The Doctor’s Advocate | Second Quarter 2013
An Ounce of Prevention
A Failure to Rescue
Dr. Jerrald Goldman and Dr. Jacqueline Ross explore the patient safety issues and risk factors surrounding a time-sensitive orthopedic complication.
—Robin Diamond, JD, RN; AHA Fellow–Patient Safety Leadership; Chief Patient Safety Officer, Department of Patient Safety
The 36-year-old male came to a local community hospital with pain and swelling in his left leg after a fall. The patient was diagnosed with a severe tibial plateau fracture (Schatzker VI) by our insured, the attending orthopedic surgeon.
That evening, the patient had an external fixation under spinal anesthesia. The next morning, he complained of decreased sensation in his foot and some loss of movement in his left toes. By mid-afternoon, the patient reported no sensation below mid-calf. The nurse noted that compartments were soft, and there was no pain with passive range of motion. The orthopedic surgeon was given this information.
Throughout the evening, the patient had ongoing complaints of pain and was treated with narcotics and elevation. The orthopedic surgeon, aware of this information, added Decadron every six hours to the order.
The following morning, nurses used Doppler to check for pulses. By late morning, the patient’s calf measurement was 14 inches. The orthopedic surgeon examined the patient and noted that he had no motor function. That evening, the leg measurement remained at 14 inches.
A CT of the left leg was performed the next day. That evening, the patient was medicated for a sudden increase in pain. Shortly before midnight, the left calf measurement increased to 14.25 inches.
Nursing documentation did not indicate that a physician was called with this new finding.
Late in the afternoon of the next day, the orthopedic surgeon saw the patient, who continued to complain of ongoing pain, decreased sensation, numbness, and an inability to move his foot.
The next day, the orthopedic surgeon returned the patient to the OR for an open reduction and internal fixation. He noted that all compartments were open and viable.
In the postanesthesia care unit (PACU), the nurses noted a delay in the patient’s capillary refill and no movement of his foot. Twenty-five minutes later, there was no dorsal pedis pulse. The orthopedic surgeon was called and saw the patient 40 minutes later. At that time, the patient complained of leg pain as a nine on a 1–10 scale.
The orthopedic surgeon noted there was no pulse per Doppler. The patient’s temperature was 101 and then rose to 101.6 with a heart rate of 135. The surgeon was aware of the vital signs. A stat spiral CT and arterial blood gas (ABG) were ordered. The CT was negative for pulmonary embolus. ABG showed metabolic acidosis.
At this point, the orthopedic surgeon ordered a hospitalist consult. Three-and-a-half hours after entering the PACU, the patient’s foot was mottled. He was sent to ICU.
There were no pulses per Doppler in the left lower extremity, and the patient had no sensation. In addition, his left foot was tight and had +2 edema. The hospitalist arrived within the hour and noted a mottled left foot. The orthopedic surgeon was aware of the finding, thought the leg would improve, and said he would follow the patient. Three hours later, the surgeon was called by two RNs with the findings of “no pulses, leg tight, calf hard, cap refill > 5 sec.” The surgeon came to the bedside in 30 minutes and examined the patient.
The following morning, the orthopedic surgeon again examined the patient, who was still unable to feel or move his toes. His creatinine kinase was elevated at 28,000. In the early afternoon, the surgeon stated he had talked with a vascular doctor. The patient continued to have complaints of pain and numbness.
The next morning, the patient was seen by the orthopedic surgeon, who noted “continued no sensation, foot warm, compartment not tight, and had pulse with Doppler.” The impression was possible hematoma compressing a nerve. The patient received two units of packed red blood cells. An ultrasound was conducted and showed no deep vein thrombosis.
Around noon on the following day, the hospitalist ordered a CT to rule out a compressed nerve. An hour later, the patient complained that his left foot felt very tight and painful. The orthopedic surgeon was notified of this new complaint.
The patient was sent to CT within 30 minutes of the hospitalist’s order, and the CT was read less than 45 minutes later as possible compartment syndrome. Again, the orthopedic surgeon was made aware of the findings immediately. When he arrived in the ICU two hours later, he removed the staples and sutures and opened the incisions. Neurosurgery was consulted, and the patient was diagnosed with ischemic compartment syndrome. He continued to complain of pain and frequently requested transfer to another facility.
Three days later, the patient was sent to the OR for wound closure. He suffered a 50 percent loss of anterolateral muscle. The patient was transferred two days later to a tertiary hospital and underwent additional surgeries. He now has extensive muscle loss, neuropathic pain, and foot drop, and he needs a brace to walk. In the future, he may need a below-knee amputation due to chronic wound breakdown.
The Expert’s Opinion
The orthopedic surgeon had the skills required to manage the fracture. Although preoperatively he described the patient’s foot as gray, cool, pulseless, and mottled, he did not develop a differential diagnosis. In particular, he failed to consider the dangerous conditions of compartment syndrome or a vascular injury. He needed to recognize not just the bone pathology, but the soft tissue damage as well.
When using an external fixator with a leg already swollen—which can further tighten the muscle compartments—there must be increased vigilance in watching for a developing compartment syndrome. This patient had the signs of compartment syndrome: pain, pallor, paralysis, and pulse deficits.
Patient Safety Lessons
The overall lesson in this case was the lack of recognition of an evolving compartment syndrome. Clearly, this patient had a very serious, complex fracture that could entail various complications. The orthopedic surgeon failed to consider alternative diagnoses.
Patient Safety Tips
- Don’t stop at the first diagnosis. Ask what else might happen or may be going on.
- Train for predictability. When known complications might occur, make sure the team is aware of what to look for and how you plan to treat any complications.
- Don’t rely on memory. In this case, the orthopedic surgeon should have reviewed how to manage a complicated fracture.
- Use your team. Consult with your pharmacist on medication management.
- Make sure the team is available to treat the patient. In this case, surgery for fasciotomies should have occurred quickly rather than using CT or vascular consults.
- Have nurses and physicians use a structured communication process, such as SBAR (Situation, Background, Assessment, Recommendation) to communicate critical or worrisome findings.
- Bring situational awareness to the table. Using the mnemonic “CUS” (“I’m Concerned, I’m Uncomfortable, this is a Safety issue”) will direct attention to issues that others may not see (i.e., the big picture).
- Anticipate that failure can occur. When you consider that something might go wrong, you can then be prepared to rescue success from failure.
- Prevent planning pitfalls. Avoid making the wrong—or inadequate—plan or not planning for the possibility of failure.