Treating the Chainsaw Laceration. Did This EP Do Enough?

15 Comments

The Case
A patient comes to the emergency department for treatment of a 4 cm laceration to his lower thigh that occurred when he accidentally hit his leg with a chainsaw while cutting wood shortly prior to arrival. The emergency department staff evaluated and cleansed the wound, then closed the wound using three staples. The patient claimed that he was given a staple remover and was told to remove the staples in one week. Emergency department staff stated that they gave him a staple remover to bring to his primary care physician to have the staples removed in 12-14 days. The patient removed the staples three days after they had been placed. Two months later, the patient returned to the emergency department with severe pain, swelling, and warmth to his knee. Further testing showed that he had suffered a quadriceps tendon laceration and had a septic joint. Despite surgical repair and cleansing of the joint, the patient had debilitating pain and will likely need a joint replacement.

The patient filed a lawsuit alleging that the medical providers performed an inadequate exam, that they should not have given him a staple remover, and that they failed to prescribe him prophylactic antibiotics. Defendants alleged that the patient’s medical care was appropriate and that he contributed to his own injuries by removing the staples three days after they were placed.

After deliberating for several days, the jury decided…


Was the patient’s care within the scope of reasonable practice? You be the judge. Comment below or fill out this survey – and it will be included in next month’s analysis.

ABOUT THE AUTHORS

EMERGENCY ULTRASOUND SECTION EDITOR
Dr. Pregerson manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. He is also an author for EPM's soundings column.

SENIOR EDITOR
Dr. Sullivan, an emergency physician and clinical assistant professor at two residency programs in Illinois, is EPM's resident legal expert. As an attorney specializing in healthcare issues, Dr. Sullivan represents physicians and has published many articles on legal aspects of medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians' Medical Legal Committee.

15 Comments

  1. Appears that the wound evaluation failed from the start. Who did it? A midlevel or boarded EP? The joint capsule had to have been comprimsed.

  2. Was the wound anesthetized and explored? Was this charted (“no FB’s or joint involvement”)? Antibiotics weren’t necessary. I’m a little surprised about dispensing the staple remover, but I guess if it was documented as far as when to remove the staples and that the pt’s private doc was to do it, it’s OK.

  3. Michael Carius on

    There is just simply too much information that has not been provided, such as the actual location of the wound, the depth of the wound, what exploration of the wound revealed, a description of the wound edges, the presence or absence of any foreign bodies. In my experience, chainsaw lacerations tend to be deep and ugly, with devitalized tissue and foreign bodies embedded. It does not seem possible that 3 staples adequately closed a 4 cm chainsaw laceration. There is simply too much information lacking here to defend or support the allegation. And by the way, the actual time of the suture removal is irrelevant, but if earlier than recommended, may have actually improved the outcome.

  4. Daniel Kemp PA-C on

    Based on this (very limited) information a number of mistakes were probably made. Clearly the initial evaluation failed to identify a violated joint space and quadriceps tendon injury. They then repaired a 4cm chainsaw laceration (likely to be irregular and complex) with 3 staples? This screams of laziness to me. This wound would have needed a thorough examination with orthopedic consultation once the tendon laceration and joint injury were identified. If it were to be closed in the ED based on ortho recommendations (not a guarantee), it would have needed a thorough cleaning and complex repair, not 3 staples thrown quickly on the skin. I would have given the patient prophylactic antibiotics and strict instructions for ortho followup. I certainly would not have given the patient a staple remover and enabled him to remove the staples himself without followup.

    Of course I notice the first comment as usual is questioning the credentials of the provider. These are not acceptable mistakes regardless of your title. As a PA I would hold myself to much higher standards to this.

  5. In adequate care. Wound should’ve been anesthetized cleaned and debrided and sutured. An X-ray may have been indicated but not enough info. I would err on the side a prophylactic anabiotic’s and a recheck in two days.
    JJT

  6. I’m not even in the medical field, but I know from previous ER visits that the PT is provided written instructions for wound care and when to see the GP for removal of the staples, along with other warnings of complications to seek immediate medical attention. Also, I am sure the PT presented symptoms of sepsis much earlier than 2 months as well as difficulty walking. The PT was negligent in not following recommended care.

  7. With the limited amount of information provided.. 50-50.
    – Limited evaluation in an injury high risk for contamination, foreign body retention and infection, as well as inadequate discharge instructions (or documentation of them)
    – Patient’s poor judgment. 3 days and self remove of staples?! Then what did he do for 2 months?!

  8. Jaime Lent, DO, FACEP on

    Agree, not enough info. Wound flushed and explored by doc, further description of wound, and 3 staples does not seem adequate for 4 cm laceration closure. What did the EP document as discharge instructions? Did the EP document discussion with the patient and that the staple remover was to be taken to the PCP? Interesting case.

  9. Mike Duerr, MD, PhD on

    Very hard to judge given the brief description of injury and course. Not sure that I understand the time lag between injury and joint symptoms. Also agree that it would seem odd to close a 4cm chain saw injury with 3 staples …
    I have never sent anyone home with a staple remover. While this might be an interesting idea for a trivial clean wound, follow up of a chain saw injury would seem more appropriately arranged to be done by either an orthopedic surgeon or the ER itself. My practice is to advise every patient with a laceration to return to either return to the ER or follow up with a specialist or PMD in 2 days for a wound check. In particular in an injury at high risk for infection (wood debris from working with a chain saw), I think that would be prudent. That being said, the opening of the wound at 3 days should REDUCE the risk of infectious complications, not increase it. In fact, I would guess that many would agree that if after thoroughly cleansing the wound with irrigation and searching for pieces of wood in the wound (quite a challenge in the ragged wounds I have seen from chain saws) you are not VERY confident that there is no retained foreign body, then it would be appropriate to leave the wound open and delay the closure. Clearly this was not the approach taken, so the presenting situation must have been different than what I envision when hearing of a chain saw injury to the thigh.
    Joint integrity and the risk for septic arthritis is a separate issue that cannot be reasonably discussed without better information at to the details of the injury.
    Just my five cents …

  10. Two months is a really long time. It will be fascinating to find out the background story of what occupied his time for so long. Likely money was an issue discussed and that’s why the remover was sent. Then he found out a PCP asks for money… Also, 4 cm is pretty short for more than a superficial chainsaw laceration unless the tip of the saw was pointed straight down or on a very narrow part of the leg. Hopefully the instructions said “return if worsening”

  11. Dennis Hughes, DO, FACEP on

    I agree with comment(s) above regarding the paucity of details in this vignette. While I realized that brevity is the “journalism de jour”, it is important for us to be intellectually honest: what is the goal of these cases? We see entirely too much “holier than thou” retrospective analysis (which is also illustrated in several comments) by members of our own profession which is clearly self-serving and adds little other than contributing to the pervasive fear existing in clinical medicine.

    So, if education is the goal then lets provide quality and a quantity of information to allow one to objectively evaluate and have a reasonable discourse. If the goal is purely to titillate the reader I suggest we should move on.

  12. Who cares if it was an APC, an FP-trained doc, or an EM-boarded doc? I know that any defendant would not be satisfied with only the above vignette read out in court, and I don’t know how we’re really supposed to answer this accurately. I’ve never heard of giving someone a staple remover as most FP clinics or UCCs should have a couple of hemostats laying around somewhere that a clinician can use to remove a staple.

  13. Niall McGarvey MD on

    Way too little information to render an informed opinion.
    The presentation colors this case a lot.
    Unfortunate outcome does not mean poor care
    Interesting that the usual emotional leap appears to be that if someone other than “you” did it then the care is questionable.

  14. Lawrence Wilson, APP on

    Calling no class on the sideways comment about advance-practice providers. I always tell my patients that my physician and NP/PA colleagues are brilliant, but as a hospitalist (former emergency medicine provider), I routinely receive patient that have been evaluated by MULTIPLE physicians (usually at least two emergency medicine physicians), that were referred to me with an incorrect diagnosis or no diagnosis at all. This frighteningly includes sepsis on a nearly routine basis for some reason, and the real kicker is that I’m the one dragged into the peer reviews when the emergency medicine physicians have been sitting on those patients for hours without providing appropriate treatment and I have implemented a full-sepsis protocol within 30 minutes after receiving the much-sicker patient.

    And DKA…I don’t know what people are thinking there. Just about everyone one of those referrals is an “ED rescue” anymore.

    I still don’t then start disparaging those physicians, even indirectly.

    As far as the patient, I could be wrong, but I suspect there was no jury decision. The patient did not follow instructions regarding staple removal, and likely ignored instructions regarding follow up. I can almost envision this patient stating “I’m not coming back just to get some staples removed; I’ll use pliers if I have to.”

  15. Comments on the case and comments on the comments: I work in small critical access places and it is interesting to read comments about Ortho consults, 2 day follow ups and wound checks with PCP or Ortho. I can’t get any of that type of thing to happen. Our 2 orthos are busy enough to not come over for every cut unless we clearly identify bone/tendon injury, and then they would come over. And our PCP clinics mostly can see folk maybe by the time of suture removal, not at 2 days. We’re typically on our own for these wounds and see them often. I agree it must not have been explored well enough, or maybe it was and a partial tendon injury was identified and the guy over-used it when he shouldn’t; we don’t really have the info we need about the wound/exploration/closure. That part is a common theme of the comments. I would like to have more info about the wound and the events in the intervening 2 months (what other injuries happened during that time, for example). Regarding the staple remover, I don’t think it is that much of an issue. We all know that half or more of our patients take out their own sutures and I incorporate that into my wound speech while suturing.

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