Author’s Note: This periodic feature will focus on legal issues faced by neurologists and other health care practitioners. It will use case studies to illustrate topics such as the elements of medical malpractice, HIPAA, informed consent, delayed diagnosis, and other issues. We hope you will find it informative and useful in your practice.Medical malpractice claims in neurology often arise from diagnostic errors, particularly missed or delayed identification of conditions such as stroke, intracranial aneurysm, or subdural hematoma, which can result in severe patient harm. As with many medical specialties, communication breakdowns and inadequate documentation are also common contributing factors. The case discussed here highlights several of these issues, including delayed diagnosis as well as deficiencies in communication and documentation.
During an acute stroke, every second counts.
Facts of the Case
Mr B was a 57-year-old White man with no significant medical history. He worked as a master electrician and owned his own company. One morning, he woke up with a headache, noticed a slight weakness in his left arm, and his speech was a bit slurred. While speaking to him, his girlfriend noticed that he seemed confused and had a tremor in his left arm. Concerned, his girlfriend convinced him to go to the emergency department (ED) of the local hospital to get examined.
In the ED, Mr B was seen by Dr E, the attending emergency physician, who recognized that the patient’s symptoms were consistent with a stroke. Dr E ordered a non-contrast head CT at around noon, which showed no acute abnormalities. He assigned the patient a National Institutes of Health (NIH) Stroke Scale score of 2.
This 'Too Good to Treat' crapola caused the whole problem, Debunked over a decade ago:
February 2015
Dr N was the on-call neurologist at the hospital that day. Dr E contacted the neurologist after examining the patient to discuss whether to administer tissue plasminogen activator (tPA). After the 2 physicians spoke, it was decided that Mr B was outside the time frame for tPA, and that he was not a candidate for intervention at that point due to his symptoms, duration of onset, and low NIH Stroke Scale score. Instead, Dr E started the patient on aspirin, admitted him for observation, and asked Dr N to evaluate the patient.
Dr N eventually arrived to evaluate the patient several hours after admission. Dr N noted acute gait instability, ataxia, headache, right mouth droop, impaired repetition, and a left arm tremor. The physician ordered a magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) to assess for infarct or vascular occlusion; however, he failed to write ‘stat’ on the order to note the urgency and instead gave it routine priority. Dr N was also unaware that the hospital’s MRI/MRA machine was currently not working and the hospital was waiting for a service call. Hours passed without the tests being performed. In all that time, Dr N did not follow up to find out why the MRI/MRA had not been completed. The rest of the day and night passed without Mr B receiving the MRI/MRA.
The next morning, approximately 24 hours after the onset of symptoms, Mr B was found unresponsive, with labored breathing and significant neurologic decline. His NIH Stroke Scale score had risen to 13. A repeat CT revealed a basilar artery thrombus. Mr B was transferred to another hospital, where an MRI revealed acute infarcts in both cerebellar hemispheres, the left mesial temporal lobe, bilateral thalami, and thrombi in the basilar and left posterior cerebral arteries. Although he underwent a mechanical thrombectomy at the second hospital, the intervention came too late to reverse the damage. As a result, the patient suffered “locked-in syndrome,” where he was aware but unable to speak or move for 5 days before he finally died from the damage caused by the severe stroke.
The Trial
After Mr B’s death, his family consulted with a plaintiff’s attorney, who reviewed the medical records and agreed to take the case. The attorney filed a lawsuit against Dr N, alleging that his failure to order the imaging on a ‘stat’ basis, failure to follow up on the order, and failure to send the patient to another hospital with a working MRI machine resulted in Mr B’s severe and life-ending stroke.
Dr N was assigned an attorney from his malpractice insurance company. After several years, the case went to trial. At trial, the defense attorney argued that the severe stroke that occurred the morning after Mr B was admitted was an entirely new and unpredictable event. The plaintiff’s attorney argued that the original stroke did exactly what it was at risk of doing: causing significant harm. The plaintiff’s attorney described the horror of “locked-in syndrome” and elicited testimony from the defense’s expert that he had previously described it as “a terrifying experience for the patient” and “a fate worse than death.”
The testimony lasted for 2 weeks, and the jury deliberated for 5 hours before returning a verdict for the plaintiff and awarding his family over $4.5 million.
Protecting Yourself
We all know that time is of the essence when diagnosing a stroke, which makes it all the more shocking that Dr N did not order the test ‘stat’. Worse still, when the test wasn’t done in the ensuing hours, Dr N did not follow up to find out why. Had the physician known that the MRI machine was down, he could have had the patient transferred to another hospital where the tests could have been conducted. With the information gained from an MRI/MRA, Mr B could have been treated.
The jury’s high monetary award indicated that they were sympathetic to the patient, were swayed by the expert’s description of “locked-in syndrome” as a “fate worse than death,” and found fault with the neurologist for failing to order tests with the proper urgency and to follow up on his own orders.
During an acute stroke, every second counts. Quick diagnosis and treatment are vital to a good outcome. Rapid intervention is essential, and tests and imaging should always be ordered on a stat basis to protect your patient… and yourself.
