Moonlighter - Recap

This is our final recap of our "Out on a Limb" Case Series!  If you missed the initial "Moonlighter" case and discussion you can check it out here.  There were a number of great responses to the questions which we'll recap below.

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Q1 - What are your options in handling this situation?

You have a few options in handling this situation. As many of the respondents chimed in, the wound definitely needs to be cleaned out and closed and the patient requires antibiotics as soon as is reasonably and safely possible, especially since the injury is already 6 hours old. The first option is to complete a sedation and multilayer repair in the ED yourself. As many people point out, this is not an excellent proposition unless there are extreme extenuating circumstances. As a solo-coverage physician, this would consume a considerable amount of your most important resource: time. It would also consume staff (for the sedation and recovery) and may not even be feasible if there are other sick patients in the department. We will discuss in depth other factors that make this a difficult option to chose in the section addressing question 2. 

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A second option would be to call in a specialist such as a plastic surgeon that could assist in the multilayer closure at the bedside. It appears that this is not an option at this rural hospital. Dr. Boyer discusses the idea of calling the general surgeon on call, which may be a more viable option. This is a phone call that is worth having with your consultant, and if they are willing to come in and close in the ED or are comfortable taking this patient to the OR for a washout and repair, this may be a legitimate option. 

The third option is to transfer the patient to a tertiary children’s hospital for subspecialty evaluation and repair. This appears to be the favored option by the respondents for a number of reasons that will be addressed in the next section. The major question once the decision has been made to pursue transfer is HOW to transfer the patient. Dr. Strong has an eloquent discussion about this point in his response, and essentially, he has concerns about the grandmother’s ability to reliably get the patient to the tertiary children’s hospital in the time window necessary. While it may be more expensive, the best option may be transport ambulance. 

Q2 - What factors play into your management decision?

There is a complex medical decision making calculus that plays into the decision to attempt repair primarily or to transfer the patient in this instance. As usual, Dr. Nelson offers some excellent (and thorough) commentary on this that is worth repeating here:

“There are several factors that would play into my decision:

• Laceration size and complexity: This appears to be a repair that will take a considerable amount of time.
• Single-provider coverage: As the only ED provider, there is the risk of being pulled away to deal with a more emergent patient in the middle of the repair. Even if the patient is sedated, you would need to leave to go run a code, for example.
• Time since the injury: It has already been 6 hours, increasing the risk of infection and complications.
• Need for sedation: This is going to be a long procedure. If you have to sedate the patient for the entire procedure, you increase your risk of sedation complications and your requirement for staffing. If the patient doesn't need sedation, this may allow you to repair it in stages as you are seeing other patients.
• ED census: Again, if it's busy and you're the only provider, this repair is not going to happen.
• Follow-up arrangements: With such a complex repair and a long time since the injury, there is an increased risk for complications, including infection and poor wound healing. If you repair this, you may be putting yourself on the hook for follow-up.
• Rabies exposure: The patient will also need to establish care for possible rabies immunizations. Given the family's transportation issues, this is less likely to occur with just regular ED visits and the patient may benefit from the social support resources that a Children's hospital could provide.
• Possible ocular injury: If there is any concern for ocular injury, this patient will need specialty care and has to be transferred. The same is true if there is concern for significant nerve or vascular injury.
• Staff comfort with pediatric intubation and sedation: Comfort with sedation and intubation in adults does not necessarily translate to comfort in these areas with pediatric patients. If this is not something you do frequently, it may not be worth the risk.
• Patient medical history: If the patient has a complicated medical history or any history of complications with anesthesia or sedation, transfer would be the better option.
• Difficulty of transfer: There should be protocols in place for transfer. However, if transfer is very difficult, this may sway towards repair in the ED”.

As Dr. Nelson eloquently relays over seven distinct points, it may be very difficult to logistically take care of this patient in an appropriate manner in your single-coverage rural ED. 

Dr. Boyer does bring up some interests thoughts in his responses to these questions in regards to potentially intubating the patient to accomplish the repair if it has to occur at your shop (i.e. severe inclement weather that absolutely precludes transfer in a reasonable time window to a tertiary hospital). While this may sound crazy under normal circumstances, in an extreme setting (unsafe road travel due to heavy snow, extreme rural location, etc.) it may not be all that crazy. If the airway were secured and the patient sedated, a thorough washout could be accomplished and a multilayered closure could be accomplished in pieces if needed based on other demands in the ED. While not an orthodox plan, it is not outside of the realm of possibility and is worth thinking about.  

Q3 - What if the wound was not a facial laceration and instead was a laceration to the upper extremity with extensor tendon involvement? Flexor tendon involvement? Does the location and mechanism of the wound alter your decision making to any degree?

We had excellent responses to this question as well. The consensus appears to be that “it all depends…”.

• A complex forearm laceration with neurovascular involvement should be transferred.
• A laceration involving flexor tendons should probably be transferred.
• A laceration involving extensor tendon only (<50% of tendon thickness involved) without neurovascular compromise may be more amenable to repair in this shop than the complex facial laceration described above.

There are several key differences between a partial-thickness extensor tendon laceration and a complex facial laceration. The first is the cometic concern. Complex repairs to the face versus the extensor surface of a forearm are completely different in terms of cosmetic concerns in children. The second is that a forearm laceration, even if it is complex, may be amenable to a nerve block or two. This may make the repair attainable in the rural ED even if you become interrupted with other critically ill patients and need to step away for a while. So, ultimately, yes; the location and mechanism of the wound does alter the decision-making tree and needs to be considered on an injury-by-injury basis. This sort of logistical medical decision making is what makes emergency medicine so diverse and challenging!