Have you ever gone to the hospital to get treatment for an injury only to have your condition worsen in some way? Unfortunately, this is actually a common problem.
One man went to the hospital with an injury that many have faced- a dislocated shoulder. The young man had been playing games with some friends when he suddenly felt a pop in his shoulder. He later went to the hospital when his pain became intolerable. But by the time the hospital was done with him a dislocated shoulder was not all that he had. The hospital had caused the man permanent injuries to his hand and arm that would cause him lifelong problems in doing everyday activities.
The National Center for Biotechnology says that shoulder displacements are among the most common dislocated joint injuries in the entire body. So you would think that hospitals are skilled in treating them properly, right? Well apparently not all hospitals are reasonably trained in this injury despite its common and regular occurrence.
The NCBI explain, “Acute dislocation is a surgical emergency and demands urgent relocation. Failure to reduce a dislocated shoulder successfully within the first twenty-four hours carries the risk that it will be impossible to achieve a stable closed reduction. The experienced trauma physician can recognize an anterior shoulder dislocation at sight. The arm is usually held in an abducted and externally rotated position. There is loss of the normal contour of the deltoid and the acromion is prominent posteriorly and laterally. The humeral head itself may well be palpable anteriorly.
On more detailed examination, there may be specific damage to the bone, vascular and nervous structures of the region. It is important to record neurovascular status before reduction is attempted. In the longer term, injury to the rotator cuff may also emerge. Each of these defects will be considered in turn.” So how did the hospital mess up something that was supposed to be pretty routine and thus cause the young man permanent nerve damage in his hand and arm? Well they certainly did not seem to follow the careful protocol outlined by the NCBI.
The doctors had first decided to reduce the young man’s shoulder. This means that they essentially planned to put his shoulder back into its socket. The NCBI details what is supposed to be done in a shoulder reduction, “A plain anteroposterior X-ray is mandatory before attempting to reduce the shoulder, as an associated humeral fracture will make it both impossible and dangerous to manipulate the humeral head by holding the shaft. A second, axillary view confirms the diagnosis and determines the direction of dislocation.” They conducted this task in a rather careless way. Multiple medical staff members were pulling the young man’s arm in various directions (thus causing traction and counter-traction) in order to put it back into its socket. After this process the young man’s shoulder swelled up an abnormal amount (no surprise there, right?).
The young man started to complain of pain and swelling early on. The hospital’s physicians eventually realized that the swelling had exceeded normal levels as well. So they next ordered a MRI to figure out what was causing the massive swelling. A resident (who is a doctor in training) read the MRI report and that’s where the problem really started.
The resident actually misread the MRI which led to a series of events that made the patient’s condition much worse than it would have been if he was treated in a timely manner. The hospital did not figure out any of this until much later.
After the MRI was performed, the patient felt a great deal of numbness in his hand. This numbness increased over the next few hours and he constantly relayed his numbness, pain, and discomfort to his nurses yet none of the doctors thought anything more about it till the morning.
A whopping twelve hours after the MRI was performed a senior doctor finally re-read the MRI to see if the resident had made any errors as the patient was experiencing numbness. The senior doctor realized that there was a complication. The MRI showed that the patient had a build up of fluid in his hand. This buildup was affecting one of his nerves and causing the numbness.
Realizing the need for speed, the senior physician immediately called for the patient to be sent into the operating room. He planned to attempt to save the patient’s arm before the injury resulted in permanent damage.
The surgeon then tried to relieve fluid from the patient’s axillary area, to no avail. But they were too late. The fluid had already caused permanent damage to the nerve.
In a nutshell this is what happened- the fluid had put extreme pressure on that nerve causing it to die. This then caused blood flow to that nerve to get cut off.
The NCBI explains the importance of treating nerve issues properly and quickly and the consequences that could erupt if they are not treated in such a manner, “Peripheral nerve injuries following anterior dislocation are common with about 10% of patients suffering injury to the axillary nerve. More sensitive studies using electromyography have reported a much higher rate of injury than this. Brachial plexus injuries are more unusual with the site of the injury often being related to the position of the arm during dislocation. Many authors recommend ultrasound screening of patients with first-time dislocations [to get a more exact diagnosis].”
Courts look at the standard of care that the physician/hospital was supposed to use when determining whether the hospital is at fault. Doctors must exercise the same degree of care as an ordinary member of their profession. Many jurisdictions only compare the defendant to professionals in a similar community. However, some jurisdictions hold professionals to a national standard.
The standard of care for doctors is usually a duty to render a quality of care consistent with the level of medical and practical knowledge the physician may reasonably be expected to possess.
When bringing a lawsuit for medical malpractice in NY, we are required to bring in medical experts to testify that the doctors and hospital staff did not adhere to the basic standards of medical care.
Experts from The Journal of Bone and Joint Surgery talk in depth about how doctors can decipher whether a nerve injury has occurred.
“The most probable clue to the presence of a nerve lesion is paresis. Although there was a clear relationship between paresis and nerve injury we did not identify a precise point in testing of muscle power that can be used to determine the presence or absence of nerve injury. We found that the best indicator of nerve injury after one week was paresis of the deltoid muscle. In order to detect nerve injury in the early stages, we tested the sensation in the distribution of the axillary and musculocutaneous nerves. Our results confirm the opinion expressed in the prospective studies mentioned above, that examination of sensation of the axillary nerve does not give a reliable indication as to the presence of lesions of the motor nerves. Abnormalities of sensation of the lower arm point to severe nerve injury.”
The experts’ analysis shows that loss of feeling in the hand, which is what the patient felt in this case, is a clear indication that there is nerve damage; yet the hospital took hours to re-evaluate the results of the x-ray.
In this particular case, there is no doubt that time was of the essence. A series of missteps by the hospital staff resulted in this young man’s delay in diagnosis. That delay led to the loss of use of his entire arm and hand.
The tragedy of this all is that this was entirely preventable. Had the doctors and hospital staff timely recognized the fluid buildup and what the numbness and tingling in his arms signified, they could have rushed him into surgery many hours earlier resulting in a decompression of the nerve while it was still alive.
This young man happened to be a former bodybuilder, and now his injured arm is atrophied, shriveled and virtually useless. What a shame.