Back Pain and Foot Discoloration [Left Leg Amputated]
Case #157
Editor’s note: This lawsuit has been covered in the press and shared widely on social media. I believe that this is the first publication of the actual expert witness opinion. Per MedMalReviewer policy, all names have been redacted.
A 35-year-old man presented to the ED on March 7.
His chief complaint was “left foot pain and turning purple”.
The triage nurse documented that the primary pain location was in his low back, he had numbness in his legs, and his left foot was cool to the touch.
Vitals were documented:
HR: 74bpm
BP: 169/97
RR: 20/min
He was assigned an ESI level of 4.
The patient was seen by a physician assistant, Mr. L.
He documented a long history of back pain and left leg numbness for weeks.
The patient told the PA that he had an MRI done 10 days previously without any noteworthy results (court records did not include the radiology report).
Exam noted “normal peripheral perfusion”.
The PA documented a differential of lumbar strain, disc herniation, sciatica, chronic back pain, and compression fracture.
He prescribed Valium and Percocet and discharged the patient home.
It does not appear that he was seen by a physician.
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6 days later (March 13) the patient returned to the ED.
The stated complaint was “foot pain” and the triage nurse documented a chief complaint of “left ankle pain, atraumatic”.
Vitals were documented:
HR 112bpm
BP 169/119
RR: 18/min
Temp: 98.4F
He was again assigned an ESI level of 4.
The patient was seen by a nurse practitioner, Mr. F.
The patient stated that he was seen previously for sciatica, that his back pain was now gone, but he had persistent left ankle pain.
He felt that the muscle relaxant had helped, but was now out of medication.
Several excerpts from the NP’s exam were included in the court records:
1+ pitting edema of the left leg
Patient was able to stand on the left leg despite reporting that he could not walk on it due to numbness of the heel and toes.
Able to extend both legs
Normal straight leg raise test
Patellar DTRs were 2+ bilaterally
Chronic numbness to outer part of left leg
Inability to dorsiflex or plantarflex the left great toe (patient reports this is chronic)
Normal capillary refill time
The NP felt that his pain was related to sciatica.
He did not refill the controlled substances, but did prescribe an anti-hypertensive (court records did not mention which one).
4 days later (March 17) he had an office visit for ongoing left leg pain.
The entire leg was mottled with no palpable pulses.
Ultrasounds of both arterial and venous vasculature were done.
He had extensive arterial thrombosis extending through the superficial femoral artery, popliteal artery, posterior tibial artery, and dorsalis pedis artery.
He had a DVT in the popliteal and posterior tibial veins.
The leg could not be salvaged and he had an above-knee amputation the next day.
The patient filed a lawsuit against the PA, the NP, and the EM group that staffed the ED.
He also sued the nurses who took care of him at each visit.
The plaintiff’s attorney hired expert witnesses.
Dr. S is a board-certified EM physician.
Dr. H is a board-certified vascular surgeon.
In this jurisdiction, the attorney writes a report describing their expert’s opinions, which are then subsequently signed by the experts:
The defense hired a PA expert:
The plaintiff requested $16,000,000 to settle the case.
After negotiating, the 2 sides could not reach a deal.
The case proceeded to trial.
The jury deliberated for 9.5 hours.
They returned a verdict for the plaintiff and awarded damages of $20,000,000.
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MedMalReviewer Analysis:
There were several things that made this a challenging diagnosis. The patient had a long history of chronic back pain and sciatica, and presented with similar symptoms. It seems that the patient checked in with foot symptoms at both visits, but for some reason kept focusing on his chronic back pain. At the 2nd visit, the NP noted reduced movement of his left toes. However, the patient apparently told him that this was chronic. It’s incumbent on a clinician to do a good history and exam, but I can also understand how the focus on back pain and the patient claiming his deficits were chronic could easily lead someone astray.
Despite the challenges, I do feel that the NP and PA fell below the standard of care. Discoloration of the foot strongly suggests vascular pathology. A chief complaint of “left foot pain and turning purple” should lead to a vascular workup in almost all circumstances.
The expert is correct to criticize the defendants for not checking pulses. From a medicolegal perspective, this should have been the main focus of the physical exam documentation. Vague notes about “normal peripheral perfusion” or capillary refill were insufficient.
I suspect that for the first few weeks, the ischemia was intermittent or due to a partial occlusion. It’s entirely possible that he could have had a palpable pulse during both visits. An acute, total occlusion would have been obvious and impossible to miss. But a subacute, partial occlusion like this is more challenging.
I was a bit surprised that the patient had both arterial occlusions and a DVT. It seems unlikely that they both occurred simultaneously. My feeling is that arterial occlusion caused the initial discoloration, and resulted in reduced movement of the leg with subsequent DVT due to immobility. Which do you think came first?
It seems that the ED group was trying to save money by having NPs and PAs staff low acuity patients without direct physician supervision. Unfortunately, this led to a massive financial penalty for the entire ED group, not just the PA and NP. The physician partners may end up paying a big price for their decision to not provide appropriate supervision. Collaborative practice between NPs/PAs and physicians with true, real-time supervision is the best ED model.
This case has many parallels to a prior lawsuit we covered, in which a patient was assigned a low triage level, seen in a “fast track” setting, and had their complaints dismissed by an NP. The very existence of a “fast track” induces medical errors due to the cognitive bias that patients are not critically ill, and that the clinician will ruin the flow of the department if they order a workup.
I have caught several vascular occlusions over the years masquerading as sciatica or benign extremity complaints. This is why it is incumbent to examine patients with back or extremity pain in a bed, undressed, with shoes off. As more and more ED’s move to the flawed “vertical flow” process that involves shuffling patients to chairs instead of beds, this becomes more challenging and these misses will become more frequent.
Good case! It reminds me of a case when I had a patient who called into my clinic asking for medications for what he thought was a gout flare of his toe. When he came in for the exam he had a blue colored toe and PVD causing his pain. Unfortunately it has become very common for patients to send mychart messages for treatment of symptoms without a physical exam, which is vital.