Compartment syndrome is one of the genuine emergencies in trauma medicine. When pressure inside a muscle compartment rises beyond the perfusion pressure of the small blood vessels supplying it, blood flow stops. Muscle tissue starts to die within hours. If the condition is recognized in time, it is treated with an urgent surgical fasciotomy, an incision that releases the pressure. If it is not recognized in time, the result is often permanent damage to the limb, and in the worst cases, amputation.
In Fortune-Ozoike v Wal-Mart Canada Corp., 2023 ONSC 421, an Ontario Superior Court of Justice trial judge found that a defendant emergency physician breached the standard of care by failing to assess a patient with a high-risk leg injury for compartment syndrome. The patient lost her leg above the knee. The court found that, on a balance of probabilities, the amputation would have been avoided had the diagnosis been made sooner.
The facts
On Boxing Day 2013, Jameela Fortune-Ozoike slipped on a clothing hanger at a Wal-Mart store and fell. She was in severe pain and was taken by ambulance to Humber River Regional Hospital. She was eventually diagnosed with a left knee dislocation, a serious orthopedic injury that carries a known and significant risk of vascular compromise.
By the next morning, the blood flow in her left leg was seriously compromised. She was airlifted to St. Michael’s Hospital and underwent vascular surgery in the early afternoon of December 27, 2013. By then, it was too late to save the leg. On January 4, 2014, Ms. Fortune-Ozoike underwent an above-knee amputation.
The trial finding
The trial judge identified two specific failures in the assessment performed by one of the defendant emergency physicians at 1 a.m.
First, the physician did not conduct a proper examination for compartment syndrome. That examination, which is part of the standard of care when compartment syndrome is a possibility, includes palpating the compartments of the affected leg and passively stretching the muscles by moving the patient’s ankle. Pain on passive stretch is one of the cardinal signs of compartment syndrome and is well known to emergency physicians.
Second, the physician failed to notify another physician of his own concerns that Ms. Fortune-Ozoike might be developing compartment syndrome. A high-risk diagnosis like this calls for escalation, not silence.
After hearing the expert evidence, the trial judge found that had the diagnosis been made sooner, on a balance of probabilities Ms. Fortune-Ozoike would not have required the amputation.
Why this case matters
For emergency physicians and the institutions that employ them, the decision is a clear and unwelcome reminder. A knee dislocation is a vascular emergency in the making. The physical examination required to rule out compartment syndrome takes minutes. The threshold for escalating concerns to a senior colleague or specialist should be low. A proper, documented assessment, escalated quickly, would likely have changed the outcome here.
For patients and families, the case shows the kind of catastrophic loss that can follow when a serious diagnosis is missed in the early hours of a hospital admission. Compartment syndrome has been described as a “must-not-miss” diagnosis in emergency medicine for decades. The fact that it can still be missed, with consequences this severe, is the reason careful and contemporaneous medical record review is at the core of every credible medical malpractice case. Symptoms that should have been recognized, examinations that should have been performed, escalations that should have happened, all of it lives in the chart.
For plaintiffs’ counsel, the decision is a useful precedent. It identifies, in plain terms, two specific elements of the standard of care for suspected compartment syndrome: the physical examination steps required and the duty to escalate. Both are findings of fact that can be cited in future cases of this kind.
If you are concerned that a delayed or missed diagnosis in an emergency department contributed to a serious injury suffered by you or a family member, see Misdiagnosis and Emergency Room Delay for more on these claims, or Suing for Medical Malpractice in Ontario: What You Need to Know for the legal framework.
Decision Date: January 16, 2023
Jurisdiction: Superior Court of Justice (Ontario)
Citation: Fortune-Ozoike v. Wal-Mart Canada Corp., 2023 ONSC 421 (CanLII)
