Med Mal Case: Hospitalist, Ischemic Leg

[ReviewOfSystems]

CTA is for treatment planning. 95%+ of acute CLI diagnoses can be made purely on clinical examination alone and in fact often the clinical exam is often superior to the CTA (for acute CLI) due to artifact from severe atherosclerotic disease making the diagnosis on imaging alone unclear.

You are also correct in that vascular surgery absolutely should not take to OR without imaging because they need imaging for treatment planning. But vascular must be consulted as soon as the diagnosis of "pulseless cold leg" is made because either they must come see the patient (in cases where they don't trust your physical exam or if it's a complex case), or CTA must be ordered immediately for treatment planning while they prepare the OR.

Ultrasound does not fit anywhere in that decision-making tree and because it does not add to patient care.

This is why I said practically speaking. Arterial ultrasound may not be the gold standard, but it is fast, contrast free, and usually gives the objective anatomical information needed for patient care. This case had a nice textbook presentation of ischemic limb, but often that presentation is not what you are going to be getting in the multiple comorbid older patients coming in with 5+ issues that need addressing.

---

Members don't see this ad.

 

[chessknt]

There are a lot of misconceptions in this thread. Acute ischemic limb is a clinical diagnosis. The fact that ultrasound was ordered & waited on is already a major delay in care. This is the equivalent of having an exertional chest pain patient + elevated troponin + ischemic ECG changes but waiting a few days for a coronary CTA and cardiac MR before thinking to call cardiology.

This med mal case does not encourage over investigating, rather it is a prime example of a modern physician lacking the clinical skills to diagnose "do not miss" diagnoses because they've gotten too used to radiology and subspecialists do the heavy lifting for them. Vascular should have been immediately consulted in a case where there are pulseless, cold legs.

Its crazy how many ischemic limbs have spontaneously recovered under my watch in septic vasculopaths on pressors despite their cold pulseless legs. Should I have called vascular to activate the OR sans imaging on them instead?

 

[Crayola227]

Its crazy how many ischemic limbs have spontaneously recovered under my watch in septic vasculopaths on pressors despite their cold pulseless legs. Should I have called vascular to activate the OR sans imaging on them instead?

How many were simultaneously complaining bitterly about their limb?

How much the patient thinks you're ignoring/shafting them is a factor in whether or not they sue you

Maybe you've just been lucking out.

What drives me nuts is people justify their care based just on outcome (good or patient doesn't sue) not really seeing that these cases illustrate just how it can go the other way.

Don't get complacent, we're talking about people's limbs here.