Dermabond

[HERBIE1]

Hospitals supply discharge instructions to all patients. They have also come a long way from a simple- "come back to the ER or call your doctor if your symptoms worsen". There are detailed, disease specific sheets that explain most of the potentially serious complications that may arise. Compliance with those instructions is up to the patient, so I would not reject something like Dermabond in the field on that basis alone. I still think that in most cases, we should not be doing wound closures in the field, for reasons I have listed before.

Additionally, I would say there are probably legal implications because our purpose would be transformed from emergency care to more of primary and/or definitive care. I'm no lawyer, but I think certain liabilities we do not deal with now would suddenly come into play.

Yes, expanding our scope of practice would probably keep us relevant, and may be the wave of the future, but I think there are many hurdles to overcome before that can happen. One would hope that with our newly expanded roles, better pay and benefits would come, appropriate for someone assuming a more evolved role in health care. Would that still be cost effective? Would the increased liability prohibit such an expansion? Would there be blow back from the established medical community? Again- in most cases, EMS will not venture much beyond where we are now unless the entire system is changed. If a crew averages 20 calls/day, how can they continue to provide EMERGENCY service if they begin spending a lot more time with patients? The fundamental mission of an EMS service is to provide EMERGENCY care and transport, and if we started doing wound closures, we become more of a rolling clinic. How will a provider/municipality be reimbursed for that, especially when so many patients are indigent or on public health assistance?

Interesting ideas, but without concrete answers- particularly those that deal with compensation and reimbursement- as well as essentially a total transformation of prehospital care, this idea will probably stall.

[usmc_chris]

I'm not sure about wound closures with something like Dermabond, but I fully agree with the concept of "treat and release," coupled with adequate education, a modified Medicare payment schedule, and an intact referral system. That is, if we chose to release a patient following treatment, we could refer them to their primary care physician or a specialist for follow-up evaluation. Ideally, we could schedule the appointment prior to departing the scene.

That being said, like the above poster said, the emergency department provides detailed discharge instructions to every patient that leaved the ED. If we were to implement such a policy as EMS, we need to be able to provide a similar document in the field. This would, of course, mean that we would most likely have to install printers in the ambulance. Alternatively, several "categories" of instructions that could be pre-printed for distribution. This wouldn't be as good as having access to the database that hospitals use to provide discharge instructions (typically, what I have seen, is the instructions are pre-selected from a database where they can pull up instructions based on the patient's chief complaint, with the physician having the option to add additional instructions should he/she choose to do so). In the area I used to work in, we had a pre-printed sheet with follow-up instructions to hand out to all people who refused treatment/transport after signing the RMA. While not very detailed, I think this concept is great, and needs to be expanded if and when EMS expands more into primary care. Whether we like it or not, we ARE the defacto primary care providers for a large segment of society. I think efforts like this are not "expanding" our "skill set" etc., but rather acknowledging what society actually uses EMS for and adjusting ourselves to better fulfill that role.

Of course, I am in full agreement that the minimum standard to allow anything like this should be a 4-year baccalaureate degree.

[HERBIE1]

I'm not sure about wound closures with something like Dermabond, but I fully agree with the concept of "treat and release," coupled with adequate education, a modified Medicare payment schedule, and an intact referral system. That is, if we chose to release a patient following treatment, we could refer them to their primary care physician or a specialist for follow-up evaluation. Ideally, we could schedule the appointment prior to departing the scene.

That being said, like the above poster said, the emergency department provides detailed discharge instructions to every patient that leaved the ED. If we were to implement such a policy as EMS, we need to be able to provide a similar document in the field. This would, of course, mean that we would most likely have to install printers in the ambulance. Alternatively, several "categories" of instructions that could be pre-printed for distribution. This wouldn't be as good as having access to the database that hospitals use to provide discharge instructions (typically, what I have seen, is the instructions are pre-selected from a database where they can pull up instructions based on the patient's chief complaint, with the physician having the option to add additional instructions should he/she choose to do so). In the area I used to work in, we had a pre-printed sheet with follow-up instructions to hand out to all people who refused treatment/transport after signing the RMA. While not very detailed, I think this concept is great, and needs to be expanded if and when EMS expands more into primary care. Whether we like it or not, we ARE the defacto primary care providers for a large segment of society. I think efforts like this are not "expanding" our "skill set" etc., but rather acknowledging what society actually uses EMS for and adjusting ourselves to better fulfill that role.

Of course, I am in full agreement that the minimum standard to allow anything like this should be a 4-year baccalaureate degree.

Excellent point. I agree that we- and ER's- DO provide primary care in a lot of cases, but not officially. We advise on proper procedures for taking meds, safety tips, advising follow ups, explaining discharge instructions or medication actions, explaining procedures and the purpose of various tests and exams, but again this is not our primary function. It's a role that we have grown into because of the problems with the health care system.

There is also a subtle, but appreciable difference between officially adopting this new role and providing the information during the course of our primary duties.

[Bieber]

Hospitals supply discharge instructions to all patients. They have also come a long way from a simple- "come back to the ER or call your doctor if your symptoms worsen". There are detailed, disease specific sheets that explain most of the potentially serious complications that may arise. Compliance with those instructions is up to the patient, so I would not reject something like Dermabond in the field on that basis alone. I still think that in most cases, we should not be doing wound closures in the field, for reasons I have listed before.

Additionally, I would say there are probably legal implications because our purpose would be transformed from emergency care to more of primary and/or definitive care. I'm no lawyer, but I think certain liabilities we do not deal with now would suddenly come into play.

Yes, expanding our scope of practice would probably keep us relevant, and may be the wave of the future, but I think there are many hurdles to overcome before that can happen. One would hope that with our newly expanded roles, better pay and benefits would come, appropriate for someone assuming a more evolved role in health care. Would that still be cost effective? Would the increased liability prohibit such an expansion? Would there be blow back from the established medical community? Again- in most cases, EMS will not venture much beyond where we are now unless the entire system is changed. If a crew averages 20 calls/day, how can they continue to provide EMERGENCY service if they begin spending a lot more time with patients? The fundamental mission of an EMS service is to provide EMERGENCY care and transport, and if we started doing wound closures, we become more of a rolling clinic. How will a provider/municipality be reimbursed for that, especially when so many patients are indigent or on public health assistance?

Interesting ideas, but without concrete answers- particularly those that deal with compensation and reimbursement- as well as essentially a total transformation of prehospital care, this idea will probably stall.

I couldn't have said it better myself. It's not my intent to try and get everyone bugging their medical director about adding dermabond to their trucks first thing tomorrow, but to get people thinking about the fact that we need to start rethinking our practices if we want to survive. Like you said, the two major hurdles that we absolutely have to address before we can even consider something like this are our educational standards and are billing schedule.

I agree one hundred percent with you. Like I said, this isn't going to be something for every ambulance but more for mobile advanced clinicians, who can afford to be out of service for the time it would take to close the wound and give the patient instruction on wound care.

USMC Chris, I agree with you wholeheartedly as well.

[dsimms]

Wound closure with either steristrips or dermabond is performed in the field by majority of paramedic practitioners in the UK. Along with providing prophylactic antibiotics and referal to other health providers for follow up such as GP, practise nurse or district nurse.

[HERBIE1]

Wound closure with either steristrips or dermabond is performed in the field by majority of paramedic practitioners in the UK. Along with providing prophylactic antibiotics and referal to other health providers for follow up such as GP, practise nurse or district nurse.

What type of training do you receive for this? Obviously you need to be familiar with antibiotics and their coverage spectrums, as well as wound closure tips.

[crotchitymedic1986]

The problem is that once you take care of that wound with dermabond, you are going to be liable for any infections that occur, because the patient will claim you did not clean it properly. You also have to realize that dermabond is basically glorified glue; it will bring the skin back together, but will leave a "scar", whereas with sutures the scars will be minimal. Probably doesnt matter for a cut on the hand or foot, but the face is a different story.

[Just Plain Ruff]

The problem is that once you take care of that wound with dermabond, you are going to be liable for any infections that occur, because the patient will claim you did not clean it properly. You also have to realize that dermabond is basically glorified glue; it will bring the skin back together, but will leave a "scar", whereas with sutures the scars will be minimal. Probably doesnt matter for a cut on the hand or foot, but the face is a different story.

Unfortunately once you break the integrity of the skin you will have a scar. Regardless of closure type

I have seen it both ways, Dermabond if done right, can leave a very minimal scar, similar to a plastic surgeon scar. But done wrong or applied too liberally or not liberal enough it can leave a bigger scar than sutures do.

Applying Dermabond on the face is a bad idea unless it's done by a competent physician.

I hate to keep coming back to physician only skill but I think that allowing EMS to apply dermabond to a non-visible part of the body(clothes covered) or to a superficial lac on the extrems is not a good nor a bad idea, training training training, but leave the lacerations to the face alone and allow a physician to look at it.

I think that dermabond should not even be considered on a child until a physician has a chance to look at the laceration and then the physician can decide to close it himself or refer the child to a plastic surgeon.

Remember, we old guys, I'm 43, we don't really care about scarring, makes us look "heroic" and a scar to an adult is significantly less of an issue than a 3 year old who has many many years ahead of them, and they deserve to have the best suture repair that we can give them, especially around the face.

I guess what I'm saying is that dermabond could be used by EMS but with pretty strict and tight restrictions.

AS for the person who said that in the UK they have been doing this for many years, I'll bet if I remember right that the education for paramedics is much more stringent and in depth than it is for our medic mill medics out there who get their education in less than 6 months at some schools. Who are you going to trust to do more skills, a medic in the UK with several years of school and training or a medic in the US with a 6 month certificate?

Consider if the laceration was on your face?

[dsimms]

What type of training do you receive for this? Obviously you need to be familiar with antibiotics and their coverage spectrums, as well as wound closure tips.

The training requirements for emergency care practioners (the type of paramedic practioner who can perform wound closure) vary across the ambulance trusts. In some areas it’s at degree level other areas specify that you have or are working towards masters level education. Unfortunately I can't go into too much detail around what there actually taught as I’m not even a paramedic yet.

Antibiotics and a range of other medications are provided by paramedic practioners using patient group directions, which are essentially protocols which allow health professionals who aren’t prescribers to supply medications for certain conditions under set circumstances. Paramedics in the UK are currently not able to access independent prescriber training due to the way the law was written when independent prescribing was introduced.