Episode 009: The Case of Running Back Rundown

Speaker 1: You are listening to Your Practice Made Perfect; support, protection, and advice for practicing medical professionals brought to you by SVMIC.

Brian: Hello and welcome to this episode of our podcast. My name is Brian Fortenberry and today we're going to be looking at a very interesting closed claim. And joining me to discuss that and get into the specifics of it is attorney Stephanie Duprey. Stephanie, thanks for being here.

Stephanie: Thanks for having me.

Brian: So, we're gonna get into the case here in a minute and certainly get into some discussion. Before we even revue the case at all, tell us a little bit about yourself, about your experience, your time here at SVMIC.

Stephanie: Sure. I began with SVMIC in 2010. Prior to that I worked as a courtroom attorney defending medical malpractice cases. That was my primary focus. And, actually, before going to law school I was a nurse and still am.

Brian: Fantastic. So, that makes it wonderful for anyone that has one of these types of cases. You understand the legal aspect, but certainly the medical aspect as well. So, I'm certain we're gonna have some fantastic discussion on this unfortunate case. For our listeners lets go ahead and read a synopsis of what's going on here. Then we'll get into some discussion. Okay?

Stephanie: Sounds great.

Brian: The crowd cheered. The football snapped. The helmets clashed as players piled onto the running back, but a more ominous snap was heard in 16 year old running back. Jason did not get up from the field. The team was admitted to orthopedics via the emergency department where studies revealed a closed fracture of the tibia and fibula with severe swelling. He was started on Morphine PCA, but complained of numbness in his toes throughout the night and the next morning. Dr. Smith performed an open reduction with intramedullary nail fixation later that day with a total tourniquet time of 80 minutes, which is at the upper limit of acceptable tourniquet time. Post-operatively Jason was given Toradol, Lortab, Morphine PCA, Phenegern, and Motrin.

He still had numbness in his toes, but he was able to move them on post-op day one. On post-op day two he had minimal toe movement and nurses documented sensation in the web spaces. Despite significant doses of narcotics moving the patient's great toe caused excruciating pain up the leg, but this was not documented by the nurses. When excessive pain prevented his physical therapy participation nurses notified Dr. Smith, who added IM Morphine. Later that evening nurses called Dr. Hudson to report the patient was having spasms with pain for which Ativan was ordered. On post-op day three Jason had increased numbness, pain, and no toe movement. Dr. Hudson split the dressing to relieve pressure and re-check the leg two hours later. At that time a diagnosis of compartment syndrome was made and the patient was taken surgery later that day.

Dr. Hudson performed a four compartment fasciotomy with debridement of necrotic muscle. Culture were positive for three organisms and the patient was placed on oral antibiotics. Jason endured six more debridement and a split thickness graft prior to discharge. Jason's skin graft showed an excellent result when he was seen in the follow up a week after surgery. However, the graft developed serious drainage three days later and oral antibiotics were added. At follow up four days later the graft had some necrosis with odor from the foreleg. Topical antibiotics were added and debridement was performed. Despite use of a wound vacuum the leg failed to heal and multiple organisms continued to be cultured.

At three and four months post-surgery necrotic tendons and muscles were documented with clawing of the patient's toes and impaired motion. After the 16th debridement exposed the fibula the patient and his family requested referral to a regional children's hospital. Five months after the initial surgery workup revealed poor sensation in motion, poor wound healing, and probable chronic osteomyelitis. He required four more debridement during this process for a total of 22. Options were discussed with the patient and family, including free flaps, exchange nailing to promote bone healing, or below the knee amputation. After contemplation Jason chose below the knee amputation in order to resume some mobility and prevent the knee from multiple surgeries. Eight months after the injury Jason underwent amputation and was fitted with the initial prosthetist two months later. 12 months after the accident the crowd cheered Jason again. Wearing a prosthetic leg he ran onto the field with the football team. A lawsuit against the orthopedist and the hospital followed.

Stephanie, this is obviously an unfortunate situation. Any time you have a young athlete like this that develops an injury that is bad enough, but then you go beyond that to the point that you have all of these procedures and surgeries and then it all ends up in a below the knee amputation and a prosthetic leg. What was the outcome of this case?

Stephanie: This case actually never reached trial. It was thought that the best course of action would be to try and reach some type of compromise.

Brian: So, obviously once the defense council along with the attorneys here looked over the evidence it was in the best interest, probably of all parties then, to make that assessment. Correct?

Stephanie: That's right. In this particular situation we looked not only at the evidence, but also some of those intangibles such as sympathy and emotion. Certainly when you're dealing with a young person of this age that has such a difficult outcome that's something to consider when deciding whether to take something to trial.

Brian: And you have to thing that, like you said, the sympathy factor for a young man who's gonna now have a prosthetic leg his entire life, a jury is gonna look at that certainly favorable you would think. What went wrong? And could this tragic outcome have been avoided or was this one of those situations that it just happened?

Stephanie: Well, no one really knows the answer to that question. No one knows if the outcome could have been avoided. Certainly there could have been actions taken that perhaps would have mitigated the likelihood of the outcome.

Brian: Okay.

Stephanie: There's some things that could've been done differently that would have increased the probability of a better outcome, but ultimately no one knows if this leg could've been saved.

Brian: You know, in hearing compartment syndrome, that's not totally uncommon. You hear that a lot whenever discussing orthopedics and particular injuries and surgeries and things of that nature. If the orthopedist had diagnosed this compartment syndrome maybe initially rather than waiting to see how bad it was gonna get could this case have been defended differently?

Stephanie: The case could've been defended differently if the orthopedist had not waited quite so long to be hands on.

Brian: Certainly.

Stephanie: It's a difficult diagnosis, but it should be in your differential, particularly when the patients experiencing as much pain as he was after being given so many narcotics.

Brian: Yeah. When you go back and you look through the story and you're seeing that there's pain and then they initiate with medication narcotics and whatnot and you hear "Okay, the pain got better, but then movement got less," and you're hearing all of these things that are, in hindsight, certainly are warning signs of "Uh oh. Watch out." And I think you make a good point. You have this communication that goes between the physician and the staff there, nurses or technicians or whoever. That is an important component isn't it, whenever these types of situations are coming up? As a physician I'm assuming that you do have to rely on those healthcare professionals to some extent to make you aware of what is going on, but certainly when you start hearing things like this you probably have to jump in there and look yourself. Right?

Stephanie: That's right.

Brian: So Stephanie, compartment syndrome, obviously a challenging diagnosis for physicians to have to make and certainly in a timely manner with the different presentations of that. If we're looking at this case, obviously it was settled. So, we're going to say in theory here what would have caused a jury to not see it from that perspective?

Stephanie: Well, juries are interesting creatures. 12 people from the community, to various background. To their credit most jurors try to listen and observe during the course of the trial and really try to understand what's going on. However, a lot of the issues in a healthcare liability action, which is now what we call medical malpractice in Tennessee, are very complex. You know, let's not forget the years of training and experience that doctors have to understand these complex issues.

We're asking a lot of our jurors. And often times it's a battle of the experts. Both sides are required to present expert testimony. Generally, both are credible, well spoken individuals. And so, jurors are often times looking at who do they believe, how do they find most credible, who do they like. In this instance with compartment syndrome it is challenging for physicians to make that diagnosis. So, to ask a jury to understand why that might be challenging is indeed a challenge. Lets not forget, as we mentioned earlier, the emotion and sympathy in this case. We really don't know how a jury would come down in this instance. It's difficult to say, but certainly emotion and sympathy are not supposed to be part of the equation, but often are. Our jurors do try to listen and hopefully they understand the science and what it takes to make these diagnoses. Whether the jury would come down one way or the other, we'll never know, but just some thoughts on how they may look at it or the factors at least that would influence their decision.

Brian: I think one of the interesting parts you were saying there, that juries are humans and they have emotions, they have feelings, and all of that. Thank you for taking the time to come in and discuss this case with us and hopefully our listeners will be able to gain valuable information to maybe help prevent some of these issues in the future.

Stephanie: Thank you for having me.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host Brain Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes at svmic.com/podcast. The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice as specific legal environments may vary from state to state and change over time. All names in the case have been changed to protect privacy.