Fort Worth, Texas,
11:04 AM

Innovative Wound Care Program Marks 20th Year at Cook Children's

Twenty years ago this month, Cook Children’s took a new approach to the lacerations, burns, dog bites and other wounds seen in the Emergency Department (ED).

That new approach, beginning in October 2001, pulled in the expertise of a plastic surgeon who trained a small team of paramedics as wound management technicians in the Cook Children’s ED. The techs became specialists for stitching up the gashes and bandaging the abrasions in pediatric patients.

One of those techs, Richard Berry, estimates that he has made almost 20,000 wound repairs over the past two decades. Berry was one of the original paramedics trained to cleanse and suture wounds. Between him and his four co-workers on the team currently, there’s always at least one technician available in the Cook Children’s ED from 10:30 a.m. to 2 a.m.

When is a wound serious enough to warrant a trip to the hospital? If severe bleeding doesn’t stop after 15 minutes of direct pressure. Or if the edges of a gaping wound don’t close. The best outcome of a stitched-up cut is the restoration of tissue function with minimal scarring.

“We see everything from fairly superficial little chin lacerations from falling in the bathtubs, and forehead lacerations that are fairly straightforward, to fingertip amputations or partial amputations,” Berry said.

The program’s launch at Cook Children’s 20 years ago brought about multiple upsides: Shorter wait time to get stitches. Lacerations closed quicker. Reduced risk for infection. And technicians who have experience and a touch of finesse backed by know-how and supervised practice.

Larry Reaves, M.D., a plastic ​and reconstructive surgeon for Cook Children's, oversees the training for the paramedics who move into the wound management specialty. Dr. Reaves described the program as a reliable tool for efficient delivery of quality care.

“Once we started it, everybody loved it. The patients loved it. The doctors in the ER loved it. It was an experiment that worked out very, very well,” he said.

The 20th anniversary marks a milestone. We at Cook Children’s are looking back at why the program was implemented, how it evolved, and what impact it makes.

In the Beginning

Back in 2001, on-call plastic surgeons were requested in the ED almost every night to stitch up various wounds, Dr. Reaves said. “This is not sustainable,” he remembers. So the idea was proposed to teach a few paramedics on staff to suture the simpler lacerations (a one-centimeter chin cut, for instance). Plastic surgeons would get called in only for the more complex wounds (anything involving the eyelid, for example, or a wound with irregular edges).

Dr. Reaves began a course that includes instruction in topics such as anatomy, anesthetics, proper examination techniques and patient/family interaction. Some of the paramedics in the first group had prior suturing experience that Dr. Reaves helped refine. It takes about a year now for new techs to complete the classroom portion and hands-on practice.

“We talk about proper preparation of the wound before you sew it up, recognizing other injuries in the wound, rinsing it well,’ he said. “Preparation of the wound is as important as the sewing of the wound.”

Berry started working at Cook Children’s as an ED paramedic almost 25 years ago, back when the skin adhesive Dermabond was the go-to fix for simple lacerations. After he learned to suture as a wound management technician, Berry took on some of the training duties for the newer team members. He enjoys the challenge of restoring a split lip, a severed fingertip or other injury.

“I love putting kids back together as close to how God made them to begin with. It’s a passion that I have for repairing. You take something that is way torn up and you’re able to put it back together where it looks like it’s supposed to.”

Growth and Expansion

Early on in the program, wound techs worked in the ED from noon to midnight. But as the number of patients increased over the years, the demand for suturing services grew. So now the techs cover 16 hours per day, from 10:30 a.m. until 2 a.m. – ideally, two techs on duty. Berry said the team typically sees eight to 12 patients each shift.

The process starts in triage, where a nurse or physician’s assistant assesses the injury and decides if that case would be best handled by wound techs. Topical numbing medication typically starts in triage, too. Parents sometimes request the on-call plastic surgeon. But as they proved their ability, the techs advanced to the more complex wounds, Berry said. Their presence in the ED reduces the frequency of calling in plastic surgeons.

“Our scope increased more than what the original plan was, but we also demonstrated that we could do it,” he said.

Child life specialists work with the techs to comfort and calm the patients while the stitches go in. Berry listed the program’s other big benefits:

  • Streamlined workflow in the department. Suturing procedures usually take 15-30 minutes, and when a wound tech does the job, it frees up the physicians to see more severely ill or injured patients instead.
  • Less time spent in the waiting room. If the wound isn’t complex, Berry said, there’s no need to wait hours for a tied-up doctor or plastic surgeon.
  • Reduced risk of infection. “The sooner you get them washed out, cleaned up and repaired, the less bacteria load there is in a wound. Just the normal bacteria that’s on the skin can migrate into the open wound,” Berry said.
  • Expertise for the best possible cosmetic result. Wounds are the techs’ #1 focus and priority. “This is what we do every day. We get very good at it,” he said. “Suturing is a technical skill. The more you do it, the better you get at it, the faster you get.”

Before discharge, the techs provide aftercare instructions regarding sun exposure and other precautions. Berry emphasizes that it can take a year for a wound to fully heal. He likes for his patients to come back to the ED so that he can remove the stitches himself and check the progress. If there’s a concern about a slow or difficult recovery, referral can be made to Dr. Reaves and the Cook Children’s Wound Care office.

Berry and Dr. Reaves describe the program as a unique collaboration with major advantages. Wound management techs in the ED cut the wait time without compromising the quality of treatment, Dr. Reaves said. “The patient wins in that situation,” he said. “We think it’s very good care.”