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Vascular insufficiency

01 February 2004

Mrs H, a heavy smoker in her forties, had been unwell for three days with aches, fever, nausea and anorexia. Dr P visited her and found that she was depressed and had contemplated suicide.

Her brother had recently died and she was having family problems. Dr P assessed her suicidal risk as low, arranging bereavement counselling and review at the surgery.

Mrs H wasn’t well enough to come to the surgery so Dr P visited her again at home. She was agitated and distressed and her family were concerned about episodes where Mrs H’s legs appeared to be cold and blue. Dr P assessed blood flow in Mrs H’s legs, noting it as ‘good’.

Dr P felt that Mrs H was now a significant suicidal risk and referred her to a local psychiatric unit. He gave a detailed history of her psychiatric symptoms and noted the symptoms of pain, cold and blueness in her legs.

On the psychiatric ward Mrs H was found to be frightened and anxious, rolling around in bed complaining of pain in her legs. Her psychiatrist documented these symptoms and found cyanosis and a macular rash affecting the feet.

This, along with a mild fever and a raised ESR of 86 mm/hr, prompted the psychiatrist to seek the opinion of Dr G, consultant physician.

Dr G assessed Mrs H’s symptoms as predominantly psychological, but didn’t formally examine the lower limb vasculature, diagnosing Raynaud’s phenomenon and acrocyanosis.

Dr G reviewed her a few days later. He considered alternative diagnoses of cold antibodies or mycoplasma-associated vasculitis, prescribing nifedipine. Dr G suggested seeking the opinion of Dr J, a rheumatologist with a special interest in vasculitis.

Mrs H’s symptoms continued unabated for several days and started to affect her hands. The psychiatric team noted persistent cyanosis of two fingers of the left hand and a raised platelet and white cell count and escalating ESR, now at 120 mm/hr. Dr G felt vasospasm was to blame, possibly of an autoimmune aetiology, and suggested a trial of steroids.

Eventually Mrs G was sent to Dr J, who immediately commenced a prostacyclin infusion and arranged arteriography.

This showed tapering obstruction of the leg arteries in the mid-calf region, felt to be consistent with Buerger’s disease.

Mrs H needed a right below-knee amputation, amputation of two fingers and the left great toe, and chemical-lumbar sympathectomy.

A legal claim, naming Drs P and G, alleged negligence due to incomplete examination, failing to consider a physical cause for the symptoms and failing to make a timely referral for expert vascular advice.

Expert opinion

We consulted experts in general practice, psychiatry, vascular surgery and a vascular physician.

Some experts doubted the diagnosis of Buerger’s disease, suspecting another idiopathic arteritis. They were largely supportive of Dr P’s clinical approach but felt that Dr G should have recognised the seriousness of the problem earlier and instituted appropriate management, or referred for advice.

Psychiatric opinion was that it was perfectly reasonable for Dr P to have made a psychiatric referral, given Mrs H’s symptoms and potential suicide risk. It was noted that Dr P had mentioned the vascular problems in his referral letter, alerting the new carers to monitor this situation.

The case went to trial and judgment went against both doctors. We appealed on behalf of Dr P as we felt expert opinion was at odds with the judgment. We reached an out-of-court settlement on his behalf, excluding him from any liability, contributing a small sum to the claimant’s costs to achieve this.

Dr G was held to be fully liable for Mrs H’s misfortunes.

Learning points

When dealing with a patient with psychiatric problems, it is wise to remember that they may also suffer physical disease. Attributing their physical symptoms to a manifestation of psychiatric illness, without adequate examination and investigation, is risky. Psychiatric aspects of a case should not cloud a clinician’s approach to symptoms that may have an organic physical cause.

The Royal College of Psychiatrists in the UK has published a report from a working group – Mental Illness: Stigmatisation and Discrimination Within the Medical Profession, (available as a PDF document fon their website, www.rcpsych.ac.uk) that explores these issues.

A brief overview from a UK primary-care perspective is available on the GP notebook website.