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By Damian D. Capozzola, Esq.
The Law Offices of Damian D. Capozzola
Los Angeles, CA
Jamie Terrence, RN
President and Founder, Healthcare Risk Services
Former Director of Risk Management Services
California Hospital Medical Center
Los Angeles, CA
Morgan Lynch, 2018 JD Candidate
Pepperdine University School of Law
News: In early 2013, a snowboarding coach fell while snowboarding, suffering serious injuries to his legs. He was transported to a medical facility and developed acute compartment syndrome. Physicians performed a fasciotomy, but the patient already suffered irreversible damage to his legs. The patient remained in the medical facility for more than a month and required ongoing medical attention after discharge.
The patient and his wife sued the medical facility and several medical professionals, who were dismissed prior to the trial. The jury verdict in favor of the plaintiffs totaled more than $6 million, covering loss of earnings, loss of consortium, and other damages.
Background: In March 2013, a professional snowboard coach fell and injured his legs while snowboarding in Colorado with his team. He was taken to a nearby medical center, where he later underwent surgery on his left tibia. After the surgery, the patient lost the ability to move the toes on his left foot and exhibited sensation problems with nerves in his left leg. The nursing staff also noted multiple issues with his foot and leg each day for several days thereafter.
The patient developed compartment syndrome in his left leg that persisted for several days. On March 10, nursing staff noted that the patient did not report tactile stimulation on sensation assessment. The patient underwent a duplex ultrasound later that same morning.
On March 11, the medical staff noted the patient experienced continued redness and swelling, uncontrolled pain, increased heat, and no strength to his left lower extremity. That evening, a surgeon performed a fasciotomy to alleviate pressure in the patient’s extremity. Multiple follow-up procedures were conducted in the days following. The patient remained at the medical center until his discharge on April 15, but required ongoing follow-up medical oversight and care.
The patient filed suit against the medical center and multiple medical professionals; however, the individual professionals were dismissed prior to trial. The complaint alleged that the facility was responsible for the negligent acts and omissions of its employees, including failure to properly and timely consult with appropriate medical professionals regarding the care and treatment of the patient; failure to ensure that he received timely and appropriate evaluation of his condition; and failure to use the chain-of-command policy to ensure that he received care and treatment for his emergent condition.
During trial, the patient’s attorney argued that compartment syndrome is an urgent condition that must be fully addressed within 12 hours to increase the likelihood that the nerves and muscles within the affected compartment of the body will survive unharmed. In this case, the facility did not treat the patient’s compartment syndrome for several days.
The jury found for the patient and awarded him $418,000 for past medical care, $190,000 for lost earnings, $48,000 for other economic losses, and $500,000 for pain, suffering, physical impairment, and loss of quality of life. He also was awarded $937,000 for future medical care, $1.14 million for future lost earnings, $1.1 million for other economic losses, and $1.5 million for pain and suffering. The patient’s wife was awarded $50,000 for loss of consortium, affection, comfort, and companionship, and $450,000 for future noneconomic losses.
What this means to you: Compartment syndrome is a condition in which pressure continues to build up in a patient’s muscles. This pressure may decrease blood flow, resulting in oxygen and nourishment deprivation to limbs. There are two types of compartment syndrome: acute and chronic. Chronic compartment syndrome, also called exertional compartment syndrome, is a condition often caused by athletic exertion and often does not constitute a medical emergency. Acute compartment syndrome, on the other hand, is a medical emergency.
Without swift treatment, acute compartment syndrome can cause irreversible damage to a patient’s muscles. This case demonstrates the harm that may result from a medical provider’s failure to promptly diagnose and provide swift treatment of an emergent condition. When a medical provider does not act within the standard of care in providing such treatment, damages to the patient — and any resulting jury verdict — escalate significantly.
Compartments are the group of muscles, nerves, and blood vessels in limbs that are covered by a sheet of tissue called fascia, which is tasked with holding the compartments in place. As a result, the fascia does not easily stretch when fluid enters the compartment, resulting in increased pressure in the compartment. This increased intracompartmental pressure in turn puts pressure on surrounding blood vessels, cutting off blood to nerve cells and muscles.
This lack of blood flow is the main concern with compartment syndrome. In acute compartment syndrome, if the compartmental pressure is not relieved quickly, tissue death will occur. But in chronic compartment syndrome, tissue death typically is not a concern.
Acute compartment syndrome is characterized by pain that exceeds what would be expected from the injury itself, especially when the muscle or muscles within the compartment have been stretched. Additional symptoms may include tingling or burning sensations in the skin, tightness or fullness of the muscle, or numbness or paralysis in the late stages of the condition.
Acute compartment syndrome is diagnosable with measurement of the compartment. Exertional compartment syndrome is characterized by pain or cramping during exercise which subsides when the activity stops. Exertional compartment syndrome is seen more frequently in patients’ legs and symptoms may also include numbness, difficulty moving the foot, and visible muscle bulging. It must be diagnosed indirectly by ruling out other possible causes of pain and cramping, such as tendonitis and stress fractures.
The treatment of acute and exertional compartment syndrome differs in that there are no nonsurgical means of relieving acute compartment syndrome. Acute compartment syndrome is treated by making an incision in the fascia covering the impacted compartment — a procedure called a fasciotomy, the procedure used in this case.
Postoperative compartment syndrome is a dangerous side effect of orthopedic surgery on limbs due to the body’s response to the assault on the limb from the initial injury as well as the manipulation of bone, muscle, tendons, ligaments, and fascia within the surgical site. Tissues swell, blood and lymphatic fluids rush to the area, and swelling builds continually unless steps are taken to reduce these effects. Elevation, ice, pain control, rest, anti-inflammatory medications, and intense assessments of the area by medical staff are critical.
The patient in this case showed warning signs of impending compartment syndrome for several days until the pain of oxygen-deprived tissues was too much for him to tolerate. Loss of sensation, decreased movement, pain, redness, and swelling are classic signs of trouble.
Another lesson to be learned from this case is that multiple care providers could have prevented the unfortunate outcome. A system of checks and balances or minor overlap whereby both physicians and staff are trained and capable of reporting and recognizing dangerous conditions may reduce injuries — and potential malpractice.
In this case, the staff identified the patient’s ailments specifically as they related to his affected limb, yet prompt action was not taken. The nursing staff diligently performed assessments of the affected limb, but either failed to notify attending physicians and surgeons or, if notified and physicians and surgeons failed to act, did not use the chain of command and escalate concerns to charge nurses, nursing supervisors, unit managers and directors, nursing leadership, medical staff office personnel, the chief of staff, and so on.
Additionally, the surgeon should have been rounding daily on the patient and performing his or her own assessment of the limb. It is often difficult for busy physicians who are required to round daily on hospitalized patients to actually enter the patient’s room and spend time on a thorough assessment; however, to do less than that is a disservice to the patient and puts the physician at risk of a malpractice action if the failure to assess is inconsistent with the applicable standard of care. Had the surgeon in this case assessed the patient’s limb more frequently, the outcome for all involved would have probably been far less disastrous and litigious.
Decided on April 24, 2018, in the U.S. District Court for the District of Colorado; case number 1:15-cv-00460.
Financial Disclosure: Author Greg Freeman, Editor Jill Drachenberg, Editor Jesse Saffron, Editorial Group Manager Terrey L. Hatcher, and Nurse Planner Maureen Archambault report no consultant, stockholder, speaker’s bureau, research, or other financial relationships with companies having ties to this field of study. Consulting Editor Arnold Mackles, MD, MBA, LHRM, discloses that he is an author and advisory board member for The Sullivan Group and that he is owner, stockholder, presenter, author, and consultant for Innovative Healthcare Compliance Group.