Summary: The patient’s left leg was injured in a motorcycle accident when his bike fell on it. The nurses who assessed the patient observed no pulse in the injured leg, indicating circulatory failure. Despite being informed of this concerning sign, the physician chose to ignore it and discharged the patient. However, shortly after leaving the hospital, the patient came back with worsening symptoms necessitating immediate surgery. Should the nurses have been more persistent in advocating for further action and treatment from the start?
The patient arrived in the Emergency Department after a solitary motorcycle accident resulting in injuries to his left leg, particularly his knee. During the incident, he lost control and became trapped beneath his bike. “About 45 percent of motorcyclist deaths are attributed to single vehicle crashes. From 1975 to 1999, over 38,000 motorcyclists have perished in these types of accidents.” The report aims to offer data for better understanding the potential reasons behind these fatalities.
According to the report, there were 11,038 fatal single vehicle motorcycle crashes and approximately 294,000 non-fatal single vehicle motorcycle crashes from 1990 to 1999. During the comprehensive evaluation by the Nursing staff, it was noted that the patient lacked a pulse in their left leg or foot and also reported severe pain and numbness in that leg. In certain situations, palpating a pulse can be difficult or even impossible to do by touch.
The use of “Doppler Ultrasound” in patients without a detectable pulse can enhance the sensitivity in identifying pulses. Despite multiple attempts using Doppler, nurses were unable to detect any pulses in various areas. Different methods exist for assessing blood flow to the lower legs. One such method is Doppler testing, which entails placing an inflatable blood pressure cuff on the leg or ankle and tracking the blood flow with an ultrasound probe. This examination may be conducted after exercising on a treadmill. The absence or decrease of pulses in certain blood vessels signifies blockages.
The doctor will evaluate the blood pressure in both your leg and arm, which is called the ankle-brachial index (ABI). Impaired circulation to the leg should be a concern for nurses or physicians, as compromised circulation in any part of the body can be a medical emergency that may result in severe damage and possible limb loss. The nurses alerted the physician about this matter, who subsequently examined the patient. While examining, the physician noted pain, swelling, and tenderness in the knee that were mentioned by the nurses.
Although the nursing staff were unable to detect a pulse in the leg using Doppler Ultrasound, the physician confirmed that a pulse was found, albeit it being difficult. The physician did not provide an explanation for this discrepancy but believed that there was indeed a pulse and attributed the pain to a “severe sprain”. Consequently, the patient was instructed to go home, rest, elevate the leg, apply ice to reduce swelling, and follow up with an Orthopedic Physician in a few days.
The physician reviewed an x-ray of the knee and found bone “fragments” indicating an acute injury. However, despite this discovery, the patient was discharged. The Nursing staff informed the patient that they could not find a pulse in the leg and suggested that it may be due to swelling from the injury. They recommended contacting the hospital if the pain worsened or did not improve. Nevertheless, during the night, the pain became severe and swelling increased.
The patient requested a second opinion from another doctor who agreed to assess his leg. The patient intended to visit a different Emergency Department the following morning. During the examination at this hospital, a provisional diagnosis of a dislocated knee and a lacerated popliteal artery was made. The severity of the leg injury prompted the physician to consider amputation. Thankfully, proficient surgeons were accessible for prompt surgery, which successfully preserved the patient’s leg. Following the procedure, the patient stayed in the hospital for thirty-five days but never fully recovered functionality in his leg.
He would sue the hospital and the physician who discharged him after his injury. The physician’s side settled the case outside of court for $275,000. The nurses at the hospital went to trial, accusing them of not taking sufficient action despite noticing signs of a medical emergency during their assessments. They argued that if they had pursued the matter further, they could have diagnosed and treated the patient’s actual injuries earlier.
Earlier treatment could have prevented permanent damage and injuries resulting from a delay in treatment. The hospital’s Nursing staff’s negligence resulted in the plaintiff being awarded $880,000 in a jury trial. The hospital intends to appeal. The questions that must be addressed are: 1. Did the Nursing staff have a duty to accurately assess and detect the patient’s injuries within their scope of practice? 2. Did the Nursing staff take sufficient measures to ensure proper evaluation of the signs/symptoms of the patient’s potential injuries?
3. Despite the physician dismissing their concerns, it is important to acknowledge that Emergency Department nurses have a responsibility to thoroughly assess and accurately evaluate the condition and potential injuries of patients under their care. It should be noted that in this particular case, the absence of a pulse in both palpation and Doppler Ultrasound after a knee injury should have raised significant concerns about vascular impairment and warranted further evaluation. The Nursing staff appropriately documented their findings extensively and reported them to the physician responsible for treating the patient.
Upon reviewing the medical chart, it became evident that the patient’s condition had potential for an emergency. Additionally, it was obvious that both the physician and nurses disregarded the patient’s symptoms. The hospital policies explicitly state that if a nurse believes the patient is not receiving proper care, they must inform a hospital supervisor. If the issue remains unresolved after notification, it should be escalated through the chain of command until resolved.
In addition to questioning inappropriate medication orders, nurses have a responsibility to question potential misdiagnoses. It is important for nurses to inquire about the reasons behind treatments, evaluations, and decisions not to perform them. When a patient’s injured extremity shows no pulse, it indicates possible vascular impairment and raises concerns. Despite the physician claiming to have detected a pulse, the nurses should have questioned why they were unable to detect it during their assessments.
While the physician in charge holds the responsibility for treating patients, this argument may have been effective in a clinic or doctor’s office where the doctor possesses more independence. However, in the hospital Emergency Department, there are prescribed procedures that must be followed. Failing to comply with these policies puts both the nurses and the facility at risk of liability in this particular situation.
