The lawyer representing Dave in this malpractice lawsuit asked a Legal Nurse Consultant to review the medical record to provide expert opinion on whether Nurse Donna and Nurse Lucinda had met the standards of care. Their opinion was that Donna and Lucinda had not meet the standards in two important areas; first by not assessing Dave’s leg as thoroughly and frequently as required by hospital policy. Secondly, by not communicating his pain, weakness, colour change and sensory loss to the doctor in a timely manner.
Their opinion was that Nurse Donna should have called the doctor no later than 2 a.m., when she documented that that Dave had severe weakness and tingling in his right leg. Since this did not happen, their opinion was that Nurse Lucinda should have performed a full assessment of the leg at the start of her shift at 8 a.m. and asked the doctor to see Dave immediately.
The Legal Nurse Consultant said that nursing documentation in the medical record indicated a lack of nursing knowledge and critical thinking, as well as a failure to meet the standard of care surrounding both assessment and communication. The opinion was that the lack of communication contributed to a delay in accessing medical attention, which the medical experts stated ultimately contributed to the loss of Dave’s leg. Based on this, the case settled out of court for an undisclosed amount of money.
The doctor who performed Dave’s surgery was also sued, but later released from the lawsuit when it was discovered that the nurses had not communicated significant clinical information to him. By the time the Orthopedic resident examined Dave, and contacted the surgeon on the morning after surgery, Compartment Syndrome had already caused irreversible damage. The opportunity to prevent or minimize the injury was lost.
What is Compartment Syndrome?
Compartment Syndrome is a potentially life-threatening condition caused by high pressure in a closed fascial space. The most common site of compartment syndrome is the lower leg (Abramowitz and Schepsis 1994) and young men with traumatic soft tissue injury are known to be at particular risk (McQueen et al 2000). It is a potentially devastating complication of tibial fractures which requires prompt recognition and intervention; as early intervention is critical to avoid permanent damage to the muscles and nerves.
Symptoms of compartment syndrome can include pain that is disproportionate to the injury, pallor of the affected limb, altered sensation (numbness, tingling), tension of the affected muscles, pulselessness below the level of the swelling and, as a late sign, paralysis. Post-operative narcotic administration may mask or dull pain, which is often the first symptom of compartment syndrome. Therefore, careful monitoring for the other symptoms is important.
The nursing plan of care for a patient with a traumatic fracture must include, among other things, knowledge and awareness of the possible development of compartment syndrome. Monitoring of color, warmth sensation, movement and pulse strength may be required as frequently as every 15 to 60 minutes, but certainly every four hours in the early post-operative period.
Depending on the lines of communication in your department, signs and symptoms of compartment syndrome must be reported immediately to the charge nurse and/or responsible physician. Based on the expected knowledge that early intervention is key, the nursing standard of care would be to notify the physician immediately, provide an accurate clinical picture of patient status, request a ‘hands-on’ assessment of the patient. If the physician does not respond promptly to the request for assessment, the nurse may be required to raise the level of concern, act in the best interest of the patient and persist in finding appropriate medical attention. This may require repeated pages/phone calls to the physician, refusing to take doctors’ orders over the phone, notifying the nursing supervisor or accessing the appropriate chain of command.
Chris Rokosh is a popular speaker on medical legal issues in nursing across Canada and the U.S. She is an RN and founder of Connect Medical Legal Experts, a Calgary-based leader in Expert Witness Services, with a database of hundreds of medical, nursing and cost of future care experts across the country. Explore this website for more information on courses and books on Legal Issues in Nursing and the role of the Legal Nurse Consultant.