Commentor Question: Lacerations and Plastic Surgeons

This blog is generated from a comment on this post: Medical Myth: Lacerations Need a Plastic Surgeon.

I do read each and every comment to the blog. Usually, I don’t comment on real life medical scenarios but I thought this had several good teaching points that could serve the public good.

The comment:

I just brought my 5 y/o into an ED with a puncture wound to the center of his forehead through which you could see his skull. I thought the attending would close the wound, but the resident did under supervision. First year, and it was late July. What are the chances of a good outcome? The attending had to tell the resident that knots were backward, etc. Should I have insisted that the attending close, or that they call plastics? It was a large urban Children’s ER.

Jordyn Says:

Thanks so much for leaving this comment and I hope you see this post.

As a mother and a nurse, I get the parental anxiety around closing lacerations. The truth is that anything that requires sutures is going to leave a scar. That’s life. Now, how big or thick the scar is depends on many factors. How it was closed. There is a learning curve to closing the skin. Lacerations can actually be closed too tightly which can be as problematic as not bringing the edges close enough together.

That being said, there are many other factors that determine how the scar will look. Does it become infected? How does the patient normally scar? Some people genetically develop very heavy scarring (called keloid scarring) and there’s nothing we can really do about that. Also, after healing, how much is it exposed to the sun?

Now, should you have allowed a resident to suture your child?

From the medical side– students need to learn and must practice, at some point, on live patients. I’m glad this first year was being monitored during the procedure. That’s what should have happened. Knots being tied backwards and needing to be redone doesn’t mean you’ll have a bad outcome. Experienced physicians redo sutures all the time. It’s more the final closure that’s important.

From my nursing/mother standpoint– you have the right to refuse a resident practicing on your child. If you are uncomfortable then absolutely speak up and state your request plainly– “I’m sorry, but I’d like an attending to close this laceration.”

Some people are uncomfortable with a nurse practitioner or physician’s assistant doing a laceration repair and request an attending. Keep in mind, that mid-level provider may have more experience than your attending physician. They may have been in practice four times as long! So maybe ask how many years they’ve been practicing as an attending before you pass over on a mid-level provider.

If you feel that you can’t make this request to the doctor directly, then you need to tell your nurse who should advocate for you.

Should you have insisted on a plastic surgeon? The truth is that pediatric ER providers close lacerations every day on moving targets— we don’t commonly sedate kids for simple laceration repairs. Plastic surgeons are generally only utilized for complex laceration repairs and would honestly be annoyed to come to the ER for a simple repair.

If you don’t like how the wound healed and the scar it left behind then you can consult a plastic surgeon to investigate a scar revision.

Hope this helps.

Are ED Patients Selfish?

When I first read it, I didn’t think it was a joke but actual research. When I read further and figured it was a humor based website– I was a little disappointed. 

Why? Because the article validated what I feel like at work many days. Parents of patients have a limited view of the total department and its needs or demands on my time. They simply want their problem fixed as immediately as possible.
The problem is, the reality of the ER will never meet those expectations of . . . really anyone. 
How often have you had to wait for a doctor’s appointment? That is, an actual scheduled time to meet with your physician. Rarely, am I seen within 30 minutes by the actual doctor. First, the office schedules you before your “real” time for paperwork, etc and also for the hope that you’ll show up on time for the actual appointment time even if you’re running late.
Did that make sense? 
My point is . . . why has it become the expectation that emergency care means you’ll be seen expeditiously? I’ll be the first to say that we’ve not helped ourselves as emergency care providers in this arena. I actually think posting wait times (like a restaurant) feeds into this idea that you’ll be seen upon arrival. 
Our goal is to save the sickest people first. That means we may not see you in order. That means we may not get to you in the hour you’ve allotted for your emergency care to take place. 
In my experience, most patients want to be seen by the provider within fifteen minutes of arrival and discharged home in sixty minutes. 
Once, when I worked in a dedicated urgent care, we had a sick infant come in who needed to be intubated. When explaining to families why there was a delay, someone actually said, “That doesn’t mean we should wait. That family should have gone to the ER.”
That may be true but now they’re here . . . with us . . . and we have to manage their illness. 
I’m not sure what the answer is. How do we make your ER visit more enjoyable? More timely yet still cost effective? Isn’t that the crux of the problem? You’re coming with a problem to be solved and a time frame in mind.
Just what if we can’t fix either? Is it our fault?

Curious to know what you think. 

Nine Reasons You’re Waiting in the ER

I thought I’d do a few posts on life in the ER. What’s it really like behind the scenes and provide some explanations on those things we can’t really say to patients but might be an explanation of why things are not moving as expediently as patients, parents and families would like. 
So, exactly why are ER wait times so long in some cases? 
1. Patient Load. Keep in mind there are only so many rooms in the ER and we can’t stop people from walking in. This is unlike EVERY other unit in the hospital that can close their doors and keep patients out. A ward unit or an ICU can say– we can’t take any more patients.

An ER is not like this. Sure, we can stop ambulances from coming. This is called going on diversion (and hospital administrators really hate that because it’s medical dollars going to another facility.) However, the ER must at least address every patient that walks through the door. 

It’s easy for an ER to become overwhelmed. Sometimes, this is seasonal like in the winter when the flu virus hits. When patients outnumber the staff and beds then ER wait times are going to go up.
2. The acuity is high. Acuity is how sick the patients are. The higher the acuity– the more sick. At times, there are few patients but those that are there are quite ill. The sicker the patients are, the more time it takes for the doctor to evaluate them and develop a game plan. The doctor may have to be at the bedside longer than normal to help stabilize the patient. More nurses are likely to be in that patient’s room doing multiple procedures to bring them back from the brink. This will create a back log for the other patients in the department.
3. A slow doctor. In all honesty, some people just don’t work as hard as others. Some doctors are very quick and efficient. Others, not so much. If the department is full, but the nurses are all sitting at the desk– this could likely be the problem. The nurses are waiting for the doctor to write orders, or develop a medical game plan, or give them an idea of how long the patient will be observed for. 
4. A slow nurse. Nurses can be the same. Just slow. Or, they have a heavy assignment and are working the best they can to get through their doctor’s orders.
5. A Code Blue. Most things will come to a halt when there is a code blue. All resources will be needed for that one patient. Radiology. Pharmacy. Lab. All hands on deck. One code blue is going to set the whole department back because that patient takes up a lot of staff and resources. It takes time to recover from those events. Also, the ER is generally responsible for sending a couple of their team members to code events that happen outside the ER which decreases the staff able to help in the ER.
6. Staffing shortages. It’s usual these days to be short staffed. That coupled with a heavy patient load is going to increase wait times. 
7. Emergency care doesn’t mean expedient care. Illness doesn’t cure in an hour. Our true goal is to find the one thing that might kill you in the next 24 hours. I know the goal of all patients, regardless of complaint, is to be out and completely well of their illness in under an hour. This is not a reality, even for the most minor illnesses. It takes time to evaluate a medical condition. Do you have this same expectation when your car is getting fixed? Often times, medical conditions can be kind of dicey to sort out so we’ll hold patients to watch and see how things develop. This is for your safety . . . not to irritate you.

8. Slow specialty response. If your care hinges on hearing back from the expertise of a consulting physician– then everyone is waiting. Us. You. Everyone.

9. Overwhelmed support services. Support services like lab, radiology and pharmacy aren’t just accountable to the ER but to the whole hospital– including outpatient services. So, if they’re overwhelmed, it will cause delays in the ER. There can be other critical patients than those just in the ED.

Hopefully, this gives some insight into why your ER wait time may be more than you’d like it to be. Although the current culture has equated emergency room care with expedient care, our goal is to treat the sickest patients first. 

Maybe consider waiting a gift. It means you’re likely not going to die today. 

What is Influenza?

Since we’re getting into “respiratory season” I thought I’d do some public service/illness education. Of course, you can always inflict your characters with these illnesses.
Just make sure you pick the right time of year. 
Most often when patients sign in with a complaint of “flu” they are really having vomiting and/or diarrhea. Flu has become a commonplace term for just not feeling well.
If this is the concern you have in bringing your child to the ER they likely have gastroenteritis which is generally caused by a viral infection of the intestinal tract. Your child should be seen in the emergency department for concern for dehydration, if any blood is noted or if they are vomiting bright yellow or green– and this was not caused from them eating a pile of yellow or green crayons.
How do we know you don’t have the flu? Like RSV, flu is a seasonal illness. It comes out to play in late fall and early winter. This is why flu shots are given around September, October and November.
Fine. But it is that time of year. The second reason we know it’s gastroenteritis is that flu is a respiratory illness . . . not an intestinal one.
Influenza is transmitted through droplets by coughing and sneezing. Typical associated symptoms are high fever (generally 102 and up), generalized muscle aches and cough.
In children, what can happen is what we term post-tussive emesis. This is when the child coughs so hard that they trigger their gag reflex and vomit. It’s more a mechanical issue than a viral one.
Do I need to go to the ER? Not necessarily. Fever can be managed with appropriate dosing of acetaminophen and ibuprofen. Remember that ibuprofen should not be given to children less than six months and no aspirin for children under 21 unless specifically prescribed by your doctor. Lots of fluids. Don’t worry too much if they’re not eating but they must drink. They should be hydrated if they are peeing at least every six hours. Don’t just give water. If you have an H2O lover at home at least alternate it with something that has some sugar and electrolytes. This can be Pedialyte or equivalent for children under 2 years and sports drinks for kids over 2. Juices are good but if you are concerned about the amount of sugar you can cut it in half with plain flavored Pedialyte.
Are you getting your flu shot this year?

Author Question: Treatment of Car Accident Victims

Taylor asks the following regarding treatment of multiple victims of a car accident. 
SCENARIO: Serious MVC involving two cars and multiple victims. All passengers were wearing seatbelts, and airbags deployed, but the crash was serious enough that victims are still severely injured.
Jordyn: When writing about the car crash—I’d have it be pretty visual that the car is near ruin. Particularly if someone has died on scene. Having the car rollover several times would accomplish this.

Taylor: Three girls (friends) were in one car together, on the way to a Christian concert. Drunk driver character had an argument with his wife about his drinking, denying that he has a drinking problem, then got angry, left the house and went out for drinks (doing the very thing they just argued about, partly to spite her and partly “to calm down”). He causes a crash with the girls.
CAR ONE: This vehicle contains only the driver.
DRIVER:The driver is a male in his early thirties. He is slumped forward in his seat, initially unresponsive, but rouses when medics address him. There is a strong smell of alcohol on his breath, and although he is responsive, he is displaying obvious signs that he is intoxicated. Upon seeing the crash scene in front of him, he becomes upset, crying and saying things like, “I didn’t mean to”, “My wife is going to kill me”, and “What have I done?” He has a bleeding laceration on his forehead and minor scrapes and bruises on his face (from the impact of the crash and airbags), and bruising from his seatbelt. Aside from these, he is uninjured. Vital signs are elevated, but within normal limits.
Jordyn: This patient would be placed in C-spine precautions. An IV/fluids started. Usually, when EMS starts an IV—they’ll grab several tubes of blood that the hospital can send to the lab. They’ll dress the laceration on his forehead and not likely worry about the minor cuts and scrapes. Whenever there is seatbelt bruising, we always worry about what would be injured underneath.
In the ER: Since he’s intoxicated, he’s not a reliable informant about his pain. So, he’ll get automatic C-spine films to rule out neck/back fracture. They might even consider a CT of his chest and abdomen (they’ll take vital signs into consideration). Law enforcement will be involved and they’ll want blood alcohol levels and if your book is in a specific/real location—I would figure out what the procedure is in that town/city. After major stuff is ruled out—his cuts will be cleaned. The laceration to his forehead would be irrigated and stitched. Tetanus shot if none in the last five years. Once he’s medically cleared, I’m guessing he would be off to jail.
CAR TWO:This vehicle contains a driver and two passengers.
DRIVER:The driver is a female, age 18. She has no detectable pulse or respirations. Apparent DOA, killed on impact in the crash.
Jordyn: She may be declared dead at the scene. That would probably be the easiest way to manage this patient.
PASSENGER ONE:Female, age 17. Managed to free herself from the car after the crash, and is sitting in the grass a short distance away. She is displaying signs of shock. Respirations are slightly shallow and rapid, skin is pale and clammy, and pulse and heart rate are elevated but still within normal limits. She is mostly responsive, but groggy/drowsy and complaining of severe headache, nausea, and dizziness. Chest and neck are bruised from her seatbelt, and she has several other bruises and superficial bleeding cuts on her body. Her right arm is bruised, swollen, and oddly angled, and she is cradling it against her chest and complaining of pain.
Jordyn: Since she is shocky, she’ll get an IV/fluids and tubes drawn for labs at the ER. Considering the mechanism of injury (the fact that one of the occupants of the crash has died) she’ll be placed in C-spine precautions as well. All surviving patients (including the drunk) will also be give oxygen (as it is treatment for shock as well). Her arm will be splinted in a position of comfort. It’s hard to know if they would give her pain medication or not—her c/o of headache, nausea and dizziness could signify head injury and giving a narcotic could complicate that assessment. So, she may just have to tough it out until she’s in the ED.
ER: Vital signs. X-rays of neck, back and deformed arm. Possible CT of the head, chest and abdomen. Often times, deformed extremities need to be reduced either in the OR or can be done under conscious sedation while in the ED. Depends on how you want to go. This patient may be able to go home if her arm can be set in the ED and no other significant injuries are noted.

PASSENGER TWO:Female, age 17. Pinned in her seat inside the car, unable to free herself. Conscious and responsive, but clearly very frightened, and displaying signs of shock. She is complaining of some pain in her neck, numbness and lack of sensation below the waist, and inability to feel or move her legs. Chest and neck are bruised from her seatbelt, and she also has several bruises and cuts on her face, arms, and legs. There is a large, deep bleeding laceration on her right lower leg.
Jordyn: Same: C-spine/back board. IV, fluids, oxygen. Get blood for labs. Laceration of right lower leg will be bandaged to control bleeding. 

ED: Largest concern for this patient is her sign of C-spine injury. So, not only would she get C-spine films. She’ll likely get CT of her neck, spine, chest and abdomen. Probably would x-ray the leg with the laceration to look for foreign bodies before closing it up. Stuff like the leg laceration can wait until a medical game plan is decided upon after they figure out what her neck injury is.

Forensic Issues: Collecting a Rape Kit (1/2)

ER nurses need to be familiar with the collection of a rape kit or Sexual Assault Examination (SAE) kit. This is good information for a novel that involves a rape victim or a character working as an ER nurse. I’m going to cover this in two parts, the first being some generalizations to consider and then I’ll move into specifics for the second post.

Sexual Assault Nurse Examiners (SANE) are nurses who have received specialized training in the collection of an SAE kit. It is not a simple one day class but multiple classes and clinical hours before the certification can be earned. It is not required that a SANE nurse be the one to collect the SAE kit. SANE nurses are not available at every hospital though you are likely to find them in major metropolitan areas.

The ED staff and police work in conjunction for the victim.

There is not a “national” standardized SAE kit. Each police jurisdiction may have their own of what they want collected.

The location of the crime is important as this will dictate what police agency handles the crime and evidence. The location of the hospital doesn’t play into this. If the crime occurred four hours away– that police jurisdiction will have to send an officer to our location.

The victim needs to give consent for collection of evidence and pictures. The victim can refuse and though we will encourage them to think about this differently, they do have the ultimate say. It is preferred that kits are collected within the first 24 hours though can be done up to 72 hours. After that time, one may still be collected but those involved may be concerned about how much evidence could be recovered and whether or not it will benefit the victim to be put through the exam.

Crime photographs are mostly managed through the police department CSI folks. Though, again, this may change in smaller, more rural locations. If you are writing specifically about a known town and a “real” hospital, it will behoove you to talk to someone there to get the details right.

If available through the police department, a victim’s assistant will come to the hospital to help the victim to understand the process. The nurse may have to advocate on behalf of the patient and ask the police if one is available. Often, these are a team of volunteers that support the police, especially during the night and weekend hours. They also receive specialized training sponsored by the police department. Smaller departments may not have one available. In that instance, an option would be to have the bedside nurse ask a chaplain to come and support the patient.

Next post we’ll talk about specifics of the kit.

Author Beware: The Law– HIPAA (3/3)

Today, I’m concluding my three-part series on the HIPAA law. I’m going to focus on how I’ve seen it violated in published works of fiction.

Image by Neven Divkovic from Pixabay

Situation 1: A hard-nosed journalist makes entry into the hospital and begins asking the staff about a current patient. One nurse pulls him aside and gives him the information. This is a clear violation of HIPAA. All media requests will go through the public relations office. For any information to be released, the patient needs to give their permission.

Situation 2: A nurse on duty calls her friend and notifies her that another victim involved in a crime spree, that her sister was a victim of, is an inpatient at her hospital. Again, unless that person has provided direct care to the patient or the patient gives their consent for the information to be released, the nurse is in violation of HIPAA. However, the author of this particular manuscript handled it well. At least she had the character divulge that she could get in “big trouble” if upper management found out what she’d done. Think back to Brittney Spears in Part One of this series.

Situation 3: A small town high school mascot falls ill on the field during a football game and is rushed to the hospital. A paramedic takes him to the ER. When the paramedic’s wife arrives, she inquires about his condition. The paramedic/husband tells her what the doctors found. Again, the wife is not providing direct medical care to the patient. This paramedic has violated the patient’s HIPAA rights by divulging this information to his spouse. Now, I understand, in small towns– this information may “leak out”. A better way for the author to have handled this would have been to have the wife of the fallen mascot tell this woman what his diagnosis was. HIPAA doesn’t apply to family members and they can willingly share information with who they wish. That may not make the patient very happy— ahh . . . another area of conflict!

Have you seen HIPAA violations in works of fiction that you’ve read?