The Verdict is In
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Patient safety in the era of a broken healthcare system.

The case of the benched pickleball player: A 32-year-old male with a history of HTN, DM and obesity, presented to the ED for 2 days of atraumatic right leg pain. He reported his pain as moderate, and he was unable to participate in practice this week. He was hypertensive and tachycardic but did not appear toxic. The provider began the workup in the department lobby and the patient was seen in a chair. The provider noted he moved with a fairly normal gait (walking in sneakers but didn’t document that). On exam, the provider raised the patient’s pantleg and noted the right lower leg had no edema, skin color was normal, and calf tenderness was present. Ultrasound to rule DVT was negative, and it was thought symptoms may be related to sciatica. The patient felt improved after pain medication, his BP and HR improved, and he was discharged with the diagnosis of leg pain. The patient was counseled to follow-up with his PCP and given instructions on musculoskeletal pain and sciatica.

The New Normal

Overcrowding in emergency departments is unfortunately a widespread global phenomenon. With reduced capacity, understaffing, space and privacy limitations, time constraints and more, the burden of professional liability risk shifts to frontline care providers. Patients not deemed to be critical by their vitals or ESI are likely to be cared for in the hall or lobby since creative space utilization is the best we can offer with current system constraints. Our system is broken, and all parties involved are bearing the brunt of the negative consequences.

While macrolevel strategies and systemwide change is needed at a bureaucratic level, each of us can apply microlevel strategies in our daily practice to reduce the risk of patient harm. At minimum return to the basics.

  • Keep your differential broad but relevant. Challenge your thinking to rule dangerous diagnoses out.
  • Maintain a high index of suspicion for serious conditions.
  • Designate a space where a history and exam can be performed in private.
  • Take time to demonstrate how you best cared for this patient by evidencing it in your documentation.

How would you have handled this?

What would be your differential diagnosis for the patient described above? Is there enough history to have a broad differential, evaluate risk factors, and rule out dangerous causes?

What is the minimum necessary exam to rule out the dangerous causes on the differential? Was enough clothing removed to evaluate the skin and foot? Was a complete and appropriate neurovascular exam performed?

This scenario is intended to be a nudge to ask yourself: Have I done the basics? In a patient with atraumatic leg pain, what is needed to rule out infections, spinal emergencies, and vascular catastrophes?

The unexpected outcome: This patient unfortunately did not have sciatica. Two days later, he presented to another ED with 10/10 right leg pain, swelling, and a cold foot. On the exam there was no palpable or Doppler pulse. CTA of the extremity showed a large arterial embolism. His known risk factors for peripheral artery occlusion were diabetes, obesity, and hypertension. Despite multiple tPA infusions, fasciotomies and thrombectomies to salvage the limb, he ultimately had a below knee amputation.

Beat them at their game!

Plaintiffs have the burden of proof to show a failure or delay in diagnosis caused preventable harm. Their attorneys work with experts to search the medical record for inconsistencies and omissions that can be used to prove their case. An improper history and physical exam is low hanging fruit for them. Despite the failures and limitations of our current systems, if your patient testifies they were fully clothed, seen in a public space, and does not recall their shoes or socks being removed, prepare for hurdles in your defense.

In this encounter, a thorough neurovascular exam may have identified the arterial occlusion sooner and led to earlier intervention. While it’s not clear the amputation was avoidable, this is the kind of case that can go either way with a jury. The one clear way a jury aligns with the defense is to give them reasons to believe your care was thoughtful and thorough. Until larger "powers that be" address the systemic challenges and fix the broken system, going back to the basics and fundamental principles of medical care will ensure better outcomes for all involved.

Survey Questions

1. The article mentions three basic microlevel strategies to minimize risk under current difficult conditions. Which of the following is not a strategy listed?

  1. Keep a broad differential
  2. Perform your intake in a private space where you can obtain a history and complete a thorough physical exam
  3. Evidence your thorough history and exam in the medical record
  4. Rely on imaging when time and space limitations hinder the ability to obtain a history and thorough exam

2. Atraumatic leg pain does not have a narrow differential diagnosis. One must consider:

  1. Infectious pathology
  2. Vascular catastrophes
  3. Spinal emergencies
  4. All the above

3. Risk factors for peripheral artery disease include but are not limited to:

  1. Diabetes
  2. Elevated BMI
  3. High blood pressure
  4. All the above (and more)