March, 2020

Vertebral Artery CVA leaves patient disabled

Excellent documentation supports standard of care

Facts: A male in his early 60’s develops sudden onset of L facial droop, dysarthria and dysphagia. His family calls 911 and he arrives in the ED 37 minutes post sx onset. He has a past hx of a-fib and was on ASA and/or warfarin until a GI bleed 5 years prior. His sx improve en route. Initial BP is 220/110. Code Stroke is called and he is seen by a neurologist within 10 minutes. A CT & CTA are both completed within 52 minutes post arrival (89 minutes post sx onset) and show a distal L vertebral artery occlusion.

Labs are unremarkable. His sx continue to improve and his NIHSS is 1 (mild dysarthria only). BP drops to 158/74 and he remains stable. He is admitted with a dx of brainstem stroke and treated with ASA only. Four hours after admission he has a brief run of a-fib and L facial numbness. Eight hours after arrival, he is found non-responsive with posturing and drooling. A repeat CTA reveals that the obstruction has now moved to the basilar artery resulting in reduced brainstem perfusion. The neurologist re-assesses the patient and treatment plan, begins tPA and consults a thrombectomy-capable tertiary center. He is transferred by fixed wing air and arrives 4 hr 15 min later [despite the receiving hospital being only 80 minutes away by freeway/cp]. His outcome is poor and the family consults an attorney who has the records reviewed by an EM expert before filing a lawsuit.
Plaintiff: The family’s concern is that a delay in appropriate treatment led to his poor outcome. They question whether he should have been treated earlier with tPA or transferred for thrombectomy.
Defense: The documentation of the encounter is superb:
* ED physician: “The risk of complications leading to significant morbidity or mortality was explained to [patient and family] as severe.”
* Neurologist (in ED): “I am concerned that this occlusion could be due to a dissection... embolism... [or] atherosclerotic thrombosis... but no atherosclerosis is seen in his other vessels... I will treat him with ASA rather than anticoagulation because I cannot be sure he had a dissection, and because ASA is a good treatment for all possible etiologies being considered. I am not administering tPA because his NIHSS score is only 1. The patient does not require transfer for clot retrieval for the same reason.”
* Neurologist (1 hr. later): “I have reviewed the case with [tertiary hospital stroke specialist] who verified that ... ASA may [have] lesser risk of hemorrhage and is okay.”
* Neurologist (6 hr. later): “I now think the patient’s initial VA occlusion was embolic, due to paroxysmal a-fib... I am giving tPA now because the risk of hemorrhage is outweighed by the potential benefit of survival/avoidance of being locked-in and permanently paralyzed. I consulted [the tertiary stroke center] to try a thrombectomy... and the family understands that he is receiving tPA outside the usual window.”
Result: Based on excellent documentation of thoughtful medical decision making, the case was found to be defensible. No lawsuit was filed.
Takeaways:
* Document. Document. Document. We cannot over-explain our medical decision-making. It is our best defense against a med mal lawsuit.
* Treatment of vertebral/basilar stroke is less firmly established than for stroke in the carotid artery distribution.
* It is not malpractice to be wrong or choose what later may be found to be a less-preferable treatment option. That is a judgement call, not negligence, but our documentation must support our choice.
* What is the fascination with air medical transport when ground transport can be accomplished quicker with fewer transfer/handoff points - especially al 2:30 AM - even though it did not affect the outcome?
Reference: Posterior circulation cerebrovascular syndromes. Caplan LR. UpToDate Online. Updated Aug 07, 2019.

Medicine is a science of uncertainty and an art of probability.

William Osler