Treating the Chainsaw Laceration. Did This EP Do Enough?
Click here to read the original case
Click here to read Dr. Brady Pregerson’s response: Evaluating Lacerations to Extremities
Wound exploration, antibiotics, and a patient’s contributory negligence are at the heart of this decision.
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. The emergency department staff evaluated, cleansed and closed the wound using three staples. The patient claimed that he was given a staple remover and 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 developed a septic joint. Despite surgical repair and cleansing of the joint, the patient had debilitating pain and likely will 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.
It didn’t take the jury long to come up with a defense verdict. Although the reasoning for the jury’s verdict wasn’t disclosed, there are several hurdles that the patient was apparently unable to overcome in his malpractice claim.
‘High Risk’ Complaint
Wound care is considered a “high risk” complaint in emergency medicine. Although payouts for lawsuits related to wound care are usually low, complaints alleging negligence in wound care tend to occur frequently. One source notes that alleged negligence in wound care accounts for up to 20% of all malpractice claims but that payouts related to wound care only amount to 3-11% of all malpractice dollars.
Most wound care lawsuits allege one of four complications:
- Failure to diagnose injury to underlying structures such as tendons, nerves, vessels, or joints.
- Retention of foreign bodies.
- Wound infection.
- Failure to suspect or diagnose compartment syndrome.
Because these issues are most common to appear in lawsuits, addressing each of them during an exam and documenting that each issue was considered would both provide optimal care to a patient and the most protection against allegations of negligence. Unfortunately, the documentation of physician examinations is often inadequate in wound care lawsuits.
In this case, there were three allegations of negligence: that the medical providers performed an inadequate history and physical exam; that the medical providers failed to prescribe the patient prophylactic antibiotics; and that medical providers gave the patient a staple remover. As a result of these alleged acts of negligence, the patient claimed that he suffered a joint infection and sequela from a quadriceps tendon laceration.
Open Joint
Perhaps the most difficult aspect of this case is determining whether evaluation and treatment of the patient’s wound was appropriate. Many patient characteristics put wounds at greater risk for infection including advanced age, immunocompromise, diabetes, peripheral vascular disease in an injured extremity, and even malnutrition.
In addition, certain wounds are more at risk for infection including puncture wounds, wounds that involve tendons/muscles/joints, contaminated wounds, bite wounds, and crush injuries. This patient had a wound involving muscle (and possibly joint) and the wound was likely contaminated given the mechanism of injury. A chainsaw injury that occurs while cutting wood will cause a jagged laceration that is likely contaminated with sawdust or other organic material. Thorough cleansing is important in such cases.
In addition, this injury occurred in close proximity to a joint. Assessing whether a violation of the joint occurred is also important – either through direct visualization, through saline load testing, or through CT scan. We don’t know how much of the patient’s quadriceps tendon was lacerated, but if the patient was able to perform regular activities on the injured leg for two months, it would be safe to reason that the tendon injury was less severe. Since the patient didn’t develop a wound infection and there is no evidence that the patient developed symptoms until two months after his injury, I have to assume that the initial wound examination and treatment was adequate.
Antibiotics
Prophylactic antibiotics may have prevented a joint infection in this case, but there are two points to consider. First, several studies show that prophylactic antibiotics provide no protection against infection in non-bite wounds treated in the emergency department (see, e.g., Cummings 1995, Thirlby 1983, Zehtabchi 2007). Second, even if the patient did receive prophylactic antibiotics, he would have finished his prescription at least six weeks before the wound infection developed. By that time, even if the antibiotics did provide some protective effect, that effect would have long faded. Failure to administer antibiotics should not have affected this patient’s outcome.
Staple Remover
While several commenters believed that giving a staple remover to a patient who has had staples placed is negligent, I respectfully disagree. In my own rural practice, several of the primary care physicians do not (and will not) stock staple removers in their offices. If the emergency department did not provide patients with a means to have their staples removed, the patients would have to make an expensive return visit to the emergency department for this procedure.
Giving a patient a staple remover is no more negligent than giving parents a syringe to dose their child’s medication or giving a patient an ACE bandage to wrap their injury. In each case, it is unfair to blame a physician if the patient uses the instrument inappropriately. I can’t imagine that the same criticisms would even be considered if a physician chose to place sutures in the patient’s laceration and three days later the patient removed the sutures with a pair of scissors.
Proximate Causation
Medical malpractice plaintiffs must prove a duty to treat, breach of that duty, damages, and a causal nexus between the breach of duty and the damages alleged. This case illustrates how causation may sometimes be difficult to prove. Actual causation requires a direct causal link between an injury and an alleged negligent act. For example, leaving a surgical sponge in a patient’s abdomen may be a negligent act, but it would be difficult to prove that the wayward surgical sponge caused the patient to suffer a heart attack the week after his surgery. The two events simply aren’t related. Proximate causation requires that there is a direct temporal relationship between a patient’s injury and the alleged negligent act. If other intervening factors could have caused the patient’s injury, then it becomes difficult to prove that the physician’s alleged negligent act caused the patient harm. In this case, the patient opened his own wound after three days. He may have worked in a dirty environment and contaminated the wound. He may have failed to regularly change dressings on the wound which caused an infection. He may have lifted weights or tripped over a curb, thereby worsening a partially-lacerated quadriceps tendon and causing an open joint. He also may have done none of these things and may have performed excellent care of his wound. The point is that the patient would have to demonstrate that the physician’s alleged negligence, and none of any intervening factors that occurred for two months after his ED visit, was the cause of his injuries. The verdict for the defense verdict may have been because the patient was unable to meet this burden of proof.
Comparative Negligence
In some cases, a plaintiff’s negligent acts may prevent the patient from recovering damages in a lawsuit. Most states will not allow a plaintiff to recover damages if the plaintiff is more than 50% responsible for his or her injuries. A handful of states (such as California, New York, Florida, and Washington) will allow a plaintiff to recover a proportionate amount of damages (as little as 1% of the damage award) even if the plaintiff is almost entirely at fault for the injuries he incurred (this case occurred in Pennsylvania). Another possibility in this case was that the patient’s actions contributed to enough of his injuries that the jury believed he was not entitled to recover any damages.
While the medical providers may have missed a partial tendon tear or even a joint injury, the patient removed the staples three days after they were placed (almost assuredly causing the wound to open) and then failed to seek further medical care for two months. We don’t know what, if any, wound care the patient performed, and we don’t know what activities the patient engaged in while his wound was healing. However, we do know that because septic arthritis tends to cause rapid onset of symptoms, it is highly unlikely that the patient was suffering from septic arthritis for two months after his injury.
Conclusion
Just as in baseball where “ties go to the runner,” in medical malpractice cases I believe that “ties go to the doctor.” This case is a close call. I think it is safe to assume that the injury caused a partial tendon laceration. Partial tendon lacerations don’t necessarily need to be repaired and we don’t know the extent of the laceration. A large tendon laceration would have required prompt orthopedic follow up. The patient didn’t seek care for two months leading me to believe that the injury didn’t affect the patient’s ADLs and that the tendon laceration was therefore small.
The scenario stated that the wound was cleansed and there is no documentation of a subsequent wound infection, so I think that the wound care, while perhaps not exemplary, was adequate. Although the patient also developed septic arthritis, I have a difficult time imagining that an asymptomatic open joint in an open wound existed for nearly two months, leading me to believe that there was some other intervening factor which caused the patient’s septic arthritis.
While I personally give a short course of prophylactic antibiotics to high-risk wounds, there is evidence in medical literature to show that antibiotics are of little use in preventing infection. Therefore, it is reasonable to withhold prophylactic antibiotic treatment. Finally, providing a patient with a tool shouldn’t be considered prima facie evidence of negligence if the patient chooses to misuse that tool. Even if the jury believed that the defendant was negligent in this case, the plaintiff would have a hard time overcoming issues of proximate causation and comparative negligence.
