A 55-year-old female presented to the emergency department with an avulsion laceration to the tip of her nondominant fifth finger. Her history included hypertension, diabetes, renal transplant, and deep vein thrombosis. Her medications included immunomodulators and warfarin.
Explore This IssueACEP News: Vol 30 – No 08 – August 2011
She presented due to persistent bleeding in her finger, yet the bleeding was controlled when she was evaluated by the triage nurse.
The physician evaluated the avulsion, anesthetized the area, then ordered wound cleansing and a wound dressing. An advanced clinical technician applied the dressing consisting of layers of tube gauze, which was then split and tied around the patient’s hand. The technician stated that he was instructed by an unknown person to make the dressing “snug.” The physician evaluated the dressing after it had been applied, but did not unwrap the finger to reexamine the laceration.
The patient was discharged on Keflex with instructions to have her wound rechecked in 36 hours and to return if pain, redness, or warmth developed. There was also boilerplate language on the discharge instructions stating that the patient should call the hospital or return if the condition worsens or if the patient was unable to reach the referral physician. In addition, boilerplate language on the wound instructions stated that the patient should call 911 immediately if experiencing “bleeding, worse pain or swelling, or any other new problems.”
Although the patient complained of numbness in her finger the night after her emergency department visit, she did not return to the ED. Instead, she made the earliest appointment available with the primary care physician 4 days later. She was seen in her doctor’s office, referred to the hospital, and admitted for possible gangrene of the finger. A hand surgery nurse practitioner biopsied her finger, confirmed gangrene, and discharged the patient for an outpatient amputation. Seven days later, the patient had a partial finger amputation due to digital ischemia and gangrene. A lawsuit was filed.
Expert Witness Statements/Allegations About Standard of Care
In his deposition, the plaintiff expert criticized the care provided in the emergency department because the patient was discharged with a tight dressing, rather than leaving the tight dressing in place for no more than an hour and then being checked for rebleeding.
The expert also criticized the physician for not supervising application of the dressing, for failure to check the dressing after it was applied, and for failure to notice that the dressing was too tight.