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Persistent pain in the leg

01 January 2013

Mr P, a 49-year-old taxi driver, had recently visited his local Emergency Department (ED) with chest pain. He ended up being transferred to the regional cardiac unit where, according to his brief discharge advice note, he had “emergency coronary bypass surgery (full discharge letter to follow)”.

Three days later after getting home he developed aching discomfort in his right lower leg and reattended his local ED, taking the discharge note with him. He was seen by junior doctor Dr B. Dr B examined his lower leg and noted that the wound from his saphenous vein harvest site looked inflamed. He documented that there were no clinical signs of a deep venous thrombosis and discharged Mr P home with a course of oral flucloxacillin.

The following evening Mr P reattended the ED as he was still getting intermittent pain and was seen by Dr A, a more experienced junior doctor. After examining him Dr A obtained the notes from the previous day’s visit and felt able to reassure Mr P that he simply had not given enough time for the antibiotics to work.

Mr P specifically asked about the possibility of deep vein thrombosis, but Dr A advised him that her senior colleague had considered that on his previous visit and felt it was very unlikely. Dr A noted in a statement she wrote for the subsequent investigation that she did not bother her senior on the evening of Mr P’s second visit as “he’d only just gone for a break”. She discharged Mr P with some stronger painkillers.

During the next two days, Mr P rang his GP Dr X on two occasions. Dr X went through his symptoms on the phone and noted that the ED had “excluded a DVT” (he had not received any communication from the ED and had not yet received a full discharge summary from the tertiary unit). He reassured Mr P that he was happy with the assessment in the ED and that he should continue taking the antibiotics and the painkillers prescribed.

The following night Mr P, unable to sleep because of the pain, reattended the ED. By now his leg was cold, pale and mottled.

Further investigation identified an embolus occluding his femoral artery, which had arisen from the site of coronary angiography he had had performed via the right groin. Despite the best efforts of the vascular surgical team he went on to require an above knee amputation.

Mr P made a claim against all the doctors who had been involved in his care prior to his last ED attendance. The claim was settled for a substantial sum.

Learning points

  • Examine your patient properly and fully – had the entire leg been assessed the femoral arterial puncture site would have been seen and may have led to earlier diagnosis of arterial problems.
  • Earlier and fuller discharge letters might have similarly alerted the doctors involved to the fact that coronary angiography had been carried out.
  • Reattending patients can easily be perceived as a nuisance, but should instead prompt consideration of why they are reattending.
  • Do not rely on a colleague’s earlier diagnosis – they may have been wrong or things may have developed further, providing clues that they did not benefit from when they assessed the patient.
  • You should always seek senior input, even if it is inconvenient.
  • Beware of blinkered decision-making. Doctors often use heuristic pattern recognition to make rapid diagnoses, eg, one’s intuition, but this can lead to errors if the wrong pattern is recognised and alternate diagnoses are not considered.1 Keep an open mind. Do not be afraid to rethink your original diagnosis.2
  • Pain out of keeping with the clinical findings or diagnosis should always prompt review – and merits more than telephone advice, especially when a patient has undergone major surgery.

References

  1. Croskerry P, Clinical cognition and diagnostic error: applications of a dual process model of reasoning, Adv in Health Sci Educ (2009) 14:27–35, DOI 10.1007/s10459-009-9182-2
  2. Williams S, Tunnel vision, Casebook (May 2011)