Failure to diagnose arterial thrombosis

by Olga Maystruk, Designer and Brand Strategist, and
Tamara Vasquez, Risk Management Representative

Presentation
On May 1, a 60-year-old man came to the Emergency Department (ED) with severe right foot pain. The patient had a history of cancer, foot surgery nine years earlier, and a recent diagnosis of deep vein thrombosis (DVT). He was taking various medications, including apixaban.

Physician action
The ED nurse performed a physical exam and documented the right popliteal pulse of 2+. The patient’s emergency severity index (ESI) was determined to be 3. The emergency medicine (EM) physician examined the patient and documented normal range of motion, no edema in the legs, and no calf tenderness. He ordered a venous doppler ultrasound of the patient’s right lower leg and an X-ray of the patient’s right foot. Neither study showed evidence of DVT.

The EM physician discharged the patient with a prescription for tramadol. The patient was instructed to seek help if there was change in color or if the foot became hot to the touch.

On May 3, the man returned to the ED reporting continued severe right foot pain. The patient’s ESI was determined to be a 4. The triage nurse noted that a DVT had been ruled out during the patient’s visit two days before. The nursing staff documented the patient’s peripheral vascular and integumentary systems being within defined limits.

The patient was seen by a physician assistant (PA) who documented no calf tenderness, no edema, no erythema, and no bruising on the foot. The patient was noted to have 4/5 muscle strength in his right lower leg, a normal gait, and a normal capillary refill. The PA reviewed the foot X-rays and doppler ultrasound from two days before and diagnosed acute pain of the right foot and plantar fasciitis. The PA recommended rest, ice, compression, right foot elevation, and a follow-up visit with a podiatrist in two days.

The next day, the man went to a different ED reporting unrelenting right foot pain with skin discoloration. No pedal pulses could be found. The CT angiogram showed a near occlusive thrombus in the right external iliac artery with more than 75 percent of the lumen narrowing. The CT also revealed a gallbladder mass invading the liver, the pancreas, and associated hepatic artery and portal vein.

On May 5, the patient was placed on a heparin drip and received a thrombectomy.

The following day, the patient underwent a four-compartment fasciotomy. On May 16, he was discharged to a skilled nursing facility with enoxaparin for anticoagulation.

Four days later, the patient was re-admitted to the hospital due to ischemic changes in the right foot. The patient underwent a below-knee amputation on the right side. He was discharged to a rehabilitation facility on May 30.

Later that year, the patient was diagnosed with Stage 3 gallbladder cancer, for which he received chemotherapy and radiation treatments.

Allegations
A lawsuit was filed against the EM physician and the PA alleging failure to diagnose arterial thrombosis resulting in below-knee amputation.

Legal implications
Consultants for the plaintiff stated that both defendant providers failed to perform appropriate diagnostic testing such as an ultrasound, a CT angiogram, and a vascular consult.

One of the defense experts felt that this patient likely had a migratory thrombotic disorder (Trousseau’s Syndrome) related to his undiagnosed gallbladder cancer. The migratory aspect of this condition results in patients developing clots transiently which appear and disappear in different parts of the body. The patient experienced re-thrombosis despite successful thrombectomy and treatment with anticoagulation. The consultant concluded that the patient’s deterioration and ultimate need for amputation was caused by his underlying conditions and was inevitable despite optimal care.

During his deposition, the patient testified that both defendants’ physical examinations included checking the pulses on his right lower leg. However, the physician failed to document those checks being performed, and the PA noted “normal pulses.” One defense consultant noted that the patient’s history obtained in the ED at both visits was inadequate. While the experts for the defense all agreed that both treatments fell within the standard of care, they noted that incomplete documentation decreased the case’s defensibility.

Disposition
The case was settled on behalf of the EM physician and the PA.

Risk management considerations
The patient had multiple risk factors that increased the risk for thrombosis including his age, history of blood clots, obesity, smoking, and history of cancer. Medical history should be closely reviewed by providers to help identify a patient at higher risk for thrombosis. Consultants for this case noted that the patient’s complete medical history was not well documented.

There was conflicting documentation about whether the patient was taking apixaban or warfarin. The patient record did not include whether medication reconciliation was conducted or whether the patient was compliant with his medications.

Diagnostic imaging was ordered and reviewed but no laboratory work was ordered. Rationale for this was also missing from the documentation. The physical assessment notes excluded specific pedal pulse checks.

Timely and complete documentation in the medical record is a crucial component of quality patient care and is critical to the defense in the event of a liability clam. The Texas Administrative Code, chapter 165, provides full and clear documentation requirements for Texas physicians, including:

“1. (A) reason for the encounter and relevant history, physical examination findings and prior diagnostic test results…
4. The patient's progress, including response to treatment, change in diagnosis, and patient's non-compliance...” (1)

Physicians practicing outside of Texas should refer to their state medical board for documentation guidelines and guidance.

On the patient’s May 3 visit, his symptoms had changed to include decreased strength, limited plantar/dorsiflexion, tenderness, and joint swelling. The PA reviewed the imaging from May 1 but did not order new imaging or laboratory work or document his rationale for not ordering new tests. The PA also erroneously documented that imaging was conducted 2-3 weeks earlier, rather than 2-3 days earlier when the imaging actually occurred.

While there was a physician available onsite in the ED during the patient’s second visit, the PA did not consult the physician during this patient visit.

According to the American College of Emergency Physicians (ACEP), “PAs and NPs should not perform independent, unsupervised care in the ED.” While the “gold standard” for ED care is care provided by an emergency physician, if PAs and NPs are used “for providing emergency department care, the standard is onsite supervision by an emergency physician.” The emergency physician must have the real-time opportunity to be involved in the contemporaneous care of a patient. (2)

Written protocols for the supervision of advanced practice providers (APPs) working in the ED should be developed.

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