A 33-year-old female was brought to the emergency department by her husband for evaluation of a diffuse headache of 4 hours’ duration that began gradually and increased to an 8 of 10 intensity over 30 minutes. The headache was associated with bilateral facial and hand numbness, slurred speech, muffled hearing, and a brief syncopal event. The patient denied fever, neck pain, vomiting, focal weakness, vision changes, or photophobia. Nurses’ notes documented that although the pain was typical of her prior migraines, the additional symptoms were not. Her medications included oral contraceptives and Topamax for migraine prevention.
Physical exam showed a young woman in mild to moderate distress. She had clear speech but a strange speech pattern that her husband stated was different from her baseline. Her neurologic examination was otherwise normal. Examination of the head and neck was unremarkable, but no hearing assessment was documented. Examination of the abdomen, chest, heart and extremities was also normal.
The patient initially received one liter of IV saline, Phenergan 25 mg IV and morphine 4 mg IV. No diagnostic testing was ordered. Two hours later, the patient was noted to be somnolent. The physician wrote discharge orders, but the patient could not remain awake long enough to dress herself. The physician re-evaluated the patient and noted that the patient was now lethargic. Narcan was ordered, but serial doses of Narcan had little effect on the patient’s level of consciousness, prompting lab testing and a brain CT.
The emergency physician read the CT scan as normal. Lab testing was also normal. With no clinical improvement 3 hours after receiving Phenergan and 1 hour after receiving Narcan, a lumbar puncture was performed. LP results were also normal. The patient’s symptoms worsened and a brain MRI was ordered. The patient deteriorated further and was intubated for airway protection.
The brain MRI revealed an acute thrombosis of the basilar artery affecting the cerebellum, midbrain and thalamus. Seven hours into the patient’s ED course a neurologist was consulted and recommended mechanical thrombectomy, which was performed nearly 9 hours after the patient first arrived in the ED. The following morning, radiologist over-read of the patient’s initial CT described an acute cerebellar stroke with a dense basilar artery sign. The patient’s stroke progressed to involve the pons, causing weakness in all four limbs. After 6 months of rehab she was able to walk using a walker. She filed a lawsuit against the emergency physician and the hospital.
At trial, the defense argued that the patient’s presentation was most consistent with migraine headache and hyperventilation, that the neurologic exam showed no concerning abnormalities, and that none of the patient’s symptoms were typical of a stroke. The defense also argued that the patient’s somnolence was a known side effect of medications she had received.
The plaintiff argued that migraine headaches and oral contraceptives are both risk factors for strokes and that the patient’s symptoms were a typical presentation of patients suffering from a posterior circulation stroke. The plaintiff expert argued that it was a breach in the standard of care to assume that syncope, speech changes, hearing changes and facial numbness were due to hyperventilation without first assessing the patient for a stroke – especially when the patient’s symptoms did not fit her typical migraine pattern. The plaintiff’s expert also argued that it was unreasonable for the emergency physician to interpret CT scans when remote night time radiology groups were widely available.
Was the patient’s care within the scope of reasonable practice?
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