Should the EP be liable for missing this zebra?

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Your chance to be the jury
When it comes to establishing a standard of care, we at Emergency Physicians Monthly are kind of old fashioned: We think it should be generated by physicians, not trial lawyers. That’s why we introduced the Standard of Care project. We present to you a real life medico-legal scenario and you get the chance to weigh in.Send your thoughts on this case to We’ll compile the results and print them next month.
A 41-year-old male went to the emergency department complaining of sharp left-sided headache, runny nose, and productive cough which began the morning of presentation. He also complained of blurriness and “fluttering lights” in his right eye that were initially significant, but that had improved by the time he reached the emergency department. The patient had a history of hypertension, coronary artery disease, and longstanding vision loss in his left eye. He also had a history of headaches. Social history was positive for cigarette use.

His vital signs were essentially normal, including a blood pressure of 147/77. The patient was alert and oriented. Visual acuities were 20/20 in the patient’s right eye, and his funduscopic examination was normal. There were no neurologic deficits noted on the physical examination.

A chest X-ray was normal. A CT scan of the patient’s head showed mucosal thickening in both ethmoid sinuses and in the right sphenoid sinus. There were no signs of bleed, shift, or infarct.

The patient received an albuterol treatment and was discharged with a diagnosis of “sinusitis and acute visual changes.” He was prescribed antibiotics, pain medication and cough medication. He was instructed to follow up with the ophthalmologist later that day to rule out a detached retina.


While being examined by the ophthalmologist an hour later, the patient became lethargic and diaphoretic. He then developed right-sided hemiparesis and aphasia.

The ophthalmologist sent the patient back to the emergency department by ambulance. At that time, the patient was aphasic and not moving his extremities. A repeat CT scan of the head showed several new findings including a density in the left middle cerebral artery and a hypodensity in the left parietal region.

The patient received tPA in the emergency department and was transferred to another hospital where he was diagnosed with a left carotid artery dissection. A clot at the dissection site dislodged and caused the patient to have a left parietal infarct.


The patient is currently unable to walk without the help of a brace and a cane and has difficulty speaking more than a few words at a time.

The patient and his family sued the physician, stating that he should have diagnosed the patient’s condition on the first visit.

Were the emergency physician’s actions within the standard of care?
Let us know by emailing or by posting your comment below. We will compile the reader results and publish them in an upcoming issue.



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

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