Joe, a 7-year-old boy, caught his foot in a trampoline at a birthday party. The next day, his father took him to urgent care where a physician diagnosed the child with a sprained ankle. When Joe’s pain persisted the following day, his mother took him to the emergency department (ED) of a local hospital.

In the ED, Joe was first seen by Nurse A, who gave the child a cursory evaluation. He was then evaluated by Physician Assistant 1 (PA1), who ordered radiographic examination. No fracture or dislocation was identified. Joe was diagnosed with a foot sprain and discharged.

The patient remained in pain and the following day his father took him back to the ED. At that time, he was seen by Nurse B, the triage nurse.

“Joey was restless and crying for most of the night,” the father told the nurse. “He also had a fever.”

Nurse B noted that Joe presented with foot pain and swelling, but she failed to assess the foot any further. She did not take the child’s blood pressure, but she did note that his heart rate was elevated at 160 beats per minute. He did not have a fever at that time.

Nurse A saw the child again on this visit but did not assess his leg. Joe was evaluated again by PA1, who applied a splint to the child’s leg and provided him with crutches. The patient was again discharged with a diagnosis of foot sprain.

That night, Joe could not sleep and was in a great deal of pain. His mother gave him an analgesic, which it did not provide any relief. At 3:00 AM, the parents took Joe back to the same ED for the third time. This time he was assessed by Nurse C, who completed a pain assessment and recorded Joe’s pain level (6 out of 10). She performed gastrointestinal, genitourinary, integumentary, neurologic, and respiratory assessments, but she did not note any skin or sensation assessment, or perform a pulse check on Joe’s lower leg.

A different physician assistant (PA2) evaluated Joe on this visit. While performing a physical examination, she noted tenderness of the left foot with mild swelling and ecchymosis of the lateral and medial aspects. She reapplied the splint and wrote a prescription for ibuprofen for pain, as needed. The child was discharged at approximately 6:00 AM with a diagnosis of foot sprain.

That same morning, Joe’s mother took him with her to work. In the bathroom, she saw that Joe’s leg had turned purple. She called his pediatrician who told her to take him immediately to a different hospital. Upon arrival Joe was noted to be pale, fussy, and uncomfortable. His left leg was cyanotic and cold to the touch. A Doppler ultrasound showed no pulses in his lower left leg, and ultrasound examination revealed deep vein thrombosis (DVT).

The child was diagnosed with compartment syndrome and taken into surgery for a fasciotomy. Following surgery, Joe developed septic shock and went into respiratory failure requiring ventilator support. This led to a lifesaving above-the-knee leg amputation.

His parents sought the advice of an attorney and sued the hospital, nurses, PAs, and the supervising physicians.