Medical Legal Briefs: Knee Dislocation

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Nurses Edition Commentary

Kathy Garvin, RN and Lisa Chavez, RN

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Erik D. -

You mention the patient was seen by a PA.
Did a physician ever see the patient in the ED? If not, did a physician co-sign the chart?
With many ED's using PA's to see "urgent care" complaints such as these (or sometimes even more complex patients) without a physician seeing the patient, the physicians are often worried about just signing off on charts of patients they haven't seen, and what their liability will be if something like this happens.
Do you know what the liability was for the supervising physician?
Erik Deede, MD

Mike W. -

The case was against both the PA and physician and both found negligent

Jonathan G. -

2 questions. 1, when you say the case was against both, does that mean that both saw/evaluated the patient?
2) if the physician did NOT see the patient, when signing off on a PA chart, I've heard saying that "I was available for consultation as needed" or something similar instead of "I agree" if you did not see the patient can make physician less at risk, is this true?

Mike W. -

I did look again and can confirm that yes, the pt was seen by both the PA and the doctor. This was not a lawsuit from signing a PA chart that did not reflect bedside care. Thx for the follow up!

Laura P., M.D. -

I would suggest that a very important aspect of ED quality care and risk management should be added to the discussion of this case. This is the issue of PA or APP supervision. At no point in the presentation was attending oversight/supervision mentioned. Whether it did or did not occur, the topic is crucial. Emergency medicine should be practiced by trained emergency physicians. Ancillary providers have an important place in our practice but not as substitutes for emergency physician care. High risk but low frequency pathology such as popliteal artery injury is the very case where the training and experience of an emergency physician can prevent loss of life or limb.

Particularly as the acuity of EM patients continues to rise, our specialty must address appropriate guidelines for the supervision of our PA and NP colleagues. EMRAP should place this crucial practice issue front and center.

Mike W. -

The case was against both the PA and physician and both found negligent for 1.5 million (was 5.2 million reduced to 1.5 mill)

Brian S. -

As an "ancillary provider"/nurse practitioner working in Emergency medical care, Urgent medical care, and Pre-hospital medical care, I subscribe to this service to: be regularly engaged in expanding my knowledge base, increasing my awareness in changing practice, and the betterment of my patient's outcomes. It's unfortunate to think the previous two comments merely reflect personal biases. I believe any clinician, no matter the credentials could have been responsible for this miss. Further, I'm not sure this case, is an illustration suggesting an overhaul to the presence of "ancillary" providers in the e.r. Lastly, I thought the narrators closed with much more appropriate/useful "take-away" point, and suggestions to ensuring fewer similar misses.

Mike W. -

Both these clinicians (the doctor and PA) saw the pt and were involved in the care. The point of this segment is to demonstrate the importance of not missing this dx, not to delve into the question of how EDs are staffed!!

Peter W. -

Wait! Wait!!! This discussion had a glaring omission. The focus was just on the difficulty in accurately diagnosing a vascular injury with a "normal exam" and ABIs. A patient who truly dislocated their knee CANNOT have a normal exam. They may have "normal" pulses, but a full knee dislocation requires ligamentous disruption. Grade 3 ligament injuries are a BASIC clinical diagnosis. The flaw in the initial assessment is that the provider did not perform an adequate knee exam which tested LCL and MCL with valgus and varus deformity nor ACL and PCL. The exam would have been positive as noted that on return the patient had total disruption of his ligaments. That did not happen after discharge. . The teaching point should be that, at a minimum, an adequate knee exam must include assessing ligaments in addition to mashing around the soft tissue and palpating pulses. If the exam documents ligamentous disruption and history suggests knee rotation, chasing the vascular injury should be the norm

Mike W. -

Good points and important info - thx Peter for sending!!

Carlos J. -

I specifically remember a module on knee dislocation and vascular injury in Obese patients from a previous EMRAP episode many years ago and have since added that consideration to my differential!

As a PA/APP 10+yrs in EM, you do have to own your craft and be up to date with potential rare complications of common complaints, especially given that APPs are more and more relegated to only fast track environments as a means of dealing with low acuity volume, which is why a diverse practice environment benefits everyone. You have to be mindful of the back pain that does need a stat MRI, the young chest pain thats a spontaneous pneumo, or the child with palpitations thats in SVT.

You have to get comfortable doing whats right, not what is fastest, and you can expect to take some heat for it nowadays, as the message is often your value isn't in being smart, its in being fast.

Having APPs only seeing low acuity cases is like buying a Lamborghini to do grocery runs, you have to take that out on the highway every now and then and give it the gas! With an experienced driver (attending/supervising MD) you will be impressed with the results.

P.S. Any Case review that starts with "The PA" is immediately doomed, the point of the case will be lost and it will ALWAYS devolve into a debate regarding scope of practice and supervision. Appropriate to include, but maybe not to lead with


Mike W. -

Thx for the message Carlos and for being a loyal EM RAP listener! When presenting these cases, I have defaulted to the accurate description; that is how the case evolved, with the PA seeing the pt first then involvement of the physician. As the medical director for Ohio's second largest PA training program (ODU with over 50 PAs per class) I am VERY sensitive to the issue of PA and physician collaboration and have recently lamented the animosity toward PAs in social media forums. It is interesting to me that much of the discussion in these threads focused around the role of the PA, when our main goal was to discuss the occurrence of vascular injury after knee dislocation and to do it in a memorable fashion (in the context of a legal case). Thx for your comments and for expertise!!

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