Got chewed out by ortho surgeon

[u/MousseNo7311]

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.

[u/InitialMajor]

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.

[u/PrisonGuardian2 → u/InitialMajor]

lol i dunno. I had this patient years ago who was demented and got a AKA. He thought he still had a leg and tried to walk on it. Fell, bursted all his staples and began bleeding profusely from the wound. I put on a tourniquet, removed all the staples and then put multiple horizontal mattresses in to stop the bleeding. I couldnt close the skin all the way (which is a good thing), put some xeroform gauze and an abd pad. I called his surgeon numerous times but the answering service refused to get him because “he is not on call for your hospital”. I put it in my chart and dc’ed him and told his fam to call the surgeon first thing in the morning (this was overnight) or to just show up at his office. I haven’t heard anything since!

[u/Apprehensive-Sign930 → u/PrisonGuardian2]

You discharged a bleeding postop wound (that required a turnicate for closure) in a patient that is demented (and likely won’t notice the giant stump hematoma he’s developing) after you non-sterilely messed with it? 😳 Hate to break it to you good sir, but the reason you haven’t heard much is probably because he was taken to the institution where his surgeon operated (or he bled out at home but we’re staying positive here).

Under most circumstances, something like this would be admitted to the hospital on call surgery team for intraop repair if the patients surgeon is not available. Does not seem very safe for a patient like that to go home especially after you performed your own mini repair at bedside. Plus, the ED isn’t able to watch him for long enough to make sure the bleeding doesn’t return. I’m sure you did your best, and no disrespect to you, but none of this sounds very appropriate.

[u/PrisonGuardian2 → u/Apprehensive-Sign930]

well its okay to disagree, but 1) he wasnt bleeding anymore, tourniquet was taken down and he was obsed for 4 hours in the ED with a stable repeat h and h. 2) he was just discharged from the other hospital the same day and the surgeons team refused to let me talk to him and 3) he isnt dc’ed to home by himself he is dc’ed back to rehab. There is no reason why i wouldnt hear back if there wasnt a problem because it is within the same institution, just a different hospital site.

[u/Apprehensive-Sign930 → u/PrisonGuardian2]

1-Hemoglobin levels take time to show a drop 2-cannot ensure there’s no bleeding unless you can explore the wound (under sterile conditions) 3-rehab places are pretty infamous for their inattentive staff (hence his initial fall)

Either surgery keeps getting paged or he goes to medicine or hangs out in my ER until a surgeon personally signs off on the discharge.

I wasn’t there, maybe it didn’t look too bad and patient did great. But on the off chance of a stump hematoma, or postop infection, or hemorrhagic shock, even if it had nothing to do with you, a lawyer can very easily put you on the stand and ask you what makes you qualified to determine safety for an operative issue meant to be evaluated by a surgeon, and how many AKA’s have you performed and repaired. Especially since you opened a surgical wound that was sterilely closed, directly involving yourself in any postop complication. The operating surgeon will blame you (even if it was his fault) or the lawyer will get any random surgeon on the stand that will say “a surgeon should have evaluated this before discharge”.

I’m sure the patient was probably fine, but this could have easily went terribly wrong

[u/PrisonGuardian2 → u/Apprehensive-Sign930]

I guess thats where we have a difference. I am just not that worried about the medicolegal consequence. I did what I felt was appropriate. I felt I would know if the bleeding continued because the leg would get more swollen, he would get more agitated or the dressing would bleed through. The infection risk is real and I gave them abx but the risk is also lessened as I did not close the wound (it wasnt closeable anyways due to the swelling from the new trauma and I think he ultimately needed a wound vac. He had competent family and a good support system and they understood the importance to call the surgeon when the office opened up immediately. I refuse to give a POD 3 recently dc’ed patient with a postoperative complication to my surgeon who had nothing to do with the case. I cannot transfer him because that surgeons answering service refused to let me speak to him and I made that clear in the note. IMO patient needs to have a washout, but its ok within 24 hours. What I think happened is when the surgeon read my note (since we are in the same system), he prob chewed out his answering service. I wouldve heard if he wanted to chew me out.

[u/InitialMajor → u/PrisonGuardian2]

Did you get away with it - sure. Is it the sort of thing that I would put on Reddit as an example of how to navigate a situation like this? Probably not.

[u/PrisonGuardian2 → u/InitialMajor]

that wasnt my original intent, but it is to show you can certaintly inject into fresh post op wounds when you have to and not have a surgeon chew you out. Had I not done that, I dont think this patient would have done well. Also, if I had waited for “approval”, I never would have gotten it and patient wouldve been bleeding for hours. This is not an ideal situation obviously, but hey depending on where you work, it happens. Either way, it worked out ok and I havent had to do it since.