Summary: The patient was involved in a motorcycle accident in which his bike fell onto and injured his left leg. When the nurses assessing the patient could not detect a pulse in that leg, an ominous sign of circulatory failure. The physician when notified chose to dismiss this fact and discharge the patient. The patient would return soon after with worsening symptoms that would require emergency surgery. Should the nurses have initially pressed for further action, treatment?
The patient was involved in a single vehicle accident involving his motorcycle and brought to the Emergency Department for left leg injuries, specifically a knee injury. While riding he had lost control and when he fell was pinned under his bike. “Single vehicle motorcycle crashes account for about 45 percent of all motorcyclist fatalities. More than 38,000 motorcyclists have died in single vehicle motorcycle crashes between 1975 and 1999. The report claims to provide data for insight into possible causes for these fatalities.
According to the report, from 1990 through 1999, there were a total of 11,038 fatal single vehicle motorcycle crashes. During that same time period, there were an estimated 294,000 non-fatal single vehicle motorcycle crashes. ”2 In the course of a detailed assessment and evaluation by the Nursing staff, it was noted that the patient had no detectable pulse in the left leg or foot. The patient was also complaining of severe pain and numbness in that leg. In some patients a pulse may be difficult to palpate, or not detectable at all by touch under normal circumstances.
In those patients a “Doppler Ultrasound” can be performed which is more sensitive for detecting pulses not detectable otherwise. Though performed several times in different areas, even with the Doppler, no pulse was detected by the nurses. “There are many ways to test blood flow to the lower legs. In Doppler testing, an inflatable blood pressure cuff is placed around the leg or ankle while an ultrasound probe tracks the blood flow. This test may be performed after treadmill exercise. Diminished or absent pulses in certain vessels are a tip-off of blockages.
The doctor is also likely to compare the blood pressure in your leg to the blood pressure in your arm, a measurement called the ankle-brachial index (ABI). ”3 A primary concern at that point to a nurse or physician should have been impaired circulation to the leg. Compromised circulation in any part of the body is a medical emergency which can lead to severe damage and the loss of a limb. The nurses appropriately brought this to the attention of the physician who would also examine the patient. In the physician’s examination, he noted the pain, swelling and tenderness in the knee also noted by the nurses.
However, he would document that he did find a pulse in the leg, though with difficulty. When questioned by the Nursing staff on why, even with the aid of the Doppler Ultrasound, they were unable to detect a pulse, no explanation was offered by the physician. As far as he was concerned, a pulse was present, the pain was due to a “severe sprain” and the patient could be discharged. His instructions to the patient were to go home, rest, elevate the leg, apply ice to keep the swelling down and to follow-up with an Orthopedic Physician in a few days.
It should be noted that the physician also reviewed an x-ray of the knee which showed bone “fragments” in the knee area representing acute injury. Despite this finding, the patient was still discharged. The Nursing staff made the patient aware that they had been unable to detect a pulse in the leg and explained that it “possibly” could be due to the swelling from the injury. They instructed the patient to call or return to the hospital if the pain got worse or did not begin to subside. That evening, the pain intensified and the swelling got worse throughout the night.
The patient then contacted another physician who agreed to take a look at his leg. The patient would present in the morning to a different Emergency Department. On examination at this hospital, a working diagnosis of a dislocated knee and lacerated popliteal artery was made. The severity of the damage to the patient’s leg was enough to prompt the physician to consider amputation. The patient was fortunate in that there were experienced surgeons on hand to perform emergent surgery and save his leg. The patient would spend a total of thirty-five days in the hospital following the surgery and never fully regain function of his leg.
He would sue the hospital where he was initially treated and the physician who originally sent him home following his injury. On review of the case, the physician’s side would settle out of court for a sum of $275,000. The lawsuit against the hospital’s Nursing staff proceeded to court. It was claimed that the nurses, even though they picked up signs/symptoms of a medical emergency in their assessments, did not do enough to see that those concerns were addressed by the physician on duty. They would argue that had the matter been pursued further, the patient’s true injuries could have been diagnosed and treated earlier.
Earlier treatment could have prevented the permanent damage and injuries the patient would sustain due to a delay in treatment. The jury trial would award the plaintiff $880,000 due to the negligence of the hospital’s Nursing staff. The hospital would appeal. Questions to be answered. 1. Did the Nursing staff have a duty to accurately assess and detect the patient’s injuries within their scope of practice. 2. Did the Nursing staff do enough to see that the signs/symptoms of the patient’s potential injuries were properly evaluated. 3.
When the physician dismissed their concerns, should they have gone over his head? There is no question that Emergency Department nurses have a duty to fully assess and accurately evaluate the condition and potential injuries of patients in their care. In this case, the lack of a pulse both by palpation and by Doppler Ultrasound following a knee injury, should have been a major “red flag” for vascular impairment and cause for further evaluation. The Nursing staff acted appropriately in that they extensively documented what they found and reported it to the physician treating the patient.
On review of the medical chart, it is clear that the patient had a potentially emergent situation developing. What is also clear, is that the physician chose not to address the symptoms present, and that the nurses left the situation at that. It was clearly stated in the hospital policies/procedures that if a nurse believed appropriate care was not being given to a patient, a hospital supervisor must be notified. If on notification the situation was not resolved, the next in the “chain of command” must be made aware until the situation was resolved.
In the same fashion, that a nurse has a duty to question an inappropriate medication order, a nurse also has a duty to a patient to question a potential missed or incorrect diagnosis. There is a duty also to inquire as to why treatments and further evaluations may or may not be performed. The lack of a pulse in an injured extremity is clearly a potential sign/symptom of vascular impairment and cause for alarm. Yet after the physician stated he “got a pulse” the nurses left the decision to evaluate further in his hands, even though he could not explain why they were not able to detect a pulse in their assessments.
It can be argued that the ultimate course of action when treating any patient is up to the physician in charge to decide. If this had occurred in a clinic, doctor’s office, or any other setting that argument might have been made successfully and a greater responsibility apportioned to the physician However, the hospital Emergency Department that the patient initially presented to had specific procedures that were to be initiated in cases like this. By not following those policies/procedures, the nurses opened themselves and the facility to liability in this case.