Reasonable Practice: Should the PA Have Caught This Case of Compartment Syndrome?

10 Comments

A 45-year-old patient came to the emergency department for evaluation of lower leg pain which had started the prior evening while playing soccer and had progressively worsened. There was no known injury. The patient was evaluated by a physician’s assistant (PA). The pain was significant and worst at the mid-shin. While the patient was able to walk, the pain was worse with ambulation and also increased with dorsiflexion of the foot. Some minor leg swelling was also present. On exam, vital signs were normal. There was no erythema or bony point tenderness. There were no cords and there was no tenderness or swelling above the knee. The PA diagnosed the patient as having a muscle strain, prescribed anti-inflammatories, and instructed the patient to follow up with the orthopedist the next day if the pain persisted. An attending physician never evaluated the patient, but later signed off on the chart.

The patient’s leg pain worsened through the night, but, according to his wife, but he refused to return to the emergency department. Instead, he went to the orthopedist the following day and was diagnosed with compartment syndrome. An emergent fasciotomy was performed but the patient suffered persistent nerve damage in his leg. He then developed chronic regional pain syndrome which spread from his leg to his back and resulted in the patient being permanently wheelchair-bound and requiring constant care.

The patient sued the physician assistant and the supervising physician. During discovery, the PA testified that he had considered the diagnosis of compartment syndrome, but had never seen a case of compartment syndrome in his career. However, his note reflected that the patient had “no evidence of compartment syndrome.” The plaintiff alleged that the PA was negligent for failing to consult his supervising attending or an orthopedist before ruling out such a serious diagnosis. The plaintiff alleged that after reviewing and signing off on the PA’s note, the attending physician should have recognized the patient had multiple symptoms consistent with compartment syndrome and should have called the patient back for further evaluation. The defense argued that the patient’s symptoms were nonspecific in nature, that nontraumatic compartment syndrome in an otherwise healthy patient is rare, and that with the patient’s history of recent physical activity, an initial diagnosis of a muscle strain was reasonable. In addition, the defense alleged that the injuries the patient sustained were caused by his refusal to return to the emergency department when his symptoms worsened through the night.

Was the patient’s care within the scope of reasonable practice?
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ABOUT THE AUTHORS

SENIOR EDITOR
Dr. Sullivan, an emergency physician and clinical assistant professor at two residency programs in Illinois, is EPM's resident legal expert. As an attorney specializing in healthcare issues, Dr. Sullivan represents physicians and has published many articles on legal aspects of medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians' Medical Legal Committee.

EMERGENCY ULTRASOUND SECTION EDITOR
Dr. Pregerson manages a free online EM Ultrasound Image Library and is the editor of the Emergency Medicine Pocketbook series. He is also an author for EPM's soundings column.

10 Comments

  1. Oh give me a break. This is a joke. We might as well only let board certified ED physicians practice then, even in fast tracks (which is where this patient would be in most departments) and then everyone takes pay cuts. At some point there has to be push back against these law suits. Should we shove a Stryker needle into every sore muscle?

  2. This case illustrates a very rare disease incidence in someone with no trauma and swelling not severe. To be honest , I am afraid I would have missed this as well. Sounds like one of those where you think , I am so glad I was not on the front lines that night. I guess if the patient’s pain was extreme with motion of the toes but that’s a tough one.

  3. Rasputin PA-C on

    Forgive me, I am somewhat taken aback by the notion that such a condescending PA hit piece was not penned by Dr. Henry, but undoubtedly his influence exudes from the page. Clearly, this is not a serious attempt to refine the practice of anyone, and in terms of a screed written enhance patient care, the malpractice is almost as striking as that insinuated from the PA.

    Key history and physical exam findings are glaringly absent such as two point discrimination and the 5 P’s most janitors are probably aware of if they mop the ER of a teaching hospital once a week. Undoubtedly, had a physician missed this, there would have been the incessant discussion of how rare compartment syndrome is accounting for only 14% of all leg pain diagnosis with specific presentations and we can’t really do compartment pressures on everyone with “minor” leg pain. Furthermore, of all the findings listed above there overly generalized terms applied such as “minor swelling”-minor to whom-, “pain with dorsiflexion”-how much pain(no grading was given) and with passive or active flexion? Did the swelling feel woody? I am assuming we are discussing the anterior compartment since you stated that the anterior tibial spine was tender. Since you say “No Known injury”, I am dubious of that unless he hopped around on one leg all night at the game, in which case it would be reasonable to presume he may have had an injury and although not necessarily indicated for every suspected case, imaging would have been helpful in this case, as would perhaps a CK and lactate, and UA.

    Having said that, it is hard to imagine the way this review has been specifically written would have warranted compartment pressures. I have never seen a case of Zika virus either, but I know how do diagnose it. A few of you perhaps would have gone straight to CP testing, but the patient was culpable in his own demise for not returning to the ER for further evaluation when the 5 P’s may have been abnormal and diagnosis less allusive.

    Next we will read that a PA missed Shwachman-Diamond syndrome, and were it not for that, nobody would impugn the mighty ER bastion. Entertaining nevertheless….

  4. Lee Morissette, PA-C on

    This was a rare presentation and not only missed by many ED providers, whether it be a MD, DO or PA, but Orthopedic Surgeons as well. ACS is high on the list of malpractice suits for Orthopedics. The basic presentation is a common complaint and ACS needs to be in the differential though many community based ED’s would not have the ability to obtain compartment pressures and it has been my experience that when consulting with Orthopedics, given the presentation and examination findings they would recommend outpatient followup. Clearly in the patient’s discharge instructions they were to return to the ED if symptoms worsened, which would have triggered further workup and additional specialty consultation.

  5. CO SIGNED w/o seeing pt. GUILTY! Why? Corporate said you have to? Wrong by you, wrong by them! They tell you that to increase their bottom line, not yours!! Will they accompany you to depositions, trial? No, they’ll engineer your dismissal!! It’s unethical by you, immoral by them

  6. This is a tough one. I agree you cannot get compartment pressures on all sore muscles and given the non traumatic injury, compartment syndrome is less likely. I also agree that patients have a duty to themselves to return if not better or if they worsen. I know this is a standard D/C instruction for every condition that presents. I do not think that the PA or doctor missed the diagnosis because it may not have been present with enough symptoms/signs to diagnose until hours later. Many times even though we tell patients to return they don’t. Unfortunately we all only get a snap shot in time. I personally have rescanned a patient with abdominal pain despite a negative CT 2 days prior done at our institution and who only had a slight WBC bump to find a ruptured appy. If we are honest we all have had patients return who did not truly have the condition on D/C but did on re eval, I know I have.
    This said I have to agree with others, typically community hospitals don’t have access to a Stryker set up and Ortho typically won’t come in for “muscle pain” but will see the next day, as in this case.
    Americans need to realize we are just people, not all knowing/all seeing super beings and they need to take responsibility for their part in their disease. We need to do our absolute best to diagnose and treat disease but to expect 100% accuracy with every complaint and often incomplete/unavailable information is not possible.

  7. Michael Carius, MD on

    No one ever missed a case in hindsight; the retrospectoscope is never wrong. That said, it is important to recognize that every clinical condition has an evolutionary history. In this case, it was likely a muscle strain and tear that led to some compartmental bleeding and swelling that ultimately led to the compartment syndrome and the complications. So, where on this evolutionary spectrum did this provider (the title or the training is not the important issue but the recognition of the differential diagnoses and how each of those was considered) actually evaluate this patient? Certainly not toward the end, since there is no mention of pallor or decreased pulses or hypoesthesia or paresthesia or paresis. So, if the presentation was toward the beginning of the evolution, then the only “evidence” for an early compartment syndrome would be the pain out of proportion to the injury and the pain on passive ROM. The treatment of a muscle strain or tear would be elevation and ice and analgesia, and, of course, close followup if the pain increased or did not improve. Presumably this was the advice that was rendered. Therefore, although we are not given the actual written record to review, this provider met the standard for the evaluation and treatment of this condition, which happened to be an early stage in the evolution of an acute compartment syndrome. I would be happy to defend this case.

  8. It’s not “Physician’s Assistant”. We are not owned like the possessive ‘s.

    It is “Physician Assistant.” Pleural would be “Physician Assistants”. Possessive would be “Physician Assistant’s”

    We practice medicine. Many of us practice emergency medicine.

    I very rarely “assist” my attending physician, unless you consider allowing them to be at home sleeping in their own bed assisting them.

    • Well said Boatswain2PA, even after all these years, so many still get this wrong.

      As I was not there, who knows how the case really presented. The written case presentation was not perfect, I’m sure for brevity of publication as well. But, having practiced high acuity EM for 14 years & lots of high speed action prior to that, I very well could have missed this. We all know we could have…Orthopods miss these things all the time!

      It’s all about that final feeling we all get. Rarely do any of us “miss” anything serious. Plus, knowing nothing about the PA nor their experience level, I hesitate to throw them under the bus. I just usually go by that “big picture” aphorism.

      When I first came out(phrasing), I got picked up by a big group down in Miami. Scared to death, mostly alone & essentially turned loose in the worst acuity ED I’ve ever seen. The group CO gave me some words of advice I live by to this day….not that I would have done any better in this case…

      He was a brilliant famous EMD for many years, he had been sued over a straight forward viral pharyngitis that turned out to be something covertly more sinister. He said to always think about these 3 rules for every sprained ankle, MI or knife in the chest I see.

      What’s gonna make them worse?
      What’s gonna kill them?
      What’s gonna get us sued?

      We all try to follow something like this, but it’s an art & we’re not perfect.

      my 2 cents,
      Captain Hindsight

  9. I’m a practicing PA that also does chart reviews and expert witness testimony for attorneys on both sides of the bench. Aside from the semantics, there is more to this lawsuit than is posted, probably due to space constraints. I have a few thoughts as to what should be inquired about by the Defense.

    Firstly, what was the disposition of this suit? It may so be that the jury (if it went to a jury) might have ruled against Plaintiff’s claims of Liability or that Defendant failed to mitigate his own damages by not seeking help later on when he had pain. Was this matter settled?

    Additionally, the things that come to mind are:

    1) If the Physician did see the patient, would his or her (The Physician) seeing the patient change anything?

    2) Did anything in the patient’s documented exam done by the PA suggest compartment syndrome; if not, where is the negligence?

    3) Can the patient have an underlying, presumably undiagnosed condition that made him more prone to compartment syndrome such as a coagulopathy or autoimmune disease?

    4) Is there any evidence that the compartment syndrome occurred before the visit to the ER, or after the visit to the ER? It may very well be that while the exam in the ER was not suggestive of compartment syndrome, he later developed compartment syndrome which brings the burden upon the Plaintiff to get medical attention immediately.

    5) Were discharge instructions clear and concise enough to inform the patient about the possibility of undiagnosed conditions that may occur later related to this injury?

    6) Did the patient actually have compartment syndrome? Just because he had a fasciotomy doesn’t mean he had compartment syndrome, that could be found in the ER on his visit.

    7) After having the fasciotomy he experienced nerve damage. Was the nerve damage caused by the compartment syndrome? Or the fasciotomy?

    8) Going back to whether or not the MD saw the patient: If the MD did see the patient, would the MD have ordered measurement of compartment pressures based on what seems like a benign medical exam? If so, would the patient have agreed to have an 18 gauge spinal needle or a Stryker needle inserted into his leg.

    9) Would compartment pressures have been normal at the time anyway? Or so slightly elevated that it wouldn’t warrant admission and fasciotomy?

    I can go on and on ripping this case apart but I would be very interested in knowing the citation or case title. If anyone wants to discuss this or another case, I’m available at ORAssist@gmail.com.

    Thank you for posting this interesting article.

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