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Not listening to the patient, other shortcuts lead to stroke misdiagnosis

In the United States, strokes in 18 to 45 year olds are on the rise

I think one of the most interesting fields of study is how decisions are made. Academically, experts, professors, and students approach the science of decision-making from diverse disciplines including behavioral economics and social psychology.

Some research suggests that 60% of medical errors and malpractice claims involving hospital emergency rooms arise from failures. I think many of these errors are related to physician decision-making that bypasses the tested and true differential diagnosis process.

One of the concepts that decision-making research has uncovered is how our brains use cognitive shortcuts. In his groundbreaking book Influence, social psychologist Robert Cialdini described it as a “click, whirr” mechanism, named after the way a cassette player sounds after pressing “play.”

Many of these shortcuts are helpful, but sometimes they’re cognitive biases that cause harm. For example, emergency medical service personnel, hospital emergency room (ER) triage nurses, and ER physicians sometimes have a cognitive bias against young patients who present with stroke symptoms.

Although many people think of strokes as happening to middle-aged or older people, the American Heart Association reports that 10–15% of all strokes in the United States happen to people between the ages of 18 and 45. Additionally, although stroke rates have declined for the general population, the rate among young people has gone up by over 40% among younger adult in the past several decades.

As a Texas medical malpractice attorney, I’ve handled quite a few stroke cases involving young people. While I don’t think that any of the health care providers involved in those cases had ill intentions toward their younger patients, I do think they allowed cognitive biases to get in the way.

• At one comprehensive stroke center hospital in Texas, a stroke team resident neurologist saw an ER patient in her late 20s who had one-sided facial droop, weakness on the same side of the body, and slurred speech (aphasia). In other words, she had textbook symptoms of an ischemic stroke.

The resident discounted the symptoms because he thought the patient may have been partying during the holiday season. She was discharged from the hospital with a diagnosis of exclusion, neurogenic disorder—in other words, the doctor felt it was all in her mind. 

A few days later, the same patient went to a different hospital and was immediately diagnosed with ischemic stroke. By then, the permanent neurologic damage was done.

• At a Texas primary stroke center hospital, ER personnel ignored patient and family reports of symptoms consistent with a posterior-circulation ischemic stroke. The ER nursing staff left the patient in the waiting area for an extended period of time, where he had symptoms of dizziness or vertigo, nausea, and vomiting. 

The triage nurse thought the patient was having a migraine headache and didn’t pay much attention to him. Meanwhile, the treatment window for clot-busting medication tPA administration passed and his impairments became permanent.

Rather than using cognitive shortcuts for decision-making, doctors, physician assistants (PA), and nurse practitioners (NP) should use the differential diagnosis process. This is something that’s taught to every physician in medical school and should be part of  the training of every PA and NP. 

Using the differential diagnosis method takes time. It means that the physician or provider must listen to the patient and family and perform a thorough examination. It requires coming up with a list of every potential diagnosis that explains the patient’s condition. Finally, through assessment or diagnostic testing, such as laboratory work or a radiology scan, potential diagnoses must be ruled out one by one, starting with the most dangerous condition.

None of the stroke misdiagnosis cases that I’ve handled would have occurred if the physicians involved had followed the differential diagnosis method. That’s because stroke would’ve been at or near the top their list and would have been worked up, resulting in the correct diagnosis and treatment.

I can’t begin to count the number of times that patients or family members and told us that doctors and nurses wouldn’t listen to them. This type of mental shortcut is a big contributor to the problem of ER misdiagnosis and is medical malpractice.

If you’ve been seriously injured because of poor hospital or medical care in Texas, then contact a top-rated, experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him by calling 281-580-8800 or emailing him right now.


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