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Discussion

questioning trauma doc's choice

long story here, but mainly i'm having a hard time swallowing what was done at a patient's bedside the other day, and i'm loosing sleep over it!here's the gist:

bad trauma (opening ICPs over 130, ICPs maintained in 80s-90s despite treatment) needed a wound vac to abdomen. to "save costs" the surgeon rigged up his own wound vac at bedside with a sterile towel in the cavity, two OG tubes in the space, your typical occlusive dsg over top, and hooked the OG tubes to a sump pump. will this save costs? sure. was the procedure sterile? yes. will this be effective treatment (in a long term sense)? i don't think so.

now, maybe his reasoning was that we simply needed a quick fix, and this pt was sure to die or have care withdrawn soon. i guess i can accept that. but if he's going to be doing this sort of thing routinely, on pt's that are expected to live - even if it is just temporary - i don't think i can stomach it. i think even a short time of having that fibrous (cotton) material in a wound bed is dangerous and sets up a bad cellular environment for more inflammation, greater risk of infection, decreased healing, and increased chance of adhesions forming later on. i base these assumptions on both common sense and on the fact that i have a masters degree in cellular and molecular biology, so understand a few things about cell/tissue behavior and signaling. i've only been a nurse, however, for a little over a year, so maybe i don't fully understand some of what his thinking was, beyond a quick/temporary measure that saved lots of money.

has anyone else seen this sort of thing? am i worrying too much? i feel like i should discuss this with my nurse manager. thanks :)

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    I would just chart what the surgeon did, what's present in the wound and let the chips fall where they may.

    I know this has got to be upsetting for you.

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    That sucks. I frequently have a hard time swallowing some of the choices doctors go with. Even if it seems inevitable that the patient won't survive or will have care withdrawn, it feels like they start down this path before the family is ready to which has always bugged me.. and they may decide to "half ass" care. It may be a waste of resources, but at the same time, it's not ethical imo to half ass the care when the family is still wanting everything possible to be done.

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    I am assuming that your concerns are that a commercial wound VAC was not applied. Is that correct?

    This is how VAC have been done for a long time. My personal feeling is that this works much better than the comercial VACs.

    The best person to ask would probably be the physician who applied the dressing. With ICPs in the 90s, the VAC was the least of this patient's problems.

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    We call this a "poor man's wound vac." Our surgeons will frequently use this set-up for an abdominal wound with high volumes of output. As far as longevity... I have had patients with them for several weeks (they go every few days to the OR for a wash-out and dressing change). I don't see anything wrong with it.

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    I've seen this technique used when the surgeon intends to bring the patient back to the OR within 24 hours. Usually for the patient that we aren't sure if more bowel is going to die and need resected, or those that end up with compartment syndrome or a dehiscence on the floor where they need opened and packed, but not necessarily surgery at that point.

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