jcash Posted September 10, 2016 Share Posted September 10, 2016 So I made a bonehead error last night at work in urgent care and I am wondering if others have had similar mistakes or can just make me feel better that I'm not the only dumbass that makes mistakes...... I was the only provider in an urgent care setting. I had just finished suturing up a chin laceration on a three-year-old who after I numbed her amazingly slept through the suturing. I walked out of her room to find I had two more lacerations waiting for me. As well as two more patients that were nonemergent and could wait. The first was a head laceration with bleeding controlled patient stable, so I then looked at the second laceration which was a shave laceration to the distal tip of the finger with profuse bleeding. So I put a pressure dressing on the finger and went to attend to the head laceration. During all this chaos I had yet another patient come in dizzy, short of breath, and elevated blood pressure of220/110. So just as I'm about to throw my first stitch in the head lac, my MA grabs me for that emergency. Pt was too SOB to lay for EKG so I had to send to ER with EMS. Once EMS arrived I was able to go back to my laceration. During this chaos, I grabbed the wrong sutures and sutured with absorbable suture's (vicryl) in the hairline of the scalp instead on nylon. In my defense their were two sets of vicryl one said absorbable one did not. So I grabbed the one that did not. I realized my mistake later that night. But it was too late to do anything about. I called my supervising physician this morning who did not seem very concerned about it and just told me to take them out sooner around five days. I feel like such a moron for making this mistake but in the midst of the chaos I'm only human and it happened! I think this solidifies for me that the stress of urgent care is probably not for me...... In hindsight I'm glad it was a mistake here and not something detrimental like ignoring the dizzy pt and her SOB. But I still feel dumb.... Oh and the finger lac also turned out to have asymptomatic HTN undiagnosed at 190/100. Not a fun night alone.... Anyone else want to share their human mistakes? Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
SHU-CH Posted September 10, 2016 Share Posted September 10, 2016 If I recall correctly from my surgery days, Vicryl retains its strength WELL beyond the typical removal time for sutures for a scalp wound - at least a couple of weeks. I would just try to remove them as normal and forget it. Because they are braided, though, they might be a little tricky to pull out. Some surgery guru on here might be able to tell you what to do if that is the case. Maybe just cut them flush? In any case, don't beat yourself up over it. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted September 11, 2016 Share Posted September 11, 2016 You're fine. Easily will last for five days but make sure that they don't stay in for a couple of months, yes months. ;-) Link to comment Share on other sites More sharing options...
JohnnyM2 Posted September 11, 2016 Share Posted September 11, 2016 Just make sure you know what Aleppo is and you will be fine. Sent from my SM-G900V using Tapatalk Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 11, 2016 Share Posted September 11, 2016 You are fine. Tough night, tough to be alone. We have all done something like this. You did no harm. Deep Breaths Link to comment Share on other sites More sharing options...
Febrifuge Posted September 11, 2016 Share Posted September 11, 2016 That's a fine example of the kind of mistake I would argue we SHOULD be making. What I mean is, it's a mistake that - You caught, quickly, without anyone having to bring it to your attention - Didn't result in any patient harm - Isn't likely to result in care of any lesser quality - Will improve the way you do things, from now on - Will be easy to avoid duplicating Like RC2 said, rule one is "primum non nocere," and you're fine, in those terms. Imagine if you were simply out of nylon, and all you had on hand was Vicryl. Would you use it, as opposed to not sewing the lac at all? If you really, really feel like you have to, you could call the patient and explain that everything is fine but in thinking about it, you would have preferred to use the other kind of suture. Make sure they know all the various things to watch for. Make sure they come back at the proper time for removal. But I think a lot of groups would be able to have an honest discussion about whether this really even counts as an error. Link to comment Share on other sites More sharing options...
Asclepius Posted September 11, 2016 Share Posted September 11, 2016 Just make sure you know what Aleppo is and you will be fine. Sent from my SM-G900V using Tapatalk Is that some sort of acronym, or something? lol Link to comment Share on other sites More sharing options...
Moderator ventana Posted September 11, 2016 Moderator Share Posted September 11, 2016 no worries on suture material not even worth losing any sleep over (you will likely make far worse mistakes that that...) just a thought - why would you even try an EKG on someone with bad SOB - top of Ddx is PE or MI - neither of which is an UC situation... One thing I learned in the realm of efficiency - don't waist time trying to rule enough out to make a patient able to stay at a lower level of care - CP goes to main side ER and the like.... I would not even count your suture material as a mistake, just an oversight Link to comment Share on other sites More sharing options...
jcash Posted September 11, 2016 Author Share Posted September 11, 2016 Than you all so much for your kind words of confidence. I called the pt and had her follow up in five days for removal. I think it will be fine but I can't wait to take them out and know it's not an issue. The problem is she can go to any of our UCs I hope she comes back to me so another provider doesn't think I'm an idiot! We actually were out of 5-0 nylon like Febrifuge said. But I could have easily used 4-0 nylon on that area. Ventana-- my first thought on the dizzy pt is to send to ER. But the EMS in my area are ass holes to be perfectly honest. So if I get an EKG that's abnormal it's better. I've had them talk a pt that just had a minor seizure from head trauma, out of going to ER via ambulance. Instead they convinced him it was ok for his wife to drive him. He could easily have another seizure on the road and cause real harm. And our UC policy is to see each pt and do some type of exams even though your initial gut instinct is call 911 or go to ER. I'm amazed at the pts that come to me with "I think I'm having a stroke." Or something equally as bad that I can't take care of..... Then they're upset I send them to ER or refuse to go..... Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
fishbum Posted September 11, 2016 Share Posted September 11, 2016 I've had them talk a pt that just had a minor seizure from head trauma, out of going to ER via ambulance. Instead they convinced him it was ok for his wife to drive him. He could easily have another seizure on the road and cause real harm. Sorry to butt into the conversation here, I'd encourage you to contact the system's medical director about this one. It sounds like something that really ought to be addressed. Link to comment Share on other sites More sharing options...
Planteater Posted September 11, 2016 Share Posted September 11, 2016 Is that some sort of acronym, or something? lol No it's a reference to the Libertarian presidential candidate's (Gary Johnson) mistake in not knowing where Aleppo is during a TV interview. It's the worst mistake he's made on the campaign trail, so people keep harping on it like it makes him an idiot... On topic- OP don't beat yourself up. Definitely not a terrible mistake! Link to comment Share on other sites More sharing options...
db_pavnp Posted September 11, 2016 Share Posted September 11, 2016 Just make sure you know what Aleppo is and you will be fine. Sent from my SM-G900V using Tapatalk Why do a handful of you use this forum like a political toilet? Link to comment Share on other sites More sharing options...
Asclepius Posted September 11, 2016 Share Posted September 11, 2016 No it's a reference to the Libertarian presidential candidate's (Gary Johnson) mistake in not knowing where Aleppo is during a TV interview. It's the worst mistake he's made on the campaign trail, so people keep harping on it like it makes him an idiot... Yes, my response was actually a tongue in cheek reference to Gary Johnson's recent snafu lol. I believe later that same day, Gary had another interview in which he said he just blanked and was thinking Aleppo was an acronym of some sort. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted September 11, 2016 Moderator Share Posted September 11, 2016 Why do a handful of you use this forum like a political toilet? Link to comment Share on other sites More sharing options...
Planteater Posted September 11, 2016 Share Posted September 11, 2016 Yes, my response was actually a tongue in cheek reference to Gary Johnson's recent snafu lol. I believe later that same day, Gary had another interview in which he said he just blanked and was thinking Aleppo was an acronym of some sort. Too funny- I didn't even catch it! I'm a little tired from working and then coming home to take care of a sick kid today. Back to our regularly scheduled programming (I hope)... Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 12, 2016 Administrator Share Posted September 12, 2016 And our UC policy is to see each pt and do some type of exams even though your initial gut instinct is call 911 or go to ER. Back on topic... That's a policy that has "we want to maximize profit" written all over it. I'm all in favor of evaluating and treating in cases where it's questionable whether any care can be effectively rendered at the current level of care, but let's not forget that holding on to patients who belong elsewhere... kills them. http://archsurg.jamanetwork.com/article.aspx?articleid=1828520&resultclick=1 Link to comment Share on other sites More sharing options...
jcash Posted September 12, 2016 Author Share Posted September 12, 2016 Back on topic... That's a policy that has "we want to maximize profit" written all over it. I'm all in favor of evaluating and treating in cases where it's questionable whether any care can be effectively rendered at the current level of care, but let's not forget that holding on to patients who belong elsewhere... kills them. http://archsurg.jamanetwork.com/article.aspx?articleid=1828520&resultclick=1 Yup you're right! We will take emergent patients directly back to a room. The MA will take insurance info. And if my assignment is two minutes to do a quick exam and say go to ER (either with family or EMS) they will still get charged from us. I can sort of understand bc I've had pts SOB but it's a mild bronchitis, or chest pain that's muscular in a young pt otherwise healthy. But there are some you know right off the bat and it'd be nice to just say go away! Well go to the ER ha ha ha Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
jcash Posted September 12, 2016 Author Share Posted September 12, 2016 Sorry to butt into the conversation here, I'd encourage you to contact the system's medical director about this one. It sounds like something that really ought to be addressed. Yes if it's bad like that they've encouraged us to call the chief for that area. I don't really understand them. We're on the same team here, helping pts. I had a 65 yr pt walk in with a large head laceration from a drunken fall. Her husband found her in a pool of blood so called 911. EMS says you're good to drive her to an urgent care. No need for ER. WTF?!? She was out of it, either from being drunk or head wound I'm not sure. But given her age and nature of the wound she needed a CT which I don't have. I sent them straight to the ER. Luckily husband was sober..... Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Guest ERCat Posted September 12, 2016 Share Posted September 12, 2016 Don't beat yourself up - that is a very minor mistake. I mistakenly ordered 2 mg Ativan at once on a 15 year old girl who came in with a coughing fit that was all an anxiety attack. I was less based dosing her and it said "max of 2 mg" so I went with the max, not thinking about the fact that I usually give ADULTS 0.5-1 mg. it was weird because I give Ativan all the time. Not enough to kill her - but it was way too much at once. Luckily when I went back in she was VERY happy and chill, and her coughing fit had stopped. Still, felt like a mistake to me because it wasn't what I intended. I also once did an I and D on this crazy screaming lady without numbing her up first. I got distracted by her constant screaming and while trying to calm her down I somehow missed the lidocaine step. Ouch. Link to comment Share on other sites More sharing options...
jcash Posted September 12, 2016 Author Share Posted September 12, 2016 Don't beat yourself up - that is a very minor mistake. I mistakenly ordered 2 mg Ativan at once on a 15 year old girl who came in with a coughing fit that was all an anxiety attack. I was less based dosing her and it said "max of 2 mg" so I went with the max, not thinking about the fact that I usually give ADULTS 0.5-1 mg. it was weird because I give Ativan all the time. Not enough to kill her - but it was way too much at once. Luckily when I went back in she was VERY happy and chill, and her coughing fit had stopped. Still, felt like a mistake to me because it wasn't what I intended. I also once did an I and D on this crazy screaming lady without numbing her up first. I got distracted by her constant screaming and while trying to calm her down I somehow missed the lidocaine step. Ouch. Thank you for sharing that. I've done that w weight based dosing and then you come out with high number. Our child population is getting bigger and more are obese. I start giving adult doses at age 8-9 sometimes. Glad everything turned out ok with your Ativan patient. I have a hard time getting abscess totally numb anyways. I'll put a ton in and they're still in pain when I I&D it. I keep telling myself I'm only human and mistakes happen. We're under so much pressure to meet our pt quota and demands of EHR etc. it's not too hard to make a mistake...... Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Guest Paula Posted September 13, 2016 Share Posted September 13, 2016 I tell patients who are undergoing the I & D that it will hurt even after I numb it. It's just a fact of life. Link to comment Share on other sites More sharing options...
RuralER/Ortho Posted September 13, 2016 Share Posted September 13, 2016 I tell patients who are undergoing the I & D that it will hurt even after I numb it. It's just a fact of life. I do as well. No good way to get it numb. Some times I'll give a PO pain med and see another patient, chart, etc for a little while. Come back and do the procedure about 30 minutes later. Seems to help somewhat, but it's time consuming. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted September 13, 2016 Share Posted September 13, 2016 Pus doesn't numb.... Sometimes I soak a sterile gauze in lido gel and lay it over the incision site. Probably more mental for me but have been told it helps. If time, IM toradol makes that injection site hurt more than my stab wound. Pus is a no win situation for pain. Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted September 13, 2016 Administrator Share Posted September 13, 2016 A bit of ethyl chloride might help for the initial incision, too, depending on how near the surface the abscess is. Link to comment Share on other sites More sharing options...
Moderator LT_Oneal_PAC Posted September 13, 2016 Moderator Share Posted September 13, 2016 Infected tissue is acidic and lidocaine requires a basic medium to be unionized and cross the nerve sheath and block sodium channels. That's why adding bicarbonate speeds up onset. Link to comment Share on other sites More sharing options...
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