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. Stories of med mal lawsuits can save lives. If you have a story to share click here.
Chuck Pilcher, MD, FACEP
Editor, Medical Malpractice Insights
Patient dies hours after discharge for “migraine”
Was the emergency physician negligent for missing her cerebral aneurysm?
Facts: A woman in her early 50’s has a gradual onset of a left-sided headache (HA) that she believes to be one of her migraines. Because of her history of hypertension, she checks her BP at home and finds it elevated at 159/108. Worried, she presents to the ED an hour after onset. Her pain has now moved to the right side of her head and rated as 4/10 but is still described as “like my usual migraines.” ROS is positive for mild nausea but negative for photophobia, eye pain or other neuro symptoms. Her meds include losartan for hypertension and only OTC meds for migraines. On exam her BP is 152/112 and is not repeated before discharge. There is no temporal artery tenderness or nuchal rigidity and neuro exam is unremarkable. She is diagnosed with migraine HA and hypertension, given a prescription for metoclopramide, advised to take naproxen, and discharged. Three hours later her husband calls to check on her. She says she rested, feels better, and is planning to have lunch. Later that afternoon her husband calls again. She does not answer and is found dead. An autopsy reveals a ruptured cerebral artery aneurysm. An attorney is consulted and the records referred to an EM expert for review.
Plaintiff: My wife had very high blood pressure that you should have rechecked. She should have had a CT or MRI to rule out an aneurysm. You didn’t give her anything for her headache while she was in the ER and made sure she didn’t get worse.
Defense: She had a history of migraines. This one was not only typical but “less bad.” It was getting better, not worse and continued to get better at home. She did not have a typical “thunderclap headache,” common with subarachnoid hemorrhage due to rupture of a cerebral aneurysm. My MDM shows that I considered the possibility of an aneurysm, meningitis, hemorrhage, stroke, and temporal arteritis. Although her BP was high, it was also high the last 2 times she was seen, specifically 156/102 and 160/98, not significantly out of range compared to previous readings. We can only guess if it would have been higher or lower if we had rechecked it. Nothing suggested the need for imaging. We are sorry for her death and that her diagnosis was missed, but my evaluation was appropriate, showed reasonable medical judgement, was within the standard of care, and was not negligent.
Result: After review of the records, the excellent MDM made the case oneof judgement, not negligence. No lawsuit was filed.
Takeaways:
- Documentation of rational MDM prevents lawsuits.
- A wrong judgement leading to an unfortunate outcome is not negligence.
- Medicine remains part art and part science, requiring as much judgement as skill.
- BP should be repeated before discharge if high or low when first taken.
- Good doctors document good MDM. Good plaintiff attorneys are generally reasonable and risk averse. Reviewing cases for them helps keep good providers from getting sued.
References/Further Reading:
- Cerebral Aneurysms. Liebeskind, DS. Medscape eMedicine. Updated Dec 16, 2024. https://emedicine.medscape.com/article/1161518-overview
- emDOCs SAH presentation, evaluation, and management
- emDOCs SAH: Why do we miss it?
- emDOCs SAH Critical Care Management
