Poor Judgment, Didn't notice Compartment?

[morningland]

I feel very awful.

A patient arrived from OR with an ORIF of the L forearm. Patient was fine and I even educated him on compartment syndrome (which what makes this so troubling). He was complaining of some numbness in his fingers, but his cap refill was

His pain actually improved through the night, but the numbness continued so I finally called the Ortho MD. He said this sounds normal and he would pass it along. When the actual surgeon came in he was a little upset that I didn't inform him of the numbness; he said cap refill sluggishness is a late sign and means nothing.

When I left, was in the process of re-evaluating to see the next steps. Anyways, I feel crushed that my poor judgment didn't lead me to just call the MD. I always call the MD when I have the slightest concern, and I am very disturbed by the thought that I may have brought harm to my patient.

I probably deserve a shellacking here and I feel horrible. I know these things make us stronger nurses, but I feel like this lack of judgment has shaken my confidence.

In my previous knowledge, the main indicators of Compartment would be severe pain, pallor, loss of movement in the limb, poor circulation... how could I overlook numbness?

[Okami_CCRN, BSN, RN]

I don't think you did anything wrong and acted in a reasonable manner. The patient complained of numbness, but you did not notice any other signs associated with compartment syndrome. You notified the orthopedist of the persistent numbness, but there did not seem to be an decompensation to the neurovascular checks you conducted. Don't beat yourself up too bad.

[roser13, ASN, RN]

I don't think you did anything wrong and acted in a reasonable manner. The patient complained of numbness, but you did not notice any other signs associated with compartment syndrome. You notified the orthopedist of the persistent numbness, but there did not seem to be an decompensation to the neurovascular checks you conducted. Don't beat yourself up too bad.

Agree.

[morningland]

Thanks so much. I really appreciate it.

I don't think I mentioned the patien arrived At 2100 but I didn't call the doc until 0600. Again , I didn't see any other symptoms and finally called because the patient said he was worried, so I wanted to reassure him.

I'm just praying he is okay and I can learn and grow from this.

[Wile E Coyote, ASN, RN]

The numbness alone is not specific to compartment syndrome, though. In regards to the pain, look more for increased or disproportionate pain on passive movement as it's a little more specific to CS.

Injury/irritation to the nerve(s) could have been pre-operative, a nerve block could have been used intra-op, it could have been carpal tunnel syndrome instead, etc. In my opinion, in the absence of large bleeding, the compartmental spaces should be pretty lax immediately after ORIF and take a little longer to become high enough for ischemia. I definitely second that the absence of a distal pulse or sluggish cap refill are late signs and a monitored patient should not get to that point before intervention. Did you get a follow up that it indeed was CS? Did the surgeon know that his/her colleague thought your report "sounded normal" ?

[OCNRN63, RN]

I picked up compartment syndrome on a peds. patient. The boy had pain that was off the charts; nothing relieved it. He also had sluggish cap return. There was just something about him that said "compartment syndrome." I called his surgeon, who had a terrible reputation for how he treated nurses. I expected to get eaten alive because I was calling at 0300, but tough rocks...the patient came first. He did bark at me at first, till I told him I thought his pt. had compartment syndrome and gave him my assessment. He asked me to check one other thing with the pt. Ten minutes later he was on the unit, and within twenty minutes we were rolling the kid off to the OR.

I don't see anything you did that was wrong. Your case was nebulous, at best.

Don't beat yourself up for not being a mind reader.

[Kitiger, RN]

You did assess carefully for other signs, and didn't find any. And it is unlikely that you will EVER dismiss numbness again, even when it really is minor.

Peace.

[morningland]

Thanks so much everyone.

I was taught that one of the hallmark signs of compartment is uncontrollable pain. By the time the doctor was called, I had already weaned him off the Dilaudid and we were on the Oral pain meds. If there was no sensation when the doctor assessed, then that symptom developed from the time I called to when he assessed.

Ambi I doing anything wrong with assessing sensation. To me, if you can tell me when finger I'm touching when I have you close your eyes, it tells me you have adequate sensation. I do have hat charted that the patient had sensation.

And be you are right, I'll never take numbness, for any reason, lightly again. I also know now about having the patient bend their toes or fingers into a fist to help assess for compartment. Of the five Ps of compartment, he only had one

[HeySis, BSN, RN]

I check not just pressure sensation like you have mentioned but also if they can sense wet or cold. I'll take an alcohol wipe and move up the dermatomes and ask the patient to tell me when they feel anything and then when I switch to a wet cloth (although it has been wet the entire time). That lets me know a bit more about sensation. Pressure can be felt more readily then cold and wet.

Another thing is that I have them describe their numbness. Is it heavy, dead weight, tingling... it just gives me more info to notice changes and to notify providers. I mainly do this to see if nerve blocks in the OR have worn off before they were suppose too. A nerve block should feel heavy like a dead weight. Our anesthesiologist will often come back to the PACU if the nerve block has worn off or didn't take well and redo it, so we need to know when that has happened.

If you continue to have questions, I'd look up the policies or talk to your educator/manager on what needs to be assessed after this surgery and how often, to make sure you are covering yourself according to hospital policy.

Don't beat yourself up, one symptom on it's own doesn't necessarily raise a red flag. It obviously didn't flag the ortho doc you called either, accept that we do our best and sometimes you just can't know.

[NuGuyNurse2b]

if it makes you feel better, OP, I learned something from your 'mistake' and thank you for sharing.

[morningland]

if it makes you feel better, OP, I learned something from your 'mistake' and thank you for sharing.

That does. If we can learn from these errors we all become stronger nurses.

Since I've been home, I've been re-studying compartment syndrome and I am feeling a little more reassured that I didn't yet have all the information needed to indicate a need to call the Doctor earlier.

For starters, his pain was under control. It had spiked slightly about three hours after he got back but the pain medication was effective and, as I said, by the morning time I had weaned him off the Dilaudid and we were solely on oral oxy, which was controlling his pain.

In my study, I reconfirmed that pain unrelieved by medication is indeed one of the early signs of compartment syndrome. That and Paraesthesia, or a feeling of numb tingling in the extremities. If the patient is exhibiting these signs, you can have them dorsal flex their hands or feet. If they can't it can be a sign of ACS (acute compartment syndrome). It makes sense, increased pressure would therefore make it harder for the Pt to flex the affected extremity.

So, looking back, would I have called the doctor for numbness. YES, of course. But maybe it wasn't an error of judgment but a lack of knowledge and I am really starting to think that if the patient had ACS, he developed late in my shift and we still caught it very early, Because I assessed sensation and it was present, but 30 mins later it was gone.

I will let you know what happened to the patient. If he is still on the unit when I go back, it is likely he had a fasciotomy.

Someone please correct any of this information if it is incorrect.

[morningland]

But when you think about it, the pain really does make sense to be the true hallmark of compartment.

If a patient is in pain simply because of the surgery, the medication should help reduce that (although, sometimes unrelieved pain from operations like a TKA need a little bit of Toradol to help keep the inflammation down).

Now if the pain is related to increasing compartment pressure, then the medication can not resolve the pain because the pressure will simply keep getting worse and worse.

This seems like solid rational to me? What do you guy and girls think?