Medical Malpractice Insights: Sentinel headache overlooked

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

Sentinel headache overlooked; patient suffers major stroke

He and his wife are both attorneys – and friends of the caregiver.

Facts: A male in his mid-50’s arrives in the ED late one night after developing a sudden severe headache with neck pain, vomiting, and disorientation. Both he and his wife are corporate attorneys and family friends of the PA who assesses him. He is given pain medication, 1L of IV saline, and an anti-emetic. No imaging is ordered. The PA advises his friend that the headache is likely the result of gastroenteritis with dehydration. He is discharged but collapses in his office 2 days later. EMS is called, and enroute to the hospital he experiences 2 cardiac arrests. On arrival he is quickly diagnosed with a stroke secondary to a ruptured cerebral artery aneurysm and hospitalized for 5 months. Despite extensive outpatient therapy, he is left with both physical and mental disabilities. His legal colleagues contact an experienced med mal attorney, and a lawsuit is filed.

Plaintiff: Because you (the PA) knew me, you probably didn’t want to give me bad news – or even think of serious alternatives. You documented no differential diagnosis, minimized my symptoms, and wrote me off as a “dehydration headache.” I’d never had a headache like this before. A CT scan is standard care for a “thunderclap headache” like mine. I had a “sentinel leak,” and if you had done a CT, you would have found it. If you had heeded the warnings for my impending stroke, you would have found my aneurysm before I had a subarachnoid hemorrhage and 2 cardiac arrests. Instead I’m disabled for life.

Defense: We met the standard of care. Your ED symptoms were not classic for brain bleeding. A CT scan might not have found the aneurysm. And there’s no guarantee we could have prevented the disability you suffered.

Result: Three weeks into a jury trial, the parties agreed to a settlement for $20 million against the hospital. The case against the PA and physicians was dismissed for unknown reasons. [Editor’s note: Presumably the hospital took the hit for them as their “agents” and to avoid a report to the NPDB./cp]


  • Migraines and tension headaches are common – dangerously so. Each one is an opportunity to apply one’s diagnostic experience and acumen to the max.
  • At least 20% of aneurysms (10-43% per UpToDate Online) leak before they rupture.
  • We must form a differential and document our MDM. One need not TEST for everything, but the rationale for one’s decision should be clear.
  • When treating family, colleagues or friends, the risk of bias, whether it be overly cautious or overly optimistic, is high. If you cannot transfer care to a more objective colleague, step back and remember “metacognition,” the psychologist’s word for “awareness and understanding of one’s own thought processes.”
  • Given the stakes with regard to relationships, one would expect caution to trump optimism. Human nature being what it is, a CT scan may be more likely to be ordered for a friend than for a patient one does not know.
  • The hospital was kind to take the heat for this one, but the ethical issue is obvious.


One thought on “Medical Malpractice Insights: Sentinel headache overlooked”

  1. From Carpenter et al 2016:
    “…neither the presence nor the absence of commonly cited SAH risk factors from history and physical examination accurately rule in or rule out this potentially lethal diagnosis. Specifically, no single history or physical examination finding significantly increases (LR+ > 10) or decreases (LR< 0.1) the posttest probability of SAH for severe headaches that peak within 1 hour of onset. In addition, many elements of history and physical examination for SAH have only fair to good inter-physician reliability, with the characterization of the headache as “thunderclap” being one of the least reproducible findings. Nonetheless, many physicians would prefer to never miss a SAH, and missed SAH remains an important cause of litigation in emergency medicine."

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