economists say can be just as easily done by an advanced EMT, and for only half the cost. Justifying our existence is going to become an ever more difficult thing if we don't become more than only capable of treating emergency conditions.

I'm not calling for us to replace primary care. I'm calling for us to do our part of weeding out those patients for whom hospital transport is unnecessary. And with proper education, and with proper funding (i.e. changing the medicare schedule to allow payment for service, not pay for transport), we can do a lot more than we currently are. Not every patient needs an ER and not every patient has a primary care doctor or one that can see them immediately, but every patient can contact EMS day or night, wherever they are, and with proper education, we can properly assess many conditions and alleviate the patient's suffering or symptoms with adequate referral to a more appropriate destination than just the ER. It's not for every patient or every primary care condition, nor should it try to be, but it ought to be more than it currently is.

Edited April 10, 2011 by Bieber

[Dustdevil]

And? Patients or their caretakers are perfectly capable of monitoring for signs of infection on their own with proper instruction.

LOL! I remember when I was young and naive like this. As I recall, it lasted only a few short months, so you should be better soon.

If people were really that responsible, would they be hurting themselves this often? Think about it.

The hospital doesn't have patients regularly return for daily wound care checkups for minor injuries--why would we?

You need to check with more hospitals and clinics before you make that assumption. But we're not talking about a hospital here. We're talking about a lone provider, with a daily personal relationship with the patient, functioning outside of her legal scope. You'd have to be pretty negligent to not regularly monitor that progress. After all, that's what friends do.

[Bieber]

LOL! I remember when I was young and naive like this. As I recall, it lasted only a few short months, so you should be better soon.

If people were really that responsible, would they be hurting themselves this often? Think about it.

I'm not saying people aren't irresponsible, but we can't be their nannies either. People have a personal responsibility for their care, and there is an established line between what we as medical providers are obligated to provide and what the patient is expected to do for themselves.

You need to check with more hospitals and clinics before you make that assumption. But we're not talking about a hospital here. We're talking about a lone provider, with a daily personal relationship with the patient, functioning outside of her legal scope. You'd have to be pretty negligent to not regularly monitor that progress. After all, that's what friends do.

It's not an assumption and I have on multiple occasions observed and taken part of the wound care process in our local ERs. The most recent (and personal) experience was when my fiancee got bit on the lip by a german shepherd at work. Now, this type of injury would most certainly be out of the question for EMS (due to the more advanced cosmetics of facial injury repair), but I can tell you that the follow up instructions did not include daily checkups. For major injuries, I can certainly imagine it would and those are not the kinds of injuries that EMS would or should be treating in the field.

In the instance you're referring to, yeah, if I was operating outside of my scope, I'd be checking that wound for signs of infection every day too. But I'm not talking about paramedics acting outside of our scope, I'm talking about adding minor wound care to the additional education I advocate EMS to adopt every day.

[Richard B the EMT]

. if you have to ask, esp if you are a parapatetic then you are in wrong biz.

period.

and yes. i am a know it all.

On presumption that OperaGhost's spell check was down, and (s)he suffers from the problem of striking 2 keys at the same time (as I do), and meant Paramedic, just remember that there are numerous systems that vary on how much the Paramedics can do before they have to contact On Line Medical Control (Mother/Father, May I?).

Also, those who claim to know it all, are viewed as ridiculous by those of us who do know it all!

Edited April 10, 2011 by Richard B the EMT

[Dustdevil]

...I'm talking about adding minor wound care to the additional education I advocate EMS to adopt every day.

Are you saying this should be "additional", as in optional? Or do you mean that it should be added to all entry level paramedic education?

Regardless, I reject either suggestion outright on multiple grounds.

First, I reject the firemonkey philosophy that we must start doing other peoples jobs in order to justify our own. A jack of all trades is usually a master of none. If you stick around here long enough, you will realise that a distressingly large number of EMS providers can't even master the simple basics, even with two years of school. If we are going to add education (of which I am the strongest proponent), it should be aimed at solidifying our foundation, not more toys. Which brings me to the next point...

IT'S NOT ABOUT SKILLS!! You yourself already made the point that very little of what we do can be fiscally justified by mortality rates. So I'm not sure where you get the notion that spending half an hour closing a non-suturable lac, then another 20 mins cleaning, restocking, and documenting a non-billable procedure, while the other crews -- who would rather be watching TV -- burn time and gas covering your territory, possibly delaying critical care to other patients, makes the slightest bit of sense on any level. If you find a system where they think that's good business, it is likely run by idiots.

A lot of medics would love to do breast exams and Pap smears too. Both are extremely simple, I could teach both in a day. But, you know what? It ain't our job. And if you by some slim chance end up working someplace where it is your job, I expect that they will teach you how, just like Dermabond or suturing. And wound closure classes are quite standard for any medic interested in such a job. Go take one, then you can sew another nifty patch next to your tactical medic, dive medic, and space medic patches that you'll never use.

Education is a good thing, bro. It's the key to our future, and our survival. Keep fighting the good fight for it. But, please slow down and get the priorities in order. Never confuse training with education.

To answer the original poster's question, I have never encountered field closure by EMS. I have seen it only in the military, clinical, remote/expeditionary, and event medical/first aid scenarios, usually under supervision of a physician or mid-level provider (NP or PA).

Edited April 10, 2011 by Dustdevil

[chbare]

This is a legal and liability slippery slope. Unfortunately, Dermabond is not ideal for numerous situations. Deciding the proper modality for small laceration repair can actually be rather complicated. Then, we must also consider anatomical, infectious, functional and astetic issues. All of the following are full of liability. I do not see the need to perform such a low yield/high risk procedure.

Take care,

chbare.

[Bieber]

Are you saying this should be "additional", as in optional? Or do you mean that it should be added to all entry level paramedic education?

All levels of paramedic need the education to properly assess and treat wounds of all kinds, however from a logistical standpoint not every ambulance should be put out of service in order to do so; the actual treatment could be performed by advanced paramedics in "fly cars" or SUVs.

Regardless, I reject either suggestion outright on multiple grounds.

First, I reject the firemonkey philosophy that we must start doing other peoples jobs in order to justify our own. A jack of all trades is usually a master of none. If you stick around here long enough, you will realise that a distressingly large number of EMS providers can't even master the simple basics, even with two years of school. If we are going to add education (of which I am the strongest proponent), it should be aimed at solidifying our foundation, not more toys. Which brings me to the next point...

Did you reject paramedics adopting 12 lead EKG capabilities because it was adopting other people's jobs? Or adding medications to our repertoire? Clearing C-spine? Advancement is for the benefit of our patients as much as it is for ours. And adding additional education and minor wound care will hardly make us jacks of all trades. Two years of school is a joke, a Bachelor's degree ought to be the minimum. I agree with you one hundred percent that education should be about solidifying our foundation, at the same time, the socioeconomics of healthcare dictate that we have to justify our existence more than we currently are. Why is anyone going to pay for paramedics with increased education if it doesn't change the quality of care?

IT'S NOT ABOUT SKILLS!! You yourself already made the point that very little of what we do can be fiscally justified by mortality rates. So I'm not sure where you get the notion that spending half an hour closing a non-suturable lac, then another 20 mins cleaning, restocking, and documenting a non-billable procedure, while the other crews -- who would rather be watching TV -- burn time and gas covering your territory, possibly delaying critical care to other patients, makes the slightest bit of sense on any level. If you find a system where they think that's good business, it is likely run by idiots.

You're right, it's not about skills. And like I've already said, wound care like what I've suggested isn't feasible until we change the medicare schedule of billing for ambulance services to reflect payment for service, versus payment for transport.

A lot of medics would love to do breast exams and Pap smears too. Both are extremely simple, I could teach both in a day. But, you know what? It ain't our job. And if you by some slim chance end up working someplace where it is your job, I expect that they will teach you how, just like Dermabond or suturing. And wound closure classes are quite standard for any medic interested in such a job. Go take one, then you can sew another nifty patch next to your tactical medic, dive medic, and space medic patches that you'll never use.

Like I said, it's not my intention for EMS to replace primary care services, but to take a greater part in the full continuum of care for our patients. And hey, if I do find a wound care class around here, I will take it! Not because it will change what I can do, but because it will give me more knowledge, and allow me to have a better idea of what my patients can expect at the ER (and even tell them what to expect).

Education is a good thing, bro. It's the key to our future, and our survival. Keep fighting the good fight for it. But, please slow down and get the priorities in order. Never confuse training with education.

Thanks. We don't have to agree on everything to agree that increasing our educational standards is a must for EMS. I know I'm ambitious, and I don't claim to know what's best for EMS, but the whole reason why forums like this exist is so we can share ideas and learn from each other.

[Just Plain Ruff]

Ill go on record here, there is no way that I'm ready to allow medics to do this procedure. No offense to anyone here but I personally do not think that we have any business closing wounds in the course of our jobs.

This should be left to the doctors and NP's and PA's.

I'm personally not comfortable with many if not all the medics I know enough to allow this.

If my son or daughter cut themselves and an ambulance came and said that they could close the wound with dermabond, I'm not gonna allow it and Ill go to the ER to get it looked at.

Again, no offense to anyone here but it just isn't gonna happen at least where my kids are concerned.

Sent from my SPH-D700 using Tapatalk

[Ridryder 911]

Yes... I'm baaack..

Like Dust described.. "educated" person. With this saying, truthfully I do see it being a standard on simple or first degree lacerations. We teach Nurses all the time on how to place steri-strips, even derma bond at some local ER's.

Again, not all lacerations should ever be thought of; but those simple lacerations that have clean edges and good proximal closing.. why not? If the wound can be cleansed well and DPT is up to date.. Should the patient recieve a transport to the ED if that is the only complaint?

Again, good active medical control and great medical education is the main key.

R/r 911

Edited April 11, 2011 by Ridryder 911