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Final Analysis by William Sullivan, MD, JD
During the trial, the plaintiff’s attorneys argued that the patient’s presenting symptoms suggested the presence of an acute neurologic problem that should have warranted further workup during the patient’s first visit. Had the patient received this extra evaluation, the plaintiff’s attorney argued that the patient would not have suffered his stroke.
Defense attorneys argued that the patient’s symptoms were nonspecific and were consistent with the patient’s previous history of vision problems and headache. In addition, the defense attorneys asserted that the patient’s workup was appropriate under the circumstances and that a carotid artery dissection is a rare condition that can be easily missed.
During trial, the parties reached a $400,000 settlement.
This case presents two issues regarding the care the patient received:
First, does the standard of care require that an emergency physician diagnose uncommon diseases? The incidence of symptomatic spontaneous carotid artery dissection in the general population is less than 3 cases per 100,000, or .003%. In other words, if we assume that an MRA costs $1,500 per exam, on average, to catch one carotid artery dissection in the general population, we would have to spend more than $50 million. The incidence of positive findings secondary to traumatic carotid dissections is approximately 1-2%.
This patient’s symptoms included runny nose, headache, cough and transient blurry vision. While headache and visual abnormalities are two of the more common presenting symptoms of a carotid artery dissection, they are nonspecific. Many of the patient’s presenting complaints are also symptoms of more common diseases such as sinusitis, a migraine headache, or even a common cold. In fact, the patient’s CT scan showed mucosal thickening in several sinuses. Transient vision changes could just as easily have been due to near-syncopal events from coughing or due to scotoma from a migraine headache.
The standard of care does not require that emergency physicians perform exhaustive testing on every patient to catch the “needle in the haystack.” It is unreasonable to perform angiograms on every patient with atypical chest pain to find the occasional stenotic coronary lesion. No reasonable physician performs MRIs on every patient with a headache to find the one patient in several thousand with a clinically significant lesion. Performing angiograms on every patient with headaches and/or transient visual disturbances cannot be expected during routine emergency department care.
The workup provided for the patient’s symptoms, in addition to the immediate follow up with a specialist were more than what a reasonable physician would have done under the same circumstances. The standard of care was met.
Even if we assume that the diagnosis of carotid artery dissection should have been made, there would still be difficulty proving that the delay in diagnosis caused the patient to have a stroke. The mortality from spontaneous carotid artery dissection is less than five percent. Morbidity is also uncommon, but when present can range from mild transient symptoms to permanent strokes. In this case, the patient was out of the emergency department for 1 hour before his stroke occurred. If further testing was performed would the outcome have changed?
Definitive diagnosis of carotid artery dissection generally requires a magnetic resonance angiogram, a CT angiogram, or a traditional angiogram – depending on the availability of these modalities at the hospital. Once the diagnosis has been confirmed, treatment options include anticoagulants, surgical repair, or endovascular stenting. In this case, even if the diagnosis was suspected and an MRA had been ordered, it is extremely unlikely that the exam would have been completed and a radiologist’s report would have been received before the patient’s stroke occurred.
It is unlikely that the plaintiff would be able to prove that the outcome would have been different even if the diagnosis was made on the first visit. Any potential negligent omissions from the emergency physician could not have caused the patient’s injuries.
Several responses suggested that an ultrasound of this patient might be appropriate, but ultrasound may lack sensitivity. One study by Arnold et al. in Stroke showed that ultrasound can miss a spontaneous internal carotid artery dissection in more than 30% of patients. This study was published in 2008, making it inapplicable to the case presented, but caution should be used when considering whether to rule out a dissection with a normal ultrasound scan.
Here are some highlights:
-Julie C Georges, RN
“I think carotid dissection in a 41-year-old man with no PMH, no trauma to the neck and resolved symptoms is a stretch I would be unlikely to make.”
-Stephen Sample, MD
“In this case the cardiac and hypertensive history tip the scale to extra caution. The patient received immediate eye follow up (obviously very important), but needed prompt neurology follow up also.”
-Bradley Pulver, MD
“Even if he got an MRI and even if he consulted a neurologist, I believe the disposition would have been the same. What does the plaintiff argue should have been done with the evidence that was available to the ER doc?”
-Sonny Sagar, MD
-Natalie Painter, DO
“Bad things happen occasionally to some unfortunate patients and sometimes they just can’t be predicted.”
-David Ross, DO
Colorado Springs, CO
“I guess a discussion on carotid artery dissection should become a topic in upcoming Emergency Physicians Monthly.”
-Jose Dionisio Torres, Jr., MD
Clinical Instructor, Emergency Medicine
New York Hospital Queens
“I do not think the EP should be held to diagnosing a dissection on the first visit. This presentation was classic for a migraine.”
-Tom Benzoni, DO
Sioux City, IA