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Failure to Examine the Evidence:

Medico Legal

The Importance of an Accurate Report of the Medical Expert (Part 2) The Case History: The Second Phase of 8 Months

Dr Angus Strover FRCS gives an indeth overview

1. After the operation of tibial tubercle transfer for patella alta and the accident resulting in a comminuted fracture of the left tibia (see Part 1), the Claimant had a successful journey by Air to his home some 600 miles from the Hospital1.

2. The Claimant was transferred back to the care of his General Practitioner and the team of Physiotherapists who would visit him daily, mobilise him on crutches and apply ultrasound to the fractured area on the left tibia.

3. The first four days were uneventful but subsequent to his spending excessively long periods out of bed at his desk the fractured leg became painful and swollen.

4. The Physiotherapists and General Practitioner, having discussed the unsatisfactory situation decided to admit the Claimant to the acute unit of the local Hospital.

5. The GP thought it wise to contact the local Orthopaedic Surgeon (Surgeon2) and ask if he would take over the treatment of the Claimant.

6. Surgeon 2 was happy with the situation but was unable to attend to the Claimant on that day and asked the Triage team to contact the Trauma Surgeon (Surgeon 3) on call for acute admissions.

7. Surgeon 3 examined the Claimant as soon as he was admitted to the ward. A good detailed history was taken.

8. One of the written observations of the Senior Triage Nurse on duty that night was that the Claimant was “comfortable in bed, reading a book with the foot of the bed elevated”.

9. Bloods were taken and the vital signs were recorded by the Triage Nurses.The temperature was recorded at 38degrees, pulse rate was 80 per minute and the C-reactive protein was (CRP) was recorded as 50.

10. A radiograph was requested and was reported as “No change since the previous radiographs from Hospital 1.”

11. Surgeon 2 discussed the situation by phone with Surgeon 3. Surgeon 2 (senior to Surgeon3) then asked the latter to take the Claimant to theatre, open the wound widely, remove any discoloured soft tissues, apply pulsed lavage and send soft tissue biopsies to the Pathology Department for microscopy, culture and sensitivity (MC&S).

12. Following this surgery the next morning the Claimant was seen by Surgeon 2 who discussed the operation with the Claimant.

13. Surgeon 2 then said that he would need another operation 48 hours later “just to be safe” and to check on the internal fixation of the fracture as he felt that more screws would be needed beyond the plate.

14. 48 hours after the first operation, Surgeon 2 went ahead with a second operation to remove all subcutaneous sutures and all skin clips and to enlarge the incision so that he could place two more interfragmentary screws beyond the distal end of the plate into the tibial diaphysis.

15. Further pulsed lavage was used and more soft tissue and muscle biopsies were removed and sent to the laboratory for microscopy, culture and sensitivity.

16. The Claimant remained for a further four weeks in Hospital and was discharged on antibiotics for 6 weeks.

17. On return to home the Claimant attended Physiotherapy appointments and the progress was diligently recorded by by the Physiotherapy team. The reports were regularly sent to Surgeon 1 who responded and admonished the Physiotherapists to increase the Claimant’s exercises and to introduce more diligent weight-bearing.

18. Radiographs were taken at monthly intervals for the next five months and the reports repeatedly state that the fracture lines were still “clearly visible”, indicating that there was apparent delayed union.

19. Surgeon 2 apparently ignored the Radiologist’s reports and continued to encourage the Physiotherapists to increase weight bearing exercises in spite of the pain that the Claimant was suffering.

20. The Claimant ( who was a self-employed professional person with Clients of his own) regularly attended his Physiotherapy sessions and struggled on with his rehabilitation but found office work was difficult and painful.

21.With the continuation of pain and the need for painkillers and crutches he had little time to concentrate on his profession resulting in a significant loss of income . His partner who was employed in town was significantly stalwart in doing all the house work as well as looking after the Claimant and maintaining a demanding occupation in the town.

Please answer following questions by ticking the appropriate replies

1. Bearing in mind that all Medical personnel in this case were in Private Practice, the Surgeon 1 who had done the original operations had heard nothing of the operations that had taken place in the home town of the Claimant. Who, in your opinion, should have taken the responsibility to contact Surgeon 1 (at Hospital 1, 600 miles away), to give him updated information about the progress of the Claimant, and particularly about the hospitalisation and further surgical treatment of his patient ?

a) The G.P. ?

b The Physiotherapist visiting the patient ?

c) The local Orthopaedic Surgeon (Surgeon 2) ?

d) The Claimant himself ?

e) Any or all of the above ?

2. Surgeon 2 had previously treated the Claimant for knee pain unsuccessfully. The Claimant had subsequently been referred by his G.P to the local Sports Medicine Consultant who, after having assessed the Claimant and having reported his findings to the GP., referred the Claimant to Surgeon 1 who operated 600 miles away.

3. Technically therefore the Claimant, having arrived back in his home town, was still under the treatment of Surgeon 1 who was not informed of the take-over of his patient by Surgeon 2 and was expecting some feedback from his patient or someone who was keeping track of his progress.

a) Would you regard that the take-over of the Claimant by Surgeon 2 could, in medico-legal terms, be illegal and consistent with an act of “supersession”?.

Yes ?

No ?

Uncertain ?

b) Do you agree that the take-over without at least a telephonic discussion between the 2 Consultants would be regarded as a “failure of Good Professional Conduct”

Yes ?

No ?

Uncertain ?

4. The Orthopaedic Surgeon 2 reacted as if he were dealing with an emergency to treat a serious infection when the Claimant’s GP contacted him asking if he would admit the Claimant to the Acute Unit of the Local Hospital because the Claimant was not managing to be nursed at home under the daily supervision of a Physiotherapist from the GP Practice.

Given the facts:

i) that the operation wound had healed and there was no wound leakage although the leg was swollen

ii) that the vital signs of temperature, pulse and respiration were within normal ranges, (slightly increased)

iii) that the Triage notes indicated that the Claimant was reading comfortably in bed with the foot elevated.

iv) that the C-reactive Protein level was reported as being 50

v) that Surgeon 3 was the Trauma Surgeon on call for emergencies and would be operating through the night

vi) Would you, taking the part of Surgeon 2 (who was unable to operate that night)

a) have reacted as in the history and called for the services of Surgeon 3 (the Trauma Surgeon on-call) to take the case to the operating theatre etc,?

Yes ?

No ? Uncertain ?

b) have waited for 12 hours with regular clinical TPR observations, 6-hourly blood tests with the option of telephonic conversations with the ward until you were able to attend a ward-round the following day

Yes ?

No ?

Uncertain ?

c) have operated only if the clinical and laboratory results indicated that there was a definite infection,

Yes ?

No ?

Uncertain ?

On the subject of ‘Pulsed Lavage’ and its effect on tissue damage. Spead of existing organisms into the deeper layers of tissues, damage to bone and non-union

1. Publications on the positive effects of effects of pulsed lavage indicate that its use is important for cleansing contaminated wounds and removal of sand, soil and other debris from compound fractures such as occur with war injuries, high velocity traffic injuries , mountaineering and accidents at work , in this case you may well have have advised the use of pulsed lavage.

2. However in this case there was no evidence of any injury with an open wound requiring the use of pulsed lavage.

3. When used to help clear the area of pus and bacteria pulsed lavage has again been shown to be useful when used with care.

4. When used with excessive pressure pulsed lavage has been shown to damage not only soft tissues but also bone. In the latter respect it has been shown to hinder the healing, causing delayed or non-union of broken bones both clinically in humans and in experimental studies using rats.

5. In wounds that are badly contaminated and those that have already shown infection, not only is a low irrigation pressure advised, but saline has been shown to be less efficacious than soap and water, which has been shown to be superior in its effects on decontaminating the wound and removing bacteria and less damaging than saline and antibiotic solutions.

Was there really any clinical or laboratory evidence of a ‘Nasty deep infection’?

Yes clinical but no lab evidence ?

No lab or clinical evidence ?

Thank you for your participation. ?