Excellent medical care requires clear and accurate communication between health care providers. We are all aware of stories of a physician who cannot read his or her own note or the progress notes of another doctor. The scribble is indecipherable. At Kassel McVey, we had the opportunity to be involved in a case involving another type of communication problem — a problem that caused permanent neurological damage to a man who had undergone what should have been fairly routine knee surgery.
Many years ago Sean had been involved in a serious motorcycle accident. He suffered several fractures of the bones in both legs. He had surgeries that put in hardware to stabilize those bones. After a lengthy recuperation, Sean did well and was back at work. Eventually, the hardware in his left leg, below his knee, began causing pain. His orthopaedic surgeon recommended surgery to remove the offending hardware. The surgeon took Sean to the operating room and opened up the leg to get access to the hardware. He incised the skin and the subcutaneous layer, the fascia. The fascia is made of connective tissue which serves several purposes including surrounding and protecting muscles and other structures. It helps divide, for example, the lower leg into compartments, each containing muscle, nerve, and blood supply. After removing the hardware, the surgeon closed the fascia to the anterior compartment in the left leg with sutures, and closed the skin. Sean was sent home that day with pain medications.
That evening the pain got so bad that Sean and his wife went to the emergency room. He had what was described by the emergency room physician as “pain out of proportion” to the relatively minor hardware removal surgery. He had numbness in his left foot. The ER physician employed a differential diagnosis, a methodology of listing potential causes of a condition, usually by ranking the list by severity. The ER doctor was concerned about “compartment syndrome.” Compartment syndrome can be a medical emergency that if left untreated can result in limb loss. It occurs when the pressures inside a compartment exceed a certain level and are capable of choking off the blood supply to nerves and muscle. Once the pressures reach a critical point, time is critical. Serial pressure readings can be taken in the leg compartments, for example, to confirm whether compartment syndrome is brewing. The gold standard treatment once a diagnosis is made is a fasciotomy, or surgery to open the fascia and relieve the pressure.
The ER physician continued to be concerned about compartment syndrome. Pain out of proportion is a key symptom. So is numbness. Moreover, Sean was at risk for compartment syndrome, having just undergone surgery to the leg. Sean’s pain could be simply post-operative pain that would resolve over several days, or it could be impending compartment syndrome.
The ER physician called the orthopaedic service on call. He received a call back from a physician’s assistant (PA) from the orthopaedic practice. The ER physician described Sean’s presentation and relayed his concern about compartment syndrome. Then the problem arose. The PA told the ER physician that compartment syndrome was not likely since the fascia had not been closed during the recent surgery, but in fact, had purposely been left open. This “information” removed compartment syndrome from the ER doctor’s differential diagnosis. He literally blew a sigh of relief and sent Sean home with more pain pills. Sean simply had post-operative pain that would eventually resolved.
Our investigation into the case revealed some disturbing findings. The PA did not participate in the hardware removal surgery and was not even present. He had no communication with the surgeon. He did not read the operative note. He had no rational basis for concluding whether the fascia was left open or closed. He testified that he assumed the fascia was left open, but he really did not know one way or the other. He did nothing to confirm his assumption, never came to the ER to evaluate the patient, and allowed the ER doctor to send Sean home.
At home, over an hour away from the hospital, Sean’s pain continued. The next day it was worse. Sean came back to the ER. The same ER physician was working and saw Sean. He called in the orthopaedic surgeon. This time Sean was immediately taken to surgery to release the pressure. But it was too late. The nerve and muscle controlling his ability to raise up his foot (dorsiflexion) were permanently damaged. He now suffers from a drop foot and must wear a brace to keep his toes from dragging when he walks.
The PA’s willingness to assume mission-critical facts was striking in light of the testimony we received from the surgeon who performed the hardware removal surgery. He told us in no uncertain terms that in orthopaedics, doctors do not speculate, they do not assume, they instead make decisions based upon data and evidence. In this case, Sean was permanently injured because of an unsubstantiated assumption.