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Made my first mistake


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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

I agree this is a learning experience, not a mistake.

There wont be any poor outcome here. 

Likely the pt did not listen and used hand extensively and caused dehisce. 

 

I always tell pts no matter how well we clean and irrigate, infection is a risk, no way to prevent, even if we give prophylax antibiotics.

I agree with not cutting corners regardless of the situation. Though I dont necessarily see dermabond as a cut corner.

 

If you have a 'boss' breathing down your neck, my personal response is they can go f7ck themselves. Likely you are getting not more than a 100k to do what you do. The 'boss' is getting paid 2-3 times that. It is likely you are seeing more patients and working during the busiest times of the day. The boss is using you as an indentured servant. Since you are just out of school,  a couple three years of this will get you a lot of exposure and experience. There wont be much longevity at a place like this though. I would hazard a guess that if you looked at the schedule, you and the other PAs are working more hours than 'the boss' on a yearly basis.

 

As for the pt and his family not liking you based upon the fact they had to come back, they can f&ck themselves too. Their behavior is an insight into how immature and unrealistic their expectations are. Not everyone gets a perfect outcome and a 2 cm lac repair that dehisced is not important in the scheme of things. I am sure the hand modeling career will be salvaged. Missing an MI or misgauging an acute abdomen is a much bigger deal.

 

Its ok to feel the way you feel now. I did when I first started out too with some of my 'mistakes'. With 15 years of retrospection and a bunch of life experience, all of what you are describing, is to me just an unpleasant part of the job. I was sitting with our director the other day, we were going over a complaint generated during a pt visit directed at me. I remembered the pt, remembered thinking I would get a complaint and that there was nothing I could really do to head that off. My response was that I guess I failed to win the popularity contest that day. I have slept like a baby through the weekend.

 

Hang in there.

G Brothers PA-C

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If its any hand injury that is an animal bite needing sutures, we still do all above, (tdap, abx always, copious lavage) but we always call hand surgeon on call before DC and they usually tell us "put a few sutures in it, splint it, send the patient to my office tomorrow". Use judgment........right?......I had one hand bite that was so severe I was positive it needed OR care. The hand surgeon was (very) annoyed that I said I wouldnt sew it due to depth and damage and he needed to see it. He wanted me to send him home with a splint, to office next day, which some may have done, i said no. He had to come in and look at it.... He went to OR that night. I feel its hit or miss depending on the doc. I see what seems one dog bite a week. leave an escape for pus somewhere in the middle of the big lacs. Also tell them no hot tubs or swimming pools. Must wear splint. It helps them avoid doing things that result in infection. Just my 1 cent. I cant afford 2.

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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.

Agreed!

 

However, the OP do currently provide coverage in fast tract/UC & doing a residency will be out of the equation for the OP due to the significant pay cut. That said, picking up per diem or PT shift in FM/IM in addition to ED work might be ideal.

 

 

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Agreed!

 

However, the OP do currently provide coverage in fast tract/UC & doing a residency will be out of the equation for the OP due to the significant pay cut. That said, picking up per diem or PT shift in FM/IM in addition to ED work might be ideal.

 

I was hired to do fast track, but as it turns out I am seeing a fair number of higher acuity patients, no level 1's though. I am currently looking for a contingent / part time at a family practice or urgent care, but my full time schedule is very unpredictable and I've found that most employers are looking for someone who can commit to certain shifts every month. Residency is out of the question for the same reasons med school with residency was out of the question: too much debt.

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I agree this is a learning experience, not a mistake.

There wont be any poor outcome here. 

Likely the pt did not listen and used hand extensively and caused dehisce. 

 

I always tell pts no matter how well we clean and irrigate, infection is a risk, no way to prevent, even if we give prophylax antibiotics.

I agree with not cutting corners regardless of the situation. Though I dont necessarily see dermabond as a cut corner.

 

If you have a 'boss' breathing down your neck, my personal response is they can go f7ck themselves. Likely you are getting not more than a 100k to do what you do. The 'boss' is getting paid 2-3 times that. It is likely you are seeing more patients and working during the busiest times of the day. The boss is using you as an indentured servant. Since you are just out of school,  a couple three years of this will get you a lot of exposure and experience. There wont be much longevity at a place like this though. I would hazard a guess that if you looked at the schedule, you and the other PAs are working more hours than 'the boss' on a yearly basis.

 

As for the pt and his family not liking you based upon the fact they had to come back, they can f&ck themselves too. Their behavior is an insight into how immature and unrealistic their expectations are. Not everyone gets a perfect outcome and a 2 cm lac repair that dehisced is not important in the scheme of things. I am sure the hand modeling career will be salvaged. Missing an MI or misgauging an acute abdomen is a much bigger deal.

 

Its ok to feel the way you feel now. I did when I first started out too with some of my 'mistakes'. With 15 years of retrospection and a bunch of life experience, all of what you are describing, is to me just an unpleasant part of the job. I was sitting with our director the other day, we were going over a complaint generated during a pt visit directed at me. I remembered the pt, remembered thinking I would get a complaint and that there was nothing I could really do to head that off. My response was that I guess I failed to win the popularity contest that day. I have slept like a baby through the weekend.

 

Hang in there.

G Brothers PA-C

 

Thank you for the advice. The patient will not lose his hand over this and the worst outcome will be that they comp his bill. In retrospect, I should have predicted this just by looking at the patient - extremely dirty (i.e. not a hand washer) and had an estimated IQ well south of 100. In my discharge instructions, I always tell the patient to come back if they have signs of infection (redness, swelling, pus, fevers) but from now one I will always include the disclaimer that infection is ALWAYS a possibility.

 

Regarding my work environment: My boss is not only breathing down my neck, he's a bully. He is constantly berating me. He is extremely rude to all of his subordinates but he is particularly nasty towards me. Actually I should clarify that he is no longer my "boss" since he has been demoted, mostly likely for the aforementioned reasons, but he still is one of my supervisors. He's one of those doctors, and I'm sure we all know the type, who obviously got into medicine for the huge ego trip. I'm at the point now where I just kind of pity him. If you have to tear other people down to feel good about yourself, you are obviously insecure. I have avoided confrontation because I am a new grad and it is expected that I will just have to take my lumps. There is a bullying culture in medicine that is alive and well and I'm told there's one of these docs just about anywhere you go.

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I'm late joining in the discussion, but I also have never seen a subQ suture for a dorsal hand wound. I am unclear as to mechanism of injury but if it's any kind of bite wound, then follow up with a hand surgeon within 24 hours is my protocol, if possible, give a Tdap, cover with Augmentin, and tell the patient to NOT stretch the wound at all. I agree that Dermabond is great for superficial lacs or post op incisions but not much else. Even if you do things "textbook" perfectly, dehiscence is always a possibility, no matter what. The more an area has the chance to move, the higher incidence of dehiscence. I also agree with the poster who said do not be too hard on yourself. Even the most seasoned of PAs, MDs (including surgeons), have this outcome. Learn from it, try not to let it scar you, and stay humble. 

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  • 3 weeks later...

rule of thumb for future.  if the wound would need more than 10 stiches you might skip dermabond.  also b e clear in discharge instructions what activities are acceptable with the wound, how to keep it clean and above all when to call the doctor if it starts to look infected.  this from a critical care nurse.  just my take.  22  years of hospital experience.

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