Patient complained of 'numbness in the groin area'
The Ontario Superior Court of Justice has found two emergency department physicians negligent for failing to diagnose a patient suffering from “numbness in the groin area.”
In Chrysostom v Kempenaar, 2023 ONSC 3664, Zorida Chrysostom went to the emergency department of Rouge Valley Ajax and Pickering Hospital in the early morning of December 18, 2012. Chrysostom complained of leg pain and reported being diagnosed with sciatica two weeks ago. Dr. Gary Mann assessed her and made a tentative diagnosis of left lower lumbar pain with sciatica. Later in the day, Dr. Jacob Kempenaar examined Chrysostom and decided to discharge her.
Ten days later, Chrysostom returned to the emergency department and was diagnosed with cauda equina syndrome. She was promptly transferred to Toronto Western Hospital-University Health Network, where she underwent surgery for this condition.
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Chrysostom commenced an action against Mann and Kempenaar, asserting they were negligent for failing to diagnose her with cauda equina syndrome.
During the trial, the Ontario Superior Court of Justice noted that the experts agreed on the differences between sciatica and cauda equina syndrome. Cauda equina syndrome is a clinical condition which involves dysfunction of the spinal nerves as they exit the spinal cord. The symptoms of this condition include pain radiating into one or both legs and neurological dysfunction, which would consist of sensation and pain or muscular weakness in one or both legs.
Sciatica is a related condition caused by a similar pathology. The experts stated that sciatica is commonly seen in the emergency department. However, the experts stressed that sciatica must be distinguished from cauda equina when assessing for presentation in the emergency department.
The court noted that the central issue in the case is whether the two attending physicians made enquiries of the plaintiff as to whether she was suffering numbness in the saddle area. If so, the attending physicians were expected to conduct further examinations, including a rectal exam and an MRI. The expert witness testified that in taking a history, it is essential for the attending physician to ask about numbness in the perineum. Another expert called by the defence said that an emergency doctor would have an obligation to ask questions specifically about “saddle anesthesia.”
Dr. Mann testified that he had no actual recollection of the patient and no record of asking the plaintiff about symptoms of saddle anesthesia. However, Dr. Mann said he would typically practice identifying red flags for cauda equina syndrome as part of his routine.
The court acknowledged that Dr. Kempenaar noted the patient’s numbness complaints. Dr. Kempenaar testified that had the plaintiff complained of numbness in the groin or the perineal of the saddle area, he would have charted that because that would have been a red flag for cauda equina syndrome.
The court found from the emergency triage record that the patient complained of numbness in the groin area, which had started the previous night. The court noted that the nursing record is a reliable, contemporaneous record of what the plaintiff told the nurse about the location of the numbness. The court stressed that if either of the attending physicians asked the plaintiff about the location of the numbness, she would have given the same response, just as she did to the nurse at the emergency triage. That answer would have included a reference to numbness in the groin area. The court accepted the expert’s opinion that a reference to numbness in the groin area is, in fact, a reference to numbness in the saddle area of the body.
The court concluded that Dr. Mann did not ask the plaintiff about the location of her numbness. While Dr. Kempenaar recorded that the patient complained of numbness in the left buttock, the court was not satisfied that he asked the plaintiff whether she had any saddle numbness. Accordingly, the court concluded that Dr. Mann and Dr. Kempenaar fell below the appropriate standard of care.
The court also found that the plaintiff did have cauda equina syndrome when Dr. Mann and Dr. Kempenaar first saw her on December 18, 2012. The plaintiff relied on the opinion of an orthopedic surgeon with a subspecialty in spinal surgeries who found that the plaintiff likely suffered from cauda equina syndrome when Dr. Mann and Dr. Kempenaar saw her. The court found that the plaintiff’s evidence is credible. Furthermore, the court said that since damages have been agreed upon, the plaintiff would have no motivation to exaggerate or mislead the court.
The court ultimately concluded that the plaintiff had established on a balance of probabilities that Dr. Mann and Dr. Kempenaar fell below the standard of care in their treatment of the plaintiff and that the plaintiff did have cauda equina syndrome on December 18, 2012.