Part 3: Depositions of treating providers in a medical negligence case resulting in bilateral leg amputations.
One of the hospital’s defenses was that it was a small community hospital. It did not have all the fancy equipment of a major urban hospital. The problem with this defense was that the hospital didn’t need an expensive machine to make the correct diagnosis. All it needed, was for someone to: a) notice the red flags; and b) pull a hand held doppler unit out of a cupboard.
Let’s see what was done to check the patient's pedal pulses:
The Physician’s Assistant
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22 Q What did you find with respect to the legs when you did
23 your examination?
24 A My examination revealed pedal edema, generalized
25 tenderness throughout the lower extremities, cool to
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1 touch with deep tendon reflexes intact and sensation
2 intact and capillary refill time intact.
3 Q What were your conclusions with respect to Ms. Ss'
4 limbs, lower limbs?
5 A That she was edematous. I believed it was likely her
6 CHF (Chronic Heart Failure) that was causing the edema. And that she had some
7 tenderness that I would treat and work up.
8 Q As you sit here today, have you second-guessed yourself?
9 Did you make the correct call that day?
10 MS. EK: Object to form.
11 A Correct call in what sense?
12 Q (BY MS. KOEHLER) In your evaluation of her lower
13 extremities?
14 A Did I do a good job?
15 Q Do you believe that you did the correct course of
16 treatment for HS?
17 A I believe I examined her appropriately and treated her
18 with what knowledge we possessed to the standard of what
19 she deserved as a patient at our hospital.
20 Q Really?
21 A Yes.
22 Q During your relatively short career had you actually
23 examined and treated a patient who ultimately would go
24 on to lose their legs?
25 A I have not.
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1 Q She was your first and only?
2 A Yes.
3 Q How did you check the pulses in her legs?
4 A I had her lift her big toe to approximate where her
5 pedal pulse would be and then using my first and middle
6 finger attempted to feel for pulses.
7 Q Could you feel her pulses?
8 A I could not.
9 Q Did you make another effort to feel her pulse? Did you
10 use any kind of machine?
11 A No, I did not use any kind of machine.
12 Q Why not?
13 A She presented with an amount of edema that palpable
14 pulses would not be obtainable.
15 Q Did you attempt to use a Doppler?
16 A I did not.
17 Q Why not?
18 A I believed her main issue was the CHF and pulling the
19 fluid off would resolve her symptoms.
20 Q But her main issue wasn't her CHF, right?
21 MS. EK: Objection. Argumentative.
22 A I - I don't know that.
23 Q (BY MS. KOEHLER) If you couldn't check her pulses
24 manually, why didn't you use a Doppler?
25 A As I said, I believed it was the CHF that was causing
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1 the pedal edema and diuresing, her as we did last time,
2 would relieve that.
3 Q What - how did you double-check your belief? Did you
4 take your belief to one of the doctors that was on call
5 or on staff and - and tell them of your assumption that
6 the lack of pulse was due to CHF?
7 MS. EK: Object to form. Compound and
8 argumentative.
9 A Are you asking me if I discussed the patient or
10 discussed that specifically?
11 Q (BY MS. KOEHLER) That specifically. I'm asking about
12 the specifical - specific decision when you couldn't
13 feel a pulse --
14 A Mm-hmm.
15 Q -- and just to assume that it was related to CHF and
16 that another course of treatment would resolve it, was
17 that something that you did on your own or did you use
18 the resources at the hospital to consult with at that
19 time?
20 MS. EK: Object to form.
21 Go ahead.
22 A I don't remember if I discussed that specific finding.
23 Q (BY MS. KOEHLER) Who would you have discussed it with?
24 A Dr. B.
25 Q Was it concerning to you that you could not detect her
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1 pulse in her legs?
2 A No.
3 Q How many patients have you examined where you could not
4 palpate their pulse?
5 A I can't give an exact number, but many who have
6 edematous lower extremities and CHF.
7 Q Yeah. Like how many?
8 A I honestly couldn't give a number. It's moderately
9 small to moderately large, I would guess.
10 Q Within - so you had been - you had been doing this for a
11 year. You can't give us an estimate? Was it something
12 that happened all the time? Was it something that was
13 occasional?
14 A Well, we have --
15 MS. EK: Objection. Calls for speculation and
16 asked and answered.
17 A We have quite a few CHF patients and at least half of
18 them will come in without palpable pedal pulses.
19 Q (BY MS. KOEHLER) Okay. And how many of them will come
20 in with mottled legs that are cool to touch and - and
21 have no pulses?
22 A All three of them?
23 Q Yes.
24 A I would say not many.
25 Q Okay.
…
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...
12 Q (BY MS. KOEHLER) Did you have access to a handheld
13 Doppler?
14 A Excuse me. Yes.
15 Q Where was it?
16 A I don't know.
17 Q Would it have been on the third floor?
18 A Not necessarily, no.
19 Q Would it be difficult to - if you wanted it to get it?
20 A No.
21 Q And if you were to use a handheld Doppler, how long
22 would that exam take?
23 A Anywhere from 30 seconds to a minute depending on how
24 difficult.
The P.A.’s mantra – is that the patient had CHF (chronic heart failure) which caused her legs to be edematous (swollen) and because of that he could not detect pedal pulses. Interestingly, the ER doctor testified exactly the opposite.
The ER Doctor
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14 Q Did you test her pulses in her legs?
15 A Yes.
16 Q Where is that noted?
17 A It's not. It isn't.
18 Q What is pedal edema?
19 A Pedal edema is swelling of the lower extremities, usually
20 foot, ankle region.
21 Q She had that?
22 A Yes.
23 Q How significant was the swelling?
24 A I don't remember it being horrible, but enough to where
25 it bothered her.
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12 Q (BY MS. KOEHLER) So you believe you did check her pedal
13 pulses but you didn't write them in the chart?
14 A I do.
15 Q And if you check pedal pulses, aren't you supposed to
16 write them in the chart?
17 A Absolutely.
18 Q And why is it important to write them in the chart?
19 A Because it would be clearly documented.
20 Q How did you test for them?
21 A Just by palpation.
22 Q Was that easy to palpate?
23 A I don't recollect.
24 Q Could you easily detect them?
25 A I don't recollect.
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1 Q Is it significant whether it's difficult to palpate?
2 A It - it can be. But it depends.
3 Q Sorry. Just one moment. Did her edema inhibit you in
4 any way from checking her pulses?
5 A I don't remember her being that edematous. I mean she
6 had edema. But there's levels of it I guess. And I
7 don't remember hers being just so doughy and large that
8 you couldn't.
9 Q How - how much edema was present?
10 MR. ANDERSON: Object to the form. Go ahead and
11 answer if you can.
12 A Try to. She had some pitting edema. But it wasn't like
13 she'd had an extra inch or layer of subcutaneous tissue
14 or anything like that.
15 Q (BY MS. KOEHLER) Was edema only in her legs?
16 A Yes. As I recall, yes.
17 Q Was it from the knee down, from the thigh down?
18 A It was mostly just from the - the ankle area up into the
19 - what we call the pretibial region.
20 Q All right. Bilaterally?
21 A Yes.
22 Q Equal?
23 A Reasonably so.
…
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3 Q If you were - if you were unable to detect a pulse in a
4 leg, would you use a handheld Doppler?
5 A You - oh, you could to see if they had a pulse. I guess
6 I misunderstood your question. Yes, you could.
7 Q Okay. Would that be standard of care?
8 MS. EK: Object to the form of the question.
9 MR. ANDERSON: Overly broad. But you can answer
10 if you understand it.
11 A It depends.
12 Q (BY MS. KOEHLER) If you couldn't detect a pulse, would it
13 be standard of care for a physician in your hospital to
14 use a handheld Doppler to see if you could detect a
15 pulse?
16 MS. EK: Object to the form of the question.
17 This isn't a witness who's an expert for all the doctors'
18 specialties in the hospital.
19 MR. ANDERSON: Lacks --
20 MS. KOEHLER: Your speaking objections, they're
21 improper. You're just supposed to say, "Object to the
22 form."
23 MS. EK: You're asking him an expert question.
24 It's inappropriate.
25 MS. KOEHLER: Then you just say, "Object to the
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1 form."
2 MS. EK: That's not my objection. My objection
3 is your question is inappropriate.
4 MS. KOEHLER: No. But your - your objections
5 are inappropriate.
6 MR. ANDERSON: I'm going to join that objection
7 and also say lacks of foundation. Go ahead and answer if
8 you can.
9 THE WITNESS: Can you repeat the question? I
10 got lost there. I'm sorry.
11 MS. KOEHLER: I'm shocked that you couldn't
12 follow that question now. The court reporter will read
13 it back to you.
14 (Pending question read by reporter.)
15 MR. ANDERSON: Same objection.
16 MS. EK: Same objection.
17 A Because the answer is still not necessarily.
18 Q (BY MS. KOEHLER) Can you elaborate?
19 A Yes. I mean I think that it may be helpful. If you find
20 it with that, that could be helpful. If you don't, it's
21 still - there's still other means you might try to use to
22 find a pulse, once again getting radiology more involved.
It is a perfect mirror opposite. The ER doctor says HS does not have much edema and that he felt her pulses but forgot to write them down in his chart notes. The PA says she had too much edema and that he could not feel her pulses.
Enter the nurse. Her knowledge is based upon her nursing notes. This means, if she doesn't keep good notes, she doesn't have good knowledge.
The Nurse :
13
10 Q Okay. So she had edema in both of her legs?
11 A Yes. But one plus is not much at all.
12 Q She had some edema in both of her legs.
13 A Mm-hmm.
14 Q Both of her legs are mottled. And you don't know if they
15 were cool to touch?
16 A I do not recall.
17 Q And she had dusky nail beds. But you don't know if those
18 were of the feet or of the hands.
19 A I do not recall.
20 Q Did you check her pulses?
21 A I do not recall. I'm sure I did, but I do not recall.
22 Q Did you chart that you checked her pulses?
23 A Well, we have a place where we chart that. And we chart
24 by omission. So if it was normal or present, then we
25 don't put anything down generally.
14
1 Q Did she have pedal pulses?
2 A Let me look through here. I don't remember. Where is
3 the cardiac? Where is the cardiac place? Oh, here we
4 go. I didn't mark anything so it must have been present.
5 I can't surmise that because I don't remember. But if we
6 leave it blank, that generally means that they were
7 present if we checked them.
8 Q They were present if you checked them, but you don't know
9 if you checked them or not?
10 A No. It was two years ago. I don't remember the
11 assessment. I don't remember her. I'm sorry.
16
13 Q Did you ever use a doppler on Ms. S?
14 A I don't remember.
15 Q Can you . . . If you choose to use a doppler if you
16 can't detect a pulse, are you authorized to use a
17 doppler?
18 A Yes.
19 Q How difficult it is for - is it for you to get one?
20 A It's not.
21 Q Where are they located?
22 A In the medication room in a cabinet.
23 Q Are they on the same floor?
24 A Yes.
25 Q Do you need special permission for that?
17
1 A No.
Photo: Slide from Timeline PPT by Duane Hoffmann.