Medical Malpractice Insights: A Tale of 2 Injection Injuries

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here. Stories of med mal lawsuits can save lives. If you have a story to share click here.

Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights

A Tale of 2 Injection Injuries

Only one patient returns to work with full use of his hand.

[Editor’s Note: The premise of Med Mal Insights is that we learn better from stories than we do from reports, “white papers” and seminars. The following story, submitted by an MMI-LFL reader, is an excellent example of a story from which we can all learn.

Patient #1: A 28-year-old male auto-body repair employee is using a high-pressure wand to spray blue latex paint on a car. He accidentally touches the tip of the wand with the tip of his left middle finger and reports the incident to his employer. The employee is surprised when his boss tells him “Get to the E.R! Right now!” He arrives in the ED of his small community hospital about 30 minutes later. The admitting nurse documents an “OTJ injury” with a chief complaint of “My boss made me come.” The EP, fresh out of residency, examines the injured finger and records it as completely normal – no tenderness, no swelling, normal painless ROM, normal capillary refill, tetanus shot up-to-date. The patient tells the EP “I told you so. I’m fine, I don’t know why I’m even here.” Reassured, the EP begins preparing discharge instructions at which point the on-duty nurse (with 10 years of ER experience) walks up, shakes his finger in the EP’s face and says “You better call the orthopedic surgeon and admit this guy! Right now!” Rather stunned, the EP reluctantly calls the on-call orthopod, fully expecting to be chastised for bothering him after hours. To his surprise, the orthopod simply says, “I’ll be right in.” He arrives, admits the patient and spends the rest of the night in the hospital monitoring the patient’s condition. Within a few hours, the patient begins feeling pain, the finger begins to swell, and he is taken to the OR. A small volar incision reveals blue paint. The incision is extended slowly as a modified fasciotomy, almost to the elbow, before clean tissue is found. The patient experiences a slow but uneventful recovery, with full use of his hand and is able to return to work.

Result: No lawsuit is filed; in fact, the patient contacts the local newspaper and his story makes the front page, including a photo of his healed incision.

Patient #2: A few months later at a larger nearby suburban hospital, a patient presents with a similar injury, but no one on that team has any experience with injection injuries. The patient is discharged, develops compartment syndrome, and undergoes major surgery with loss of his middle and ring fingers. A lawsuit is filed against the EP and hospital. The defendants agree that the case cannot be defended and settle for a large but undisclosed amount.

Takeaways:

• Experience matters. If you’ve seen one, you’ll never miss another.
• Injection injuries can be treacherously innocent-looking.
• Assume the worst when any patient is even suspected of having an injection injury.
• Monitor for several hours before discharge. Progression of pain and swelling usually presents in a matter of a few hours.
• Once symptoms arise, immediate surgery is required and may be more extensive than expected.
• As so often happens, listening to our nurses saves our butt.

Reference:

• EM@3AM: High-Pressure Injection Injury
• High-Pressure Injection Injuries. Johnson DB. OrthoBullets.com. Updat-ed Jun 23 2021. https://www.orthobullets.com/hand/12104/high-pressure-injectioninjuries