Limb Ischemia Post-Surgery: Court Sees Grounds For Suit For Nursing Negligence.
Legal Eagle Eye Newsletter for the Nursing Profession
October 2014
The legal standard of care requires that any patient exhibiting signs or reporting symptoms of limb ischemia must be evaluated immediately.
Limb ischemia is a medical emergency requiring rapid restoration of blood flow to avoid amputation.
If the signs and symptoms are consisted with early-onset ischemia, the standard of care requires an arteriogram to confirm lack of blood flow, followed by immediate surgical intervention to restore blood flow if compromised blood flow has been detected.
For the patient’s nurses, the legal standard of care requires them to chart the patient’s complaints that point to the onset of ischemia and promptly report those complaints to the physician.
If the nurses in this case had reported the patient’s complaints promptly to the physician, the physician could have done an immediate assessment, ordered an emergency arteriogram and seen to an angioplasty to restore blood flow to the patient’s leg before tissue death had progressed to the point that amputation was necessary. COURT OF APPEALS OF TEXAS August 28, 2014
The patient came to the hospital’s emergency department by ambulance with severe abdominal pain.
The problem was diagnosed as a perforated duodenal ulcer.
An arterial line was placed in the patient’s right superficial femoral artery in preparation for abdominal surgery.
After surgery to repair the ulcer the patient awoke in the ICU, hit her right leg with her hand and then fell back asleep.
A few minutes later, when a nurse came into the room to check on the patient, family members at the bedside reported to the nurse that the patient was hitting her leg as if to complain that she was in pain.
The nurse said she would make a note of it and tell the doctor, and also told the family to tell the doctor. Fifteen minutes later the family approached the physician in the hallway and reported the patient’s apparent complaint of right leg pain. The physician told them the patient’s stomach was their main concern and they would deal with her leg after she woke up and her breathing tube was removed.
The family went back to the patient’s room and gave the patient pen and paper. The patient wrote a note that her right leg was hot and numb. The family showed the note to a nurse, who told them to tell the doctor when the doctor came back to the room. The family did not speak with the physician again that night and spent the rest of the night in the waiting area.
At 6:00 a.m. the physician discovered there was no pulse in the patient’s right leg. An angiogram followed which revealed that the catheter inserted into the right leg for the arterial line had blocked blood flow to the right leg, resulting in irreversible ischemic tissue damage. The patient’s right leg had to be amputated.
The patient’s lawsuit faulted the nurses’ failure to chart and report the patient’s complaints to the physician.
The Court of Appeals of Texas ruled the patient’s medical expert’s opinion stated grounds for a lawsuit against the hospital for the nurses’ negligence.
According to the patient’s medical expert, the six characteristic signs and symptoms of limb ischemia are:
1. Pulselessness: An absent or weak pulse in the affected limb is an early warning sign of ischemia;
2. Pain: The presence and progression of pain to the affected limb is also an early warning sign of ischemia;
3. Pallor: Paleness of the skin on the affected limb is also an early warning sign and is generally followed by cyanosis, which is a dark bluish or purplish coloration of the skin due to deficient oxygenation of the blood;
4. Poikilothermia: Unusual temperature variation, a cold or hot limb, is also an early sign of ischemia and the coolness and pallor is usually one level below the point of occlusion on the arterial tree;
5. Paresthesia: The loss of sensation for light touch, two-point discrimination and vibration is a crucial finding because it may represent the first sign of tissue loss, and;
6. Paralysis: Paralysis of the limb is an indication of advanced limb-threatening ischemia, usually requiring immediate vascular surgery to avoid amputation.
The Court did not accept the hospital’s argument that the hospital was absolved of responsibility for the nurses’ errors and omissions by the fact the physician failed to take action after the family reported the patient’s complaints of right-leg pain directly to the physician about fifteen minutes after the nurse first became aware.
At that point, according to the hospital’s attorneys, the patient’s symptoms were the physician’s problem and the hospital’s nurses had no further responsibility to monitor, assess and advocate for their patient.
The Court noted that the hospital could cite no legal authority to back up the argument it was making, because apparently there is no such legal authority. In a healthcare malpractice case various providers in different specialties can be held negligent concurrently for the same bad outcome. Hospital v. McBride, 2014 WL 4260121 (Tex. App., August 28, 2014).
More references from nursinglaw.com
http://www.nursinglaw.com/ischemia.htm