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The Expert: Dr. Gregory Moneta, a vascular surgeon and professor at the Oregon Health Sciences University, testifies to the standard of care in dealing with a patient who complains of symptoms similar to that of the plaintiff.
Testifying in a 2018 Florida medical malpractice trial over a patient’ below-the-knee amputation, vascular surgeon Dr. Gregory Moneta details the standard of care for treatment of acute ischemia of a lower extremity due to a blood clot, or embolism.
A key issue was the alleged delay in the proper treatment of the patient’s leg, given various symptoms he detailed. The discussion at trial in this clip begins with identification of the signs and symptoms of acute ischemia. Moneta, from Oregon Health Sciences University, details how a painful leg that is cold is evaluated with a “Doppler machine” that amplifies the pulses in the leg as a noise that the treating physician can evaluate. A patient with an acutely cold, painful leg that still has good pulses that are audible by Doppler exam may not be having an arterial embolic problem at all. This could be an indication that one is dealing with a “viable limb” that is not in immediate danger.
However, if the arterial pulses are inaudible by Doppler exam, the condition is likely to be more emergent. The evaluation should then determine if the patient can move the leg, whether the leg is painful, and whether it has proper sensation. Limited range of motion or muscle weakness in combination with limited sensation should be very concerning to the examining physician, Moneta explains. These symptoms are likely related to an acute event that should be addressed before the leg is permanently damaged.
Moneta explains that “capillary refill” is a test performed by pressing on a toenail bed to blanch it, then seeing how quickly the color returns. This is an older method of circulatory evaluation which is quite subjective and depends upon the examiner’s perspective. It can also be influenced by venous filling of the capillary instead of arterial blood. As a result of these inaccuracies, “most of us don’t use it anymore,” he says.
Nevertheless, positive findings as described here should be treated promptly since the leg is being deprived of oxygen, and “You don’t know which way this is going to go.” It is likely to get worse as one delays. A patient who still has movement in the leg, but where the extremity is cold, painful, and lacks audible pulses should be treated promptly according to the standard of care. In this case, the patient was worse, having the additional problems of rest pain, mild or moderated motor weakness, and loss of sensation. The expert states that this is “an order of magnitude more serious” than what was first discussed as needing prompt care. That leg is “trying to die” and needs better blood supply very quickly.
Reviewing treatment options, the vascular expert explains that treatments differ according to why and how this extremity arrived at this situation. Moneta expresses confidence that this was an acute process since the patient had no prior symptoms of deficient blood flow and no symptoms in the opposite extremity.
When asked if this patient was treated in a timely manner given the signs and symptoms that he presented with, Moneta says without hesitation, “No he was not.” Indeed, the patient was not even evaluated by the vascular surgeon in a timely fashion. If he had been evaluated appropriately by the surgeon consulted to do something about this, there would have been three possible options: remove the clot surgically, bypass the clotted area to get blood flow around it, or try to dissolve the clot chemically. The first of these is called an embolectomy, a fairly standard procedure. The expert describes this plainly. The involved arteries are surgically exposed, then special balloon-tipped catheters are run down the vessel beyond the clot. The balloon is inflated and the catheter withdrawn, pulling out the clot which will be formed into a tube the shape of an artery, and removed “like a snake.” It is an operative procedure which is “quite gratifying,” he adds.
This case was also quite gratifying to the plaintiff, as he was awarded $4.9 million after Moneta’s testimony.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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