Knowing when to refer a patient to a specialist can be tricky. Some practitioners regularly refer, often at the insistence of the patients themselves. Other clinicians are more conservative and prefer to monitor the situation themselves before sending the patient elsewhere. Trying to find the right balance can be challenging. In this case, a nurse practitioner learned that sometimes it’s better to err on the side of caution.

Ms. G worked with a family practitioner in the suburbs of a midsize city. She had been with this physician for five years and enjoyed the independence of seeing patients unsupervised and making her own clinical judgments. The physician, Dr. M, always discussed cases with her, providing input and suggestions. He also listened to her thoughts and ideas, and she felt encouraged and enthusiastic about her work.

One of Ms. G’s patients was a 70-year-old widow with diabetes who had been coming in regularly over the last year for checkups and mostly minor complaints. Mrs. D was in the waiting room one morning when Ms. G arrived for work. Once Mrs. D was shown into the examining room, Ms. G asked her why she had come in. Mrs. D revealed an ulcer on the heel of her right foot that she said had been there for the past two to three weeks. Ms. G diagnosed the wound as cellulitis and prescribed cephalexin (Keflex) 500 mg t.i.d. for 10 days, warm soaks, and bacitracin for topical treatment.

One month later, Mrs. D returned on a day that Ms. G was out of the office. Dr. M saw the patient, who had come in with a complaint about frequent nosebleeds. When Ms. G next saw Mrs. D’s file, she saw that Dr. M had noted “right heel ulcer also” on the patient’s chart but had not mentioned any treatment. Ms. G intended to ask the physician about this, but the waiting room was crowded, and she soon forgot about the issue.


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Mrs. D returned three weeks later and was again seen by Ms. G. This time, she reported redness, swelling, and a burning sensation on her right heel. Ms. G noted that the heel had a 4  4-cm area of blackened eschar. She prescribed collagenase (Santyl) ointment and saline dressings. At a follow-up appointment three days later, the heel’s condition was unchanged. Ms. G was starting to become concerned and spoke to Dr. M about the patient. The physician felt that the wound was being treated properly and simply advised Ms. G to call him the next time Mrs. D came in.

Two weeks later, Mrs. D was back, distraught because the treatment did not seem to be working. Ms. G called in Dr. M, and they both examined the wound, which was the same size and showed no improvement (the black eschar was still present). Dr. M told the patient that Ms. G had been treating the wound properly and advised Mrs. D to continue with the collagenase ointment and saline dressings. However, the patient returned a week and a half later, noting that her condition had worsened. The ulcer had increased to a 6  7-cm blackened area. Mrs. D was then referred to a wound clinic.

Evaluation at the wound clinic revealed a 3.4  4-cm, full thickness, stage 3-4 ulcer of the right heel. The examination also revealed redness of the foot and ankle as well as 2-3+ bilateral lower-extremity edema. Pedal pulses were not palpable on either leg but were audible with a Doppler. The wound clinic ordered noninvasive vascular studies, dry dressings, a vascular surgery consult, and a continued course of cephalexin. The vascular surgeon found a large area of necrosis on Mrs. D’s right heel and noted that her noninvasive vascular studies were consistent with right superficial femoral artery occlusion with severe ischemia of the right lower leg. The patient was told that an above-the-knee amputation would be necessary, which was performed two months after her last visit to Ms. G and Dr. M. Subsequently, the amputation site became infected and, despite attempts to clear up the infection (antibiotics, incision and drainage of the wound), Mrs. D’s conditioned worsened, and she died from sepsis.

Ms. G and Dr. M were shocked to hear of the patient’s death, but they were even more shocked when they were served with papers notifying them that they were being sued for malpractice. Their defense attorney explained that the lawsuit alleged that the clinicians were negligent in treating Mrs. D and that the plaintiff (Mrs. D’s son) was claiming that his mother should have been referred to a wound specialist much sooner.

“She died more than two months after we treated her,” Ms. G told the attorney. “She had been seen by several other physicians by that time. Why sue us?”

The attorney had no answer.

“It was reasonable for us to treat the wound conservatively at first,” said Dr. M. “We did refer the patient for further treatment when she didn’t respond.”

“Yes,” said the attorney, “but the allegation is that you waited too long to send her to the wound clinic.”

After discussing their options, the clinicians decided to settle out of court for $900,000, an amount covered by their malpractice insurance.

Legal background

Had this case gone to trial, the defendants would have argued that they had been compliant with the standard of care by treating the patient and referring her to a specialist when she wasn’t responding. They would have had a chance of being found not liable by faulting the vascular surgeon, hospital, or wound clinic. But even when there is a chance of winning, many defendant health-care practitioners choose settlement over a trial. Trials are expensive, lengthy, and take an emotional and psychological toll on everyone involved. Sometimes it is simply a better practical solution to settle out of court and avoid the potential hardship.

Protecting yourself

In patients with diabetes, wounds must be taken very seriously, as they can quickly turn into situations requiring amputation. In this case, about three months elapsed between Mrs. D’s initial visit and her referral to the wound clinic. This was simply too long—especially considering that her wound never seemed to respond to any of the treatments prescribed by Ms. G and the physician. To protect yourself (and your patients), vigorously monitor wounds (especially foot and leg wounds) in diabetic patients, and refer them to specialists sooner rather than later if there is no improvement.