Mrs. C, aged 57 years, was brought to the emergency department of a local hospital complaining of severe abdominal pain. Following an exploratory procedure, an arterial line was placed in the patient’s right femoral artery, and Mrs. C underwent surgery.

During the operation, a perforated duodenal ulcer was discovered and repaired. After surgery, Mrs. C was taken to the intensive-care unit to recover. Her sister and adult daughter were with her at the hospital.


On duty and caring for Mrs. C that evening was Ms. M, a 27-year-old nurse who had been working at the hospital for about a year. Ms. M liked her colleagues, but found that some of the surgeons could be brusque and intimidating, especially Dr. S, who was the surgeon caring for Mrs. C. Dr. S tended to brush off anyone who was not a physician. Ms. M had attempted to ask him questions in the past, but Dr. S was not amenable to answering these questions. 



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At 8:30 PM that evening, Mrs. C, who was still intubated, began waking up briefly. Her sister and daughter, who were in the room with her, noted that when she woke up, she would hit her right leg, as if it were bothering her.

At 8:45 PM, when Ms. M came in to check on the patient, the family asked Ms. M about this behavior. Ms. M told them that she would make a note of it and report it to Dr. S. Ms. M also advised the family to tell the physician about the issue directly when they saw him.


When Ms. M left the room, however, she was needed urgently in another patient’s room, and she neglected to make a note in the patient’s chart or to try to find the physician.


At about 9 PM, the family saw Dr. S in the hallway and told him that Mrs. C had awakened several times hitting her right leg and trying to mouth something about the leg. 


“Our primary concern right now is her stomach,” Dr. S replied. “We’ll look into the complaint about her leg later, once we’ve taken the breathing tube out.”


Mrs. C’s family was still concerned, however, and at 9:15 PM, they gave her a piece of paper and a pen so she could communicate her complaint.

She wrote that her right leg was “hot and numb.” The family showed the note to Ms. M, who advised them to show it to Dr. S when he returned. However, the family never saw the physician again that night. At about 10 PM, the family retreated to the waiting room, where they remained all night. 

At 6 AM, Dr. S returned to Mrs. C’s room. An examination determined that Mrs. C had no pulse in her right leg. An angiogram revealed that the catheter inserted into her leg for the arterial line had blocked blood flow to the leg, resulting in ischemia of the right lower leg. Due to the level of irreversible tissue damage caused by the blocked artery, Mrs. C’s right leg had to be amputated.


After she recovered, Mrs. C sued the hospital and the surgeon. Ms. M was not sued personally, but the hospital was sued as her employer, based on her alleged negligence. The surgeon was sued personally and retained his own defense attorney. 


The hospital’s defense attorneys attempted to have the case against it dismissed. They argued that the plaintiff had not established that Ms. M had breached the standard of care and that once the surgeon was notified of the patient’s complaints by the family, it was his responsibility and not Ms. M’s. 


The plaintiff argued that once the family told Ms. M that Mrs. C described her leg as “hot and numb,” Ms. M had a duty to act. The plaintiff introduced an expert who reported that the standard of care required that nurses and doctors who become aware of a patient’s leg complaint look for and respond immediately to any of the following characteristic symptoms of limb ischemia, often grouped into a mnemonic known as the 6 Ps: pulselessness, pain, pallor, poikilothermia, paresthesia, or paralysis.

The expert noted that a patient exhibiting any of these symptoms should be evaluated for ischemia without delay, as it is an emergency that requires rapid restoration of blood flow. 


The expert also noted that Mrs. C had complained of two of the six signs of ischemia: poikilothermia and paresthesia. It was a breach of the standard of care for Mrs. C not to be assessed immediately for ischemia. The expert said that Ms. M was “required by the standard of care to chart the complaint and promptly report it to the patient’s doctor. This was not done.” 

Legal background


The hospital attempted to absolve itself of responsibility for Ms. M by claiming that since the patient’s family notified the physician, it was the physician’s, and no longer Ms. M’s, responsibility to attend to the situation. However, the plaintiff’s expert made a convincing argument that the standard of care required Ms. M to chart the complaint, assess whether the patient had any of the 6 characteristic symptoms of ischemia, and alert the physician to the complaint of a “hot and numb” limb. The court refused to dismiss the case against the hospital as the employer of Ms. M. The case eventually settled out of court for an undisclosed sum.


Protecting yourself


Ms. M made several mistakes, but perhaps her biggest one was not acting as an advocate for her patient. Ms. M failed to chart the patient’s complaint twice. The first time, she even told the family that she was going to make a note of it but then did not do that.

The second time, when the patient was clearly showing signs of ischemia, not only did Ms. M not chart the issue, but she failed to immediately notify Dr. S (or another physician) and thus, deprived the patient of the chance to be diagnosed and treated in time. This was an emergent condition, yet Ms. M did not treat it as an emergency.


As a clinician, you are your patient’s advocate. It may often be the case that you see a patient more frequently than the physician does, and the patient may be more comfortable speaking with you. It is your duty to act on behalf of that patient, which means charting complaints, assessing potentially dangerous conditions, and making sure that your patients are getting the medical attention they need.

Ann W. Latner, JD, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.


This article originally appeared on Clinical Advisor