Lacerated artery. Health, Medicine, Nursing Case Study

Physician Dismisses Nursing Assessments, Question of Nurse Advocacy.
Rowe v. Sisters of Pallottine Missionary Society, 2001 WL 1585453 S.E.2e – WV
Summary: The patient was involved in a motorcycle accident in which his bike fell onto and injured his left leg. When the nurses assessing the patient could not detect a pulse in that leg, an ominous sign of circulatory failure. The physician when notified chose to dismiss this fact and discharge the patient. The patient would return soon after with worsening symptoms that would require emergency surgery.
The patient was involved in a single vehicle accident involving his motorcycle and brought to the Emergency Department for left leg injuries, specifically a knee injury. While riding he had lost control and when he fell was pinned under his bike.
“Single vehicle motorcycle crashes account for about 45 percent of all motorcyclist fatalities. More than 38,000 motorcyclists have died in single vehicle motorcycle crashes between 1975 and 1999. The report claims to provide data for insight into possible causes for these fatalities. According to the report, from 1990 through 1999, there were a total of 11,038 fatal single vehicle motorcycle crashes. During that same time period, there were an estimated 294,000 non-fatal single vehicle motorcycle crashes.”2
In the course of a detailed assessment and evaluation by the Nursing staff, it was noted that the patient had no detectable pulse in the left leg or foot. The patient was also complaining of severe pain and numbness in that leg.
In some patients a pulse may be difficult to palpate, or not detectable at all by touch under normal circumstances. In those patients a “Doppler Ultrasound” can be performed which is more sensitive for detecting pulses not detectable otherwise. Though performed several times in different areas, even with the Doppler, no pulse was detected by the nurses.
“There are many ways to test blood flow to the lower legs. In Doppler testing, an inflatable blood pressure cuff is placed around the leg or ankle while an ultrasound probe tracks the blood flow. This test may be performed after treadmill exercise. Diminished or absent pulses in certain vessels are a tip-off of blockages. The doctor is also likely to compare the blood pressure in your leg to the blood pressure in your arm, a measurement called the ankle-brachial index (ABI).”3
A primary concern at that point to a nurse or physician should have been impaired circulation to the leg. Compromised circulation in any part of the body is a medical emergency which can lead to severe damage and the loss of a limb. The nurses appropriately brought this to the attention of the physician who would also examine the patient.
In the physician’s examination, he noted the pain, swelling and tenderness in the knee also noted by the nurses. However, he would document that he did find a pulse in the leg, though with difficulty.
When questioned by the Nursing staff on why, even with the aid of the Doppler Ultrasound, they were unable to detect a pulse, no explanation was offered by the physician.
As far as he was concerned, a pulse was present, the pain was due to a “severe sprain” and the patient could be discharged. His instructions to the patient were to go home, rest, elevate the leg, apply ice to keep the swelling down and to follow-up with an Orthopedic Physician in a few days.
It should be noted that the physician also reviewed an x-ray of the knee which showed bone “fragments” in the knee area representing acute injury. The patient was discharged.
The Nursing staff made the patient aware that they had been unable to detect a pulse in the leg and explained that it “possibly” could be due to the swelling from the injury. They instructed the patient to call or return to the hospital if the pain got worse or did not begin to subside.
That evening, the pain intensified, and the swelling got worse throughout the night. The patient then contacted another physician who agreed to take a look at his leg. The patient would present in the morning to a different Emergency Department.
On examination at this hospital, a working diagnosis of a dislocated knee and lacerated popliteal artery was made. The severity of the damage to the patient’s leg was enough to prompt the physician to consider amputation. The patient was fortunate in that there were experienced surgeons on hand to perform emergent surgery and save his leg.
The patient would spend a total of thirty-five days in the hospital following the surgery and never fully regain function of his leg. He would sue the hospital where he was initially treated and the physician who originally sent him home following his injury.
It was claimed that the nurses, even though they picked up signs/symptoms of a medical emergency in their assessments, did not do enough to see that those concerns were addressed by the physician on duty. They would argue that had the matter been pursued further, the patient’s true injuries could have been diagnosed and treated earlier. Earlier treatment could have prevented the permanent damage and injuries the patient would sustain due to a delay in treatment.
Questions to be answered.
1. Should the nurses have initially pressed for further action, treatment when the physician discharged the patient? Why or why not?
2. When the physician dismissed their concerns, should they have gone over his head?