Medical Malpractice Insights: Managing the inadequate consult

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Managing the inadequate consult

Patient discharged from ED with huge pituitary adenoma

Facts: An adult female presents to the ED with sudden onset of a 10/10 headache, vomiting, vertigo, and photophobia. No history of significant headache in past. Remainder of the Hx is non-contributory. Exam finds the patient with a hoodie over her face and a wet washcloth over her eyes. Neuro exam documents normal cranial nerves. No tests for visual acuity, visual fields, or vertigo are documented. WBC is 16,800, and the rest of the labs are normal. A cervical artery dissection is suspected, and a CTA of the head and neck is ordered. It shows a large (27 x 22 x 31 mm) pituitary adenoma with central necrosis, displacement of the optic chiasm, invasion of the cavernous sinus, destruction of the sella, displacement of the 3rd ventricle, and compression of both carotid arteries. She is treated with zofran, dilaudid, and fentanyl, and the headache decreases to 6/10. A neurosurgeon (who is on call for 6 hospitals at the time) is consulted by phone. The EP reads the CT report to him and documents the consultant’s recommendation: “Have the patient call my office on Monday for an appointment in the next 2-3 weeks. We’ll arrange MRI later.” The patient is discharged with zofran and vicodin. Her symptoms continue and 3 days later she is found unarousable, aphasic, and hypotensive with R-sided hemiplegia. A repeat CTA shows a hemorrhage into the now-enlarged adenoma and an occluded left carotid artery. She undergoes surgery and is left aphasic, incontinent, hemiplegic, and hormone deficient. Her husband says, “I think she recognizes me…sometimes…when I visit her in the nursing home.” A lawsuit is filed against the EP, neurosurgeon, and hospital and proceeds to trial.

Plaintiff: You knew I had a huge pituitary adenoma that needed urgent care. You requested a neurosurgical consult from a doctor who was on-call for SIX hospitals and never saw me. You then deferred to his totally unacceptable advice and did not challenge him or get me proper care. I had “pituitary apoplexy” and should never have been discharged. If I had been admitted and had surgery, I would not be in this condition now.

Defense: I was looking for a cervical artery dissection. The pituitary adenoma was an incidental finding; these can be managed over time. Your adenoma had already progressed to the point where surgery 3 days earlier would not have made a difference. I’ve never heard of “pituitary apoplexy.”

Result: A jury rendered a defense verdict after a 1-week trial, apparently based on the plaintiff’s failure to prove that earlier surgery would have resulted in a better outcome, i.e., failed to prove “causation.”

Takeaways:

• “Anchoring bias” was in play here, i.e., closing one’s mind prematurely.
• “Confirmation bias” then came into play, i.e., allowing the pituitary adenoma to be considered an incidental finding.
• Hindsight is always 20/20.
• A hospital that allows surgeons to be on-call for multiple hospitals at one time and must transfer a patient because a surgeon is busy elsewhere is at high risk for liability and an EMTALA violation.
• Emergency physicians have no obligation to accept an incomplete or substandard consultation with which they are uncomfortable. This one was clearly unacceptable – and likely unexpected.
• Should EP’s find themselves in a similar situation, there are multiple options:
  1. Tell the consultant “I am uncomfortable sending this patient home. Please come see the patient.”
  2. “So if you aren’t coming to see the patient, who should I call to get a 2nd opinion?”
  3. “If you aren’t coming and there’s no one else to call, I have to call our Medical Staff leadership.” Notifying the hospital CEO or CMO is also advised.
  4. Consult an internist/hospitalist for a second opinion. Another set of eyes on a problem like this can provide support for one’s disposition plan.
  5. Transfer the patient to another facility, documenting the reason. That is likely to be an EMTALA issue if the patient is transferred because an on-call doctor refuses to see that patient).
• Juries like physicians and support them at trial in about 85% of cases.

Reference:

• Pituitary Apoplexy. Vaphiades, MS. Medscape eMedicine. Updated: Jun 03, 2022.
• Pituitary Apoplexy. Khoujah D. UMEM Educational Pearls. Updated Aug 6, 2022. https://umem.org/educational_pearls/3291/