Lack of Requisite Surgical Skill, Inadequate Symptom Documentation Cited for Permanent Disability

Allegation:

Plaintiff alleged that the physician was not qualified to perform the surgery, failed to adequately communicate with his PA, and failed to appropriately document the patient’s complaints.

The Case: 

A 49 YOF (5’4”, 195 lbs.) underwent a right endoscopic carpal tunnel release performed by the defendant orthopedic surgeon. Surgery was performed without incident and the patient was discharged with prescriptions for Norco; tramadol; and ranitidine. 

The patient had a medical history of chronic hepatitis C, diabetes mellitus type 2, chronic pain syndrome, degenerative disc disease in the thoracic spine, and fibromyalgia. Her surgical history included bariatric surgery, tubal ligation, appendectomy, oophorectomy, and cholecystectomy. 

On post-op day one, the patient had complaints of numbness to the median distribution and was seen by the co-defendant orthopedic PA who worked with the defendant orthopedic surgeon. The incision was noted to be intact with mild swelling and the patient rated her pain 4/10. The PA noted the numbness was not in the palmar cutaneous distribution and the impression was that the numbness would improve. 

Three days later the patient continued to complain of pain and saw her PCP. The next day the defendant orthopedic surgeon examined the patient due to persistent complaints of pain and paresthesia. During this exam, the patient stated that she was using ibuprofen for pain control. The surgeon noted ecchymosis consistent with a hematoma. At this time, the patient advised the defendant that she had a history of bleeding which required a blood transfusion following a prior surgery. The surgeon advised discontinuation of the ibuprofen and any other anticoagulants, plus ice and elevation of the hand. Norco was prescribed to control the pain. 

Several days later the orthopedic PA again examined the patient. The patient complained of shooting pain to her wrist, palm, and to her shoulder when she turned. The PA noted the wrist incision was healing without signs of infection, redness, or discharge. The stitches were removed, and steristrips were placed. The diagnosis was resolving hematoma and ecchymosis. Patient instructions included ice, elevation, home exercises and a compression wrap with a velcro splint. 

Over the next month, both the PA and defendant orthopedist saw the patient. She noted numbness to her fingers with sharp shooting pain to her hand. Pregabalin and diazapam in addition to oxycodone were prescribed. Although the wrist incision was well healed, there was mild swelling and tenderness to the operative site. Almost three months post-op the patient had continued swelling throughout her hand with persistent disabling pain. At this time the patient continued to work and continued using oxycodone outside of work hours for pain control. The defendant orthopedist continued her on oxycodone and gave her referrals to occupational therapy and a second opinion for an orthopedic hand surgeon. 

Neurology performed an EMG of the RUE which revealed prominent acute axonopathy of the distal median nerve likely in the region of the carpal tunnel. Neither the median nor the ulnar nerve appeared to be affected. The presurgical EMG was obtained and compared to the current EMG. The neurologist concluded there had been severe interval worsening of the patient’s median neuropathy. 

An orthopedic hand surgeon saw the patient. This surgeon noted that the patient had a well-healed transverse scar at the volar wrist flexion crease. She displayed significant hypersensitivity around the scar with positive Tinel’s both proximal and distal. This physician also felt the patient had complex regional pain syndrome (CRPS) type 2. The patient decided to proceed with surgical exploration of the median nerve. 

Prior to this surgery, an MRI of the right wrist was ordered. The MRI showed abnormal signal within the median nerve, somewhat abnormal contour of the median nerve, and abnormal signal within the thenar musculature which was interpreted as denervation. 

The surgery consisted of an internal neurolysis of the median nerve followed by excision of the neuroma-in-continuity and median nerve repair. 

Several months after the second surgery the patient continued to have increasing pain and sensitivity. She was referred for pain management and underwent a right-sided ganglion block. After this procedure, the patient reported 90% improvement. Despite this initial improvement the patient continued to require narcotics, lidocaine infusions, several nerve blocks, occupational therapy and eventually underwent another surgery for median nerve repair. The patient had persistent limited flexion of her thumb and wrist and persistent pain with CRPS issues. The patient was deemed permanently disabled. She filed suit against the orthopedic surgeon who performed the initial surgery, the orthopedic PA, and the hospital. 

Expert Testimony & Outcome 

An expert witness for the plaintiff testified that the defendant’s lack of requisite skill caused the patient’s injuries. Another expert opined that the PA breached the standard of care by failing to adequately document the patient’s symptoms and complaints, and not reporting the information to the defendant surgeon. Defense experts were not supportive of the care and treatment provided by the PA and orthopedic surgeon. The defendants agreed to settlement. 

Risk Management Strategies 

Documentation in the medical record should include substantive information. For example, the worsening pain and numbness reported by the patient in this case should have been included and reflected in the physician’s clinical oversight.   

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