Trauma Patient Suffers Severe Infection Due to Inadequate Wound Cleaning

This case involves a man who injured his hand while working with a potato harvester at a large factory farm. The man was seen at a local emergency room where the wound was closed using sutures, following which he was discharged with a prescription for antibiotics. A week later, the man returned to the ER with complaints of severe pain in his hand. Doctors elected to perform an exploration of the man’s wound. During the exploration, doctors discovered the presence of dirt and plant matter that had not been removed from the would before it had been closed. The man was immediately hospitalized and placed on broad spectrum antibiotics, however he suffered significant tissue damage as a result of the infection.

Question(s) For Expert Witness

1. How often do you treat dirty injuries?

2. Have you ever had a patient develop this complication?

3. What would be the standard of care for closing this type of wound?

Expert Witness Response E-120618

I see dirty wounds a few times per month. I have not personally had a patient develop a severe infection from a wound that I irrigated and repaired. Timing of wound closure should be within 6 hours of the wound. In general, wounds that are clean with minimal devitalization can be closed primarily. If this was not done initially, it would be possible to "convert" a contaminated wound with aggressive cleansing to a fresh-appearing wound with no signs of debris. Only then could primary closure be considered. If this cannot be accomplished due to contamination or deep wounds, then OR debridement should be considered to facilitate primary closure. Alternatively, you could do delayed primary closure in which as much cleaning as possible is done, the wound is covered with gauze, PO abx are given and the wound is reassessed in 4-5 days. If it doesn't appear infected at that point, then you can do the repair. Cleansing of any wound should not be considered complete until there are no visible contaminants and the tissue appears pink and viable. As the Physician Director of Quality for my Emergency Department, I coordinate our departmental case and peer review process, examining close to 100 clinical encounters per month for quality and safety issues.