Did this patient need thrombolytics? A peer-review of expert-witness testimony

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A 42-year-old patient was unloading a truck when he developed sudden nausea and dizziness. He was found in a bathroom vomiting. When his co-worker approached him, he was unable to describe what happened to him. An ambulance was called 10-15 minutes later when the man complained of numbness in his right arm, his tongue, and the left side of his face.
The patient arrived in the ED approximately 40 minutes after his symptoms began. On arrival to the ED, the triage nurse noted that the patient had right-sided weakness and felt that his legs were “rubbery.” He vomited on more than one occasion and had persistent dizziness. The emergency physician evaluated the patient within 30 minutes and did not note any right–sided weakness, but did note that the patient remained nauseous, dizzy and generally weak.
A CT scan of the head was ordered approximately 35 minutes after the patient’s arrival. Shortly afterwards, a CT scan of the posterior fossa was also ordered. Two other patients were waiting for CT scans ahead of this patient, one patient waiting for a scan of the abdomen and pelvis, and one 74–year–old waiting for a CT of the head.
The patient’s CT scan is not completed for another hour and 17 minutes. By the time the “wet read” of the CT scan is available, the patient’s symptoms had been present for 3 hours. The EP elected not to give thrombolytic therapy and did not contact consulting services until four hours after the patient’s symptoms began. The patient was admitted to internal medicine and neurology services with a diagnosis of CVA. Ultimately, the patient was diagnosed with a cerebellar stroke and died during his hospital stay.
The Expert Testimony
In a deposition, the plaintiff’s expert, Frank Baker, MD, made the following statements:
1. He works single coverage in a hospital that sees approximately 19,000 patients per year. He works approximately eight 12–hour shifts per month, sees 10–12 stroke patients per month, and gives thrombolytic therapy 4–6 times per year.
2. Physicians should not administer tPA without speaking to a consultant because they need to have the agreement of someone who will care for the patient after the patient leaves the ER.
3. The symptom complex of dizziness, vomiting, and ataxia should not cause a physician to consider migraine headaches or inner ear problems in their differential diagnosis. Instead, this symptom complex is specific for a cerebellar stroke.
4. It is “rare” that a patient arrives and can get a CT of the head within 3 hours of symptom onset in a stroke.
5. The patient in this case would not have become neurologically worse if he had received tPA within three hours because the clot causing the stroke would have dissolved and would not have reformed.
6. A patient with improving or resolved weakness in the extremity but persistent facial numbness should still receive tPA because a focal finding was still present.
7. In 2002, no reasonably well–qualified emergency physicians would have disagreed as to whether this patient needed tPA
8. In 2001, no reasonably well–qualified emergency physicians would have disagreed on whether the risks of giving tPA outweighed the potential benefits of giving tPA to this patient.
Find out why the expert felt the emergency physician acted below the standard of care.

Also, write in to make your voice heard on the tPA issue.
The expert further stated that the emergency physician’s actions fell below the standard of care for the following reasons:
1. Failing to perform or failing to document a full physical examination including the patient’s coordination, cerebellar function, and gait.
2. Failing to consult the neurologist or neurosurgeon within three hours of the patient’s symptoms to discuss whether tPA should have been given.
3. Failing to expedite the CT scan of the patient’s head so that the results would have been available within 3 hours.
Specifically, the expert believed that other patients needing CT scans should have been made to wait and stated that “all things being equal,” a 42-year-old should receive preferential treatment over a 77-year-old when both need CT scans of the head.
Are the expert’s statements accurate?
Did the emergency physician act within the standard of care?
EPM’s exclusive Standard of Care project hinges on your input. Write in and tell us your analysis of this case and accompanying expert witness testimony. We’ll compile your verdict in an upcoming issue. Send responses to: [email protected]


SENIOR EDITOR DR. SULLIVAN, an emergency physician and clinical assistant professor at Midwestern University in Illinois, is EPM’s resident legal expert. As a health law attorney, Dr. Sullivan represents medical providers and has published many articles on legal issues in medicine. He is a past president of the Illinois College of Emergency Physicians and a past chair and current member of the American College of Emergency Physicians’ Medical Legal Committee. He can be reached at his legal web site http://sullivanlegal.us.

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