Why wasn't my son's infected toe washed and cleaned in the ER?
September 30, 2012 11:34 AM   Subscribe

Why wasn't my son's infected toe washed and cleaned in the ER?

Recently my autistic son developed, very quickly, an infection in his fourth toe, left foot. The entire toe swelled, became purplish red, and drained a bit of pus, and the infection was spreading up his foot. Concerned because he has diabetes and any foot problem is serious, and also worried because it might be a spider bite, I took him to the ER. Over the five and a half hours we were there, he had x-rays to rule out breaks, and blood work---8 vials--to check various vitals and his white cell count. But at no time did anyone wash his toe. As a matter of fact, he walked on the floor of his ER cubicle in bare feet---until I hurried to put his sock back on. I was glad that I had cleansed his toe with vinegar, which we had at hand and which doesn't hurt, before we left for the ER. Several times, as we waited in the cubicle, I washed his toe again with cleansing wipes that were on the counter of the ER.
Eventually he was given a a wide-spectrum antibiotic IV, then released with the antibiotic prescription.
I am curious as to why no nurse, PA, physician, or other clinical health worker did any wound cleaning? We are wondering if it's perhaps because they rely solely on antibiotics? My uncle, an exceptionally competent abdominal surgeon who began practicing in the days before antibiotics were widely available, prescribed them rather sparingly when they came into use, believing that the body's defenses should be given a chance, and that too much reliance on antibiotics might result in weakening the body's natural defenses. (He did not hesitate to prescribe them when they were necessary, of course, and was grateful that antibiotics transformed abdominal surgery, making it much safer.)
Don't get me wrong---I was grateful for the care, and for the antibiotics--but am still curious as to why no one cleaned the wound?
Many thanks, hive mind.
posted by ragtimepiano to Health & Fitness (15 answers total)
It sounds like a lot of the infection is internal. How big is the wound? Could messing with it be more likely to introduce new bacteria (especially in a hospital, yikes) than to make any real dent in the existing infection?

FWIW, for little toe infections like that, I've had a lot of success with hot salt-water soaking.
posted by thirteenkiller at 11:39 AM on September 30, 2012 [1 favorite]

There was a wound opening, about the size of a pencil head eraser.
posted by ragtimepiano at 11:41 AM on September 30, 2012

I'm pretty sure they don't usually do any more cleaning of people/ parts than is neccessary to treat the problem. They don't have time.
posted by windykites at 11:49 AM on September 30, 2012

Did they dress the wound at all or put anything on it?

Foot wound care is actually really complicated, and it's not as simple as just washing it. The wipes you used on his foot might have actually harmed the healthy tissue surrounding the wound as well, for example, depending on what was in them.

Additionally, it's not really their job to keep your son from walking on his bare foot--if you're suggesting that they delayed unnecessarily in dressing it, I would suggest that they were either busy, which happens in an ER where someone might be having a heart attack or bleeding severely, or they needed the results of pending tests in order to determine the best way to treat and dress the wound.
posted by the young rope-rider at 12:02 PM on September 30, 2012 [2 favorites]

(I am not a doctor, by the way)
posted by the young rope-rider at 12:02 PM on September 30, 2012

I don't think this was an oversight.

With an infected wound, there's always a danger that the surface will heal over while active infection remains inside, and it seems likely that they were just trying to make sure that didn't happen.
posted by jamjam at 12:15 PM on September 30, 2012

Speaking as someone who got a pretty wicked staph infection after having a massive plantar wart burned off the bottom of my foot, I'd guess that if it was intentional they just didn't want to spread more germs around into the open wound. My doctors told me we always have a pretty good amount of staph on our skin at all times. Maybe this was an attempt not to make things worse?
posted by bitter-girl.com at 12:17 PM on September 30, 2012

It's hard to say without having been there. It could have been an accidental oversight, or it could have been the result of a busy ER in which no one really had time to come by and do wound care, or it could have been a purposeful choice.

If it was done on purpose, my best guess would be that the doctor felt that anything they did to the wound would have compromised the process of healing. Diabetic foot wounds are serious because they generally heal very slowly if it all. If your son's toe wound looked like it was closing on its own, had no obvious foreign bodies, and there was no need for debridement, then leaving it alone is not a bad idea. Pretty much all antiseptic agents are damaging to the skin, and using them on wounds can delay healing. Those cleansing wipes you used were probably not a good idea, since they were likely saturated with bleach or alcohol, which irritate skin (and, if the ER was anything like the ones I've worked in, they were intended for cleaning contaminated surfaces, not human bodies). If you're going to clean his toe, rinse it gently with saline.
posted by bookish at 1:18 PM on September 30, 2012 [2 favorites]

That the ER let you leave without clearly communicating an agreed upon wound care plan for you and your son to follow means they did in fact fuck up in a very important way, that they did not clean the wound does not necessarily.

That said, even with the knowledge that there is an opening about the size of a pencil head eraser (~5mm), we have absolutely no way to even begin to adequately answer your question. Having no access to your son's foot:

We do not know how open the wound is, have no idea how deep the wound is, no idea how vascularized the wound is, how healthy the flesh around the wound is, where on the toe the wound is, how much of the toe is infected, what kind of infection it is (If its G+ve, G-ve, looks fungal under a scope, smells like Pseudomonas, smells like Staphylococcus, green, purple, yellow, white?) whether the wound has an even or wavy edge to it, whether any foreign bodies were present in the toe, how healthy the rest of the foot is, whether the luna of the nail looks fucked up, whether the nail plate looks fucked up, whether the nail root feels intact or looks intact in the X-ray, whether the bone looked healthy in addition to intact in the X-ray, whether the eponychium is intact, how well your son was walking on the foot, how clumsy your son would likely be with the wound, how well your son would likely understand the prospect of debridement, how cooperative he would likely be during a debridement procedure, or how eligible your son would be for local or general anesthesia. Even if you had the education to know the profoundly non-intuitive ways to properly assess these things and communicate them, we would still have an awfully hard time giving you advice that would be anywhere near as reliable as what you should have gotten at the ER.

Not all wound infections need either superficial cleaning or debridement, and the best practice for many wound infections very specifically involves no cleaning of the wound itself whatsoever, particularly foot wounds. With many wounds, any attempt to remove infected tissue or even infected pus may damage heathy tissue necessary for combating the infection and adequate healing. Especially if the harsh chemicals like the ones found in cleaning wipes are used. Also, if your uncle has not been practicing recently he may not be an ideal source of wound care information as the field has evolved dramatically even over the last two or three years, much less the last five or ten. The best advice we can possibly give you is to follow the instructions given to you at the ER, or if they failed to provide instructions, to call up your son's GP/pediatrician for an appointment. If your son does not have a GP/pediatrician then it would be appropriate to find an Urgent Care Facility to make an appointment. As you know, adequate foot care is especially important for your son with his diabetes, and this is very much worth taking seriously.

There is no where near enough information for a competent health care worker to provide you with adequate advice beyond encouraging you to seek someone who can actually give you competent advice. To be clear, please do not do anything to the wound beyond gently rinsing the outside, not flushing the inside, with sterile saline (that is water with a physiological concentration of salt and NOTHING else) without a competent medical professional advising you to do so as part of a larger wound care plan.
posted by Blasdelb at 1:45 PM on September 30, 2012 [20 favorites]

In the trauma center I used to work at (nurse's aid), we rarely did anything but put new wet-to-dry dressings on infected open wounds like the one your describe (in addition to the appropriate antibiotic treatment, of course). The idea, I believe, was that the wound was already infected and no amount of flushing would clear the infected tissue. If anything it may interfere with the body's natural defense of the infected area. With serious wound infections, we referred the patient to wound specialists. I'm not sure how they treated them.

Heavy debridement is generally reserved for fresh wounds that aren't infected yet, usually before stitching. The flushing clears out damaged tissue and debris--the type of stuff that causes the infection in the first place.

I wouldn't worry about it. Just keep an eye on it and whether or not the home antibiotics are working. (And please please please do not stop his antibiotic treatment until the doctor gives the okay, even if it looks like the infection is gone.)
posted by Kevtaro at 2:46 PM on September 30, 2012 [1 favorite]

Thanks, everyone, that sheds some light.
The ER was not at all busy. When we passed the central desk, I noted that only about 1/5 of the 45 cubicles were in use, and there seem to be no urgent cases. It was a quiet night at the ER.
posted by ragtimepiano at 4:00 PM on September 30, 2012

We will be following up with our primary care physician, a personal friend and a fellow alumni.
posted by ragtimepiano at 4:03 PM on September 30, 2012

The ER was not at all busy. When we passed the central desk, I noted that only about 1/5 of the 45 cubicles were in use

The busy-ness of the ER depends more on the number of staff working at that time, and the severity of the cases that come through the door, than the number of rooms occupied. ERs are not always staffed to take as many patients as they have room for. And the patients who come in with a life-threatening, time sensitive issue (heart attack, stroke, sepsis, etc.) get seen more quickly. Even if you saw a bunch of nurses sitting around at computers, it is likely that they were busy charting assessments, reviewing lab results, making plans of care, etc., all of which are just as important as the face-to-face time in a cubicle with a patient. I think it's not good that they didn't give you more information about the expectations, or assess your expectations so they could correct any misinformation. But the lack of wound cleaning doesn't sound like a mistake.
posted by vytae at 4:38 PM on September 30, 2012 [7 favorites]

The ER should give your son appropriate treatment even when busy. You have every reason to expect answers to questions; call them and ask. You're not being difficult, you have a legitimate question about the care provided.
posted by theora55 at 7:45 PM on September 30, 2012 [1 favorite]

hello ragtime piano, IANYD but I am an ER doctor.

I do not wash out draining abscesses (collections of pus). I drain them and pack them if necessary. There is no point to washing an abscess site that is draining. The treatment for the abscess is for it to drain and heal. It is already infected. Draining an abscess is not a sterile procedure because it is already full of bacteria.

Your son not only had a draining abscess, he also had what sounds like a surrounding cellulitis ("infection spreading up his foot"). There is no amount of washing that will help get rid of an infection that is already moving through the tissues. Antibiotics are not necessary for an abscess, but they are necessary for an abscess with a surrounding cellulitis.

That being said, I know what happens on ER floors and I would never never walk around on an ER floor with bare feet, especially with an open wound! It completely skeeves me out when people let their kids run around the ER barefoot. Gross! This was not the staff's responsibility though - they're not babysitters, they're healthcare workers, and even when there aren't many other patients in the ER, that doesn't mean they're not doing a complicated procedure on a very sick patient in the next room. The number of staff on duty is usually proportionate to the number of patients, so the fewer patients there are, the fewer doctors and nurses there are, too.
posted by treehorn+bunny at 6:20 AM on October 1, 2012 [2 favorites]

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