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.”

In Cook Children’s Emergency Department, treating gunshot victims requires all hands on deck. The moments are precious as staff work against the clock to save young lives. The goal? To rescue every child who comes through the sliding doors. The reality? Children with gunshot wounds are among those most likely to die from their injuries.

For emergency room physicians like Dan Guzman, M.D., caring for shooting victims is particularly bothersome because gunshot wounds are preventable. He fears he will see many shooting victims in the coming months as summer is typically a busy time for this type of injury.

“Kids are out of school, and parents are working,” he said. “Children will find a gun that’s not locked or hidden, and a matter of seconds can change a family’s life.”

As of May, 35 children have already been treated at Cook Children’s with gunshot wounds in 2021. Two died. Compare that to 2019 when 41 children were treated for gunshot wounds, including five deaths, and 2020, which totaled 47 patients and four deaths.

“We are five months into 2021 and are on track to exceed prior years,” Dr. Guzman said. “We haven’t reached the halfway point and we’ve already lost two patients.”

While most of the situations stemmed from unintentional gunshots, Dr. Guzman says all of the incidents could have been avoided.

“The vast majority of the kids that we see suffer from head and neck injuries. It's almost impossible to save a life because the damage has been done to the brain.” Dr. Guzman said.

Celeste Calhoun and Jill Plunkett are emergency room nurses with a combined 20+ years of experience. They both agree that seeing gunshot victims coming through the emergency department has happened more often than they’d care to see.

“Gunshots are preventable for children,” Calhoun said. “Children don't go out with an intent to harm each other. They usually obtain the gun because it was left open or out, and by playing with it. Not knowing that it's loaded or what it can do when they aim it at someone and squeeze the trigger.”

Plunkett says her husband was raised around police officers and guns, she and her husband made it a point to teach their two children about gun safety and education at a young age.

“We have guns in our home, they were never loaded and my children didn’t even know the code to the safe until they were adults. They knew the guns were in our home, and if they ever wanted to see them or had questions, my husband would take them out and educate them, but they were never accessible,” Plunkett explained.

Dr. Guzman agrees that education is key. He says he understands why parents may feel they need guns for the safety of their family, however, there is a safe way to have a weapon in the home - locked up.

“Let's put our guns away. For the safety of our children, let's make sure that we're making the right choices,” Dr. Guzman said. “If you can buy a safe, 100%, get a safe and put that gun away. This is not about who can have a gun or who shouldn't have a gun. The bottom line is our children’s safety.”

Dr. Guzman worries that recent state legislation coupled with a spike in gun sales nationwide could lead to more unintentional child shootings.

“Last year (2020) was a bad year, we saw more injuries than we’d seen in the last five years,” Dr. Guzman explained.

The plea is simple. If there are guns in your home, educate your children and make sure they are in a safe and secure place.

“We want to help people avoid having to be in our emergency department, to be safe at home, and live a long life without ever having to see us,” Dr. Guzman said.

Calhoun, who is also a mother, shares another piece of advice that is often forgotten by parents.

“Make sure you know where your child's going to visit and play,” Calhoun said. “If they're going to another home with another child, have that awkward conversation with the parents to find out if they have guns in their home and what safety precautions they take to protect their children.”

Lastly, Dr.Guzman says when educating families, it is important to note that handguns are not the only kind of gun that can injure a child.

“We hear about handguns and firearm accidents in the news,” Dr. Guzman said. “We can’t forget children are injured by BB guns and pellet guns too. I’ve seen children die from BB guns and pellet guns, so we have to be cognizant at all times.”