A patient presents to the emergency room of a major local hospital with ulcers on the heels of both feet. The patient is more than 40 years old, smokes, and has hypertension but is not a diabetic.
It is determined that the patient has peripheral artery disease. The patient is admitted to Dr. X’s service. Dr. X is a vascular surgeon with a special interest in endovascular devices for peripheral artery disease. However, Dr. X, for whatever reason, is out of the country. Dr. Y is covering.
The patient is clueless about these behind-the-scenes circumstances.
A week later, Dr. Y performs a conventional femoral popliteal bypass on the right leg, presumably, to prevent amputation. A week after that, Dr. X returns and operates on the left leg, replacing a supposedly blocked portion of the left femoral artery with a state-of-the-art endovascular device, presumably to save the leg.
After both surgeries, a “family meeting” is arranged at the hospital. Neither Dr. X nor Dr. Y is present. A vascular surgery resident, a podiatrist, and the hospitalist are in attendance. Their purpose is to obtain consent for a left below-the-knee amputation. This is the leg upon which Dr. X inserted the endovascular device into the left femoral artery. The right leg, upon which Dr. Y performed a femoral-popliteal bypass of the right femoral artery, does not raise concern.
Questions arise. Why is the right leg fine and the left leg not? Why is a femoral-popliteal bypass performed on the right leg and not on the left? What about wound care? Their only answer is that dressings are regularly changed, and there is no infection in either heel bone.
If so, why not save the left leg with a second revascularization procedure rather than amputating it? These doctors know, but never admit, that the endovascular device inserted by Dr. X is not functioning. The left leg is in jeopardy; the right leg is not.
When questioned about a transfer to another local hospital in the same health care system, which has a reputation for limb salvage second to none, they answer: The family must make those arrangements if such a transfer is desired.
The patient wants the transfer and refuses the amputation. The doctors assure the patient that because there is no infection, there is still time to reconsider.
The patient is sent from the ICU to a nursing station and is now under the care of another hospitalist, who cooperates. For six days, wound care becomes noticeably better, and arrangements for transfer to the aforementioned hospital are underway.
Unfortunately, the patient is switched to another nursing station where another hospitalist is in charge. The ulcers on both feet are unattended and, unbeknownst to the patient, the transfer is stopped. Finally, maggots are seen infesting the decubitus on the left side.
Why else would maggots infest a wound if not for the lack of wound care?
The patient develops a life-threatening septic shock and consents to a below-the-knee amputation performed by Dr. X. After the amputation, Dr. X revises the stump, which results in a left above-the-knee amputation.
Following these surgeries, the parade of transfers to nursing stations continues. In the meantime, an infection in the wound where Dr. X first inserted the endovascular device goes unnoticed. Finally, Dr. X debrides this abscess and removes the device. Three months after admission, the patient is discharged to a rehabilitation and nursing facility, where he or she resides today.
At a post-operative appointment with Dr. X, the truth comes out. The endovascular device is not functioning. Dr. X obstructs the transfer because “it would have made no difference.” Furthermore, a narrative is underway to make it appear that the patient contributes to these problems by rejecting an amputation. However, no one of sound mind would grant consent for amputation when told that there is no infection, that there is still time to consent, and that a transfer to the other hospital known for limb salvage is being arranged.
While residing at the nursing and rehab facility, the ulcer on the right heel receives wound care. However, previous months of no wound care have a price, and an x-ray is suspicious of infection in the heel bone. At long last, an appointment is made with the wound care clinic at the same hospital reputed for limb salvage, and surgical debridement is scheduled.
After partial excision of the heel bone, the right leg is salvaged. This speaks volumes about potential salvage of the left leg had only doctors been diligent about transfer to this facility because, at the time, there was no infection.
For the reader’s convenience, two important journal articles are cited. In Circulation Research, there are 230 million similar patients worldwide, and many undergo limb-salvage procedures. In Annals of Vascular Surgery, after 14.5 months, 67 percent of patients who undergo revascularization surgery have complete wound healing; 12.2 percent die; 1.8 percent have other complications; 17 percent require a second revascularization procedure, but only 2 percent require amputation.
Is this amputation the background risk or medical malpractice? Using the risk management tool in my earlier articles, I prove malpractice with 95 percent confidence. However, who better to answer this question than ten prominent medical malpractice plaintiff attorneys? Yet, despite professing commitment to duty, patient safety, and advocacy, none agree to represent this client. As each points out, they work on a contingency basis. This does not mean there is no merit. It simply means this case is just not worth their time or effort to litigate. Their only advice is to seek another opinion.
If I, as a physician, should ever not help a patient, for whatever reason, I would never leave that patient swinging in the breeze as do these lawyers to this client. Society expects me, as a physician, to consult with a colleague, who can help. What society expects of lawyers remains to be seen.
Howard Smith is an obstetrics-gynecology physician.
