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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