August, 2021 Welcome to Medical Malpractice Insights - Learning from Lawsuits. If you're a first-time reader, sign up here (free) to receive each monthly issue in your inbox. This issue of MMI-LFL has learnings from 2 cases that did not become lawsuits after review. Don't miss Dr. Bill Smock's input on strangulation injuries below the first case. | Delayed dx of carotid artery dissection Would a more timely dx have made a difference? Facts: An intoxicated adult male in his mid-40’s decides to trim the limbs on a tree in the middle of the night. Despite his inebriation, he wisely fastens a makeshift safety rope around his waist and climbs the tree. Unfortunately, he slips. As he falls about 7 feet, the rope slides up around his neck. He hangs there for at least a minute before friends cut him down.
Facts/Chronology:
0121: Arrives in the ED with ligature marks, redness and swelling on his neck. GCS=8, BP 102/56, P 59.
0138: Vomits and may have aspirated.
0201: BP is in the low 90’s.
0209: First seen by EP. Altered mental state is thought to be due to alcohol intoxication. Low BP raises concern for traumatic hemorrhage.(?)
0233: Orders placed for CT of neck/head and CTA of chest/abd.(?)
0236: Lab orders for CBC, CMP, Drug screen, PT/PTT and TSH(?).
0243: Pt. has grand mal seizure. Ativan given. Seizure stops.
0315: BP remains in 80’s.
0400: Intubated for CT (now 2 1/2 hours post arrival). CT head/neck unremarkable. CTA chest/abdomen shows possible aspiration.
0436: Drug screen neg except for BA of 142.
0507: CTA of head/neck ordered.
0523: CTA of head/neck finds a dissection and complete occlusion of the L internal carotid artery. There is also hypo-perfusion of the entire L cerebral hemisphere. IR is consulted and advises heparin only.
0530-1434: Pt. remains in ED and shows signs of herniation while awaiting ICU bed.
1434: Chaplain is called. Patient expires in ED shortly thereafter.
The pt's wife consults an attorney. The records are sent to an EM expert for review.
Plaintiff Concern: The doctor assumed my husband was just drunk. The ED was totally disorganized. It took way too long to find out what was wrong with my husband. It took forever to get any answers.
Defense Arguments: Despite the delay in obtaining a CTA of the head/neck that made the dx of a L carotid artery dissection with complete occlusion, an earlier diagnosis would not have altered the outcome. This was a very severe traumatic hemispheric stroke that was not survivable. While the care was clearly not optimal during the first 4 hours, the neck injury from accidental hanging was the cause of death, not the delay in diagnosis.
Result: No lawsuit was filed.
Takeaways:
* Assuming that an intoxicated trauma patient’s altered mental status is due to alcohol is dangerous. Rule out the worst things first.
* ED and DI volumes fluctuate. Staffing every day for surge volumes is impossible
* When delays occur, communication with patients and families is critically important.
* If your negligence isn't the only cause of death, you're generally off the hook.
References: I received the email below from Dr. Bill Smock, a long-time reader of MMI-LFL and a nationally known expert on strangulation injuries. Dr. Smock's own case story and the poster below summarize a standard for strangulation injuries./CP] | Case Story: A 50 yo woman was beaten and strangled unconscious. The victim had multiple visible facial and neck injuries and was taken to the ED by domestic violence detectives and a forensic nurse. When the EP failed to order a CTA of the neck, the detectives and nurse advised the patient to go to a local academic ED for a second opinion. The NP there ordered the neck CTA which showed a Grade 3 dissection of the ICA. She was seen by neurosurgery, admitted and treated with ASA only. Fortunately she had no stroke or other adverse event.
Comment: The major risk for strangled patients is a vascular injury. I have seen multiple cases of carotid dissections from strangulations and am amazed at how few ED physicians know of the importance of a CTA, even for those without visible external trauma. Readers may contact me if they would like to explore the topic further. Below are the imaging recommendations of the Training Institute on Strangulation Prevention.
Bill Smock MD FACEP
Police Surgeon, Louisville (KY) Metro Police Department
Medical Director, The Training Institute on Strangulation Prevention, San Diego, CA |  Click on poster for full size view. | |  Click on poster for full size view. | | Patient dies hours after PCP evaluation for headache Missed cerebral aneurysm: Negligence or not? Facts: A woman in her early 50’s develops a gradually increasing L sided headache. Her BP on her home device is 159/108. She suspects she is having a migraine but is equally concerned about her BP. She calls her PCP who sees her in his office an hour later. She says that the HA is "like my usual migraines." The pain is now only on the R side at 4/10 and is aggravated only by climbing stairs. One notation describes the pain as“throbbing,” another says "not throbbing." ROS is negative for photophobia, positive for mild nausea. PMH includes hypertension treated with Losartan and migraines not requiring prescription meds. Exam reveals a BP of 152/112, normal neuro, no temporal artery tenderness or nuchal rigidity. BP is not repeated but records show her BP as high as 156/102 and 160/98 on 2 previous visits. She is diagnosed with migraine HA and hypertension, given a prescription for metaclopramide, advised to take naproxen and discharged. Her husband calls her 3 hours later. She tells him she feels better after resting and is planning to have lunch. Her husband calls again later that afternoon. She does not respond. She is found dead and an autopsy reveals a ruptured cerebral artery aneurysm. An attorney is consulted and the records referred to an EM expert for review.
Plaintiff: My wife had very high blood pressure that was never rechecked by her PCP. She should have had a CT or MRI to r/o an aneurysm.
Defense: She had a hx of migraines and this one was not only typical but “less bad.” She did not have a typical “thunderclap headache.” My record shows that I considered the possibility of aneurysm, meningitis, hemorrhage, stroke and temporal arteritis. Her BP was not significantly out of range compared to previous readings; we don’t know whether it would have gone up or down if I had rechecked it. Nothing suggested the need for imaging. We are sorry for her death and that her diagnosis was missed. But my evaluation was appropriate, showed reasonable medical judgement, was within the standard of care and not negligent.
Result: After an expert review of the records, the case was found to be defensible and no lawsuit was filed.
Takeaways:
* Medicine remains part art and part science, requiring as much judgement as skill.
* A wrong judgement leading to an unfortunate outcome does not equate to negligence.
* Documentation of rational MDM prevents lawsuits.
* Good plaintiff attorneys are generally reasonable and risk averse. Reviewing cases for them helps keep good providers from getting sued.
Reference: Cerebral Aneurysms. Liebeskind, DS. Medscape eMedicine. Dec 06, 2018. | Superior pilots use their superior judgment to avoid situations requiring the use of their superior skills. Anonymous commercial airline pilot | About Medical Malpractice Insights - Learning from Lawsuits Background:
* our most egregious mistakes become lawsuits
* our least defensible lawsuits are settled pre-trial with confidentiality clauses, and
* anonymously telling the stories of such lawsuits promotes learning and reduces patient harm.
Mission:
* to improve patient safety
* to educate physicians
* to reduce the cost and stress of medical malpractice lawsuits.
CME Credit: MMI-LFL qualifies for Level 2 CME credit on an hour-for-hour, self-reported basis.
Subscribe (FREE): Click here to subscribe. Then click the confirmation email in your inbox. Personal email addresses work best.
Support MMI-LFL: If you find this project educational, click here to donate to keep it coming.
Submit cases or near misses: If you know of a case of medical malpractice (or a near miss) that has teaching points to share with other docs, please contact me. Cases are anonymized for publication.
Archives: An Archive of past issues can be viewed here.
Disclaimer: Med Mal Insights is solely for the education of healthcare providers and does not constitute legal advice. Charles A. Pilcher MD FACEP, Editor
Medical Malpractice Insights | |
