By William Sullivan, DO, JD, FACEP - Lead Author

A 55-year-old female presented to the emergency department with an avulsion laceration to the tip of her non-dominant fifth finger. Her history included hypertension, diabetes, renal transplant, and DVT. Her medications included immunomodulators and warfarin.

She presented due to persistent bleeding in her finger, yet the bleeding was controlled when she was evaluated by the triage nurse.

The physician evaluated the avulsion, anesthetized the area, then ordered wound cleansing and a wound dressing. An advanced clinical technician applied the dressing consisting of layers of tube gauze, which was then split and tied about the patient's hand. The technician stated that he was instructed by an unknown person to make the dressing “snug.” The physician evaluated the dressing after it had been applied, but did not unwrap the finger to re-examine the laceration.

The patient was discharged on Keflex with instructions to have her wound rechecked in 36 hours and to return if pain, redness, or warmth developed. There was also boilerplate language on the discharge instructions stating that the patient should call the hospital or return if the condition worsens or if the patient was unable to reach the referral physician. In addition, boilerplate language on the wound instructions stated that the patient should call 911 immediately if experiencing “bleeding, worse pain or swelling, or any other new problems.”

Although the patient complained of numbness in her finger the night after her emergency department visit, she did not return to the emergency department. Instead, she made the earliest appointment available with the primary care physician 4 days later. She was seen in her doctor's office, then referred to the hospital and admitted for possible gangrene of the finger. A hand surgery nurse practitioner biopsied her finger, confirmed gangrene, and discharged the patient for an outpatient amputation. Seven days later, the patient had a partial finger amputation due to digital ischemia and gangrene. A lawsuit was filed.

Expert Witness Statements/Allegations Regarding Standard of Care
In his deposition, the plaintiff expert criticized the care provided in the emergency department because the patient was discharged with a tight dressing, rather than leaving the tight dressing in place for no more than an hour and then being checked for re-bleeding.

The expert also criticized the physician for not supervising application of the dressing, for failure to check the dressing after it was applied, and for failure to notice that the dressing was too tight.

The expert also stated that even if the patient had followed up as instructed in the discharge instructions, she still would have lost her finger. According to the expert, whether the patient was negligent for failing to follow the discharge instructions depended on what the patient thought based on the symptoms she was experiencing, not necessarily on what the discharge instructions stated.

The defendant physician alleged that the care was appropriate and that he should not be responsible for a bad outcome because application of dressings and discharge instructions are a nursing task and not a physician task.

Issues Considered by the Standard of Care Review Panel

Overview of Management of Fingertip Amputations
The decision on whether to manage a fingertip injury conservatively or surgically depends on the amount and type of tissue loss, the location, and the amount of bony exposure. Treatment of fingertip injuries may be as simple as applying a bandage or may involve skin flaps, skin grafts, or revision of the site for further amputation.

In general, wounds of less than 1 square centimeter without bony exposure require only a non-adherent dressing. Wound contraction will almost always provide a satisfactory cover for the soft tissue defect. While secondary intention takes longer than other forms of treatment (averaging 2 months to heal), several studies have shown that conservative treatment of fingertip injuries results in excellent sensation, function, and cosmetic results when healing is complete.

Wounds greater than 1 square centimeter or involving bony exposure will usually require more extensive treatment and, depending on the emergency physician’s experience and comfort with performing bony revision and skin grafting, may need evaluation by a hand specialist.

Composite grafts (simply reattaching the amputated portion of the digit) have a high failure rate in adults and older children. However in young children and infants, composite grafts remain at least partially viable in 75% of cases.

Are physicians required to re-evaluate and unwrap all dressings applied by other allied health professionals?
Wound care and placement of dressings are medical treatments that a physician may delegate to other allied health professionals. Whether a physician is responsible for supervising other health professionals who perform those tasks in the emergency department is a question of law. The Standard of Care Review Panel did not believe that there was a general duty to supervise health professionals performing every aspect of their job functions, although such a duty could be created through state statutes or through a contract between the physician and the hospital or contract management group.

Without knowing if a specific duty existed in this case, the Standard of Care Review Panel was unable to comment on whether the physician acted reasonably under the circumstances described. However, the Panel did not believe that the standard of care requires that physicians unwrap and re-evaluate dressings applied by other allied health professionals. None of the literature the Panel reviewed suggested such management, and several Panel members felt that requiring such a practice would be counterproductive.

Is it proper to discharge a patient with a “snug” tube gauze dressing to the finger?
When tube gauze is placed on a patient’s finger, there is no practical method to measure the pressure generated by that dressing. Regardless of the pressure of the dressing, there is also no way to predict if a patient will develop ischemia at the site of the dressing placement.

The physician who submitted this case for evaluation presented several articles regarding dressing applications and case studies relating to finger ischemia from wound dressings. One article noted that pressure from several different applications of tube gauze did not exceed 40 mmHg. Another article noted that it would take 13 layers of elastic gauze in order for internal finger pressures to reach more than 50 mmHg and that 13 layers of cotton gauze would reach internal pressures of approximately 20 mmHg.

The Standard of Care Review Panel concluded that use of tube gauze dressings is appropriate for many types of finger injuries, including avulsion lacerations to the fingertips, such as occurred in this case. Given available literature on tube gauze dressings, the Review Panel concluded that it would be difficult to generate pressure sufficient to cause finger ischemia when “snug” tube gauze dressings are placed.

Does a patient have a duty to follow discharge instructions?
Discharge instructions serve many functions, including providing patients with a tentative diagnosis, instructing patients on further treatment recommendations, and directing patients on when and under what circumstances they should seek further medical care. The Review Panel did agree that certain discharge instructions can be related to a patient’s perceptions. For example, an instruction to return for worsening pain or “new problems” would depend on the patient’s perception of increasing pain or new problems. There are also instructions that do not depend on patient perceptions, such as “have wound rechecked in 36 hours.”

In this case, the patient received instructions to have her wound rechecked in 36 hours. She also received instructions to “return if pain, redness, or warmth developed.” The patient experienced only numbness in her finger, not pain, redness, or warmth. The discharge instructions also instructed the patient to return if her condition worsened or if any new problems developed, language that included the patient’s new complaints of finger numbness.

Discharge instructions do create a duty for patients to follow the recommendations contained within the instructions. While not germane to the standard of care, the Standard of Care Review Panel believed that it was important to note that a patient’s failure to follow discharge instructions does not prevent a patient from filing a lawsuit against the provider. Instead, failure to follow discharge instructions is an example of “contributory negligence” or “comparative negligence,” which are affirmative defenses to a lawsuit. Once an affirmative defense such as contributory or comparative negligence is alleged, a jury must then determine whether the patient’s negligence contributed to the patient’s injury, and, if so, what percentage of that injury was attributable to the patient’s own negligence. In many states, patients who cause more than 50% of their injuries are prevented from recovering any damages in a lawsuit.

Conclusions of the Standard of Care Review Panel  

1. The standard of care does not require that wound dressings be re-evaluated on an hourly basis for re-bleeding.
2. There is no reliable and readily-available method to determine the pressure inside of a tube gauze dressing. According to literature on the subject, it would be quite difficult to create pressure sufficient to induce finger ischemia inside of a standard tube gauze dressing. The standard of care, therefore, does not require that physicians check the pressure of such dressings after they have been placed.
3. Placement of dressings is one of many duties that physicians may delegate to other qualified health care providers. While physicians may choose to observe other health care providers during and after performance of these duties, failure to do so is not a breach of the standard of care.
4. Patient understanding of discharge instructions is an important aspect of follow up care and good outcomes. When discharge instructions are clear and unambiguous, and when patients have not voiced any questions regarding the instructions, it is reasonable for health care providers to assume that patients have understood those discharge instructions as written.
5. The consensus of the Standard of Care Review Panel was that the provider in this case met or exceeded the standard of care in managing this patient.

References:
Vaughn G, Fingertip Injuries. EMedicine.com http://emedicine.medscape.com/article/824122

NCEMI.org, Superficial Finger Tip Avulsion. http://www.ncemi.org/cse/cse1002.htm  

Wheeless CR III. Finger Tip Injuries. http://www.wheelessonline.com/ortho/finger_tip_injuries_1  

Giandoni MB, Vinson RP, Grabski WJ. Ischemic complications of tubular gauze dressings. Dermatol Surg. 1995;21:716-8.