An interesting opinion out of the Dallas Court of Appeals dealt with a situation in which an emergency room doctor, nurse practitioner, and physician’s assistant allegedly contributed to the misdiagnosis of a patient with a brain bleed.
The case is styled Baylor Medical Center at Waxahachie v. Wallace, 278 S.W.3d 552 (Tex. App.—Dallas 2009, no pet.). You can read the opinion here.
The male patient went to the emergency room (ER) and was initially seen by a physician’s assistant (PA). The man explained that he was a smoker with neck pain from his head down to his shoulders, along with nausea and vomiting. He shared that the previous day he had broken out in a sweat. He told the PA that he was concerned because his mother had been diagnosed with two aneurysms and thought he might be at risk.
A nurse practitioner (NP) became involved in the patient’s care. The patient’s wife recalled the NP telling the patient not to worry about an aneurysm, because if he had one, he would already be dead.
After some routine blood work and tests showed that the patient had high blood pressure, the PA discussed the case with the ER doctor, who ordered pain and blood pressure medications. They discharged the patient from the ER less than three hours after he had arrived, without the doctor ever seeing him.
A week later, the patient returned to the ER, again complaining of neck and back pain. The healthcare providers documented in the medical record that he had a headache and had been vomiting. This time, he was seen by doctor, who ordered a CT scan. The radiologist interpreted the CT scan as showing a subarachnoid hemorrhage.
Subarachnoid hemorrhage is a type of stroke where there’s bleeding between the brain and the space around it. This type of stroke is called a hemorrhagic stroke. Hemorrhagic strokes can’t be treated with the clot-busting drug tPA because they are caused by a bleed, rather than a clot.
Hemorrhagic strokes are life-threatening medical emergencies that require immediate care. The standard of care requires administration of medication to stop vasospasm in the brain. In some cases, it’s also necessary to take the patient to surgery to repair the bleed.
In the medical malpractice lawsuit, a board-certified neurologist wrote an expert report in favor of the plaintiff that defined the standard of care that was missed by multiple healthcare providers. His report explained that when a patient goes to an emergency room with a very bad headache, and doesn’t have a history of headaches, it should trigger a thorough workup and testing by the doctor, physician’s assistant, and/or nurse practitioner.
In my experience, people who are suffering from a brain hemorrhage or aneurysm describe the headache as the worst headache of their lives. If you hear someone talking that way, it’s important to get them to the hospital immediately.
The medical expert went on to explain that when a person presents to the ER with a severe headache, neck pain, nausea, and high blood pressure, and shares that he is a smoker with a family history of cerebral aneurysm, it’s clear that any doctor, PA, or NP should recognize a significant possibility that the patient is experiencing brain bleeding.
The neurology expert elaborated in his report that, at a minimum, testing should include a CT scan and, if the scan is read by a radiologist as normal, a spinal tap. The spinal tap, or lumbar puncture, is a procedure where a sample of cerebrospinal fluid (CSF) is collected for analysis in a laboratory. If there is blood in the fluid, it is a sign consistent with a brain bleed.
It’s no surprise that the medical expert disagreed with the nurse who felt that no additional testing was needed to rule out a brain aneurysm because the patient wasn’t already dead. Instead, the neurologist believes that the nurses, NP, and PA should’ve recognized the risk to the patient and made sure that the patient was seen by a physician before being discharged from the ER on the first day.
Nurses and mid-level providers, such as nurse practitioners and physician’s assistants, have an independent duty to advocate for proper care that’s necessary to ensure patient safety. Just because the doctor is busy and doesn’t want to take time to see the patient, doesn’t mean that it was safe for the patient to be discharged. Sometimes, advocacy involves going over the doctor’s head, which is called invoking the chain of command.
According to the expert, if appropriate testing had been done on the first day that the patient showed up at the ER, it would have shown a subarachnoid hemorrhage. He would’ve then been hospitalized and received urgent care, including surgery to repair the aneurysm and medications to stop vasospasm. Instead, because of a one-week delay in diagnosis and treatment, this patient experienced a severe stroke and permanent brain damage.
Stroke medical malpractice cases, like all cases involving emergency room care and hospitals, are challenging under Texas law. That doesn’t mean that they are always impossible to pursue, however. If you or a loved one has been injured by poor stroke or other healthcare in Texas, a top-rated experienced Houston, Texas medical malpractice lawyer can help advise you on your rights.
