▪︎ Case Study with Medical and Legal Insights: Blood Clot Misdiagnosed as Sciatica in ED Resulting in Leg Amputation and $28.8M Verdict.

In this ED misdiagnosis blood clot case study, the plaintiff, a 35-year-old man, presented to the emergency department (ED) of a General Hospital on March 7, 2015, with complaints of back pain and a cool, discolored left foot that was turning “purplish” [per plaintiff’s counsel description. However, medical records document “discoloration”.] He was triaged by a registered nurse, who routed him to the lower-acuity “ambulatory” area.

There, a physician assistant (PA) evaluated the plaintiff. Despite documentation in the triage note and the PA’s own assessment that the foot was cold and discolored, the PA diagnosed the plaintiff with sciatica, prescribed pain medication and muscle relaxants, and discharged him. At trial, the PA testified he was unaware of any foot complaints.

A registered nurse then discharged the patient. Notably, the discharge paperwork she signed acknowledged the foot’s purplish discoloration, but she testified she was unaware of that symptom at the time.

On March 13, 2015, the plaintiff returned to the same ED with persistent foot discoloration, coolness, and now severe ankle pain — in the absence of any trauma. He was evaluated by a nurse practitioner (NP), who focused exclusively on the plaintiff’s back complaints. The NP did not ask about or assess the foot or ankle and again diagnosed sciatica. The plaintiff was discharged home with medication.

On March 17, 2015, the plaintiff presented to a different a Clinic Medical Center. There he was seen by a physician whose exam revealed a cool, mottled, pulseless lower left leg. He ordered an ultrasound, which confirmed an arterial clot extending from the thigh to the foot. A vascular surgeon determined that the tissue was nonviable, and the plaintiff underwent an above-the-knee amputation the following day.

At trial, the plaintiff’s experts—including an emergency physician, ED nurse, and vascular surgeon—testified that the providers breached the standard of care by failing to investigate the vascular symptoms. The vascular expert opined that timely intervention on either March 7 or March 13 would have saved the plaintiff’s leg.

The defense claimed the plaintiff did not explicitly report foot or ankle symptoms and only complained of back pain. However, documentation contradicted this. The trial lasted three weeks, and the jury awarded $20 million, which totaled $28.8 million with interest. This verdict was confirmed in 2024 after various appeals.

Do you think this care was below the standard of care?

Medical and Legal Lessons Learned from ED Misdiagnosis

1. Be Aware of Vascular Warning Signs

• Key Symptom Awareness: A limb that is cold, discolored, painful, or numb is a potential vascular emergency. These signs warrant immediate evaluation, including imaging (e.g., ultrasound).
• Clinical Pearls: Purplish or blue discoloration and coldness are not compatible with benign back pain alone and require vascular rule-out.

2. Read and Integrate Triage Notes

• Avoid Information Gaps: The PA did not review the triage note, missing key symptoms already documented.
• Best Practice: Triage notes should be mandatory review material before or during any evaluation. If unread, key complaints may be missed.

3. Avoid Anchoring Bias (Premature Closure)

• Problem: Several providers focused solely on back pain, prematurely concluding the diagnosis was sciatica.
• Solution: Keep a broad differential, especially when symptoms do not perfectly align. Return visits and progression of symptoms demand renewed scrutiny.

4. Be Aware of What is Documented in the Medical Records

• Disconnect: The discharge note referenced a purplish foot, yet the discharging nurse claimed to be unaware of this.
• Risk: Signing off on documentation without verifying its content creates both clinical and legal exposure.

5. Respond to Escalating Symptoms

• Clinical Responsibility: The patient’s worsening symptoms over multiple visits should have prompted higher suspicion and more aggressive evaluation.

6. Ensure Team Communication and Continuity

• Fragmented Care: No provider seemed to fully synthesize or hand off the patient’s complete symptom picture.
• Recommendation: Implement and reinforce handoff protocols and team-based review, especially for high-risk presentations.

7. Listen to the Patient

• Underappreciated Clues: The patient asked about his purplish foot at discharge—an opportunity that was missed.
• Reminder: Patients often signal severity, even if they don’t use clinical language. Dismissing these cues can be catastrophic.

8. Train for High-Risk, Low-Frequency Conditions

• Education Gap: Arterial thrombosis in young patients is rare but serious.
• Action: Include vascular emergencies and diagnostic pitfalls in continuing education and simulation-based training.

Conclusion:

This ED misdiagnosis case is a powerful reminder that missed details, unchecked assumptions, and poor communication can result in a devastating outcome. Providers should be vigilant, curious, and need to communicate —especially when faced with symptoms that suggest something more than a routine musculoskeletal complaint.

Let me know what you think!

To learn more about these legal topics, check out our courses on demand:

➡️ The Nurse’s Law School – A Practical Legal Guide for Nurses (7.6 CE Hours)

➡️ Legal Issues in ED Nursing

Sincerely,
Laurie Elston JD BSN
www.NursingLawCenter.com
Law Office of Laurie R. Elston Inc.
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