**MRI AND HEAD CT RESULTS LISTED AT BOTTOM OF CASE**
11/5/23: 59yo F Hx HTN, DM calls 911 for left-sided upper and lower extremity weakness, onset when she woke up that morning at 830am. She arrives via EMS to ER approximately 9am. Stroke alert initiated, (Note: this facility is listed a stroke entry point per EMS protocols and is thrombectomy capable). Dry CT head and Head CTA unremarkable with no other abnormalities in lab work. MRI and stat neurology consulted. Failed swallow study. The neurology consult that was created noted that the staff spoke with “Dr. C”, asking to speak to the on-call neurologist (Dr. W. was not available?) However, there was no indication that anyone called back or came to see patient. Admitted to internal medicine, placed on ASA and Lipitor. Neuro consult “pending”
The MRI was not completed until 730pm on 11/6. MRI result is “an acute infarction involving the right internal capsule and adjacent cerebral peduncle”. There is an addendum to the MRI result that states that several attempts were made to contact neurology without success. It reported a 45-minute delay and the report of the critical results were eventually given to attending. Unknown what the attending did with that info
Multiple nurses note beginning on November 7th night shift report that Neuro had still not come to see PC. This was put in by Nursing supervisor at 2024hrs on 11/7: “DR C. CALLED FOR CONSULT STATED DR W. IS THE PERSON TO CALL, ‘I DON'T DO IN HOUSE CONSULT’. DR W CALLED STATED THE PATIENT IS ‘NOT ON MY LIST’ AND SHE WILL ASK ARNP TO PUT ON HER LIST. THANKED.”
November 8th at 6:30 p.m. PC has progressively worsened slurred speech. Nursing note states: “Pt complaining of progressive slurred speech. RN put in call to DR (attending) and AMN is aware and stat CT order.” (CT order is put in by attending, not Neuro). CT result is unremarkable, no changes since first.
11/9 approx. 8pm: PC found sitting on the floor by staff because she was so weak, she could not make it to the bedside commode. No one knew about this until she rang her bed alarm and an unknown amount of time later. The nursing staff attempted to contact the attending and was told they were aware and if no injury, continue to monitor. When staff kept paging for neurology, there are notes say that “no neurology was available” for consult.
The next day, 11/10, day shift reports still having left side of weakness and having head pain. Neurology has still not seen the patient. Later that morning, they were setting her up to be discharged, however the patient refused to leave because she had not seen a neurologist. This was approx. 8am.
It was at that point that the nurse supervisor contacts the neurologist and told them she was refusing to leave. A “routine” neurology consult was put in at 12:38pm. A third neurologist “Dr. B” arrived and changed per meds to ASA and Plavix. PC was later discharged at 8:40pm.
Neurology consult full note:
“History of Present Illness:
59-year-old female with hypertension hyperlipidemia diabetes woke up with left-sided weakness and dysarthria she is been on aspirin at home. Normal vision no numbness. No seizure-like activity.
Assessment:
Right subcortical stroke lacune due to hypertension while on aspirin
MRI brain independently interpreted by me right subcortical infarct
CTA head and neck independently interpreted by me unremarkable
EKG independently interpreted by me sinus rhythm
Echo normal
Hypertension
Hyperlipidemia
Diabetes
Plan:
No IV thrombolytic because she is outside the window
Plavix 75 mg q.day and aspirin 81 mg q.day
Atorvastatin 40 mg q.h.s.
Losartan 50 mg q.day
Metformin 850 mg b.i.d.
Physical occupational speech therapy
Clear for discharge from neuro standpoint and follow up with Neurology”
PC still has left sided hemiparesis with use of walker and slurred speech.
We are in need of neurologist expert who is experienced in stroke alert on-call situations and is an interventionalist.
Points of contention:
1-Despite the 5-day delay in seeing the patent, would it have made a difference in her outcome? Especially with Aspirin/Lipitor vs. Aspirin/Plavix changes down he road?
2-How could a facility be a stroke entry point and put a STAT neuro consult in for a stroke alert and not have anyone call back or see patient for 5 days, especially since PC was being discharged and had to refuse to leave to get MD interaction?
3-Was the MRI delayed due to this web of miscommunication?
4-Could there have been in intervention despite being outside the window? Thrombectomy?
5-Overall, was the neurologist discharge note/treatment plan appropriate?
MRI RESULT 11/6
FINDINGS:
There is no abnormal! caudal descent of the cerebellar tonsils
beyond the foramen magnum. The ventricles, sulci and basal
cisterns are proportionate in size and configuration. The 4th
ventricle is midline.
Subcentimeter focus of gradient blooming in the deep right
parietal lobe on image 16 suggests hemosiderin deposit from old
focal hemorrhage. There is no evidence of an acute intracranial
hemorrhage or extra-axial collection. There is no mass effect.
1cm focus of true restricted diffusion is noted in the posterior
limb right internal capsule/anterolateral right cerebral peduncle
as on series 305images 11 and 12. No other diffusion abnormality
present.
IMPRESSION:
ACUTE INFARCT INVOLVING RIGHT INTERNAL CAPSULE ANDADJACENT
CEREBRAL PEDUNCLE.
NO HEMORRHAGE OR MASS EFFECT.
CTA RESULT 11/5:
Findings: There is no evidence of internal carotid stenosis.
Small plaque noted without significant stenosis at the carotid
bulb bilaterally. The common carotid arteries are unremarkable.
The intracranial portion of the internal carotid arteries appears
unremarkable for significant stenosis.
Middle cerebral arteries, anterior cerebral arteries, posterior
cerebral arteries, basilar artery and vertebral arteries are
unremarkable for significant stenosis.
Impression: Unremarkable CT angiogram of carotid arteries and
circle of Willis.
CT DRY 11/8 AFTER WORSENING SLURRED SPEECH:
FINDINGS: No acute intracanal hemorrhage, mass orarea of mass
effect is appreciated. Bilateral periventricular regions of white
matter hypodensity are present consistent with chronic
microangiopathy. The extraaxial spaces are clear.
IMPRESSION: No acute intracranial abnormality by CT.
Files:
No questions yet!
Do you believe there might have been medical error?
Yes the consult paradigm at this hospital is in serious need of work however in terms of medical treatment, I do not see a clear error. Changing from aspirin to clopidogrel/plavix earlier is unlikely to have made any material change in her case.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Theres no way to prove that her worsening was due to a medical error as opposed to the natural progression of her stroke
What makes you a good expert for this case?
Fellowship trained, triple board-certified Vascular and Neurocritical Care Neurologist with a decade of clinical experience in inpatient/outpatient, Neuro ICU and telemedicine settings at JC-certified Comprehensive Stroke Centers. Trained at Baylor College of Medicine with premier clinicians and neuroscientists at the world renown Texas Medical Center in Houston, TX. As part of commitment to high-quality and evidence-based medicine, serves as a Diplomate of the American Board of Psychiatry and Neurology and member of the Stroke Council of the American Heart/Stroke Association.
How often do you encounter cases similar to this one in your practice?
I see stroke on a daily basis, I fortunately am not involved in cases where there has been a significant delay in care such as this one.
Do you believe there might have been medical error?
It seems as though there was a long delay for the neurologist to see the patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Even though there was a delay in getting a neurologist to evaluate the patient, based on the information provided, I don't think it led to harm.
What makes you a good expert for this case?
I am a board certified neurologist and neurocritical care physician at an academic medical center. I have authored over 100 peer reviewed articles on neurological diseases. I have served as an expert on several prior cases and have provided live trial/deposition testimony for both the defense and plaintiff. Please see my CV for further information.
How often do you encounter cases similar to this one in your practice?
I am a board certified neurologist and neurocritical care physician at an academic medical center. I take care of approximately 500 patients with stroke per year.
Do you believe there might have been medical error?
This case revolves around evaluation of the patient presenting with an acute ischemic stroke. Based on the provided description, it appears that the patient arrived in time to warrant an acute stroke alert, but for inexplicable reasons she was not seen by any neurologist for an evaluation of the possible stroke. A neurologist should have confirmed the definitive last-known-well time. Did she awaken at 8:30am with the symptoms? Or did she wake up normal and develop the symptoms shortly thereafter? If the latter, then she would have potentially been a candidate for intravenous thrombolytic administration. To answer question #2 (How could a facility be a stroke entry point and put a STAT neuro consult in for a stroke alert and not have anyone call back or see patient for 5 days, especially since PC was being discharged and had to refuse to leave to get MD interaction?) - It should not have happened. This is a clear breakdown in their system and an error. To answer question #3 (Was the MRI delayed due to this web of miscommunication?) - possibly, but it didn't have an impact on her care
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Based on the description, it seems that most likely the patient had symptoms immediately upon awakening. If her last known well time was >4.5 hrs from presentation, as it would almost certainly be if she woke up with the symptoms already present, then she would not be a candidate for intravenous thrombolytics (except in rare scenarios based on imaging criteria, and that would not be considered standard of care). And without a large vessel occlusion she was not a candidate for endovascular therapy. There is also no evidence that differences in aspirin/lipitor or aspirin/plavix administration early on would have made a difference in her outcome. As a result, even though her not being seen by a neurologist for 5 days is pretty egregious, it is not likely that it led to a change in outcome in this case. Ultimately the neurologist's treatment plan prior to discharge was appropriate.
What makes you a good expert for this case?
I am a board-certified neurologist and neurointensivist with extensive experience in the evaluation and management of acute ischemic stroke patients, administration of thrombolytics, evaluation for endovascular therapy, and stroke care after these interventions are performed or considered.
How often do you encounter cases similar to this one in your practice?
I manage patients with acute ischemic strokes nearly every single day in my clinical practice, so I see similar patients regularly. Although I have not previously encountered a 5-day delay in neurologist evaluation for such a patient.
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Comments are accepted only from Neurocritical Care (Neurology) experts.