Without knowing if a specific duty existed in this case, the Standard of Care Review Panel was unable to comment on whether the physician acted reasonably. However, the Panel did not believe that the standard of care requires that physicians unwrap and reevaluate dressings applied by other allied health professionals. None of the literature the Panel reviewed suggested such management, and several Panel members felt that requiring such a practice would be counterproductive.
Explore This IssueACEP News: Vol 30 – No 08 – August 2011
Is it proper to discharge a patient with a “snug” tube gauze dressing on the finger?
When tube gauze is placed on a patient’s finger, there is no practical method to measure the pressure generated by that dressing. Regardless of the pressure of the dressing, there is also no way to predict if a patient will develop ischemia at the site of the dressing placement.
The physician who submitted this case for evaluation presented several articles regarding dressing applications and case studies relating to finger ischemia from wound dressings. One article noted that pressure from several different applications of tube gauze did not exceed 40 mm Hg. Another article noted that it would take 13 layers of elastic gauze for internal finger pressures to reach more than 50 mm Hg and that 13 layers of cotton gauze would reach internal pressures of approximately 20 mm Hg.
The Standard of Care Review Panel concluded that the use of tube gauze dressings is appropriate for many types of finger injuries, including avulsion lacerations to the fingertips, such as occurred in this case. Given the available literature on tube gauze dressings, the Review Panel concluded that it would be difficult to generate pressure sufficient to cause finger ischemia when “snug” tube gauze dressings are placed.
Placement of dressings is one of many duties that physicians may delegate to other qualified health care providers.
Does a patient have a duty to follow discharge instructions?
Discharge instructions serve many functions, including providing patients with a tentative diagnosis, instructing patients on further treatment recommendations, and directing patients on when and under what circumstances they should seek further medical care. The Review Panel did agree that certain discharge instructions can be related to a patient’s perceptions. For example, an instruction to return for worsening pain or “new problems” would depend on the patient’s perception of increasing pain or new problems. There are also instructions that do not depend on patient perceptions, such as “have wound rechecked in 36 hours.”