Medical Malpractice Insights: Pain out of Proportion

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights


When you smell “POOP,” search for the source. 

Delayed diagnosis of compartment syndrome leads to hefty trial verdict

 

Facts: A 56-year-old carpenter suffers a L elbow and L leg fracture in a 16 foot fall from a scaffold and presents to the ED in the late afternoon. Appropriate imaging is done, the orthopedic surgeon attending is called, and the patient is admitted to the hospital. On arrival on the floor, he complains of severe pain in his L arm but not in his equally broken L leg. He and his wife both ask the nursing staff repeatedly for something for the pain. Six and 1/2 hours after admission he is finally seen by a first year resident in orthopedics. Nothing is documented about the severity, type, or location of the pain. Morphine is ordered. No mention is made of possible compartment syndrome either on that visit or a follow-up visit 3 1/2 hours later that night. The orthopedic surgeon sees the patient that morning and finds that his L hand is completely numb. A fasciotomy is done 2 hours later but the patient’s arm remains useless. An attorney is contacted, and a lawsuit filed against the resident, attending and hospital.

Plaintiff: I had a broken leg and a broken arm, but my arm pain was far worse than my leg pain. I’d never had pain like that before. It was awful and kept getting worse all night. My wife stayed with me all night asking for help. You paid no attention to it and there’s nothing in my record that shows you gave any thought to a possible compartment syndrome. Orthopedic residents should know about compartment syndrome and “pain out of proportion” (POOP) on the first day of their training. I have had to have multiple surgeries as a result of your delay in my care. My arm is deformed, I can’t work as a carpenter, and I can’t even hold a hammer or a steering wheel. You should better supervise your residents, especially at night. They should not be working shifts that last well over 24 hours or have to care for as many as 60 patients a night.

Defense: We disagree. There is no objective test for compartment syndrome. You had no classic signs. We are very sorry for your injury but do not believe our resident’s work hours were a factor in your care. You had an unusual presentation. Diagnosis was very difficult.

Result: A settlement could not be reached, and the case went to trial. The jury felt that there was clearly an avoidable delay in rendering the appropriate care, resulting in a plaintiff verdict for over $1 million against the defendant hospital.

Takeaways:

  • Compartment syndrome is a serious condition that must be diagnosed quickly and treated as an emergency.
  • The key steps in patients with severe fracture pain are:
    • Think about compartment syndrome. Include it in your evaluation and differential.
    • Perform a focused history and exam.
    • Document your medical decision-making.
  • The primary symptom is pain out of proportion (POOP) to the injury itself.
  • Other causes of POOP including necrotizing fasciitis and limb ischemia, among others.
  • Early fasciotomy is a must to prevent serious and permanent injury to the affected limb.

Reference:

emDocs – The Dreaded Acute Compartment Syndrome

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