85 year old patient sent to skilled nursing facility for rehab. COVID patient with a history of diabetes mellitus with diabetic neuropathy and falls. Two weeks into the admission staff observes non-pitting edema in left foot. Orders obtained from the attending for a left foot venous ultrasound.
Attending performs a telemedicine consult the next day (day 2). He charts the presence of constant, mild bilateral foot pain. Believing it to be neuropathic pain, he increases the patient’s gabapentin. No mention of the ultrasound or the results. A nurse charts that the edema is still present in the foot, which is now cool to the touch with faint pedal pulse. The nurse notes that the doctor is made aware.
A remote radiologist reviews the ultrasound performed on day 2. He finds no blood flow in the posterior tibial ven and contacts the ‘emergent connect system.’ He gives report and confirms read back.
Three days later( day 5), the nurse charts that she reviewed the results with the attending. It’s a late entry but supposedly this communication happened on day 2. The attending's note from day 5 does not mention the conversation with the nurse or the results of the ultrasound. However, the attending orders the patient to be transferred to a local hospital where he ultimately undergoes a left leg below the knee amputation.
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Do you believe there might have been medical error?
this is an elderly gentleman who was recovering from covid which is known to cause thromboembolic events. He probably also had very limited mobility secondary to being on isolation because of the comorbid and the excessive fatigue and weakness associated with covert infections. So he had at least 3 risk factors for thromboembolic event, his age, his limited mobility, and covid not to mention his other comorbidities. The clinician subsequently should have had a high index of suspicion for thromboembolic event from the get go. another possibility could be that the nurse failed to notify the physician about the results of the ultrasound and the case the building would be liable.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
this patient most probably had some degree of peripheral vascular disease. This coupled with diabetes and the swelling related to his DVT could have significantly impeded the blood flow to the lower extremity that caused the amputation. He probably was doing okay prior to the but the increased pressure caused an extrinsic occlusion of the arterial circulation to the lower extremity
What makes you a good expert for this case?
I have been practicing postacute care medicine for around 25 years and over the last year taking care of over 500 covid patients both in the acute and postacute care arena
How often do you encounter cases similar to this one in your practice?
as mentioned above I have taking care of over 500 covid patients over the last year. so I would say very frequently
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