This case involves the care and treatment of an adult patient who presented to the emergency department of a Level II trauma center following a crush injury to the right foot sustained at a construction site. At approximately 11:00 a.m. on March 18, 2024, a steel beam weighing approximately 1,000 pounds fell onto the patient’s right foot while he was working. The patient initially sought care at an urgent care facility where preliminary imaging was performed. Because of the severity of the injury and the limited capabilities of the urgent care center, the patient was directed to the nearest emergency department for further evaluation and treatment.
The patient arrived at the Level II trauma center emergency department at approximately 1:45 p.m. Radiographs of the foot and ankle were obtained and interpreted as demonstrating findings concerning for a midfoot fracture and possible dislocation. The emergency department physician documented several clinical findings that raised concern for compartment syndrome, including severe pain reported as 10 out of 10, significant swelling of the foot, a tense and swollen appearance of the foot, pain with dorsiflexion of the toes, and decreased two-point discrimination. Based on these findings and the crush injury mechanism, the emergency physician documented concern for a possible developing compartment syndrome and sought consultation from the on-call orthopedic surgeon.
The medical records indicate that the emergency department physician attempted to contact the on-call orthopedic surgeon multiple times. At some point, communication occurred between the emergency department and the on-call trauma surgeon, who relayed that he had spoken with the orthopedic surgeon while the surgeon was in the operating room. According to the documentation, the orthopedic surgeon and trauma surgeon were both in the hospital and indicated that the fracture pattern was concerning and suggested that the patient required evaluation by podiatry and/or transfer to another facility for further assessment, as podiatry services were not available at the presenting hospital. Neither the trauma surgeon nor the orthopedic surgeon came to the emergency department to evaluate the patient in person.
Following this recommendation, the emergency department began efforts to transfer the patient to another hospital. A centralized transfer center became involved in attempting to locate a facility that would accept the patient for further evaluation and treatment. The transfer process encountered delays while attempts were made to identify a receiving hospital. Ultimately, at approximately 5:45 p.m., another hospital accepted the patient for transfer on behalf of their orthopedic service.
During discussions with the receiving orthopedic surgeon, concern was expressed regarding the time-sensitive nature of compartment syndrome and the limited window in which fasciotomy should be performed to prevent irreversible tissue injury. Despite acceptance of the transfer in the late afternoon, transportation was not immediately available. Because the receiving hospital was located approximately 160 to 165 miles away, the decision was made to transport the patient by medical helicopter. According to the transfer center documentation, the flight remained pending at the time of the 8:00 p.m. shift change.
The patient ultimately departed the Level II trauma center by helicopter at approximately 8:51 p.m. and arrived at the receiving hospital at approximately 11:30 p.m., nearly twelve hours after the original injury occurred. After evaluation at the receiving hospital, the orthopedic surgeon confirmed the diagnosis of right foot compartment syndrome and the patient underwent emergent fasciotomies in the early morning hours of March 19, 2024. The patient remained hospitalized for several days and was discharged on March 21, 2024.
Following the injury and surgical intervention, the patient has experienced ongoing complications involving the right foot, including persistent swelling, nerve injury, chronic pain, impaired ambulation, difficulty walking, and decreased range of motion. The patient continues to seek medical treatment for these symptoms and functional limitations.
The case presents several issues for expert review. These include the standard of care applicable to the evaluation and management of suspected compartment syndrome following a crush injury, the obligations of an on-call trauma surgeon when contacted by the emergency department regarding a potential compartment syndrome, and whether the trauma surgeon should have personally evaluated the patient and provided definitive surgical treatment at the presenting Level II trauma center.
There were several Level I and Level II trauma centers located closer than the receiving facility that ultimately accepted the patient. The receiving facility was in the same health system as the transferring system.
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Do you believe there might have been medical error?
1. Compartment syndrome of the foot is a difficult diagnosis with specialized management often left to the foot and ankle orthopedic specialists rather than trauma surgeons or general orthopedic surgeons. 2. It would have been reasonable for the index facility to try their best at decompressing the foot prior to transfer as it is not uncommon for transfers to encounter delays, even if the decompression is not perfect, rather than risk delays in decompression due to transfer. 3. It is difficult to attribute much of the residual symptoms and dysfunction legally to the delay in compartment rather than the injury and fracture itself, but it is more likely than not that the delay contributed to these residual deficits and symptoms.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
see above response, #3 has the details
What makes you a good expert for this case?
I am a trauma surgeon who deals with compartment syndrome of the extremities and abdomen on a weekly basis and make the judgment of diagnosis and whether to offer surgery or not on a weekly basis. I work at the busiest level I trauma center in New England, and am a professor of surgery at Harvard Medical School. I am also a nationally reknown safety and quality expert, and served previously as the Chief Patient Safety Officer of The Joint Commission.
How often do you encounter cases similar to this one in your practice?
weekly- very often. I also review cases if there is suspicion of delays in care on a daily basis
Do you believe there might have been medical error?
Either the orthopedic surgeon or trauma surgeon should have come to personally evaluate the patient. Compartment syndrome is a time sensitive diagnosis which would’ve been better treated locally and then transfer if transfer is absolutely necessary, but knowing the logistics of transport to another facility should have raised concern that this would not be taken care of in a timely manner. This could’ve had even more disastrous complications like foot amputation.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Post injury nerve damage is likely due to a prolonged compartment syndrome, which may not have been an issue had the compartment been relieved in a timely fashion.
What makes you a good expert for this case?
I currently function as Trauma medical Director and actively participate in the care of traumatically injured patients. I am bored certified in surgical critical care and General Surgery. I am asked to evaluate these types of cases in my clinical practice regularly.
How often do you encounter cases similar to this one in your practice?
Couple times a year. Most compartment syndrome rule outs do not end up needing fasciotomy, however those that do require that it be done in a timely manner as a surgical emergency usually.
Do you believe there might have been medical error?
Based on the information available, there are multiple medical errors and more specifically, systems errors that occurred in this case. It is never acceptable to delay trauma and orthopedic evaluation for this type of patient especially when the ER physician has already expressed concern for compartment syndrome. This is considered an emergent consultation that requires evaluation within the hour. The patient presented as a clear mechanism that required evaluation by the trauma team formally. It is ultimately the responsibility of both the trauma team and the orthopedic team to come evaluate the patient and, more importantly, to mobilize colleagues in the event they are unable to come to the bedside. If the orthopedic surgeon was not in an emergent case, they should have scrubbed out and evaluated the patient. If they were in an emergent case, than a colleague or backup orthopedic partner should have been contacted to evaluate the patient and get the patient to the OR. If orthopedic surgery was not "comfortable" with the case, it is their job and the job of the trauma team to initiate and expeditiously arrange for transfer to another accepting facility, not to leave this to the emergency physician which clearly led to several hours of delay in care. This is especially unacceptable if the patient was to be transferred within the same hospital system with familiarity with other staff in the system.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As above, if the trauma and orthopedic teams had evaluated the patient and expedited transfer quicker, there is a high probability that the patient may have avoided many if not all of complications due to the delayed management.
What makes you a good expert for this case?
I am board certified in both general surgery and surgical critical care. I functioned as a full time active clinical acute care surgeon for several years in a level 1 academic center which included emergency general surgery, trauma surgery, and critical care. I also functioned as medical director of the surgical intensive care unit (SICU) which included objective multidisciplinary peer review of complications and mortalities. I also functioned as co-chair of the critical care operations at the same level 1 trauma center and was responsible for oversight of 5 ICUs in the system including clinical practice guideline creation and modification. I have over 4000 operative cases and over 15,000 ICU/critical care cases throughout my career and am very familiar with systems based practice. I have over 7 years of experience within medical expert witness with over 100 cases reviewed in addition to deposition and court room testification.
How often do you encounter cases similar to this one in your practice?
While compartment syndrome cases are rare overall, I have reviewed several similar cases in the past. However, I have reviewed many similar cases where there was delayed care and resulting preventable patient harm.
Do you believe there might have been medical error?
Concern for compartment syndrome is a medical emergency and must be addressed in the most urgent of manners. Any delay could cause premanant damage or amputation
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
No one disagreed that this was compartment syndrome but there was not prompt action to get the patient the care he needed. There is 2 ways this case should have been handled. 1. Ideally, the ortho surgeon should have gone down to evaluate the patient and made a viable plan to get the fasciotomies done. If she/ha is not available, the trauma surgeon should have gone to see the patient, and then should have spoken to the ortho surgeon about a plan. The trauma surgeon could have admitted the patient and got some pain control on board an posted the case in the OR so that when the ortho surgeon got out if the OR, it was all set for the patient to get fasciotomies and fracture reduction. 2. The other way would be for the trauma surgeon to go evaluate the patient and then make arrangements to send the patient to the local level one (NOT the level 2 160+ miles away). Call the transfer ambulance and get the patient out. Call ahead to the local level one (both ortho and ED) to alert them of the situation. Then stay with the patient until transport arrives. This is not a case that the vast majority of general surgery boarded trauma surgeons would do. Successful cases require a height level of skill by the operator
What makes you a good expert for this case?
I am professor of surgery at a busy verified level one trauma center with 20 years of experience. I manage compartment syndrome of the lower and upper leg as well as the gluteal area, and assist in managing the post op care of compartment syndrome patients who have hand, foot and arm who have been treated with fasciotomies
How often do you encounter cases similar to this one in your practice?
This is a rare injury, but I manage compartment syndrome many times per year.
Do you believe there might have been medical error?
With the clinical suspicion of compartment syndrome, there should have been an attempt to transport the patient to the nearest trauma center, not necessarily the trauma center within the same healthcare system. This led to a delay in definitive care for time-sensitive intervention for compartment syndrome.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delay in transport led to a delay in definitive care, of which compartment syndrome requires time-sensitive intervention to prevent permanent and irreversible damage to the extremity.
What makes you a good expert for this case?
I am the Trauma Medical Director and Department of Surgery Chair at a Level II Trauma Center. I have provided medical expert witness services for both plaintiff and defendant for years and have extensive experience with cases substantially similar to this.
How often do you encounter cases similar to this one in your practice?
As Trauma Medical Director and an actively practicing trauma surgeon, I encounter cases similar to this on a regular basis.
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