EMS Question Regarding Incident In Emergency Room

[Mike Mathers]

Hello,

For obvious reason I'm not going to say were I was or the date that it happened, but I'm a EMT-B in NJ. Cut to the chase: so I was with my partner and we were transporting a child (with mother) who had a laceration of the eye that definitely was going to need stitches. As we are leaving the child and mother in the ER, I politely go to the mother (the MOTHER ONLY) and make the recommendation that she make sure a plastic surgeon stitches him up. Well when I said that the ER tech. (who was in the room & overheard me) went crazy and started staring me down. After I leave the room she comes up to me and tells me I'm not allowed to recommend that because I'm not a doctor. I replied to her that I can make any recommendation I want and explained to her that personally it's what I recommended. (Keep in mind I showed her multiple apparent scars that I have on my own face that required stitches in the past).

Did I do something wrong?
What would you guys have done?

 

[DesertMedic66]

I can see why the tech had a problem. The hospital has other options aside from just stitches. It would suck to have a medic/EMT tell you one thing and the hospital doesn't do it.

IMO unless you know 100% that the hospital is going to do what you say then your better off withal merging along the lines of "the nurses and doctors will take care of you and fix you up".

 

[TransportJockey]

I can see why the tech had a problem. The hospital has other options aside from just stitches. It would suck to have a medic/EMT tell you one thing and the hospital doesn't do it.

IMO unless you know 100% that the hospital is going to do what you say then your better off withal merging along the lines of "the nurses and doctors will take care of you and fix you up".

This. Usually on the face, anymore, they're trying to use glue and steristrips so that people don't always have to get sutures done on the face. As someone who used to be an ER paramedic, I used to hate when field crews told the patient that the hospital WOULD DO a course of treatment. It got the pt really upset when they thought we weren't doing what was best for them

 

[Handsome Robb]

What Desert said.

Maybe different wording would've helped. "Hey I've had to have stitches on my face multiple times that left these scars. It may be worth asking if a plastic surgeon is able to do the stitches but that also may not be possible depending on the hospital."

Or something like that. Also, would've done it in the unit rather than in the hospital in front of staff.

I would assume most hospitals would use a plastic surgeon for facial stitches if they had the resources.

One question for clarification, you said a laceration of the eye. Are you saying it was a lac on the actual globe or on the eyelid/near the eye?

I've got a scar on my face from running into a pole when I was a little kid and getting stitches in a small-town ER in my face so I feel you on that one. I'm lucky though and it's faded quite a bit with age.

 

[Mike Mathers]

What Desert said.

Maybe different wording would've helped. "Hey I've had to have stitches on my face multiple times that left these scars. It may be worth asking if a plastic surgeon is able to do the stitches but that also may not be possible depending on the hospital."

Or something like that. Also, would've done it in the unit rather than in the hospital in front of staff.

I would assume most hospitals would use a plastic surgeon for facial stitches if they had the resources.

One question for clarification, you said a laceration of the eye. Are you saying it was a lac on the actual globe or on the eyelid/near the eye?

I've got a scar on my face from running into a pole when I was a little kid and getting stitches in a small-town ER in my face so I feel you on that one. I'm lucky though and it's faded quite a bit with age.

Sorry, I meant to say laceration above the eye.

Thanks everyone, I see where you guys are coming from. In the end it really isn't my business. I was just trying to help (I guess a little to much).

 

[OnceAnEMT]

Sorry, I meant to say laceration above the eye.

Thanks everyone, I see where you guys are coming from. In the end it really isn't my business. I was just trying to help (I guess a little to much).

I know exactly what you mean, and I've come into that situation a few times myself as I am often the first contact for walk-ins and EMS patients (save for the crew) as a Tech. Usually the first or second question is, "What's going to happen next?" I explain the usual procedure depending on the generic c/c. But there are those times where its specific, like a simple trauma. I suggest you either nudge towards the hospital staff, or compile all options. Explain that it could be a number of different things and it is up to the doctor. Could be glue, could be sutures, could be staples, could be nothing. The less decisions you have to make the less trouble you could dig yourself into. You're certainly not obligated to provide those types of answers since you don't play a part at that point. Even I often wave off for the physician. Even the nurse will, since they aren't making the diagnosis either, and aren't doing any of the trauma treatment that isn't medication/blood work related.

 

[medicsb]

This will seem like I'm piling on and I guess I am in a way... But, this is a problem of knowing just enough to be dangerous. In some cases, yes, a plastic surgeon may be indicated to take care of a facial laceration on a child (or an adult). However, not all lacerations require sutures. And just because it is on the face, does not mean a plastic surgeon is needed. Plastic surgeons are not miracle workers. You're especially undermining the physician or PA (or CRNP) that may be tasked with closing the wound. Even if they did it as well as a plastic surgeon, you've now set an unrealistic expectation and the potential for the parent and child to think they got poor care because a plastic surgeon did not do the closure. Additionally, not all hospitals have plastic surgeons available to come in and suture facial lacs on children; again, another unrealistic expectation.

You were not trying to help "too much", it was that what you thought was helpful actually was not that helpful. Though, I do not think you meant any harm. Anyhow, chalk it up to a learning experience.

 

[DesertMedic66]

What Desert said.

Maybe different wording would've helped. "Hey I've had to have stitches on my face multiple times that left these scars. It may be worth asking if a plastic surgeon is able to do the stitches but that also may not be possible depending on the hospital."

So that explains what happened to your face...

 

[Tigger]

I will not recommend something quite as specific as this to a patient. However if a patient wants to be seen at the local hospital with extremely limited capabilities, I may advise them against it. I wouldn't want an ER doc who does only a few sutures a year to sew me up when I have better options less than hour away.

 

[Mike Mathers]

This will seem like I'm piling on and I guess I am in a way... But, this is a problem of knowing just enough to be dangerous. In some cases, yes, a plastic surgeon may be indicated to take care of a facial laceration on a child (or an adult). However, not all lacerations require sutures. And just because it is on the face, does not mean a plastic surgeon is needed. Plastic surgeons are not miracle workers. You're especially undermining the physician or PA (or CRNP) that may be tasked with closing the wound. Even if they did it as well as a plastic surgeon, you've now set an unrealistic expectation and the potential for the parent and child to think they got poor care because a plastic surgeon did not do the closure. Additionally, not all hospitals have plastic surgeons available to come in and suture facial lacs on children; again, another unrealistic expectation.

You were not trying to help "too much", it was that what you thought was helpful actually was not that helpful. Though, I do not think you meant any harm. Anyhow, chalk it up to a learning experience.

I appreciate what you are saying, but you are making a lot if assumptions here. The whole point of a plastic surgeon is that he/she specializes. 9/10 the plastic surgeon will have more expertise. The physician will tell you one thing while the plastic surgeon will tell you another.

Also, a reason I recommended it is that a lot of people won't even realize that as an option. The option won't be given to them simply because the ER wants to get them in and out as soon as possible. Plastic surgeon definitely cares more about the appearance of a scar than a physician would.

What if the hospital did have a plastic surgeon on hand (knowing he could do a better job) but just let the physician take case if it? Just playing a little devils advocate.

 

[Handsome Robb]

So that explains what happened to your face...

Yup lol.

Almost lost my left eye too. Hit a horizontal bar and ended up with stitches on the bridge of my nose and just lateral to my left eye. Good thing I don't have exophthalmos!!! 8)

 

[Mike Mathers]

This. Usually on the face, anymore, they're trying to use glue and steristrips so that people don't always have to get sutures done on the face. As someone who used to be an ER paramedic, I used to hate when field crews told the patient that the hospital WOULD DO a course of treatment. It got the pt really upset when they thought we weren't doing what was best for them

Remember I only recommended that they have a plastic surgeon look at. I never told them what and what not the doctors will do.

 

[DesertMedic66]

I appreciate what you are saying, but you are making a lot if assumptions here. The whole point of a plastic surgeon is that he/she specializes. 9/10 the plastic surgeon will have more expertise. The physician will tell you one thing while the plastic surgeon will tell you another.

Also, a reason I recommended it is that a lot of people won't even realize that as an option. The option won't be given to them simply because the ER wants to get them in and out as soon as possible. Plastic surgeon definitely cares more about the appearance of a scar than a physician would.

What if the hospital did have a plastic surgeon on hand (knowing he could do a better job) but just let the physician take case if it? Just playing a little devils advocate.

And what if the hospital didn't have a plastic surgeon on staff or on duty that day? What if the plastic surgeon doesn't go to the ER for small injuries like that? We can "what if" all day long.

100% of the facial lacerations I have transported to the ED have been treated by the ED doc.

 

[Mike Mathers]

And what if the hospital didn't have a plastic surgeon on staff or on duty that day? What if the plastic surgeon doesn't go to the ER for small injuries like that? We can "what if" all day long.

100% of the facial lacerations I have transported to the ED have been treated by the ED doc.

True. But what if your ED doc use to be a plastic surgeon!!!

 

[Handsome Robb]

Then they probably haven't practiced plastic surgery in a long time and might not be any better than the other ERPs.

 

[medicsb]

I don't think I'm making very many assumptions because much of what I am saying comes from experience, training, and education. You seem to assume that an EM physician will not consult a specialist if they feel that they are out of their depth because they want to get the patient "in and out". However, EM physicians are used to consulting specialists when the need arises. You, who have no experience closing lacerations, is not the one to make any sort of suggestion about care. If the physician evaluates a wound and determines that a specialist (who is also a physician, even a plastic surgeon, by the way) is needed, they will consult. Many lacerations, including ones on the faces of children are within bounds of an EM physician. And, uh, EM physicians (and other specialties) do care about patient outcomes including scarring; it is wholly disrespectful of you to make a blanket assumption that they do not just because they are not trained in plastic surgery.

And you also do not know if a plastic surgeon could do a better job. They may not be able to depending on the characteristics of the wound. You might be surprised at how well non-plastics physicians (or even PAs or CRNPs) can close wounds.

I appreciate what you are saying, but you are making a lot if assumptions here. The whole point of a plastic surgeon is that he/she specializes. 9/10 the plastic surgeon will have more expertise. The physician will tell you one thing while the plastic surgeon will tell you another.

Also, a reason I recommended it is that a lot of people won't even realize that as an option. The option won't be given to them simply because the ER wants to get them in and out as soon as possible. Plastic surgeon definitely cares more about the appearance of a scar than a physician would.

What if the hospital did have a plastic surgeon on hand (knowing he could do a better job) but just let the physician take case if it? Just playing a little devils advocate.

 

[Mike Mathers]

I don't think I'm making very many assumptions because much of what I am saying comes from experience, training, and education. You seem to assume that an EM physician will not consult a specialist if they feel that they are out of their depth because they want to get the patient "in and out". However, EM physicians are used to consulting specialists when the need arises. You, who have no experience closing lacerations, is not the one to make any sort of suggestion about care. If the physician evaluates a wound and determines that a specialist (who is also a physician, even a plastic surgeon, by the way) is needed, they will consult. Many lacerations, including ones on the faces of children are within bounds of an EM physician. And, uh, EM physicians (and other specialties) do care about patient outcomes including scarring; it is wholly disrespectful of you to make a blanket assumption that they do not just because they are not trained in plastic surgery.

And you also do not know if a plastic surgeon could do a better job. They may not be able to depending on the characteristics of the wound. You might be surprised at how well non-plastics physicians (or even PAs or CRNPs) can close wounds.

First, it aren't realizing what I'm trying to say. Having 2 facial lacerations and 1 laceration on my leg (all which needed stitching) I know I'm entitled to speak on it based on personal experience (I have not received any formal training). What you are saying is right "by the book" but you don't realize in poor, underprivileged communities this not possible/ all known. I'm not trying to bash EM physicians; they are great at what they do & are really nice people. Rather what I'm trying to say is to just get a second opinion before beginning to fix the laceration by a specialist. It's like getting your car fixed after an auto-collision. You don't just go to 1 auto body shop to get a quote, you go to multiple to get quotes and compare prices. That is all I was trying to say. I'm not trying to bash EM physicians at no means necessary.

 

[Ewok Jerky]

Did I do something wrong?
What would you guys have done?

Don't ask for opinions and then argue about it. Obviously you feel you did nothing wrong.

I have closed facial lacs as a student under an ED physician's supervision, so no, not all facial lacs require plastics. I would probly refrain from giving medical advice/opinion beyond your scope while on duty. In your private life, sure, tell everyone to request plastics, but when dropping a patient off in the ED you don't have the training to give such advice. Would you tell every patient with chest pain they need a nuclear stress test?

 

[JPINFV]

Hello,

For obvious reason I'm not going to say were I was or the date that it happened, but I'm a EMT-B in NJ. Cut to the chase: so I was with my partner and we were transporting a child (with mother) who had a laceration of the eye that definitely was going to need stitches. As we are leaving the child and mother in the ER, I politely go to the mother (the MOTHER ONLY) and make the recommendation that she make sure a plastic surgeon stitches him up. Well when I said that the ER tech. (who was in the room & overheard me) went crazy and started staring me down. After I leave the room she comes up to me and tells me I'm not allowed to recommend that because I'm not a doctor. I replied to her that I can make any recommendation I want and explained to her that personally it's what I recommended. (Keep in mind I showed her multiple apparent scars that I have on my own face that required stitches in the past).

Did I do something wrong?
What would you guys have done?

I don't think I'm making very many assumptions because much of what I am saying comes from experience, training, and education. You seem to assume that an EM physician will not consult a specialist if they feel that they are out of their depth because they want to get the patient "in and out". However, EM physicians are used to consulting specialists when the need arises. You, who have no experience closing lacerations, is not the one to make any sort of suggestion about care. If the physician evaluates a wound and determines that a specialist (who is also a physician, even a plastic surgeon, by the way) is needed, they will consult. Many lacerations, including ones on the faces of children are within bounds of an EM physician. And, uh, EM physicians (and other specialties) do care about patient outcomes including scarring; it is wholly disrespectful of you to make a blanket assumption that they do not just because they are not trained in plastic surgery.

And you also do not know if a plastic surgeon could do a better job. They may not be able to depending on the characteristics of the wound. You might be surprised at how well non-plastics physicians (or even PAs or CRNPs) can close wounds.

Your experience with consulting physicians is, what, again?

Your experience with closing lacerations is, what, again?

I can assure you that EPs close their fair share of lacerations and that there is a significant lack of plastic surgeons sitting around at home waiting with abated breath for the ED to consult them for a simple lac repair.

 

[JPINFV]

First, it aren't realizing what I'm trying to say. Having 2 facial lacerations and 1 laceration on my leg (all which needed stitching) I know I'm entitled to speak on it based on personal experience (I have not received any formal training). What you are saying is right "by the book" but you don't realize in poor, underprivileged communities this not possible/ all known. I'm not trying to bash EM physicians; they are great at what they do & are really nice people. Rather what I'm trying to say is to just get a second opinion before beginning to fix the laceration by a specialist. It's like getting your car fixed after an auto-collision. You don't just go to 1 auto body shop to get a quote, you go to multiple to get quotes and compare prices. That is all I was trying to say. I'm not trying to bash EM physicians at no means necessary.

They are free to leave and get a "quote" at a different hospital. I facial lac is not life threatening and EMTALA doesn't mean that the patient gets to dictate which, if any, specialties gets consulted.