Better to make sure that you do an extensive exploration of the wound, irrigate generously and for sure warn the patient of a potential occult FB and to return if any symptoms occur when an ultrasound could confirm.
It seems inappropriate to me to have a surgeon, possibly, or presumably a hand surgeon, to attest to the appropriateness of clinical care in this situation. There are always many extenuating circumstances to a case. For a similar injury, I personally would likely get an x-ray. However, there are so many potential circumstances in which an x-ray may not have felt to have been definitively indicated or necessary for one reason or another. Perhaps, the resident did not appropriately or thoroughly pressure irrigate the wound which might have dislodged the glass fragment, or it might have not. The point is, they should have had an emergency medicine physician attest to the appropriateness of care rather than a specialist as an emergency medicine resident will obviously not have the same specialization as a hand surgeon, and would not approach the clinical situation in necessarily the same manner. Comparing what the surgeon states that he would have done in that situation is completely inappropriate. While their viewpoint is certainly relevant, in terms of being an expert witness, clearly an emergency medicine provider would have been more appropriate to attest to the standard of care in this situation. Also, it is very likely that the patient was recommended to follow up with a hand specialist for any complications, I know that this is something that I always inform patients to cover the bases, of course, this may not have been documented in which case “it did not happen.” It is fortunate that the ER attending physician was not named in the suit (or if they were it was not apparent from the article), as they would generally expect even a first year resident to be competent to manage a simple laceration repair. Given the reported clinical examination at the time of the injury, it sounds as though the fragment migrated, but was not causing damage to the owner nerve at the time of the injury. it is easy to say that this was overlooked, and perhaps it was, however hindsight is 20/20, and we all know that laymen do not understand the complexities and considerations of resource availability that emergency medicine providers must juggle on a daily basis. It is unfortunate what happened to the patient in terms of injury, however, I believe we are too quick to jump to finding someone to blame rather than accepting that as human beings, we cannot foresee every possible potential adverse scenario. Nothing is so simple, however, having a surgical specialist attest to the appropriateness of care of an emergency medicine resident is absolutely inappropriate and sets a very dangerous precedent.
I can't think of a circumstance where an X-ray wouldn't be indicated with shattered glass lacerating a hand. This is EM 101, cheap and easy test, standard for 50 years. With the recent EM match results the last few years, supervisors and teachers need to be careful
Better to make sure that you do an extensive exploration of the wound, irrigate generously and for sure warn the patient of a potential occult FB and to return if any symptoms occur when an ultrasound could confirm.
Remember not all foreign bodies are visible on X-ray, including some types of glass. And of course wood splinters, etc. Not a slam dunk.
Definitely true. This would have been more defensible if they had gotten a false negative x-ray rather than just not doing it at all.
It seems inappropriate to me to have a surgeon, possibly, or presumably a hand surgeon, to attest to the appropriateness of clinical care in this situation. There are always many extenuating circumstances to a case. For a similar injury, I personally would likely get an x-ray. However, there are so many potential circumstances in which an x-ray may not have felt to have been definitively indicated or necessary for one reason or another. Perhaps, the resident did not appropriately or thoroughly pressure irrigate the wound which might have dislodged the glass fragment, or it might have not. The point is, they should have had an emergency medicine physician attest to the appropriateness of care rather than a specialist as an emergency medicine resident will obviously not have the same specialization as a hand surgeon, and would not approach the clinical situation in necessarily the same manner. Comparing what the surgeon states that he would have done in that situation is completely inappropriate. While their viewpoint is certainly relevant, in terms of being an expert witness, clearly an emergency medicine provider would have been more appropriate to attest to the standard of care in this situation. Also, it is very likely that the patient was recommended to follow up with a hand specialist for any complications, I know that this is something that I always inform patients to cover the bases, of course, this may not have been documented in which case “it did not happen.” It is fortunate that the ER attending physician was not named in the suit (or if they were it was not apparent from the article), as they would generally expect even a first year resident to be competent to manage a simple laceration repair. Given the reported clinical examination at the time of the injury, it sounds as though the fragment migrated, but was not causing damage to the owner nerve at the time of the injury. it is easy to say that this was overlooked, and perhaps it was, however hindsight is 20/20, and we all know that laymen do not understand the complexities and considerations of resource availability that emergency medicine providers must juggle on a daily basis. It is unfortunate what happened to the patient in terms of injury, however, I believe we are too quick to jump to finding someone to blame rather than accepting that as human beings, we cannot foresee every possible potential adverse scenario. Nothing is so simple, however, having a surgical specialist attest to the appropriateness of care of an emergency medicine resident is absolutely inappropriate and sets a very dangerous precedent.
In general I agree that it should be an expert from the same specialty, but in this case I think getting the xray is so obvious that I'm ok with it.
I can't think of a circumstance where an X-ray wouldn't be indicated with shattered glass lacerating a hand. This is EM 101, cheap and easy test, standard for 50 years. With the recent EM match results the last few years, supervisors and teachers need to be careful
did they xray the glass fragment and confirm it was radio opaque? Some glass is not. If not, an xray would not have helped.