Failure to monitor patient exhibiting signs of stroke

Presentation

A 58-year-old woman with a history of morbid obesity, type 2 diabetes, hypertension, and high cholesterol was transported by EMS to Hospital A’s emergency department (ED). She reported blurred vision, pain in her left eye, and numbness in her right leg to the EMS technicians.

Before calling 911, her right side had become increasingly weak and she had lost her balance. The numbness lasted for about one hour and resolved during her transit to the hospital.

In the ED, the patient reported a frontal and parietal headache with occasional dizziness, mild nausea, and pain in both eyes. She stated that she only rarely experienced headaches. She provided her current medications as regular insulin on a sliding scale, metformin 500 mg, aspirin 81 mg, and a medication for hypertension that she could not recall.

Physician action
The on-call neurologist examined the patient and noted an essentially negative neurological exam with the exception of hypertension. He admitted the patient with a diagnosis of transient ischemic attack vs. complicated migraine. He requested physical therapy and occupational therapy consults.

The neurologist also ordered an MRI and carotid Doppler studies, or MRA, of the neck. The MRI could not be obtained because the patient exceeded the weight limits of the hospital’s MRI machine by more than 20 percent. A head CT was ordered instead of the MRI and the results were noted as unremarkable.

The MRA radiologist noted that the MRA results showed no blood flow in the left carotid artery. However, it was also noted that there were technical difficulties during the studies due to the thickness of the patient’s neck. The radiologist recommended correlation of the results with an additional MRA or CTA.

The defendant documented in his notes that the patient was given the opportunity to obtain her work-up and care at another facility, but she refused to be transferred. The neurologist made arrangements for an outpatient MRI the next day at a facility with equipment that could accommodate the patient.

Upon discharge, the neurologist informed the patient that it was possible that she had suffered a stroke and may have a left carotid occlusion. She was instructed to resume her diabetic regimen of metformin and insulin by sliding scale, and prescribed ranitidine, omeprazole, lisinopril, loratadine, furosemide, levothyroxine, and simvastatin. Her aspirin dosage was also increased from 81 mg to 325 mg. A follow-up appointment was scheduled in one month.

The patient did not go to her scheduled MRI appointment the following day. The physician called the patient and, during a conversation with the patient’s husband, discovered that the patient woke up that morning with memory loss as well as the same symptoms she had the day before.

After transport and admission to Hospital B, her condition deteriorated. At Hospital B, she exhibited signs of diplopia, dizziness, confusion, and an inability to form sentences. A head CT revealed a left hemispheric infarct in the left posterior cerebral artery. During admission, she sustained another stroke.

The patient experienced cognitive and visual deficits, aphasia, right-sided hemiparesis, and a neurogenic bladder. She was moved to a nursing home.
 

Allegations
The patient’s family filed a lawsuit against the neurologist alleging:

• failure to order appropriate tests;
• failure to obtain test results in a timely manner; and
• failure to appropriately monitor the patient who had experienced symptoms of an impending stroke.

Legal implications
Multiple consultants from different specialties reviewed the case and agreed that the neurologist should have ordered further studies of the left carotid artery before discharging the patient. The consultants all offered multiple testing options to the MRI, including CT angiogram and carotid arteriogram.

However, the consultants also noted several strengths in the neurologist’s care, such as adjusting the patient’s medication to reduce the risk of future stroke; arranging an MRI study at a different facility; and calling the patient the next day to follow up and ensure the patient had kept the MRI appointment.

The plaintiff’s expert stated that the neurologist did not meet the standard of care because he did not keep the patient in the hospital during the 48-hour “high risk period” after the patient’s transient ischemic attack. The expert also stated the neurologist should have obtained inpatient testing such as a CT angiogram or contrast angiogram of the left carotid during the 48-hour “high risk period.”

Disposition
The case was settled on behalf of the neurologist.

Risk management considerations
The neurologist in this case failed to order additional or alternative tests as recommended by the radiologist. If choosing not to order alternate or additional tests recommended by the radiologist, documentation of the rationale for that choice should have been included in the record.

In addition, if a patient refuses a test or procedure, formally document that refusal. In this case, the neurologist documented that the patient did not want to be transferred to another facility. Having a formal document signed by the physician and the patient that describes the risks ensures that the patient receives the necessary education to make an informed decision.

In this case, the patient’s size caused technical difficulties with the testing equipment and complications in obtaining tests. An MRI machine with greater weight capacity was needed to perform a test that could have made a significant difference in the patient’s quality of care and outcome. Maintaining a list of locations that can serve patients with special needs can help prevent similar cases. Effective communication with these locations may help explain a potential emergency and expedite having the test performed the same day.