Made my first mistake

[Acromion]

Two days ago I saw a patient with a lac to the dorsum of the left hand. The laceration was about 2.5 cm long with clean edges, down to the adipose with no tendon involvement. X-rays were negative for foreign body and I irrigated extensively. The ER was slammed and I've been under a lot of pressure to move the patients through faster. Out of expediency, I decided to use dermabond instead of suturing, even though the little voice in the back of my head told me to just suture it.

 

Well, of course the patient bounced back tonight with his family in tow complaining of  dehisced wound and cellulitis. In triage they requested not to see me. My attending saw the patient and had a tech put some steri-strips on the dehisced portion and started the patient on antibiotics. I went in to see the patient and apologized for the poor outcome, which was very awkward because the entire family refused to speak with me or even make eye contact.

 

My supervising doc laughed it off and seemed totally unperturbed by the incident. He says he will sometimes dermabond on hands himself.  I, on the other hand, feel terrible. I feel bad I've put this patient through unnecessary complications due to my poor judgement. I want more than anything to be seen as competent, but as a new graduate PA, going to work is a daily exercise in humility. 

 

Couple things I've learned: 1.) don't cut corners even if you have a full waiting room and your boss is breathing down your neck to get your door-to-doc time down. 2.) listen to that little voice in the back of your head 

 

EDIT: demographic details removed

[Derbingle]

I would say it wasnt a mistake, it was an experience. Hand wounds often get infected/cellulits. The family was prob irritated bc they thought he should have had sutures. Glue works on superficial, dry thin skin. Not much else. They always come back wet and open. Dont be too hard on yourself. Ps too many details for thenpublic forum. I would edit it to make it more generic. For your protection.

[moestown1016]

Agree with it's an experience. We have probably all done something similar. Listen to the nagging voice -it has saved my butt a few times :D

[Guest Paula]

I agree with the little voice in the head and to listen to it.  I've not listened a few times and have regretted it.  ERs can be tough places to work and don't cut corners and if you are unsure ask the attending at document like crazy.

[ventana]

read an interesting article the other day that was basically saying

1) do the same thing the same way every time - rather the ER is full, or empty, rather you are fresh or tired..... so on and so forth..... Their is typically reasons we do somthing that way and cutting corners is bad

 

2) NEVER say to a familyl the ER if way busy or you are at the end of a shift, or you had people call in sick...... never really thought about this, but that gives them ammo if something does go wrong. Instead just chug along at your regular pace and demeanor when in the rooms.... afterall it is just another shift

 

 

 

 

 

 

 

On a side note - I used to follow all the guidelines on Abx treatment with wounds, but the had a very respected mentor provide some very sound wisedom - we need our hands........ give em ABX if in doubt. I have thought of this more then once since and I have changed my prescibing patterns to reflect this. I don't give everyone ABX, but I now give out more then I used to. A classic example of this is a dog bite on the hands, which I didn't used to use ABX for, but now if it is beyond superficial, I at least offer it to the patients.....

 

 

 

 

 

As for a screw up? Not sure it was the best outcome, but not thinking this is a screw up either. It is a learning experience. Screw ups are where someone dies or seriously injured. Oh yeah and by the way sometimes you will do everything perfectly and the patients still get worse or have a horrible outcome......

 

 

 

 

learn from it, don't beat yourself up to hard, look at not only the specific medical issues in this one case, but also the work flow issues that you experienced at the time so that you can be wise to a similiar situation in the future (ie a busy ER)

 

 

 

 

 

Above all, I don't think there is a PA out there (worth anything) who has not made some type of error in retrospect - it comes with the job......

[UGoLong]

Anyone in a new job makes mistakes and that includes PAs. If you're unsure, ask for advice. Try not to let other pressures deter you from your own good judgment. And, as you have in this case, learn from your mistakes and teach the lessons to the newbies that will come up behind you.

 

I suspect that every new provider gets prodded by those with more experience to be faster, especially these days. Speed comes with experience. Even for experienced providers, you have to know when something comes along that demands that you slow down and focus. 

 

All of this comes with time and experience. The fact that this case has affected you so much tells me that you take your job seriously and will not forget the lesson. I'd be your patient any time.

[GetMeOuttaThisMess]

Uh, allow me to bring to light another reason why the family may have "appeared" perturbed.  Squeaky wheel gets the grease and I wouldn't be surprised if maybe they were playing the "ED Lotto" and trying to get the charges dropped.  One of the greatest inventions of all time, aside from a PB&J, is the running horizontal mattress stitch, regardless of what part of the body you use it on.  Fast closure (forget simple interrupted stitches away from the face, and sometimes even there), heals great, no "railroad tracks", and you don't have to worry about inverted skin edges. 

[Z PA-C]

I dislike dermabond. It has a major skin allergen as an ingredient. Unfortunately, I didn't know that until after the horrific reaction and scarring on my wound. Sutures all the way.

[cinntsp]

On a side note - I used to follow all the guidelines on Abx treatment with wounds, but the had a very respected mentor provide some very sound wisedom - we need our hands........ give em ABX if in doubt. I have thought of this more then once since and I have changed my prescibing patterns to reflect this. I don't give everyone ABX, but I now give out more then I used to. A classic example of this is a dog bite on the hands, which I didn't used to use ABX for, but now if it is beyond superficial, I at least offer it to the patients.....

 

 

The literature we have at this point supports giving abx for bites to the hand whether closing it or not.  PMID 11406003.  There was an interesting segment on the topic of animal bites in the March EMRAP.

[Acromion]

 

 

I suspect that every new provider gets prodded by those with more experience to be faster, especially these days. Speed comes with experience. Even for experienced providers, you have to know when something comes along that demands that you slow down and focus. 

 

 

 

Herein lies the problem at my job. I was hired into this position straight out of school and thrown into a busy rural ER staffed by 1 doc and 1 PA. I was given only 3 days of orientation where I was working with another PA. During the interview process I was very candid about my experience. I told them I was looking for a group that was willing to work with a new grad. I told them that I would be slow at first and have lots of questions. Well, lo and behold, after a couple months of me hobbling through, a couple docs apparently had enough of me and tried to get me fired. Since the group is no longer democratic, they had to plead their case to corporate, who put the kibosh on that idea. They gave me an opportunity to pick up my pace so I put the pedal to the metal and I am now routinely seeing up to 30 patients per 12 hour shift.

 

Our ER has a very high volume of narc seekers and malingerers, something I didn't encounter on my rotations. Learning to deal with these patients effectively has been really tough. When I started, I would let them drag me down the rabbit hole with their numerous and seemingly life threatening complaints (i.e. chest pain, abdominal pain, worst headache of their life - all at once), but now I'm starting to recognize the hypodilaudemia / hypochondriac patients and managing them more effectively without them hanging out in the ER for 3 hours while I work up every complaint. It's been a little depressing because some days I feel like my job is to just deal with the crazies and get them out of the ER so the docs don't have to deal with them. 

 

So, I've stepped up to the plate and increased my patient volume. It's been a tough learning experience. I am seeing patients that I have no idea what to do with and I need lots of help with. I am routinely staying late or coming in on my days off (without compensation) to finish my charts. I'm still unsure whether this place is right for me. 

[Acromion]

Thanks for the advice. I routinely give Abx for bite wounds. I think I will start doing the same for deeper hand lacs.

 

Uh, allow me to bring to light another reason why the family may have "appeared" perturbed.  Squeaky wheel gets the grease and I wouldn't be surprised if maybe they were playing the "ED Lotto" and trying to get the charges dropped.  

 

Yeah patient was self-pay (i.e. No-Pay) 

 

What patients don't understand, and I think what makes medicine very hard, is that sometimes bad outcomes happen.

 

What makes it particularly hard as a PA, is that if there is a bad outcome it's because you are the PA.

 

That dynamic is what makes me sometimes want to go into a speciality with a narrower scope and less room for error.

[acozadd]

Hindsight is 20/20. Perhaps the patient was using his hands for heavy lifting/repetitive activities and that led to his complication. I wouldn't beat yourself up over it. It could have gotten infected even with sutures, and could have ultimately opened up regardless of sutures.

[cinntsp]

Thanks for the advice. I routinely give Abx for bite wounds. I think I will start doing the same for deeper hand lacs.

 

 

You should get EMRAP if you don't subscribe already and check out that March episode.  Here's the summary:

 

[EMEDPA]

 One of the greatest inventions of all time, aside from a PB&J, is the running horizontal mattress stitch, regardless of what part of the body you use it on.  Fast closure (forget simple interrupted stitches away from the face, and sometimes even there), heals great, no "railroad tracks", and you don't have to worry about inverted skin edges. 

excellent advice. here is a quick video showing the technique:

[feedme]

This is probably not the worst mistake you could've made (think dentist that killed his pt extract icing several teeth at once despite warnings from his assistant and despite pt not doing well).

[GetMeOuttaThisMess]

The great thing about the running horizontal mattress is that once you get good at it you can even finagle ways to use it on skin flaps.

[KMD16]

Excellent advised thus far. My only advise is to get a FM per diem or PT on your days off. Don't ask me why. Good luck.

[EMEDPA]

The literature we have at this point supports giving abx for bites to the hand whether closing it or not.  PMID 11406003.  There was an interesting segment on the topic of animal bites in the March EMRAP.

I've seen the studies. that being said, the worst QA case we had recently was a PA following the guidelines who cleaned a 1 hr old dog bite wound in a young healthy person well, loosely sutured it, placed the pt on abx, only to have them return 2 days later with tenosynovitis requiring OR debridement. PA almost got fired, doc who signed chart(but didn't see pt ) was livid. that one episode almost made our whole group have to present 100% of pts and have them seen by a doc before they leave the dept. The senior PAs(myself included) all basically said we would quit if we went to a mandatory doc eval model and we narrowly averted all being replaced by NPs. moral of the story for me(and this has always been my practice)- all dog bites on hand get copiously cleaned, abx, tdap, and if they require any significant closure have hand surgery do it. 15 years ago our doc group trusted us and would have said that could happen to anyone. the atmosphere now is it happened because a pa saw the pt and no doc would have made the error. we went from a group of older mellow er docs(many were grandfathered from fp) to a group of young em docs who never met a pa before joining our group because the local em residency is at a place with zero pas.  did I mention I am looking for a new job.....

PS : the PA who did the closure didn't get fired burt continued to get crap from some of the docs and micromanaging so left anyway when he found a good exit strategy a few months later...

[Acromion]

Excellent advised thus far. My only advise is to get a FM per diem or PT on your days off. Don't ask me why. Good luck.

 

Well I'm going to ask you why anyway.

[GetMeOuttaThisMess]

I've seen the studies. that being said, the worst QA case we had recently was a PA following the guidelines who cleaned a 1 hr old dog bite wound in a young healthy person well, loosely sutured it, placed the pt on abx, only to have them return 2 days later with tenosynovitis requiring OR debridement. PA almost got fired, doc who signed chart(but didn't see pt ) was livid. that one episode almost made our whole group have to present 100% of pts and have them seen by a doc before they leave the dept. The senior PAs(myself included) all basically said we would quit if we went to a mandatory doc eval model and we narrowly averted all being replaced by NPs. moral of the story for me(and this has always been my practice)- all dog bites on hand get copiously cleaned, abx, tdap, and if they require any significant closure have hand surgery do it. 15 years ago our doc group trusted us and would have said that could happen to anyone. the atmosphere now is it happened because a pa saw the pt and no doc would have made the error. we went from a group of older mellow er docs(many were grandfathered from fp) to a group of young em docs who never met a pa before joining our group because the local em residency is at a place with zero pas.  did I mention I am looking for a new job.....

PS : the PA who did the closure didn't get fired burt continued to get crap from some of the docs and micromanaging so left anyway when he found a good exit strategy a few months later...

 

So what did the "geniuses" say that they would have done differently?  They obviously don't understand the concept that if you're going to be in the ED first of all, and then secondly use advanced providers, that you have to have your big girl panties on at all times (no offense ladies).  This outcome could have, and certainly has more times than we could count, happened to them just as easily.  Luck of the draw.  They obviously didn't take a moment to consider their wallets before looking like such "uninformed individuals" (changed the aggressive language).  As an addendum, a PS who would occasionally take ED call would admit ALL facial bites for IV abx and observation due to the infection risk in his mind despite his initial level of care.

 

E, what are the general demographics of the principal parties?  Older or younger?  I'm going to presume older since they would theoretically have had less exposure to APs, but have not been able to resist the urge of increasing their bottom line with usage of same.  I could also argue the financial bottom line only approach with younger physicians.

[EMEDPA]

So what did the "geniuses" say that they would have done differently?  They obviously don't understand the concept that if you're going to be in the ED first of all, and then secondly use advanced providers, that you have to have your big girl panties on at all times (no offense ladies).  This outcome could have, and certainly has more times than we could count, happened to them just as easily.  Luck of the draw.  They obviously didn't take a moment to consider their wallets before looking like such "uninformed individuals" (changed the aggressive language).

E, what are the general demographics of the principal parties?  Older or younger?  I'm going to presume older since they would theoretically have had less exposure to APs, but have not been able to resist the urge of increasing their bottom line with usage of same.  I could also argue the financial bottom line only approach with younger physicians.

the docs agreed retrospectively that it should have not been sutured and should have been seen by ortho hand within 24 hrs. easy to be a monday morning quarterback. of course when a doc misses something like myocardditis(which is caught by a pa when the pt bounces back 2 hrs later) it's because it was "an atypical case with a challenging presentation and a good learning experience for everyone".

we have 2 groups of PAs, those of us 40-60 with 15-35 years experience( about 1/2 the group) and a bunch of folks age 25-35 who have been PAs less than 5 years(it was one of these who sutured the dog bite). the docs used to all be 50-60 with a mix of MD and DO. now there are a few in that demographic and most are 30-35 right out of residency (and all MD- don't get me started on the difference) at their first jobs with 0-5 years experience, having trained at a place that uses no PAs. the old guys know what we are worth, the young guys have no idea that the pa group contributes 40k to the yearly 350k salary of each doc and works a larger share of the nights/weekend/holidays.  this is mostly the fault of the recruiting and hiring practices of the group. I don't think they even mention the presence of 15 pas in the group(we are employees, not partners) during interviews. I worked with one new doc a few years ago his first day and he didn't understand the entire concept of having to sign pa charts at the end of the shift on pts he had never seen. he refused and the chief took him aside and explained that he got 1/2 the RVUs for each chart he signed. then it wasn't a problem anymore.....

[GetMeOuttaThisMess]

FWIW, if that had been me, and the wound edges were poorly approximated, I would have loosely closed one simple interrupted about every 2 cm.  No, it would not have been a running horizontal mattress :-).  I would have automatically given a hand referral name but most likely would've just asked the patient to come back in 24 hours for a recheck if I had any concerns to start with.  Thinking back on this thread, I now remember that we had a guy years ago come in with a bite wound to the hand that got infected.  Initial presentation, laceration from human bite, no tendon deficit, cleansed, closed, received an abx. door prize and was sent on his way.  Came back the next day with infection.  Someone tried a novel concept and actually spoke with the patient.  How'd he get the bite?  Punched a guy in the mouth.  What was in the wound?  A piece of tooth.  I never was involved, and was happy to not have been the initial provider.

[Gordon, PA-C]

All of us make mistakes, the good thing is that your mistake didnt cause any permanent injury or death.  You sound like a person I would love to work with if you were willing to own up to your mistake and apologize.  The people that get into trouble with mistakes is not because they made the mistake, it is because they fail to own it.  If you fail to own it, then its highly likely you wont learn from it and you will make the same mistakes in the future.

 

I'll tell you 2 horrible mistakes that I made years ago while I was in training:

 

1.  As a brand new PA student, one of the doctors asked me to put in a foley on a patient who was going to the OR for a thoracotomy.  I had seen foley caths put in before and I knew the basic steps, but I had never done one myself.  Easy right?  So I insert the cath, it seems to be very deep inside this guy, so I assume the bulb is inside the bladder.  I inflate the cuff, and I notice that its a little stiff and requires some pressure to inflate.  About 2 hours into the operation, the anesthesiologist tells the surgeon that there is blood coming out of the foley cath.  Urology comes to evaluate, they scope his urethra and this guy has a tear in his urethra from the bulb expanding into his urethra.  They had to stitch him up.  I went to the family/patient later and told them what happened.  Obviously they were upset but it would have been worse if I hadnt told them about it and they found out later from someone else.  I think that made the difference between me getting sued or not.

 

2.  During my ER rotation, a 6 month old kid with a mic-key button comes in with vomiting and diarrhea.  He is well appearing and the presumptive diagnosis is viral gastroenteritis.  The parents who are spanish speaking, are adament that they want me to open his tube and vent him because his tummy is "swollen."  I hem and haw about it for awhile, but the parents are absolutely insistent that it needs to be done.  I was nervous about it because I hadnt worked with mic-key buttons a lot, and I didnt want to make the parents mad. Against my better judgment, I tried to vent the tube.  So when I try to open the button, the whole freaking tube comes out and formula just starts pouring out of this open area on this kid's stomach.  In a panic, I quickly put the tube back in and hold it in with tons of gauze.  Urgent page to peds surgery, they come down, reinsert, reinflate the baloon, Gastrogaffin series thru the tube shows good placement.  Spent about 10 minutes apologizing to the family.

 

 

In my case, both of my major mistakes came because I was uncomfortable with something but did it anyways, whether it was pressure from doctors or parents.  Listen to that small voice inside of you!

 

 

[Acromion]

My only advise is to get a FM per diem or PT on your days off. Don't ask me why. Good luck.

 

BTW, KMD, I think this is a very passive aggressive comment.

[EMEDPA]

BTW, KMD, I think this is a very passive aggressive comment.

I think they were just implying that a firm grounding in primary care is helpful to a career in em. I agree to some extent but think working urgent care, fast track, or doing a residency are also all acceptable paths.