Medical Malpractice Insights: SAH 3 days after ED visit and a good MDM

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Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Subarachnoid hemorrhage 3 days after ED visit

Being wrong is not negligent if you document your MDM

Facts: A 54-year-old male awakens at 3 AM with severe neck pain so severe that he calls 911. EMT’s find him sweaty with a BP of 180/100 and “massaging the base of his neck and head.” He has a prior history of neck pain for years but “never this intense.” Triage nurse documents “head pressure,” confirms that he was sweating PTA and records that motion of neck “feels like my bones are crunching.” Pain is 7/10. ED physician confirms complaint and documents an absence of neck stiffness, neurologic deficits, headache, and vision changes as well as “no other complaints, modifying factors or associated sx.” Exam finds neck “supple” with no carotid bruits. GCS is 15, and the neurologic exam is negative for motor/sensory deficits and focal weakness. BP in ED is 145/91. ED course and MDM says “I considered and do not suspect meningitis, CVA, SAH, ICH or mass lesion.” Patient is given 30 mg of IV ketorolac, discharged with ibuprofen and diazepam, and instructed to see his PCP in 2-3 days. Three days later he is found confused and wandering in a stranger’s house and brought back to the ED by the police. A CT finds a subarachnoid hemorrhage and a CTA finds no aneurysm. He undergoes a ventriculostomy but is left with neuro deficits and seeks legal advice about filing a malpractice lawsuit.

Plaintiff: You should have suspected an SAH on my first visit and done a CT scan. You didn’t do any tests to rule out the problems you identified in your differential diagnosis.

Defense: Your neck pain was not typical of a cerebral SAH. I evaluated you, found no neurologic symptoms or signs, felt that your neck pain was not related to anything inside your skull, and did not believe an LP or CT scan was necessary. I documented my findings, discussed them with you, and advised you to see your PCP. Your SAH could have happened after I saw you. Even if you did have an SAH at the time I saw you, there is no guarantee your outcome would be any different.

Result: An EM expert reviewed the records for the plaintiff’s attorney and found the facts as reported above. He advised the plaintiff’s attorney that the defendant’s evaluation would meet the standard of care and was well documented. No lawsuit was filed.

Takeaways:

* Clinical judgement can be used to eliminate some diagnoses from the differential; tests are not mandatory for every possible dx.
* The “Ottawa SAH Rule for Headache” is compelling, but insufficient to prove negligence by itself.
* Sometimes we are wrong. That does not mean we are negligent. In this case, documentation supported rational – if not perfect – clinical judgement.
* Had the physician not been so thorough in documenting her findings and MDM, a lawsuit might have had merit. That does not mean that the plaintiff would win. It just means everyone loses – except the defense attorneys.

References:

1. Subarachnoid Hemorrhage. Becske T, Medscape eMedicine. Updated: Dec 2, 2017. https://emedicine.medscape.com/article/1164341-overview
2. Subarachnoid Hemorrhage, The Skeptics Guide to EM. Oct 13, 2013. https://thesgem.com/2013/10/sgem48-thunderstruck-sah/