Despite the routine nature of wound care in EDs, “many wounds are initially managed inappropriately, and can result in significant complications and mortality,” warns Gillian Schmitz, MD, FACEP, associate program director in the Department of Emergency Medicine at University of Texas Health Science Center in San Antonio.
Up to 20% of all malpractice claims involving ED care and up to 11% of malpractice dollars paid out by emergency physicians (EPs) are related to wound care, she notes.
“There is tendency to think that wounds aren’t a big deal compared to heart attacks. But it’s worth spending an extra minute to perform a complete exam and document it,” Schmitz emphasizes. Retained foreign bodies and missed vascular injury are the most common allegations Schmitz sees in claims against EPs involving wound care. She offers these risk-reducing practices:
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Avoid saying, “Your X-ray looks fine. You can go home.”
“Plain radiology has traditionally been the screening method of choice for retained foreign bodies, but a number of things can be missed on a routine film,” Schmitz says. EPs might instead tell patients, “We don’t see anything at this time, but the X-ray is a limited study. If symptoms continue or pain worsens, you need to come back and get the wound re-evaluated.”
“EPs tend to forget X-rays are not going to pick up a fair amount of objects, or even fractures that don’t show up initially,” Schmitz says.
Sensitivity of ultrasound is largely based on the amount of training the EP has had, she adds. Even CT scans have limitations. “If a wood object is left in place for more than 48 hours, it absorbs water and has a density similar to soft tissue and can be missed,” Schmitz says.
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Don’t tell patients that there isn’t a foreign body in the wound.
Instead, the EP might state, “I don’t see anything at this time, but that doesn’t mean that there isn’t a small fragment hidden in there,” and that patients should come back and have the wound re-evaluated if the wound appears infected. “Manage the patient’s expectations,” says Schmitz. A malpractice claim is more defensible if the ED chart indicates the EP explored and irrigated the wound and didn’t see anything, and that the EP advised the patient of the risk that a foreign body may still be present.
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Explore the wound through the entire range of motion, and document this.
“Tendon injuries can be subtle,” Schmitz says. “Unless you flex the hand, you are going to miss the injury to the tendon underneath.” If the EP documents that the patient appeared to have intact motor sensation, says Schmitz, “you may still miss something, but at least you’ve thought about it and documented it.”
Schmitz often sees ED charts that document the wound’s size and location, and contain procedure notes of the laceration repair, but are missing any documentation of the neurovascular status. “If it later turns out to be an injury to a tendon or vessel underneath, it’s hard to prove that you didn’t miss it,” says Schmitz.
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Consider calling in the wound care team.
EPs who don’t hesitate to call in cardiology or neurology consultants when appropriate might not think of calling in the wound care team for challenging cases. “They may get a consult for everything else, but for whatever reason, that seems to be the piece that doesn’t happen in the ED,” Joan Cerniglia-Lowensen, JD, an attorney at Pessin Katz Law in Towson, MD, says.
If a total body inspection isn’t completed in the ED and the patient later has a bad outcome, she warns, “the conclusion is going to be that either it was not present at admission, or it worsened as a result of bad care. I have seen this to be a very large pitfall for emergency physicians.”
EPs tend to “gloss over” the total body assessment in the ED, says Cerniglia-Lowensen. “Just as we talk about heart failure and lung failure, this is skin failure. It’s an important part of the general assessment,” she says. If hospital or nursing staff are sued because of failure to present skin breakdown, the EP can also be named in the suit because “when you look backwards, the patient came in in the same condition,” Cerniglia-Lowensen says. “It is a general risk management issue for the entire institution.”
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Joan Cerniglia-Lowensen, JD, Pessin Katz Law, Towson, MD. Phone: (410) 339-6753. E-mail: [email protected].
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Gillian Schmitz, MD, FACEP, Associate Program Director, Department of Emergency Medicine, University of Texas Health Science Center, San Antonio E-mail: [email protected].
