Legal Review & Commentary

Improper treatment of broken arm results in brain damage: $6.5 million settlement in Washington

By Jan Gorrie, Esq., and Mark K. Delegal, Esq.
Pennington, Moore, Wilkinson, Bell & Dunbar, PA
Tallahassee, FL

News: A child whose arm fracture was so severe the bone broke the skin was taken to an emergency department (ED), where the arm was temporarily set. After several delays in receiving appropriate follow-up care, a massive infection set in and was discovered too late for proper treatment. The child now suffers from permanent brain damage and epilepsy. Combined, the treating physicians and hospital settled the case for $6.5 million.

Background: A 9-year-old girl fell from the monkey bars at her school and broke her forearm. The fracture was severe enough to have caused the bone to pierce her skin. She was taken to a small community hospital ED, where the ED physician ordered X-rays that showed a fracture of the midshaft at the left radius and ulna. The ED doctor also noted that she had sustained a puncture wound, which the doctor presumed was caused by her bone breaking the skin.

The emergency physician called an orthopedic surgeon for a consultation. He was in surgery and asked that the patient be sent to his office.

The two physicians, who eventually became defendants in the controversial case, report conflicting versions of what happened next. The ED doctor testified that it was critically important to advise the surgeon of the puncture wound so that he could prescribe antibiotics immediately. She contended that she:

• called the surgeon’s office to impress upon his staff the need to tell him of the puncture wound;

• told the patient’s mother that it was critical she take the child to the surgeon’s office and tell him of the wound;

• highlighted in yellow the information regarding the puncture wound on her handwritten ED note and gave it to the patient’s mother to give to the referral doctor.

The surgeon, the surgeon’s staff, and the mother denied under oath having been on the receiving end of any of these steps. The surgeon claimed that if he had known of the wound, he would have had taken the child to surgery and placed her on antibiotics within six hours of the accident.

When the surgeon saw the child, he reviewed the X-rays but did not unwrap the arm. He scheduled a procedure to set the bones the next day and sent her home. The patient missed the appointment to have her arm re-set and, the next day, returned to the surgeon’s office with significant swelling in the arm. She was admitted to the hospital and a fasciotomy was performed with internal fixation to improve circulation. Due to postoperative symptoms of infection, an order for a blood work-up was written by an infectious disease nurse. When the orthopedic surgeon saw the order, he canceled it, saying it was unnecessary.

The next day, nurses noticed a brownish drainage, which had a bad odor. The nursing staff contacted the infection control director, who took a wound culture. The blood work-up showed low sodium, which can cause brain swelling. Approximately one-half hour after the blood was drawn, the child showed indications of neurological compromise. The nurses gave the blood results to the surgeon, who failed to respond. Later that night, a nurse noted the dressings surrounding the wound were completely saturated and smelled foul.

The surgeon was called again, and he told the nurses to loosen the dressing. The nurse then re-contacted the infectious control director, who found the signs — in the blood-test results and wound drainage — consistent with a developing infection.

By the next morning, the patient showed signs of more neurological problems. Because the operating orthopedic surgeon was going out of town, the patient’s care and treatment were transferred to the operating physician’s partner, who then failed to address the critically low sodium level and failed to recognize she had developed a serious wound infection.

The child began having grand mal seizures. Despite the doctor’s order for close monitoring, the nursing notes did not indicate that this occurred. The child was eventually transferred by helicopter to another hospital, where it was determined that hyponatremia (low sodium) caused the seizures. The child now suffers from epilepsy and permanent, uncontrolled daily seizures, and through the process sustained significant, permanent organic brain damage.

The plaintiff claimed that care by the ED doctor and both orthopedic surgeons fell below the standard, and that their combined negligence created irreversible harm. The plaintiff maintained that the hospital failed to provide medically prudent follow-up care.

The defendants claimed that the others were at fault. The ED physician blamed the orthopedic surgeon for not following up on her notification of the gravity of the situation, surgeons blamed the ED physician and the hospital for not communicating, and the hospital blamed the surgeons for failing to respond to repeated calls.

And, in the end, all of the defendants settled for a combined amount of $6.5 million.

What this means to you: When errors on the part of health care providers are apparent, and particularly when coupled with an extremely poor outcome, it is often best to settle rather than to pursue costly litigation. "In this instance, it was appropriate that all defendants settled, for not one of them communicated effectively with other health care professional and follow-up care was inexcusably absent after each encounter," says Cheryl A. Whiteman, RN, MSN, CPHRM, a risk manager for Cigna Healthcare of Florida Inc., whose opinions do not necessarily reflect Cigna’s.

While the ED physician may have professed to have recognized the need for prompt follow-up treatment, it seems she did not provide any follow-up herself. "The emergency department physician simply relied on leaving messages with another physician’s office staff and with a distraught parent," Whiteman says.

"Even if she did leave these messages, it is obvious that physician-to-physician communication would have been more effective, if in fact, her message was to convey the fact of the puncture wound. Had the [ED] physician spoken directly to the surgeon, it is likely that the child would have been admitted to the hospital and immediately scheduled for debridement surgery.

Further, antibiotic therapy could well have been initiated in the ED or shortly after admission, which would have also mitigated the opportunities for the impending massive infection to set in. "A critical aspect of physical examination is to visually inspect and palpate the injured area. Radiological films should be utilized to determine a diagnosis in conjunction with the physical findings. The surgeon was remiss in omitting this element in his examination," she explains. "Another opportunity to get the child to surgery and start antibiotics was lost as a result of his incomplete physical exam," she says.

"Treatment at this juncture or in the [ED] would have prevented the circumstances that led to the missed appointment that further delayed necessary and required treatment. As a result, when this child was finally taken to surgery, she required a fasciotomy in addition to the internal fixation of the bones," adds Whiteman.

"Once [the patient was] admitted, both the physician and hospital staff further contributed to the child’s infection and electrolyte imbalance. The infectious disease nurse should have had the authority to write orders for blood work when clinically indicated without interference from the physician. This should routinely be a part of the check-and-balance system provided by an infectious disease program.

"Had the blood work been drawn as initially ordered, early recognition of a drop in her sodium level may have occurred. When the order was cancelled, the infection control director should have been notified rather than waiting another day when the wound starting draining brown, foul-smelling secretions. Those tell-tale signs were indications that things had gone too far. Without prompt recognition of hyponatremia, the child’s neurological status was significantly compromised," she says.

"When the surgeon first failed to respond and then did not recognize the severity of the situation, the nursing staff should have utilized their chain of command," she adds. "The infectious disease nurse and infectious disease director should have been involved with notifying nursing administration and the chief of surgery, particularly when the signs of infection were so apparent.

"Prompt action was not taken and, in fact, when the operating surgeon handed the care of this patient to his partner, he was obviously not informed of the potential seriousness of her situation," observes Whiteman. "Had the initial delays in surgical intervention and antibiotic therapy not occurred, the adverse sequence of events in this case may well have been averted. In the absence of prompt emergency department and/or surgeon’s treatment, a more aggressive infectious disease program could have prevented the devastating epilepsy, uncontrolled seizures, and significant organic brain damage," she adds.

"Time is critical, particularly in the treatment of a pediatric patient. A missed or delayed diagnosis is always possible in the absence of repeated thorough assessments. Positive outcomes often hinge on effective communication between health care professionals. Further, a facility’s infectious disease program cannot be effective if members of the medical staff are allowed to simply override infectious disease orders," Whiteman explains.

"And, finally, members of the nursing staff must advocate for the patient, which may include reporting potentially critical situations to administration when they believe appropriate care is not being provided. Had any or all these things occurred, this little girl’s arm would have probably healed and she would have returned to a normal life," concludes Whiteman.

Reference

• Jane Doe, Minor vs. Drs. Does, et.al., anonymous county (WA) Superior Court.

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