Ethical/legal to suture without a license?

[danzman]

Had an interesting discussion tonight with my EM attending. After I sutured up a kid's leg, one of the techs came up and asked me if I still had any lido left over. At this hospital each lac gets its own bottle of lido (some places just have a "community" bottle) and someone seems to always run off with the left over amount. I asked my attending if it was OK and he said it was no problem. When I asked to tech what he wanted with it he claimed that it was nice to have around in case he needed to sew up something during a camping trip etc' This prompted the discussion.

If your next door neighbor came to you with a big laceration on his arm and for whatever reason didn't want to go to the hospital would you sew him up? What if you were just an ER tech or medical student and didn't have a license to practice medicine but knew how to do a basic suture job?

To my surprise my attending didn't seem to think anything was wrong with me, a 4th year student, sewing up a wound on someone outside the hospital, but there was some gray area about the use of lido. He claimed it was basic first aid and that anyone could buy sutures and just use topical OTC anesthetics.

Personally, I don't think its something I would ever do, but I could see a situation where it could be useful. I have seen a few times where people have sewed themselves or loved ones up using a needle and thread with pretty good results. I wonder if it could be classified as "practicing medicine without a license"?

Any thoughts?

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[Apollyon]

Had an interesting discussion tonight with my EM attending. After I sutured up a kid's leg, one of the techs came up and asked me if I still had any lido left over. At this hospital each lac gets its own bottle of lido (some places just have a "community" bottle) and someone seems to always run off with the left over amount. I asked my attending if it was OK and he said it was no problem. When I asked to tech what he wanted with it he claimed that it was nice to have around in case he needed to sew up something during a camping trip etc' This prompted the discussion.

If your next door neighbor came to you with a big laceration on his arm and for whatever reason didn't want to go to the hospital would you sew him up? What if you were just an ER tech or medical student and didn't have a license to practice medicine but knew how to do a basic suture job?

To my surprise my attending didn't seem to think anything was wrong with me, a 4th year student, sewing up a wound on someone outside the hospital, but there was some gray area about the use of lido. He claimed it was basic first aid and that anyone could buy sutures and just use topical OTC anesthetics.

Personally, I don't think its something I would ever do, but I could see a situation where it could be useful. I have seen a few times where people have sewed themselves or loved ones up using a needle and thread with pretty good results. I wonder if it could be classified as "practicing medicine without a license"?

Any thoughts?

The bolded is the money. He's wrong - black letter wrong. Suturing is not "basic first aid". Suturing involves doing more trauma to a traumatized area. Steri-strips and glue and hair tying do not. Also, lidocaine for subQ injection is a prescription item.

It is practicing medicine without a license, if the person doing it is not a licensed provider.

 

[canjosh]

The bolded is the money. He's wrong - black letter wrong. Suturing is not "basic first aid". Suturing involves doing more trauma to a traumatized area. Steri-strips and glue and hair tying do not. Also, lidocaine for subQ injection is a prescription item.

It is practicing medicine without a license, if the person doing it is not a licensed provider.

With one notable caveat...if the duty has been delegated appropriately by someone with a medical license to an appropriately trained person, it's perfectly legal as well. i.e. a paramedic repairing lacs on an oil rig, or the same paramedic repairing a lac in the ED. These are examples of a physician extended his/her license to someone else.

As an interesting aside, I used to work in a pediatric tertiary referral center where paramedics in the ED who were trained by the plastics guys repaired every lac that came to the ED. Vermilion border stuff, digit near-amps, intraoral, whatever, if it didn't need to go to the OR for plastics--they did it. It was the entirety of their job in the ED, so they were quite skilled, and it freed up the physicians to take care of other stuff. I'm sure Apollyon and others know about these instances, I'm just throwing it out there for others that might otherwise be unaware of these circumstances.

 

[Apollyon]

With one notable caveat...if the duty has been delegated appropriately by someone with a medical license to an appropriately trained person, it's perfectly legal as well. i.e. a paramedic repairing lacs on an oil rig, or the same paramedic repairing a lac in the ED. These are examples of a physician extended his/her license to someone else.

As an interesting aside, I used to work in a pediatric tertiary referral center where paramedics in the ED who were trained by the plastics guys repaired every lac that came to the ED. Vermilion border stuff, digit near-amps, intraoral, whatever, if it didn't need to go to the OR for plastics--they did it. It was the entirety of their job in the ED, so they were quite skilled, and it freed up the physicians to take care of other stuff. I'm sure Apollyon and others know about these instances, I'm just throwing it out there for others that might otherwise be unaware of these circumstances.

Well, you're describing "delegated practice", which is by law in various districts. To my best knowledge, a physician can't, arbitrarily and unilaterally, decide to extend their license to cover someone else. I mean, just because I say it is so doesn't make it so. The plastics guys had to be independently rich to cover that, because I don't think any med mal insurer would allow a covered person to spread it around like that. What if the paramedic gives the kid a Sylvester Stallone lip? Facial cosmetic screw ups are $$.

 

[EM_Rebuilder]

I will not say its right, but I understand where he is coming from...

Its like a carpenter taking a piece of plywood off a job, or a waiter taking home the extra chicken. The tech is barely paying the bills, and 'just a small lac' would cost him or his family/friends hundreds if not thousands to have repaired.

Are there risks by him doing it? Absolutely. I think any person that allows him to do it understands that risk and is willing to take the risk to save X number of dollars. From a medicolegal standpoint, it is certainly against the law to 'practice medicine without a license'. With that said, nobody is going to go after him for suturing somebody once every two years. If he started doing this quite often and openingly charging money for it.. that would be a problem.

 

[Farmer2DO]

At one point, when I didn't have insurance, I needed a scalp laceration sutured, and had our veterinarian do it. He's one of the smartest, most competent medical providers that I know, and is a very skilled surgeon. (Interstingly, he's a large animal vet.) He's a close family friend, and I trusted him completely.

 

[Apollyon]

See, folks, I'm not saying any reasonably deft and/or intelligent person can't do it. The question was legal and ethical, which it isn't.

And, as for the vet, large animals are large animals, and a human is a somewhat large mammal.

 

[Groove]

Hmm... Kind of a beer and popcorn strange trivia question...

The Lido... def illegal and unethical.

As for suturing as an ER tech... I guess it wouldn't be "illegal" since you're not on the job, it's your neighbor and you can technically do anything he asks of you, no matter how inane as long as you and he both realize the risks and complications along with the fact that laceration repair is not within your realm of training or expertise. If you knew the complications, then yes, it would be unethical of you to suture him. If you don't, then I guess it wouldn't.

As a med student... You're not a MD yet, you're just a medical student. There's no pt-physician relationship established and again... I don't think anything about this would be illegal. Unethical? Absolutely.. because you should know better, and he's placing more trust in you as a "medical student" to know what you're doing. There's a reason that laceration repair by a med student is technically supposed to be "supervised" in the hospital.

Is it over a joint? Dirty? Last tetanus? Feel comfortable evaluating for tendon/nerve/muscle injury? Feel comfortable with the myriad of laceration repair techniques that would give the best cosmetic effect? Educated about all the potential complications? Do most laceration repairs turn out just fine? Sure, but anything can happen. The last thing you need as a med student is your neighbor getting a septic joint or perm tendon injury after you sutured his seemingly shallow and clean hand lac.

But hey... in the end, I guess it's not all rocket science. After all....

Rambo sewed up his own arm.

 

[Ibid]

Rambo sewed up his own arm.

That's nothing....http://en.wikipedia.org/wiki/Leonid_Rogozov

 

[theseeker4]

As for suturing as an ER tech... I guess it wouldn't be "illegal" since you're not on the job, it's your neighbor and you can technically do anything he asks of you, no matter how inane as long as you and he both realize the risks and complications along with the fact that laceration repair is not within your realm of training or expertise. If you knew the complications, then yes, it would be unethical of you to suture him. If you don't, then I guess it wouldn't.

As a med student... You're not a MD yet, you're just a medical student. There's no pt-physician relationship established and again... I don't think anything about this would be illegal. Unethical? Absolutely.. because you should know better, and he's placing more trust in you as a "medical student" to know what you're doing. There's a reason that laceration repair by a med student is technically supposed to be "supervised" in the hospital.

Are the bolded parts true? Does it vary state-by-state? I was under the impression that practicing without a license was illegal, period, regardless of whether the patient agreed. Maybe I am wrong, but that is what my not-yet-in-medical school understanding of the situation is....

 

[The White Coat Investor]

My techs did all the suturing when I was in the military. They had less training than paramedics.

I sutured family as a med student and didn't think twice about it.

 

[Groove]

Are the bolded parts true? Does it vary state-by-state? I was under the impression that practicing without a license was illegal, period, regardless of whether the patient agreed. Maybe I am wrong, but that is what my not-yet-in-medical school understanding of the situation is....

Yea but in a sense you're not really practicing anything. I'm not a lawyer, but if I give my buddy legal advice on something because I've researched it or had experience, etc. , am I practicing law? The original question is only complicated for lawyers or legal/ethics analysts, not for most people with a good dose of commen sense.

 

[theseeker4]

Yea but in a sense you're not really practicing anything. I'm not a lawyer, but if I give my buddy legal advice on something because I've researched it or had experience, etc. , am I practicing law? The original question is only complicated for lawyers or legal/ethics analysts, not for most people with a good dose of commen sense.

I understand the point of the analogy, but relying on common sense to apply to the law is often a mistake. I guess a better question would be: how often, if ever, are people prosecuted for "practicing without a license" if they perform minor, but greater than "first aid" procedures on others without representing themselves as licensed healthcare professionals? If it is never prosecuted unless the person performing the procedure is misrepresenting themselves, the question on legality is moot.

 

[BF2BC EMT]

This is interesting, I guess it's alright if they're are trained or supervised. Legally I would think it's ok. The only reason I say that is because I know family docs "teach" their MA's to do certain procedures, that are definitely not taught in whatever school MA's attend. They've been doing it for years. Different thing same concept.

 

[danzman]

This is interesting, I guess it's alright if they're are trained or supervised. Legally I would think it's ok. The only reason I say that is because I know family docs "teach" their MA's to do certain procedures, that are definitely not taught in whatever school MA's attend. They've been doing it for years. Different thing same concept.

But then what if the MA's went home and sewed up a family member? Then what if there was a bad outcome? Its the fine line between helping someone via first aid and going beyond into the relm of "medical care." I could see a situation in which a tech, med student, or even physician, provided basic first aid to an injured stranger who later had a bad outcome. Put a band-aid on a little kid at a soccer game who later gets MRSA, etc.

I think I would be comfortable sewing up most lacs to family or friends (clean, tetanus up to date and so forth), just as I would be OK looking at a 2yr old with a mild fever and giving advice. But outside of those select few people, I'd be too worried about a bad outcome.

 

[docB]

There's an old saying about contracts which is "The contract never comes out of the drawer unless there's a problem."

This is kind of the same thing. If someone is doing this and no one ever raises and objection, there's no bad outcome or the person who suffers the bad outcome just sucks it up then there will very likely not be a legal problem. Is it technically illegal (the suturing, not the lido, that's clearly illegal)? Probably.

Now is it ethical? That's a tree falling in the forest kind of question. There's not really a definite answer there. It's ethical if you assume that the provider is trying to the best of their ability to help the patient and they're probably doing it without compensation. It's unethical in that they should realize that they're probably not the best person to be doing it, they may be doing it to avoid paying a bill that would make the situation safer, the patient will have no recourse in the event of a bad outcome and (this is a big one with the undertrained, over equipped tech level provider) they may be doing it just to show off.

 

[Lawsonc]

I wonder if the good Samaritan law can be applied. While a layperson cannot justify open heart surgery in court, it is my understandings that well meaning interventions are covered.

On that same note at least in "public" if a first responder, EMT, Medic, and I am going to make the assumption Nurse or Doctor (off duty) performs a procedure they are not covered and can be held liable.

 

[jbar]

I wonder if the good Samaritan law can be applied. While a layperson cannot justify open heart surgery in court, it is my understandings that well meaning interventions are covered.

On that same note at least in "public" if a first responder, EMT, Medic, and I am going to make the assumption Nurse or Doctor (off duty) performs a procedure they are not covered and can be held liable.

First of all Good Sam laws say you can't be held liable if something bad happens even though you did your best with your level of training. Most would argue that techs, med students etc have not been trained to suture uncertified. I'm sure most could do it fine, but good sam is much more "I'm trained in CPR, I did CPR. I know first aid, I tried to stop bleeding." Furthermore, it doesn't cover any well meaning intervention. It is for first aid. If you are on a plane and someone is delivering a baby and you have no training, Good Sam covers you if you try to catch the kid and do the best you can. It wouldn't cover you because you decided a month ahead of time to help your friends have a baby at home even though you aren't trained.

As to your second point, doctors are never "off duty." They are have a license to practice medicine in that state. If I want to suture in my house, I can do that. But I wouldn't be covered under Good Sam. I would be held to the standards of care of my profession. Now if I did something crazy in the field that I didn't have the equipment or training for, like I was a radiologist and tried to crack the chest, that is another matter.

Also there is a difference between being held legally responsible for a bad outcome, and being financially covered. As a doc most of my malpractice insurance is through the hospital where I work, and I don't think it applies to what I do off duty. I would need personal malpractice coverage for that.

 

[Xerxes1729]

I wonder if the good Samaritan law can be applied. While a layperson cannot justify open heart surgery in court, it is my understandings that well meaning interventions are covered.

On that same note at least in "public" if a first responder, EMT, Medic, and I am going to make the assumption Nurse or Doctor (off duty) performs a procedure they are not covered and can be held liable.

This stuff all varies by state. In Colorado:

"13-21-108. Persons rendering emergency assistance exempt from liability. (1) Any person licensed as a physician and surgeon under the laws of the state of Colorado, or anv other person, who in good faith renders emergency care or emergency assistance to a person not presently his patient without compensation at the place of an emergency or accident, including a health care institution as defined in section 13-64-202 (3), shall not be liable for any civil damages for acts or omissions made in good faith as a result of the rendering of such emergency care or emergency assistance during the emergency, unless the acts or omissions were grossly negligent or willful and wanton. This section shall not apply to any person who renders such emergency care or emergency assistance to a patient he is otherwise obligated to cover."

 

[alreadylernd]

And, as for the vet, large animals are large animals, and a human is a somewhat large mammal.

Some larger than others!

 

[Hamhock]

That's nothing....http://en.wikipedia.org/wiki/Leonid_Rogozov

I just followed the links from that wiki page and read about a woman who used a kitchen knife to perform her own C-section.

She didn't close, but I still find that even more amazing than the appy.

HH

 

[canjosh]

Well, you're describing "delegated practice", which is by law in various districts. To my best knowledge, a physician can't, arbitrarily and unilaterally, decide to extend their license to cover someone else. I mean, just because I say it is so doesn't make it so. The plastics guys had to be independently rich to cover that, because I don't think any med mal insurer would allow a covered person to spread it around like that. What if the paramedic gives the kid a Sylvester Stallone lip? Facial cosmetic screw ups are $$.

I see your point about regional differences in legality. To the best of my knowledge, the paramedics suturing in this situation are operating under the license of the emergency physician. The EM physician sees the patient, says you got a suturable lac, sends the paramedic in to do the repair, and then the repair is checked by the physician prior to discharge. It's not arbitrary and/or unilateral delegation, and the individual physician can always decide to not delegate. It seems to me that you might consider splinting a fracture in the same light--the physician delegates it to a tech of some sort, and is accountable for the outcome--but there is sufficient oversight to minimize the med mal risk. I'm just wondering where an insurance policy would draw the line for somebody like an emergency physician, where various procedures are delegated to others.

As I understand it, this is the same sort of delegation/extension of license/whatever-you-call-it that goes on between field EMS providers and their medical directors--which has inherently less oversight than the suturing situation.

I apologize to the OP for the digression. 👍

 

[Lawsonc]

I see your point about regional differences in legality. To the best of my knowledge, the paramedics suturing in this situation are operating under the license of the emergency physician. The EM physician sees the patient, says you got a suturable lac, sends the paramedic in to do the repair, and then the repair is checked by the physician prior to discharge. It's not arbitrary and/or unilateral delegation, and the individual physician can always decide to not delegate. It seems to me that you might consider splinting a fracture in the same light--the physician delegates it to a tech of some sort, and is accountable for the outcome--but there is sufficient oversight to minimize the med mal risk. I'm just wondering where an insurance policy would draw the line for somebody like an emergency physician, where various procedures are delegated to others.

As I understand it, this is the same sort of delegation/extension of license/whatever-you-call-it that goes on between field EMS providers and their medical directors--which has inherently less oversight than the suturing situation.

I apologize to the OP for the digression. 👍

Field Personnel at any level (EMT, Medic, Nurse) work under the county, department, city, company, medical director (physician). We operate under his/her license, but in the case of EMS if someone in the field messed up, I think it would be pretty damn hard to go after the Medical Director. Depending on your area and location, and or department policies (be it they purchase it or you do) I know of many field level personnel that carry their own insurance.

I also know of a few states that have legislation that makes going after the individual field personnel and the medical director extremely difficult if not impossible. Due to the fact that emergency medicine is just that "emergent" and unpredictable. As long as negligence, abandonment or assault/battery did not occur, the courts will throw out any cases against the EMS system.

Then there is the all mighty unions in some parts of the country and systems, that unfortunately protect some people that really ought to not be protected.

 

[Farmer2DO]

See, folks, I'm not saying any reasonably deft and/or intelligent person can't do it. The question was legal and ethical, which it isn't.

And, as for the vet, large animals are large animals, and a human is a somewhat large mammal.

While I may be big, I'm not quite the size of one of my cows 😀