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Errors in Hand Therapy
994 Plays2 years ago
Josh and Miranda talk about errors made in hand therapy practice. From treating the wrong side to more significant errors.
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Transcript
Introduction to Hand Therapy Academy
00:00:07
Speaker
Hi, I'm Josh McDonald. And I'm Miranda Materi, and we are Hand Therapy Academy. Today we're going to talk about mistakes that we've seen, and we're going to be a little vulnerable and talk about some mistakes that we've made in therapy. So these all happen. Nobody's perfect. We're all humans. We're all going to make some mistakes and some screw ups, some big, some small.
Mistake of Treating the Wrong Hand
00:00:26
Speaker
We're talking about some of those. I'll go first. One of the ones I've done
00:00:31
Speaker
More times that I'd like to admit, busy clinic, patients coming in and out, and people coming and going, and you have a patient come in and sit down in front of you, and you take him out of the hot pack or whatever, and I was with it. One particular patient stands out, and we sat down, and she had just this soft tissue pain to her Cenar eminence, and we're working through stuff, and we're chit-chatting, and we're finished. We got like 15 minutes of soft tissue and some iced dim, and I scoop back and say, all right, I'm gonna go get you some exercises. And she says, you know what, it's the other hand that's bothering me, right?
00:01:01
Speaker
And of course I knew that. I totally knew that. I thought we'd treat both sides today. I said, nope, that was me totally getting it wrong. And I said, and I kind of like, I didn't want to blame the patient. I said, is there a reason you let me do that the whole time? I said, no, I just wasn't sure what was happening. Like 15 minutes is a long time to not know what's happening. But I guess it just shows you how passive some patients just kind of trust that you're doing the right thing.
00:01:27
Speaker
yep yep here i was treating the complete i could have been doing a foot massage for her for all it mattered because it wasn't treating the affected side and i finished and thought i apparently need to be better about either a keeping track or b checking my notes before patients come through because i just wasted 15 minutes other than giving her a massage on her other hand i guess that's better than doing like a wrong side of surgery which i think is somewhat common
00:01:50
Speaker
Yes. Yes. I didn't amputate the wrong limb or anything. That's important.
Equipment Safety: Paraffin Burns
00:01:54
Speaker
Yeah. Yeah. So I've been on a lot of panels where we study medical errors. And I think a big part of studying the errors is what, you know, trying to think of what you learn from the error and then sharing it with other people so they can learn from it as well, which I think is hard because it takes a lot of vulnerability and
00:02:15
Speaker
So I do like to share, especially when I have students, I like to share some of the mistakes I've made in hopes that they can learn from it, maybe not make the same mistake, but also show them that it's okay to talk about it and it's okay to take the steps to rectify it too, right? So a lot of times when something goes wrong, you don't want to admit what you did was wrong, but actually that's really what we should be doing. So I will share my ear
00:02:43
Speaker
And this happened when I was a newer therapist and I was at a clinic where we had a technician that would check the temperatures in the morning and then in the afternoon. So there was always a log of
00:02:55
Speaker
the temperature of the paraffin and the temperature of the hydroculator and all those things. So you can always see the log. So I never checked temperatures, right? I always trusted that the tech or someone else was doing it. And I was taking a patient back to do paraffin. And this patient was an older male and he dipped his hand in the paraffin and immediately started jumping up and down like a crazy person and saying, ow, ow, ow.
00:03:24
Speaker
And I was so mortified and we had to, I immediately had him sit down and I got my supervisor and we had to call the net nurse. So it was like emergency nurse that had to come over and evaluate the patient and make sure that he was okay. And then we also had to, and thankfully everything turned out being okay. It wasn't like where he had to do wound care or it was just a very superficial,
00:03:53
Speaker
burn, but I remember doing loads of paperwork and kind of going through and I was thinking, oh my gosh, am I going to get fired for doing this? And actually I was thankful I had like a really good supervisor that was very supportive and we just kind of worked through it and thankfully no.
00:04:10
Speaker
adverse actions came from that or you know, I wasn't fired or anything like that. But we did have to do a lot of paperwork. Yeah, yeah, that's good. That's good. I'm glad he ended up being okay. That's, that's an important part of the story. Yeah. And so from that, I learned now whenever I do paraffin with the patients, I make sure I check the temperature immediately beforehand.
00:04:29
Speaker
And sometimes I will check it on myself as well. Because if anybody gets a burn, I want it to be me and not my patient. And then the other thing I learned from it is that people have different sensitivities to heat, which we all know. But one thing I didn't know was that redheads, in particular, have greater sensitivity to heat. They're very complex people. So I didn't know that. And I also learned that they also metabolize
00:04:58
Speaker
sedatives differently. So even when they're going under anesthesia, sometimes they'll require more than say someone else would. So it's kind of an interesting learning thing. Okay, interesting. All right.
00:05:09
Speaker
Well, we've both been a little bit vulnerable.
Misdiagnosis and Clinical Instincts
00:05:11
Speaker
Now let's talk about some other maybe medical errors that we've seen out there in the community, maybe come across our doorstep a little bit. I had a patient who had a, it was a cook in a restaurant kitchen and was cutting meat and cut through his thumb, kind of through that Palmer aspect of the web space.
00:05:29
Speaker
And went to the hospital, they sewed him up, was a hand surgeon that did the surgical repair. And he said, basically, you just cut through soft tissue, just the muscle belly a little bit, no major structures damaged. Just go to therapy and manage the scar tissue because he'd been immobilized for a couple of weeks as a just-in-case. He came in and he had really no FPL pull through, no activation of that IP joint into flexion.
00:05:56
Speaker
And we worked on it for, you know, got to that six-week mark, but everything from the op report said, no FPL rupture. Like the doctor clearly said, no FPL rupture. Sent him back for a follow-up, normal follow-up visit. And doctor said, yeah, that doesn't seem right. Let's get him for an MRI. And sure enough, he had lacerated the FPL in that accident.
00:06:16
Speaker
And so it was this validating thing for us as therapists in the clinic at the time to say like, we need to trust our instincts on things and say like, hey, this doesn't seem right. It's way early at week four to be so caught up in scar that he's getting no activation, not even like the skin kind of puckering with pull, but the scar is binding up like he had done scar, but there was no sign that anything past the scar was happening at all.
00:06:45
Speaker
Maybe I should have sent the patient back a little sooner. Maybe that wouldn't have made a difference. I don't know. But trusting ourselves and saying like, Hey, this, we see these things clinically and maybe the doctor was in there with eyes, but you never know what happened. Maybe he ruptured after like it was a little Nick and then just the scar tissue had an impact on that and he did something that that muscle belly pulled free and ruptured it. But that was a just a missed FPL rupture. Yeah, interesting.
00:07:11
Speaker
I would say two other common errors I've seen have been involving COBAN. Actually, that one I am part of the studies that I've been on. There's actually been quite a few that have occurred because of COBAN and then also quite a few that have occurred because of a hot pack.
Patient Safety: COBAN and Hot Packs
00:07:26
Speaker
Sometimes we think our hot packs are safe, which if you follow the proper protocols and precautions, they are. But if the patient doesn't have a good sensation, you have to be very careful about putting them in the hot pack because
00:07:39
Speaker
For one, if they can't feel how hot it is, they're not going to let you know. And then I also caution against anybody putting weight on top of the hot pack to get more of a stretch. So sometimes when you have those PIP flexion contractures and you want to heat them up and get a stretch on them while they're in the hot pack, you know, I've seen people where they put the heavy weight on and it kind of loads the hand down, but then you're also pushing those tips of the finger into the hot pack. And if they don't have good sensation, then they can end up with blisters,
00:08:06
Speaker
In fact, I had one patient that ended up with a blister and then developed osteomyelitis and then he actually ended up advancing to a ray amputation just in a young guy, a young healthy guy. So sometimes, you know, things can go very wrong from a hot pack. And then the second one I'll tell you about briefly was a patient that had a lidocaine block and she was wrapped in co-ban and she was totally the co-ban on until she came in to see
00:08:34
Speaker
Us and she came in to see us and her whole tip of her finger was necrotic and black And that was just because she couldn't feel right. So they put it on too tight and then she couldn't notify Or she was she couldn't feel that it was too tight So she didn't know and she was wasn't going back to that doctor for after she saw therapy So that was another one I've seen so if they don't if you don't have good sensation You got to be really careful of what modalities you're using and then if you're a kid
00:09:01
Speaker
Sometimes kids won't tell us.
General Safety Advice in Therapy
00:09:03
Speaker
Yeah. And kids don't know what is supposed to be happening, so they'll think it's okay and not tell us or not have awareness of their body. I think skin integrity is another thing. In our elderly population, in our diabetic population, sometimes the EDS population, they may have compromised skin integrity, so they are more susceptible to heat and some of the other modalities. So we got to be careful as we apply those to make sure we're following precautions and
00:09:28
Speaker
I'd always rather, like if I'm putting on a hot pack, I'll say instead of folding it over on the patient, I'll just put a layer of towel on top to keep the lower levels heat in without that extra weight, without that extra heat source from both sides of the hand. And if they say, I don't really feel like that was beneficial, then maybe we can add to it. When in doubt, go less. Yeah, and add more towels.
00:09:50
Speaker
Yeah, yeah. And you're right, following that towel layer process, because sometimes it's not that the hot pack was too hot, it's that we forgot a layer of towel or the extra layers in there. We all have done that at one time or another where you were on autopilot and you just missed something, but those things can make a difference in matter. Yeah. And then the other thing is not every patient needs a hot pack, right? So if they do have compromised sensation, I think it's okay to not do a hot pack. Yeah, yeah, absolutely.
00:10:17
Speaker
All right. Well, there's always mistakes we're going to make. We're humans. We goof things up. And sometimes it's a little thing and it's a funny story. And sometimes it's a big thing and it causes a problem, but always try to follow precautions and stay on top of things and make sure we're taking the best care of our patients. Yes. So if you need more information or have questions, email us info at handtherapyacademy or check out our website, handtherapyacademy.com.