Time Is Tissue: What a $7.6 Million ER Verdict Teaches Attorneys About Missed Vascular Injury

By Tracy L. Liberatore Esq, PA-Emeritus

Every emergency clinician learns the phrase early: time is tissue. When an artery to a limb is blocked, the muscle and nerves below it start dying on a clock. A Florida jury just put a number on what happens when that clock runs out in the emergency room.

On September 18, 2026, a Lee County jury in Florida’s 20th Judicial Circuit returned a verdict of more than $7.6 million for Rebecca Knowles, a woman who lost her leg after a fall at home dislocated her total knee replacement. The jury found that the emergency physician and the physician assistant who treated her were negligent and that their negligence caused the amputation. The case is Knowles v. Ensley, D.O., et al., No. 2024-CA-006215.

I practiced as a physician assistant before I went to law school, and I now spend my days matching attorneys with clinical experts. A case where a PA sat at the defense table gets my full attention. This one is a clean lesson in how a vascular case is built, how it is defended, and what the record has to show either way.

What happened in the emergency room

According to trial coverage and the plaintiff’s firm, Ms. Knowles fell at home on December 14, 2022, and dislocated her left knee replacement. She was taken to the emergency department at Cape Coral Hospital. Over roughly four and a half hours in the emergency department:

  • X-rays were taken shortly after arrival, and the physician assistant ordered CT angiography to look for an arterial injury.
  • The emergency physician tried and failed to reduce the dislocated knee.
  • The CTA showed a blockage of the popliteal artery, the vessel behind the knee that supplies the lower leg and foot.
  • That result came back as she was leaving the PA’s care. The PA relayed it to the orthopedic surgeon who was taking over her care. A vascular surgeon was not called with it.

She was admitted, and her artery was not repaired until the next evening, after a transfer to a different hospital. The attempt to save the limb failed, and her leg was amputated on January 11, 2023.

Two stories about the same four hours

The defense told jurors that the providers followed protocol. They ordered the right study quickly, attempted a reduction, and relayed the result to the surgeon taking over. Defense counsel argued that no honest witness in the same specialty would call that care substandard.

The plaintiff’s answer was that ordering a test is not the same as acting on it. Her counsel showed the jury a photo a friend took of her leg in the ER. The leg was visibly discolored, a classic sign of lost blood flow, and the discoloration does not appear anywhere in the chart. Counsel also stressed that nobody examined her vascular status in person that night and that no vascular surgeon was contacted while she sat in the department. Her vascular surgery expert testified that an artery blocked too long leaves the muscles and nerves beyond it dead, and that timely restoration of flow would have saved her leg.

The jury deliberated about four hours. Plaintiff’s counsel asked for roughly $12 million and reported that no settlement offer was made before or during the three-day trial.

Why knee dislocations are a vascular emergency

This is not obscure medicine. The popliteal artery is tethered above and below the knee, so a dislocation can stretch, tear or clot it. Three clinical points come up in almost every one of these cases:

  • A pulse does not clear the patient. A foot can have a palpable or Doppler pulse and still have a significant arterial injury. That is why the standard workup includes an objective measure such as the ankle-brachial index, with CT angiography or a vascular consult when the numbers or the exam are abnormal.
  • The window is hours, not days. The teaching goes back to a 1977 series in the Journal of Bone and Joint Surgery, which concluded that vascular repair has to be done within six, or at most eight, hours of the injury. In that series, 86 percent of patients not treated inside that window lost the limb. Clinicians still work to that target.
  • A result is only as good as the person who receives it. An abnormal CTA that reaches a surgeon who cannot revascularize the leg is, for the limb, the same as a CTA that reached nobody.

What I would pull from the record

Whether you represent the patient or the providers, these cases are won or lost on time stamps. Before committing to a position, I would want every one of these:

  1. The triage note and first exam. Color, temperature, capillary refill, pulses and sensation of the affected limb, with the time each was charted.
  2. Nursing neurovascular flowsheets. How often the limb was checked, by whom, and whether any change was escalated. Gaps here are often where the story is.
  3. Pre- and post-reduction checks. Every reduction attempt should be followed by a documented neurovascular exam.
  4. The imaging timeline. When the CTA was ordered, performed, read and communicated, and to whom. Pull the radiology audit trail and any critical result call log, not just the final report.
  5. Consult records. Page logs, call times and who was contacted. In this case the gap between the orthopedic surgeon and a vascular surgeon was the center of the trial.
  6. Supervision and scope. For a PA or nurse practitioner, the supervising physician’s role that shift and the department’s protocols for limb-threatening injuries in effect on the date of care.
  7. Transfer records. Why the patient waited, when the receiving facility accepted her, and what the ischemia time looked like on arrival.
  8. Anything outside the chart. Family photos, texts and time-stamped messages. The most persuasive exhibit in this trial was a picture that never made it into the medical record.

The defense side of the same file

Med Legal Pro works with defense counsel as well as plaintiffs, so it is worth saying plainly: this verdict does not mean every missed vascular injury is a liability case. The defense questions are just as record-driven. Was the injury already irreversible when she arrived? What part of the delay happened after the ER handed her off, and to providers who are no longer in the case? Did the department’s protocol actually require a direct vascular consult, or does it route through orthopedics? A strong defense expert can answer those questions from the same time stamps.

The right experts for a delayed vascular care case

Florida requires a standard of care expert to be a similar health care provider to the defendant, and most states have a version of that rule. A case like this one typically needs:

  • An emergency medicine physician for the physician’s standard of care.
  • For a PA defendant, a physician assistant with emergency department experience, or an emergency physician who supervises PAs. Florida’s statute lets a qualified physician speak to the PA standard of care.
  • A vascular surgeon to address timing, salvageability and causation, to a reasonable degree of medical certainty.
  • An emergency nurse when the flowsheets and escalation are at issue.
  • A life care planner and economist for future medical needs, prosthetics and lost earnings.

Getting the specialty match right at the start protects the case from a motion to strike and from an easy line of cross-examination by opposing counsel.

How Med Legal Pro helps

Med Legal Pro matches attorneys with screened, litigation-trained physician, PA and nurse experts in medical malpractice, personal injury, nursing home and long-term care, and wrongful death cases. We work with plaintiff, defense and criminal attorneys, and every expert we place is trained to write opinions that hold up under scrutiny.

Call 844-633-5345 or submit your case at medlegalpro.com/submit-a-case.

Sources

This article is provided for informational purposes only and does not constitute legal or medical advice.

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About Tracy L. Liberatore Esq, PA-Emeritus