This story of a man in his 50s and a bungled MRI scan illustrates what can happen when doctors and nurses don’t talk to each other.
The situation started when this man went to a hospital emergency room after a week of flu-like symptoms including the typical fatigue, nausea, and vomiting, but also with problems keeping his balance and walking. He was an overweight man—actually, morbidly obese—which turned out to be very relevant to the poor care that he received.
After he was admitted to the hospital, he was seen by an internal medicine doctor and a neurologist. The neurologist ordered an MRI to be done the next morning.
The MRI wasn’t performed at the facility because the patient couldn’t breathe well and had chest discomfort when lying flat. Most MRI scanners are configured to require the patient to lie flat for the scan, but some facilities have open MRI scanners that allow the patient to stand up.
No one notified the neurologist about this problem, so he learned about it when he saw the patient the next morning. He wrote in the medical record that the patient would need to be sedated before another attempt to do the MRI scan.
The next day, a pulmonologist saw the patient and documented in the medical record that because of the patient’s large body size, he couldn’t fit within the hospital’s MRI machine.
There was no direct communication documented between physicians, or between hospital staff and doctors, as the MRI delay continued.
Ultimately, four days after this man was admitted, he was transferred to a larger hospital that had an open MRI scanner. As soon as the scan was performed, it was obvious what his problem was: this patient had an epidural fluid collection that was causing a spinal cord injury from the levels of thoracic vertebrae T1 to T5.
All along, this man had a dangerous medical condition called spinal epidural abscess, which is an accumulation of infected fluid that compresses the spinal cord. This is an emergency medical condition that will cause permanent injury unless it’s quickly diagnosed and treated.
The physicians at the first hospital certainly didn’t behave like they were in a hurry to figure out what was going on with this man. The patient felt that his obesity might have caused them to be biased against him.
That’s hard to say, but it’s clear that the medical diagnostic process failed in that hours and days passed by while doctors didn’t speak or coordinate with each other to get the fast action that this patient needed. This left him with complete motor and sensory paralysis from the waist down. With earlier diagnosis and surgical treatment, though, he would have likely regained full function.
As a former hospital administrator, I describe this type of case as a system failure. A system failure is when multiple healthcare providers or institutions drop the ball, as opposed to an isolated mistake occurring. Here, the errors included:
• The neurologist who ordered the MRI didn’t follow-up to make sure it was done. He just wrote the order and didn’t pursue the issue.
• The hospital’s nursing and radiology technical staff didn’t alert the neurologist that the scan couldn’t be performed because of the patient’s breathing and pain issues.
• The pulmonologist didn’t speak with the neurologist about how the man could not fit into the hospital’s MRI scanner because of his large body size.
It’s not enough for doctors and other healthcare providers to merely write about problems in the medical record. They have to take concrete action to advance the patient’s care, particularly when there’s the possibility of a dangerous medical condition such as spinal epidural abscess.
If you’ve been seriously injured because of poor hospital or physician care, then contact a top-rated, skilled Houston, Texas medical malpractice lawyer to discuss your potential case.
