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Nurse practitioner botches cauda equina syndrome diagnosis, discharges patient from ER

Teen is left with life-long leg, bowel, bladder, and sexual problems

One of the challenges facing physicians and nurses in an emergency room setting is that patients come in with symptoms that often can be explained by several medical conditions. Some of these conditions may be extremely common and routine, while others are less common but dangerous and severe when present.

In these situations, the standard of care requires the physician, nurse practitioner, or physician’s assistant to create a differential diagnosis list of every possible diagnosis that could explain the patient’s problems. Then, through physical exam, patient history, lab work, or radiology studies, each potential diagnosis on the differential diagnosis list is ruled in or out, starting with the most dangerous condition.

Take, for example, the story of the teenage girl who went to hospital emergency room because she was experiencing severe pain in her lower back plus numbness that she described as present in her hips and legs. As is normally the case, the patient was first seen by a triage nurse who documented her symptoms in the medical record. Next, a separate registered nurse assessed the patient and wrote in the medical record that she had back pain and pelvic numbness.

On this particular day, the patient wasn’t evaluated by a physician. Instead, a nurse practitioner saw her and decided to discharge her from the emergency room without ordering any diagnostic radiology imaging.

Severe lower back pain is one of those conditions that can be caused by a variety of different diagnoses. The medical literature reflects that the most commonly missed diagnosis for back pain is a spinal epidural abscess, which is a collection of fluid in an abscess capsule that can compress the spinal cord. There are standard, inexpensive lab tests, including CRP or ESR levels, available for doctors or mid-level providers (nurse practitioners or physician’s assistants) to order and rule out this dangerous condition.

When you add numbness into a patient’s constellation of symptoms, some other things should come to mind. One of them is cauda equina syndrome. The cauda equina is a bundle of nerves, accounting for L2–L5, S1–S5, and the coccygeal nerve, that hang down from the bottom of the spinal cord. When the cauda equina is compressed, it can cause several symptoms, including lower back pain, leg pain in a sciatica distribution, groin numbness (sometimes described as saddle paresthesia), and urinary retention (inability to urinate).

This young lady who went to the emergency room shared enough information with the triage nurse and bedside nurse, which was documented in the medical records, to require adding cauda equina syndrome into the differential diagnosis list. The patient complained of severe lower back pain, along with numbness in the hip, leg, and pelvic regions.

For some reason, though, the nurse practitioner who saw the patient didn’t act and chose to discharge the patient. Instead, the nurse practitioner should have ordered an MRI, which would’ve identified the problem and led to a neurosurgical consult.

Oddly, the triage and bedside nurse went along with the nurse practitioner’s plan, rather than advocating for the additional medical care that the patient needed.

As a result of the collective mistakes by the nurse practitioner and nursing staff, the patient returned to the emergency room a few days later with the same complaints plus urinary retention. On that visit, a physician ordered an MRI that showed cauda equina syndrome.

The treatment for cauda equina syndrome involves returning a patient to surgery to decompress the nerves. If that had happened with the first emergency room visit, she would likely have completely recovered. As result of the delay, though, even though she was taken back to surgery, she was left with permanent symptoms, including leg pain and lower extremity motor weakness, as well as bowel, bladder, and sexual dysfunction.

I’ve handled cases where patients suffered from cauda equina syndrome as a complication from lumbar spine surgery. In other cases, like the one that we just discussed, it can develop independently from surgery.

If you’ve been seriously injured because of mismanagement of back pain, numbness, or other neurological symptoms, then contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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