Top 25 Medical Malpractice Cases of a 25 Year Career – Acute Compartment Syndrome
Medical malpractice cases are very complex.
In this series of articles BC and Alberta personal injury and medical malpractice lawyer Angela Price-Stephens describes her top 25 notable medical malpractice cases of her 25-year career to date. Her selection of cases is a representation of the breadth of her experience, the complexity of cases, the twists and turns in the evidence and the dramatic benefit to her clients and their respective families by successfully pursuing their claim with Angela and her team.
Angela has litigated cases across Canada and England and Wales. The names and distinguishing details of the cases referred to in this series of articles have been changed to protect the client. In all cases of settlement for medical malpractice the lawyers for the defendant healthcare providers insist on a confidentiality clause in which the existence of a settlement (payout of money to the former patient, irrespective of whether an admission of liability was made) must remain a secret.
In the fourth of this series of articles we look at the case of Tom, a 32-year-old corrections officer who sustained closed (not piercing the skin) fractures to his lower left leg (tibia and fibula) in a cross-country skiing accident. The failure to diagnose and treat acute compartment syndrome caused the loss of the entire muscle in the lower leg leading to ‘drop foot’, reduced ability to walk and chronic pain.
What is Acute Compartment Syndrome?
The muscles within the lower leg are enclosed within four separate ‘compartments’. The compartments are made up of relatively inelastic fibers. Acute compartment syndrome occurs when the pressure of the tissue within a closed compartment is greater than the pressure in which the blood is perfused through the tissue. The pressure increases due to trauma to the leg including broken bones, bleeding into the compartments and swelling. The blood supply is essentially ‘squeezed’ off to the tissue. Over a period of hours increasing damage is done to the tissue, including nerves. After a certain period of time without blood the tissue dies. The critical time period, after which death of tissue occurs, is approximately 6 hours.
Failure to Recognize the Risks
Tom was a fit and very active young man when he sustained the fractures to his lower leg. He was attended to quite quickly on the mountain side and taken by ambulance to the local hospital in the Interior of BC. He arrived at the hospital within 2 hours of the accident. There was a significant delay in Tom being assessed by the doctor in the emergency department. The emergency room physician called for an orthopedic surgeon and Tom was taken into surgery to reduce (put back into place) the fractures. Despite the reduction of the fractures the increasing level of pain reported by Tom after surgery ought to have been a red flag to the doctor and nursing staff that acute compartment syndrome was developing. Tom was kept in hospital overnight for observation, but the observation ordered was inadequate. There were very limited nursing records of the appearance of the leg (including colour and swelling) or pulses at the ankle or pain level. The defendant nurses gave evidence at discovery that they ‘charted by exception’ meaning they would only note a sign or symptoms if it was outside what was expected in the circumstances. Angela argued that ‘charting by exception’ is not appropriate in a post-surgical situation and in any event such a charting technique is only acceptable when the hospital has an appropriate protocol in place authorizing such a practice. No such protocol was in place.
Premature Discharge from Hospital
The following afternoon the orthopedic surgeon gave a verbal order authorizing discharge, without undertaking a bedside review. When this order was conveyed to Tom he asked not to be discharged. He was in too much pain. The extent of the swelling to Tom’s lower leg, increasing pain and numbness to his foot where not properly documented or communicated to the doctor. Tom was sent home with oral painkillers with follow up to the orthopedic clinic, despite his wish to remain in hospital. A nurse, identified during the proceedings, told him pain after surgery was normal and not to make a fuss.
In the first few hours at home he called the hospital twice trying to obtain more effective pain relief. He described the pain as unbearable. A review of the chart confirmed that Tom had been on an intravenous Patient Controlled Anesthesia (PCA) right up to the time of discharge. There had been no weaning of the PCA and no proper pain control established prior to his discharge.
Tom called a friend and neighbour to help him. The friend was also a nurse and on arriving at his home recognized that the pain was excessive for a post-operative condition. She also gave evidence as to the abnormal swelling and paleness of the foot and lower leg. The foot was cool to the touch. She recognized the medical emergency and called an ambulance to take Tom back to the hospital. On arrival at emergency Tom was once again falsely reassured and given intravenous morphine. It was late that same evening that the acute compartment syndrome was recognized.
The only definitive treatment for acute compartment syndrome is cutting into each of the affected compartments (fasciotomy) along the length of the lower leg to reduce the pressure in the compartment. By the time this procedure was undertaken in Tom’s case more than 36 hours had elapsed since the original surgery. An extensive amount of muscle and soft tissue had died. The dead tissue was removed and the wounds left open to allow the full extent of the necrotic tissue to declare itself. Further debridement (removal of dead tissue) was required. By the final debridement no muscle in the lower leg remained.
A common complication of a delay in treatment of compartment syndrome is infection. Tom suffered extensive infection which spread to his bone (osteomyelitis). It was resistant to treatment and likely contributed to the extent of soft tissue lost.
Tom was away from work for 5 months and had a graduated return to work over a 3 month period. Rehabilitation was limited in that the complete loss of muscle in this lower leg meant he was unable to control his foot and ankle. He required a device to keep his foot in position to assist him walking. His gait was permanently affected which caused lower back and hip pain as his body compensated for the pronounced limp. He had chronic pain in his lower leg which remained a daily experience almost 4 years after the injury and was likely permanent.
Through expert evidence Angela demonstrated that acute compartment syndrome ought to have been a recognized, if not anticipated, complication of trauma to the lower leg. Both the doctor and the nurses failed to recognize this risk and to take steps to monitor for the condition. Nursing notes were inadequate to establish what monitoring had been undertaken. There was a breakdown in communication between the doctor and staff nurses with regard to Tom’s condition in the post-surgery phase and at discharge. It was a breach of standard of care for the doctor to discharge Tom without a bedside assessment and so soon after surgery, given the ongoing risks of developing acute compartment syndrome.
The weight of the evidence against the doctor and health authority, including the nurses, was significant. It was established that had the acute compartment syndrome been recognized and treated in a timely manner, Tom would likely have recovered from his fractures without permanent pain or dysfunction.
A further expert evidence was obtained to establish the full extent of the losses suffered by Tom as a result of the negligent delay in diagnosis and treatment of the compartment syndrome. This included the loss of past wages, the reduced capacity to earn an income and cost of future care.
The case was settled on favourable terms at mediation.
Angela Price-Stephens is an English and Canadian lawyer who focuses on serious personal injury arising from the negligence of others, mostly health care professionals. Of her 25-year career approximately half of that time has been spent defending health authorities, doctors and other healthcare professionals. That experience is now used exclusively for the benefit of injured patients.
For more information on this article, or for a confidential discussion of your claim, contact Angela Price-Stephens at 250 869 1124, or send her a confidential email at firstname.lastname@example.org.