Wound care is 25% of all medicolegal lawsuits. They are not the biggest lawsuits, but they are by far the most frequent.
Our goals are common.
1. You want to avoid an infection.
2. You want to put the skin back together.
3. You want to minimize the scar and avoid infection.
Think of the worst case scenario, always. It’s contaminated. There is nerve or tendon injury. There is a retained foreign body. The pateint can die from this wound because of tetanus.
If it is tetanus, no big deal, we boost people every five years. In the ER, if they didn’t have a tetanus shot and went five years, we update it.
Studies show patients who were not immunized from tetanus but then received their tetanus shot had protective antibodies four days later. That’s important to know because the intubation period for Clostridium tetani is about two to three weeks.
So, if someone comes in and for some reason you forgot to give them a tetanus or they just didn’t get it, you still have a good week to make sure they get tetanus on board.
Don’t get burned with hands.
We see all sorts of hands. You can have a tendon laceration that needs surgical fixing and the patient can still move it.
In fact you can have a 90% tendon laceration and still have some movement. You have to document full range of motion versus resistance.
You have to say “move your finger; now push against my finger” and compare with both sides.
Along with full range of motion we also inspect two-point discrimination. Two-point discrimination is the ability to discern that two nearby objects touching the skin are truly two distinct points, not one.
What if you have a somewhat nasty finger? After a digital block you realize you did’nt perform two point discrimination. So by failing to test the nerve, you put the finger to sleep. How can you test it?
Soak the hand. It’s the nerve that causes the fingertip to prune. If you see half the finger is pruned, the other half isn’t, then they got the nerve. If the finger completely prunes you are fine
Retained foreign bodies
Be very careful with retained foreign bodies, especially glass!
There are 64 different types of glass, and they can all be seen on x-rays, even as small as 0.5 mm. If you have a patient with a glass laceration, get an x-ray. The highest risks are from your puncture wounds and motor vehicle crashes. Retained glass can happen.
Wood however is tough. If you have a patient with a stick jabbed into their arm and they feel like the broke it off, x-rays are silly because they just won’t work. Numb it up, make some incisions and go and poke around with a Q-tip and see if you are feeling stuff.
Plantar puncture wounds. The jury is out. I do not have good advice for you. Someone steps on a nail and the nail goes through their shoe and into their foot and they come in with a plantar puncture wound. That can be as simple as making sure their tetanus is up to date and say see you later. It could be as bad as they got a piece of rubber from their shoe embedded in their foot. They will get an osteomyelitis that is debilitating and they are going to spend four months off their feet.
Remember, there is no standard of care when it comes to planter puncture wounds. The best advice I can give you is to document everything you do, and document your reasoning behind it.
A few closing thoughts and some literature-based recommendations. We know that shaving the hand is bad. Don’t do it. It increases wound infection rates by five times. Soaking is bad. No one with a hand wound should have their hand soaking in Betadine or water. It increases bacterial counts. That is something that was taught, we kind of always did it, they always did it. Literature now shows that it increases bacterial counts.
So, if there should not be soaking. How do you clean the wound?
Don’t put anything in a wound that you wouldn’t put in your eye.
Would you put Betadine in your eye? No, of course not. Would you put hydrogen peroxide in your eye? No, I would not do that either. Saline – fine.
Remember take precaution with wounds. After all, 25% of all mediolegal lawsuits come from wound care.
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John Bielinski, Jr., MS PAC is a practicing emergency medicine clinician, and has been lecturing nationally for more than ten years, teaching the tactics that have proven invaluable in his career as a medical professional.