Out on a Limb - Moonlighter

This is our final in a series of 3 posts entitled "Out on a Limb."  The first 2 posts looked at the practice of Emergency Medicine in a setting far different than the Emergency Department.  In this post, we will return to the ED but look at how the constrained resources of a rural practice setting can impact patient management. As with the previous posts, this post is accompanied by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month (July 15), the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during our Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

You are a 4th year EM resident moonlighting on your first day in a remote area as the solo provider that has minimal availability to consulting services. The nearest major hospital is approximately 100 miles away.

A 5 year old child enters your ED at 3 am with a large, complex laceration to the face from a dog bite which will likely require sedation and a layered closure.  His injuries were sustained approximately 6 hours ago. The wound is complex and will require a multi-layered closure and there are a couple of areas of tissue avulsion. You have 1 or 2 cases of similar experience from approximately 1 year ago on your plastics rotation. Taking a quick inventory of your supplies, you realize you have all of the suture materials you will need as well as ketamine and a monitored setting with nurses who are competent and experienced with conscious sedation in adults. As you discuss the case with the patient’s concerned grandmother (who assumes primary responsibility for the child) she expressed that she does not own a car and a friend had to drive them to the ED. She may be able to arrange a ride 100 miles away but she will have to call a number of people and it’s 3 am and you have doubts about her competency to achieve this. She mentions to you that she does not have much money and is worried about the ED bill...

Q1 - What are your options in handling this situation? 

Q2 - What factors play into your management decision?

Q3 - What if the wound was not a facial laceration and instead was a laceration to the upper extremity with extensor tendon involvement?Flexor tendon involvement? Does the location and mechanism of the wound alter your decision making to any degree?

We're looking forward to seeing your thoughts on this case! When responding please indicate the question you are responding to with Q1, Q2, etc.