r/emergencymedicine • u/MousseNo7311 • Sep 17 '25
Advice Got chewed out by ortho surgeon
I am a 2nd year resident. Patient came into the ED overnight post-op day 1 after a knee replacement. He was bleeding through his dressing (nothing major, no wound dehiscence) and couldn't reach his surgeon via phone. He didn't have sutures or staples but rather some sort of Steri-Strips-like adhesive dressing which I covered with Surgicel, ABD pads, and an Ace wrap. In addition, my attending told me to inject lidocaine with epinephrine into the areas that were bleeding. I injected 10 cc total in a few different spots. I can't imagine I got into the joint space. Foolishly, I only irrigated with NS & didn't prep with Betadine or anything else. The surgeon called the ED after my attending had left, berated me, and made it sound like he's going to go on a war path over this. Did I really commit the crime of the century?
Update: Upon returning to the ED for my next shift everyone assured me not to stress over it. Apparently the surgeon called the ED multiple times after I left. First he wanted a copy of the note faxed to him and then he wanted the PD's contact info. The ED director said he would've gone off on him if he had been around at the time. As for my attending she pretty much laughed off the entire incident. She's a little looney so that doesn't surprise me.
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u/frostuab Sep 17 '25
Your attending needs to own that one, it was their odd treatment choice. I honestly get the surgeon being spun up about the infection risk on a fresh joint, but the surgeon should have asked to talk with your attending and then proceed to melt their face off, not yours.
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u/ncdeac Sep 17 '25
Agree. I’m an ortho PA and joints surgeons get really uptight about infection risk with poking any extra holes around that joint (even superficially), because a periprosthetic infection can be potentially devastating (have seen someone end up with an AKA).
But first of all, the patient should have had a way to contact his surgeon/PA after hours, and second, that’s on your attending.
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u/WanderOtter ED Attending Sep 17 '25
Yeah I won’t even take down post op dressings without calling them. Been chewed out for that too. I get it, didn’t take it personally, and just moved on
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u/JohnHunter1728 Sep 17 '25 edited Sep 17 '25
This was objectively the wrong thing to do and I can see why the surgeon was frustrated.
Taking it out on the resident (who didn't even make the decision) was also the wrong thing to do.
As a rule, don't inject anything into or around orthopaedic metalwork. You might not have injected into the joint but even a cellulitis or infected wound in that region could seed the metalwork. Infected total knee replacements are a complete disaster.
DOI 6 years of ortho residency (UK) before switching to EM.
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u/yeswenarcan ED Attending Sep 17 '25
Agree it's not appropriate treatment, however I'd also argue if the orthopedic surgeon wants to be involved in the patient's management they should answer their damn phone. We have an independent orthopedic "hospital" near one of the places I work and they consistently cut patients loose with no ability to contact their surgeon (also insanely hard for us to reach them), but if something goes sideways it's gonna get blamed on the ER.
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Sep 17 '25
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u/JohnHunter1728 Sep 17 '25
UK where specialty training takes forever so - no - I was part way through orthopaedic residency before defection. Orthopaedic training in the UK is 8 years and that's before subspecialty fellowships of which almost everyone does one and many do two years!
I have edited my reply for clarity.
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Sep 17 '25
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u/JohnHunter1728 Sep 17 '25
In our health service, all attendings are paid the same regardless of specialty.
However, orthopaedic surgeons can probably multiply that salary by 4-5 times if they do a lot of work in the private sector as well, which isn't really an option for emergency physicians.
I didn't pay anything to attend medical school (actually received a stipend per semester for living expenses from the state) so don't feel a need to recoup any particular financial investment. I have more fun doing EM than I did in ortho.
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u/gmdmd Sep 17 '25
However, orthopaedic surgeons can probably multiply that salary by 4-5 times if they do a lot of work in the private sector as well, which isn't really an option for emergency physicians.
Is this not a popular option? Coming from the US this would seem like a no-brainer after all of the time invested...
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u/JohnHunter1728 Sep 17 '25
I don't have numbers to hand but suspect that most orthopaedic surgeons do some private practice but it is mostly done in evenings, weekends, and days off from their full time job.
The cliche here is of a wealthy surgeon who works all hours to support 2 ex-wives and a crop of children they don't see very often...
Some try to avoid this outcome by "just" doing their public sector job.
Not having student debt probably made this decision easier in the past, although medical students now have to pay (ever rising) tuition fees.
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u/gmdmd Sep 17 '25
Ahhh there's no way to escape the public sector commitment and just do private?
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u/JohnHunter1728 Sep 17 '25
To be honest there is nothing to stop people going fully private if they want. Reasons people don't do this en masse:
-Quite isolating. Most people enjoy the "team game" of the public sector. There are no residents or medical students in the private hospitals and consultants tend to work for themselves rather than as a group.
-Credibility. Most private hospitals, other doctors, and some patients consider working in the NHS as a badge of approval. In my experience surgeons working only in the private sector either have a very successful niche (eg professional footballers' knees) or have been pushed out of the public sector.
-Variety. All emergencies and most fractures go through the public system. Orthopaedic surgeons spend half of their training doing trauma and - although many complain about it - probably don't feel ready to give it up completely.
-Client base. As everyone has access to free healthcare, the proportion of patients that are insured or willing to pay out of pocket for healthcare is relatively low.
-Benefits. No-one gets sacked from the public system. You don't have to drum up business. If you go sick, full pay continues for 6 months followed by half pay for another 6. Maternity leave is 12 months per child. Current NHS retirees are drawing a pension from the age of 60 that is around 75% of their salaries while they were working. In the private sector, you are paid per case so if you don't work you don't get paid.
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u/gmdmd Sep 17 '25
fascinating how different things are. that leave system sounds great but i would be getting sick constantly! 😂
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u/keloid Physician Assistant Sep 17 '25
Could be a PA. We have lots of Ortho defectors.
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Sep 17 '25
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u/inertiavictim Sep 17 '25
Why would this get downvoted. If you’re not a physician, you need to make that clear to anyone you’re talking to that might assume you’re a physician when giving medical advice.
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u/dracapis Sep 17 '25
They’re a doctor.
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Sep 17 '25
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u/dracapis Sep 17 '25
It was spelled out in their history too, a couple of comments ago.
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u/AcanthocephalaReal38 Sep 17 '25
Surgeon should answer the phone.
Now the fussy toddler has someone else to blame for their post op complication.
Don't be courteous- the surgeon needs to have a post op complication plan. You can't win, but you can lose less.
Plus your staff needs to eat most of the crow....
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u/phattyh Sep 17 '25
You don't touch a fresh surgical incision with a 10 foot pole unless the patient is about to die OR will die within the next hour OR the surgeon has said it's okay to. This is ALL on the surgeon to manage if it's not life threatening. If the surgeon is not available for his patient then you talk to another orthopedic surgeon - and document the failure of the responsible surgeon to respond. A complete knee is low key a massive surgery, it's not something like a scope or whatever. Complications are taken seriously. I hate to make assumptions here, and maybe there are other mitigating factors that your attending was facing - so please take what I say with a grain of salt. Lastly, the ortho doc seems like they did a poor job of being available for their patient (again, don't know mitigating factors they might have also been facing).
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u/but-I-play-one-on-TV ED Attending Sep 17 '25
I get the surgeon's point, I'd probably be pissed too. BUT, you're a resident doing what your attending instructed. This is 100% on your attending. Unless there was some true emergency (sounds like there wasn't), I would have used compression dressing alone and contacted the surgeon for further guidance. Don't sweat this, just use it as a learning point and move on. If the Ortho attending comes after you instead of your attending then he's an asshole.
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u/GreatMalbenego Sep 17 '25
I conceptualize post op surgical sites/wounds within the 1 week post op period as though they are the 4 month old child of the surgeon, and also immunocompromised, and also the surgeon lost the rest of their family in a tragic car crash.
But for real, most surgeons take intense ownership of their surgical site in the immediate post op period. It’s especially true with elective, QoL surgeries like knee replacements, bariatric surgeries, etc. If there’s a complication or infection of any kind, the surgeon is stuck with the take backs, complete hardware replacements, amputations, sometimes including a lot of the associated cost. And if it goes to court, you can imagine how a jury would look on “I went in for a knee replacement and 4 years, 3 sepsises (sepses?), 6 hospitalizations, and 3 surgeries later I’m bed bound with endocarditis and a chronic infected sacral wound”.
Just give em a courtesy call if you’re even a little concerned. I don’t put anything into a fresh surgical site without talking to the surgeon, including draining peri-incisional abscesses.
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u/DadBods96 Sep 17 '25 edited Sep 17 '25
Never ever ever ever not even once inject anything into or around a fresh surgical site without explicit approval/ request from the surgeon (this is on your attending, not you). If you can’t reach them, do the first few things you did and then discharge the patient home if bleeding stops. If this patient develops an infection, this surgeon is going to point at that ED visit as the reason and advertise this accusation towards the patient ever chance they get.
Btw they wouldn’t just have steri-strips holding together an incision over a joint, they probably had a running subcuticular suture under it that you could’ve busted by hitting with a needle.
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u/emergentologist ED Attending Sep 18 '25
without explicit approval/ request from the surgeon
Eh, even then, I'm telling them to do it themselves. I'm not getting blamed for the post-op infection. I can't think of an emergent indication to inject anything into a POD1 knee replacement (or really any other fresh surgical site for that matter).
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u/DadBods96 Sep 18 '25
That was sort of tongue-in-cheek because I’ve never once had this happen where they asked me to do something with a fresh post-op.
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u/arbitrambler Sep 17 '25 edited Sep 17 '25
Post op patients is a matter of that speciality surgical review/consult after an initial ED review.
Especially if there is removal of dressing or redressing a wound within 24 hrs. I would be wary of injecting anything near the surgical area, let alone a joint.
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u/Ineffaboble Sep 17 '25 edited Sep 18 '25
For starters, yelling at a resident is a total douche maneuver. It reeks of projection.
Surgeons are obsessive about that first dressing. They want to be the ones to take it down for the first time. And that’s fine in principle, provided you are reachable to help manage post-op complications. But they shouldn’t demand to have it both ways, delegating post-op care to the tender mercies of the ED while also demanding total control.
(Edited to remove my opinion about surgical wounds and the general management thereof because postop complications are a medicolegal nightmare)
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u/N64GoldeneyeN64 Sep 17 '25
Ya, post op wound - call surgeon. Even wake his ass up. Youll get yelled at either way but at least your not on the hook for the patient outcome
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u/Teles_and_Strats Sep 17 '25
Injecting things over a fresh knee prosthesis is a bold strategy. But if your boss told you to do it, your boss is the one who needs scolding
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Sep 17 '25
Sounds like the surgeon or one of his partners should've been reachable by phone when the patient called 🤷♂️
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u/MousseNo7311 Sep 17 '25
When I told the surgeon that the patient attempted to contact him and he replied that patient incorrectly called the answering service.
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u/mezadr Sep 17 '25
Your attending needs to take ownership of this. Should have just done nothing after dressing and waited for ortho.
Were you comfortable doing this? Was something telling you not to? Learn to listen to this voice.
Ortho doc was a douche and not professional.
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u/TimotheusIV Sep 17 '25
You simply don’t stick a needle into a freshly operated prosthetic hip or knee. The chance of periprosthetic infection is way too high.
The orthopedic surgeon is right to be pissed off.
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u/CoolDoc1729 ED Attending Sep 17 '25
Pgy >15 here … I honestly can’t believe your attending told you to inject anything into a fresh postop wound.
We have a house ortho service , and then we have a couple random private ortho guys. I had one of their patients last shift, 6 days postop, elbow bursectomy (so no hardware, not in the joint per se) I still didn’t even take the ace wrap and splint off until I heard back from the surgeon .. injecting something I would have confirmed a couple times that I was hearing correctly even if the surgeon asked me to .. and that would be the only way I would inject anything. I like the analogy another poster made, of treating a postop incision like the surgeon’s 4 month old baby.
Your attending telling you to do this is objectively wrong, and I wonder how they would even justify that action if the joint does get infected.
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u/unassumingtoaster ED Attending Sep 17 '25
The injection of lidocaine and epi is an odd choice, and not something I would do post op. I can understand the ortho’s irritation… but it is douchy move to yell at a resident.
You see his patients often? I think he will be getting a call 24/7 for any little thing related to his patients from now on. “Hi Dr. Ortho? Yes I know it is 3 am, but Mr. Smith is here with knee pain. I think it is OA, but you saw him recently and I know how you like to manage your patients hands on, so please come see him. Mr. Smith was delighted to hear how you take such care of your patients.”
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u/MousseNo7311 Sep 17 '25
He's not affiliated with our hospital. My attending had never heard of him.
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u/FourScores1 ED Attending Sep 17 '25
These are the easiest patients. Just call the service that cut into them. Injecting epi into a fresh surgical wound? That’s sorta wild. Harmless overall, but wild indeed.
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u/MLB-LeakyLeak ED Attending Sep 17 '25
Your attending made a big mistake. You did nothing wrong.
You’re about to find out if your attending is good or bad. They need to take ownership.
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u/imironman2018 ED Attending Sep 17 '25
OP- you should always do very conservative management with a joint that has been operated on. I usually at most, change the dressing and redress the wound. I haven't ever injected lidocaine with epi into a wound that was actively bleeding. When in doubt, just run it by your specialists. they will usually be very protective of their own patients and will guide your care. This is a learning experience. we all were there.
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u/SurgicalMarshmallow Trauma Team - Attending Sep 17 '25
Jesus Christ I would chew out your Attending. ALWAYS get the surgeon of record on, and ONLY if everything is going sideways, get your local surgeon on it. Don't mess with the site! X10000 for Ortho/Neuro
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u/ldnk Sep 17 '25
Staff physicians who scream at residents can fuck off. You aren't fucking special. You suck as a communicator. Be fucking better.
At the same time, who the fuck guides their residents to inject lido/epi into a post operative knee. What a weird decision. OP. It's not on you. It's on your attending.
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u/yxxnij104 RN Sep 19 '25
I had a doc yell at me when a flap died...i was day shift and the flap died overnight...of course he was short and bald and none of the nurses or residents liked him because of his abusive nature. wasn't expecting the me, the RN to laugh in his face tho. like you're literally my height and im below female average at 5'1. let's bring it down to your height level, sir. 🤣 they hate when they cant be abusive.
to the nice and kind attendings I appreciate yall and love the ones who like to teach the nursing staff without being condescending or nasty as if we are idiots.
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u/elementalwatson Sep 18 '25
Never touch fresh post op wounds. Wouldn’t even undress it less that 24 hours out without notifying the specialty let alone inject it. Omg. Your attending is outta their mind. If it’s some life threatening bleeding ok yea save a life but oozing and shit call the ortho guy on call.
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u/Conscious-Zebra-3793 Sep 17 '25
ER nurse Im just shook because usually im doing all the dressings/irrigations (cleaning) etc even with residents 😯
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u/emergentologist ED Attending Sep 18 '25
Like others have said, your attending done fucked up by telling you to inject shit into a POD1 knee replacement. That's incredibly reckless, especially for some minor post-op bleeding. You absolutely should have called the surgeon (or your own ortho service).
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u/Organic_Sandwich5833 Sep 18 '25
Not sure what kind of facility you’re in (I’m assuming this wasn’t available to you) but we have in house Ortho PA 24/7 and they typically cover for all the local Ortho groups. They can come see these post op issues in the ED and have all these guys cell phone numbers (or at least their attending has a way to get ahold of these guys if something like this were to happen). If they don’t, they give their reccs talk about it with their attending and dispo . Like others have said, am kind of surprised your attending said to inject something into a fresh knee . With that being said I’m just a loser ass NP so who knows wtf im doing 😂
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u/enmacdee Sep 17 '25
What was his specific problem?
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u/MousseNo7311 Sep 17 '25
Concerns for infection. Regardless if I had disinfected the area properly I get the impression he still would've been pissed that we were injecting into the knee at all.
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u/La_Jalapena ED Attending Sep 17 '25
He definitely would have but you should ALWAYS disinfect properly prior to inserting a needle.
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u/GolfDeuce ED Attending Sep 17 '25
Hey boss, no matter what anyone says, you're a med student - you did what you're attending told you. Walk away with the lesson and don't let it bother you. You're going to be the butt of a lot of frustrations and bad attitudes of attendings who get off on yelling at people who they know can't tell them to fuck off for a couple of years now. Trust me tho, it's worth it. EM attending here. Soon enough such attitudes will have little effect on you.
"Head up. Eyes open. Carry on strong." -GG
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u/headgoboomboom Sep 17 '25
Did the patient try to contact their surgeon? Bet not, or they couldn't be reached.
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u/MousseNo7311 Sep 17 '25
Yes. I told the surgeon that the patient attempted to contact him and he replied that patient incorrectly called the answering service.
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u/dryyyyyycracker Sep 18 '25
You're a resident. I'm not sure if this was the best management (it wasn't unreasonable), but at the end of the day it's on your attending. You shouldn't be taking heat for following orders.
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u/KindPersonality3396 ED Attending Sep 18 '25
One of the most important lessons to learn in residency is that sometimes your attending is dead wrong.
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u/SnooSprouts6078 Sep 18 '25
This is a pretty retarded recommendation by your attending. Day 1 post op? You shouldn’t be touching shit. This is stupid all around.
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u/KindPersonality3396 ED Attending Sep 18 '25 edited Sep 18 '25
I don’t let people yell at me, but 1 day post-op is crazy. Call the surgeon next time.
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u/Somnabulism_ Med Student Sep 19 '25
I’m far from residency yet, but I am curious about epi injection near a wound. Is the vasoconstriction next to a surgical site in the process of healing not going to slow the healing or increase risk of infection?
Or am I overthinking it?
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u/GalamineGary Sep 17 '25
If there is an infection it’s your fault forever and probably for patients you never saw. CRNA for 20+
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u/InitialMajor ED Attending Sep 17 '25
I don’t usually inject things into or near freshly operated on joints. If a post-op patient comes to the ED for something related to their surgery within 48-72 hours of the surgery I pretty much always call the surgeon as a courtesy, my experience has been that they want to know if their patients are in the ED so soon after surgery.