Medical Malpractice Insights: Sudden collapse, hemiparesis & dysphasia – What’s the differential?

How do 7 docs over 20 hours miss a thoracic aortic dissection?

Facts:

Emergency Care:

• About 10 PM a 69-year-old hypertensive male suddenly collapses and strikes his face on the floor while bowling with friends. He is unconscious and EMS is called.
• On arrival in the ED, he is described as unresponsive with left hemiparesis and a single episode of vomiting. His BP drops as low as 71/49 but responds to a fluid bolus. He awakens after 30 minutes in the ED (60 minutes from collapse) with dysphasia and retrograde amnesia. This resolves within minutes, as does his left hemiparesis. An EKG, head CT, portable chest x-ray, and troponin are normal. The emergency physician diagnoses a “TIA with syncope” and admits him to his PCP for further evaluation.
• His PCP phones in orders for consults from cardiology and neurology.

Inpatient Care:

• Mid-morning, the cardiologist sees the patient for “syncope” and orders another EKG and enzymes. All are normal.
• About 4 PM the PCP finally sees the pt who is sitting up in bed awaiting the neurology consult and complaining only of occasional mild chest pain. The PCP’s note includes no differential diagnosis. He mentions the “syncope” but not the “TIA.” In fact, no one ever acknowledges the emergency physician’s diagnosis of a TIA, nor the patient’s brief episode of hypotension or his neurological events, only “syncope.” The PCP notes that the cardiologist thinks “it’s not a heart problem” and that the neurologist should arrive shortly to determine if the patient can be discharged. He then signs out to a colleague, telling no one, not even his colleague, and leaves the hospital.
• By 7 PM the neurologist has not arrived. The RN tracks him down by phone and tells him that the PCP needs his opinion on discharging the patient. Based on the nurse’s report, the neurologist decides that the patient’s “syncope” can be evaluated as an outpatient.
• The nurse then tries to call the PCP and discovers that he has signed out to a colleague. She tracks down the covering PCP and tells him that the cardiology eval is negative and the neurologist says the patient’s “syncope” can be worked up as an outpatient. The on-call PCP (who has never seen the patient) gives the nurse a verbal order to discharge the patient – 20 hours after his arrival.
• On the way home, the patient collapses and dies in the car.
• An autopsy reveals a Type A thoracic aortic dissection with pericardial tamponade and partial obstruction of the brachiocephalic artery. A complaint is filed with the state medical board which identifies lapses in the standard of care. A lawsuit is then filed.

Plaintiff:

* Let’s begin with my CXR. Everyone on both sides of this case agrees that, in hindsight, my mediastinum was obviously widened, and the radiologist missed it. If any of you had looked at my chest x-ray, and not just taken the radiologist’s word for it, you would have made the diagnosis. But you didn’t look.
* On top of that, the emergency physician correctly diagnosed my TIA, but all of you focused only on my fainting. None of you ever asked, “Why did he have a TIA?” People don’t have hypotension, hemiparesis, and dysphasia for an hour after fainting.
* You should have gotten a chest CT, an echocardiogram, or an ultrasound. You would have found my dissection.
* My nurse was the only one coordinating my care. You doctors never talked to each other.
* You let a neurologist “phone in” his consultation.
* A PCP shouldn’t just leave without telling his covering doc about plans for his patients in the hospital.
* Something was seriously wrong, and you made me prove it by sending me home to die. You should all be ashamed of yourselves.

Defense:

* Even if we knew you had a TAD that caused your TIA, you probably would have died or been disabled. TAD’s have bad outcomes. Short term mortality is 10-15%. Ten year mortality is between 30% and 88%.
* We couldn’t transfer you in time to make a difference.
* Getting a neurologist to see you or keeping you in the hospital would not have changed anything.
* Your chest pain was minimal and fleeting.
* And one more thing… Maybe you had the dissection after you left the hospital. (Whoa!)

Result: The mediation panel found fault with the patient’s care. The lawsuit was settled for an undisclosed amount before trial.

Takeaways:

– View your patient’s x-rays and other imaging yourself. Radiologists, admit it or not, miss things about 2-3% of the time, especially when they are provided with insufficient clinical information by the ordering physician (1).

– Attending physicians and consultants should read and pay attention to the ED notes.

– A TIA is a whole different animal than syncope. Syncope almost never has prolonged LOC or neurologic symptoms and is serious in <2% of patients (2).

– An echocardiogram is the first test for unexplained syncope (2).

– A search for an underlying etiology of the TIA is necessary. This patient had an ABCD2 score of 5 which equates to a 2-day risk of stroke of approximately 5% and a 5 year risk of at least 25%. In the course of finding the cause of the TIA, the TAD would have been identified (3-6) .

– Consultants should actually talk to the doctor who is asking their opinion.

– Phoning in a consultation is not the standard of care.

– Clearly communicated handoffs or sign-outs are important, especially those done in the middle of a workup

Reference:

1. Error and discrepancy in radiology: inevitable or avoidable? Brady AP. 2017 Feb; 8(1): 171-182 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5265198/
2. AHA/ACCF Scientific Statement on the Evaluation of Syncopehttps://www.ahajournals.org/doi/10.1161/circulationaha.105.170274
3. Transient Ischemic Attack, Medscape eMedicinemedscape.com/article/1910519-overview
4. Thoracic aortic dissection, Medscape eMedicinehttps://emedicine.mecom/article/2062452-overview
5. Thoracic Aortic Dissection, Black J and Manning W. UpToDate Online. Sep 28 2016
6. Aortic Dissection Treatment and Management. Mancini M, Medscape eMedicine, Dec 2, 2015.