Physician Legal Review & Commentary: Woman awarded $5 million when failure to test results in bilateral leg amputations

News: In 2008, a female patient presented to the emergency department of a local hospital with severe pain in her feet and legs. After examination by a physician’s assistant (PA) and written approval from the emergency department physician, she was diagnosed with cellulitis and discharged home. Later the same day, the patient was found unresponsive in her home and rushed back to the emergency department. Following diagnostic testing, she was found to have blockages in the arteries of her lower legs, requiring amputation of both legs below the knee. The woman sued the physician, the physician’s assistant, and their employer, and she claimed that they failed to timely diagnose the arterial blockages and prevent the amputation of her legs. The jury awarded the patient $5 million.

Background: A 61-year-old female patient was brought by ambulance to a local hospital due to severe pain in her feet and legs, which also were cold to the touch. She was examined by the physician’s assistant, who discovered that the patient had a diminished distal pulse, bilateral leg soreness, leg pain, and leg redness. The defendants contended that a venous Doppler ultrasound examination indicated that the patient had no blockages in the veins of her legs. The patient, on the other hand, claimed that no such tests were performed. The patient was diagnosed with cellulitis and discharged home about noon, with a prescription for antibiotics and pain medications. She also was told to place ice on one of her legs.

The patient and her family complained that she never got to see a doctor and begged for her to be admitted to the hospital. However, the physician was mainly unresponsive and simply poked his head into the room and said, “We don’t admit people for cellulitis.” This interaction is the only one the physician had with the patient, although he signed off on the diagnosis and recommended discharge.

About midnight that night, the patient was found unresponsive in her home by family members. She was brought back to the emergency department and, following diagnostic tests, was determined to have blockages in the arteries of her lower extremities. As a result, both legs had to be amputated below the knee.

The patient thereafter sued the physician, the physician’s assistant, and their employers for medical malpractice, and she claimed that they failed to timely diagnose and treat her arterial blockages. She argued that her legs would not have required amputation had she been properly diagnosed and the blockage timely discovered. She contended that had either of two simple tests been conducted within six hours of her arrival that morning, her legs could have been saved.

Defendants argued that they did not deviate from the standard of care in their treatment of plaintiff. They maintained that when she first arrived, acute venous problems were ruled out by a normal venous ultrasound and an acute arterial problem was ruled out by the presence of pulses, thus leaving infection as a result of cellulitis being the most likely cause of the plaintiff’s complaints. Defendants asserted a major change in plaintiff’s condition took place later that night following her discharge, which resulted in a cardiac arrest from a lack of blood pressure and pulse. Such conditions were not present or foreseeable during the initial visit.

The jurors returned a verdict in favor of plaintiff and awarded her $5 million. The jurors applied the standard of care of ordinary negligence and not gross negligence, as required under Georgia law when a physician or healthcare provider is providing “emergency medical care.” The jury determined that the patient did not receive “emergency medical care” because she was in stable condition during her initial visit, despite having been treated in the emergency department.

What this means to you: The causes of occluded arteries are numerous and may include longstanding peripheral arterial disease (PAD). Some risk factors for PAD include diabetes, smoking, and hypertension. Symptoms of peripheral arterial disease may include cool/cold feet to touch, pain in the legs, or loss of pulses in legs or feet. A simple diagnostic test done in these cases is a Doppler study that confirms the presence or absence of pulses in the lower extremities.

Because PAD is a widespread disease of the arteries, the presence of PAD in the lower extremity arteries is a strong indicator that there is also PAD in the arteries of the heart and brain. PAD has two major complications associated with its presence: limb complications such as nonhealing wounds, ulcers, gangrene, and loss of a limb, and risk for stroke and/or heart attack.

The information above sets the stage for the case at hand. This patient presented with classic symptoms of PAD: extreme pain in her lower extremities and feet that were cold to the touch. Despite the claim by the emergency department staff that appropriate testing to evaluate an occlusion was performed, the wrong test was performed. Herein lays the crux of this case.

The physician assistant performed a venous Doppler study instead of an arterial Doppler study. The arterial study is performed using the same Doppler machine, but the transducer device is placed in a different area of the leg to better capture atrial blood flow. Had this study been performed in the emergency department, it was possible that the article occlusion would have been diagnosed and treated in a timely fashion.

Additionally, a physician never properly assessed this patient, nor did he complete an adequate history and physical. The patient was never queried regarding a condition called intermittent claudication that presents as pain in the leg and feet while walking and indicates lack of blood flow to the legs. Instead of completing a comprehensive history, physical, and diagnostic testing, the emergency department staff incorrectly diagnosed the patient with cellulitis. Because redness and pain in the extremities are frequently seen in both conditions, arterial occlusion can, to the untrained eye, be mistaken for cellulitis. At a minimum, the patient should have been seen by a consulting surgeon to determine a definitive diagnosis.

If the arterial occlusion is allowed to continue for more than six hours, the tissues undergo irreparable damage, as was seen in this case. Needless to say, had the staff been more astute to this vascular emergency, they would have acted more aggressively in their overall treatment plan. However, once the patient was discharged and ultimately returned approximately 12 hours later in critical condition, the permanent damage was done.

The issues in this case are the lack of an adequate history and physical and the failure to recognize a vascular emergency. Comprehensive education on the signs and symptoms of vascular emergencies would be required for the emergency department staff. Also, there was a lack of PA supervision, and the hospital’s policy on PA supervision might need to be revisited and reinforced.

Reference

2012 WL 6136433 (Ga. State Ct., Sep. 24, 2012) 2010-C-13313-4.