Medical Malpractice Insights: Dirt left in wound leads to infection

Dirt left in wound leads to infection.

Dirt present on X-ray. Radiologist missed it. EP doesn’t over-read.

509 words… 2 minutes

Facts: An adult female falls from a ladder, lands on her elbow and sustains an avulsion. She is seen briefly by the ED physician who orders “wound cleansing” and an elbow x-ray for “elbow pain.” The tech cleans the wound and documents it as 2cm long and “dirty.” She cannot remove the debris despite using “tweezers, cotton swabs and sponges” and reports this to the ED physician. Meanwhile, the radiologist reports the x-ray as showing “no radiopaque foreign bodies” and “no acute abnormality.” The ED physician documents suturing a 3 cm laceration in a single layer, omitting any reference to any wound exploration, cleansing or debridement. He does not mention viewing the x-rays himself. The patient sees her PCP when the wound appears infected, and a repeat x-ray is ordered. This shows two specks of dirt, also visible on the x-rays from the ED. Recovery is prolonged and a lawsuit is filed.

Plaintiff: I sustained blunt trauma to my elbow from falling onto a dirty surface in my yard. It was severe enough to tear the skin and inject dirt into the wound. Elbow avulsions often contain dirt in the depths of the wound; mine did, as the tech told you. You did no further cleaning; didn’t debride the wound edges; didn’t tell the radiologist that I had an open wound; and didn’t consider antibiotics, a drain, or simply leaving the wound open to heal on its own. And you didn’t look at the x-rays yourself, which you are trained to do. You just closed it with the dirt still in it. And the radiologist missed the dirt specks in the soft tissues of my elbow. His later claim that they were “bone islands” in the olecranon process is ludicrous.

Defense:

Radiologist: Of course I saw the FB’s on the x-ray. I thought they were incidental “bone islands” so I didn’t document them. “Orthogonal positioning” proves they were “in the olecranon process.”

EM Doc: I depend entirely on the radiology report. I don’t ever view x-rays myself. I always clean dirty wounds. I just didn’t document it.

Result: The patient healed with scarring. Negligence was present. Care cost over $55,000 (damages). Causation was present because the damages resulted from the negligence. But long-term disability was minimal to none, so the case settled pre-trial for an amount below the expectations of both the plaintiff and her attorney.

1. 2019 Model of the Clinical Practice of Emergency Medicine, p. 11. ABEM
2. Wound Closure Technique. Medscape eMedicine. Danks RR, Jun 22, 2021.