Patient was admitted to the ER Hospital 1 on 2/6/25 at 1949 (7:49 pm) and discharged at 2210 (10:10 pm). Total stay in the ER was 2 hours, 21 minutes. Patient had a blood pressure of 224/125 on admission and a blood pressure of 226/132 at discharge which qualifies as a hypertensive crisis, which can lead to Stroke, Heart attack, Aortic dissection, Kidney failure, Hypertensive encephalopathy (confusion, seizures) and that it is not safe for someone with that blood pressure to be discharged without urgent treatment and monitoring.
Patient gave the ER doctor a history of slurred speech and facial droop "a few days ago" and a history of a syncopal episode (fainting or dizziness) "about a week ago." The ER doctor failed to obtain a CT of the head to rule out stroke. It appears from the comments in the record that the ER staff thought the patient had high blood pressure due to anxiety. The blood pressures Patient had both at admission and discharge from the ED at Hospital 1 were stroke inducing levels and constituted a medical emergency. Patient should have also undergone blood tests and other diagnostic tests to rule out end organ damage prior to discharge.
The next morning, Patient was transported via ambulance to the ER at Hospital 2 and admitted to the ER on 2/7/25 at 10:52 am. Her presenting symptoms included left sided weakness. Had a NIHSS Score of 16 when evaluated by the tele-neurologist. A CTA of the head revealed a stroke in the right MCA. Neurologist felt was not a candidate for TPA (clot buster drug) or thrombectomy due to the delay in diagnosing the stroke.
Based on the care rendered to the Patient in the ER at Hospital 2, the ER at Hospital 1 failed to obtain a neurology consult, failed to administer TPA and failed to obtain a CTA of the head to image the blood clot in the right MCA. Had the ER at Hospital 1 rendered proper care to Patient, she may have fully recovered from the stroke. However, by the time she got to Hospital 2 the following morning, it was too late for medical or surgical intervention to mitigate the permanent neurological damage from the stroke.
Patient suffered a stroke that occurred on 2/6/25. Patient was airlifted to a local hospital where she lived 11 days and then died from the effects of the stroke. Patient did not have serious co-morbidities or a history of heart attack or cardiovascular disease prior to stroke.
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Do you believe there might have been medical error?
Although severely elevated blood pressure does not automatically constitute a hypertensive emergency in the absence of documented end-organ damage, the patient’s overall clinical presentation at the initial ED visit should have been recognized as highly concerning and warranting a substantially more thorough evaluation. The combination of blood pressures in the 220s/130s, a history of slurred speech and facial droop in the preceding days, and a recent syncopal episode are all significant warning signs. Taken together, these symptoms raise the possibility of a transient ischemic attack, evolving stroke, or other acute neurologic process. Under accepted emergency medicine standards of care, these historical features should have triggered a targeted workup that included, at a minimum, neuroimaging, basic labs, assessment for end-organ injury, and consideration for neurology consultation. In many similar cases, such a constellation of risks leads to short-term hospital admission for monitoring and serial neurologic examinations, particularly when the patient reports prior focal deficits. While elevated blood pressure alone may not have mandated emergent pharmacologic treatment, dismissing the patient’s symptoms as anxiety without performing appropriate diagnostic testing represented a missed opportunity to identify a potentially evolving stroke. A more comprehensive evaluation would have had a reasonable likelihood of detecting abnormalities suggestive of cerebrovascular injury and altering the clinical course. In summary, although the hypertension itself may not have required emergent blood-pressure reduction, the symptom complex surrounding it was sufficiently alarming that a more robust diagnostic approach and likely admission were medically indicated. The failure to pursue this evaluation represents a potentially significant deviation from expected practice and supports the conclusion that a medical error occurred.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A more comprehensive evaluation or admission at the initial visit could have identified concerning neurological findings or would have allowed for close monitoring, which in turn may have led to a significantly earlier recognition of a new or evolving stroke. Earlier detection could have enabled time-sensitive interventions. While it is impossible to state with certainty that the outcome would have been fully prevented, it is medically reasonable to conclude that delayed diagnosis and treatment likely contributed to a worse outcome.
What makes you a good expert for this case?
am one of only a small number of physicians nationwide who is triple board-certified in Emergency Medicine, Emergency Medical Services (prehospital medicine), and Critical Care Medicine. I am a Fellow of the Academy of EMS, a Fellow of the American College of Critical Care Medicine, and a Fellow of the Academy of Wilderness Medicine. I am an Associate Professor at a large academic medical center affiliated with a top-five public university, where I serve as Vice-Chair and Service Chief of the Department of Emergency Medicine. In addition, I hold multiple institutional leadership and executive roles spanning emergency care, prehospital operations, critical care delivery, and hospital-wide quality initiatives. I have extensive experience caring for critically ill and injured patients across the emergency department, prehospital environment, and intensive care unit, and I have provided bedside emergency care for more than two decades. I have taught hundreds—if not thousands—of medical students, resident physicians, fellows, advanced practice providers, paramedics, and other allied health professionals across all stages of training. I also mentor junior faculty members across each of my clinical subspecialties. In my administrative and leadership roles, I participate in numerous hospital committees and regularly conduct peer review, provide systems-level guidance, and oversee corrective actions related to patient safety and quality of care. I serve as a medical expert for both plaintiffs and defendants and am committed to timely communication; I respond to inquiries within 24 hours and review medical records promptly and comprehensively.
How often do you encounter cases similar to this one in your practice?
I practice in a large quaternary-care emergency department where I routinely evaluate patients across the full spectrum of hypertensive presentations, including asymptomatic hypertension, hypertensive urgency, hypertensive emergency, as well as patients with stroke-like symptoms and confirmed strokes. I assess and manage these conditions multiple times each shift.
Do you believe there might have been medical error?
Blood pressures such as 226/132 on discharge are considered hypertensive emergencies. The patient should not have been discharged with an uncontrolled blood pressure of this magnitude. The risk of a stroke is high with a blood pressure in this range. A CT scan should have been performed given the history of slurred speech, facial droop and syncope. A neurologic consultation however was not necessarily indicated and TPA administration was definitely not indicated if the neurologic examination did not reveal any focal neurologic deficits. The information about a neurologic examination and an NIHSS score is not given but TPA would not be indicated if the NIHSS score was very low and the patient was without debilitating neurologic deficits.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The failure to control the patient's blood pressure was likely the cause of her stroke the next day. The timing of her symptoms before presentation to hospital # 2 is not detailed but if the last known well time was less than 4 1/2 hours before she presented to hospital # 2 then she may have been a condidate for TPA at that time. More information is needed to form an opinion regarding causation at hospital # 2.
What makes you a good expert for this case?
I am triple board certified in Emergency Medicine, Internal Medicine and Critical Care. I have 40 years of experience in medical-legal case evaluations and have reviewed more than 2000 cases. I have testified in more than 100 trials and have testified in more than 200 depositions. I have more than 40 years of experience in direct patient care at a level 1 trauma center and a Comprehensive Stroke Center.
How often do you encounter cases similar to this one in your practice?
I encounter similar cases on at least a weekly and sometime daily basis.
Do you believe there might have been medical error?
The patient presented with hypertensive crisis, with documented blood pressures of 224/125 on arrival and 226/132 at discharge. Blood pressures of this severity constitute a medical emergency requiring treatment, monitoring, and evaluation for potential end-organ damage, especially in a patient with no known history of such hypertension or CAD. There is no indication that antihypertensive therapy was initiated, that diagnostic studies were performed, or that the patient was monitored to determine response to therapy. Discharging a patient with persistently crisis-level blood pressure without evaluation or treatment falls below the standard of care. It is even more concerning given this patient reportedly had no history of such BP issues and even more concerning in light of her recent neurological symptoms. In addition, the patient reported recent neurological symptoms, including slurred speech and facial droop several days prior to presentation, as well as dizziness or a possible syncopal episode approximately one week earlier. Although these symptoms had reportedly resolved, their presence in conjunction with severe hypertension required consideration of transient ischemic attack (TIA) or cerebrovascular accident (CVA). The standard of care in this scenario mandates, at minimum, CT scan of the head, laboratory evaluation for end-organ injury, and further neurological assessment and monitoring. No such evaluation appears to have been pursued.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
While the patient would not have been a candidate for thrombolytic therapy at ED #1 in the absence of active neurological deficits and given the reported timing of prior symptoms, failure to appropriately evaluate the possibility of ongoing or evolving cerebrovascular pathology may have contributed to the deterioration documented at ED #2 the following morning. In summary, the combination of severe uncontrolled hypertension and recent focal neurological symptoms, even if resolved, required diagnostic imaging, blood pressure management, and likely hospital admission with neurology involvement. The failure to undertake these steps represents a deviation from the standard of care expected of an emergency medicine provider. Given the presentation of severe hypertension and recent neurological deficits, this patient required careful BP management and advanced imaging such as CT/CTA. It is unlikely a patient would present with such hypertension due to anxiety given no history of such hypertension and the recent neurological symptoms.
What makes you a good expert for this case?
Although I am not a critical care specialist, the issues in this matter pertain to initial emergency department evaluation and management, which fall squarely within my training, experience, and expertise. I am a board-certified emergency medicine physician with over seven years of attending clinical experience. I have evaluated and managed a broad spectrum of patients across rural emergency departments, busy community hospitals, and Level II trauma center. I have also participated in the training of medical students and residents.
How often do you encounter cases similar to this one in your practice?
Hypertensive crises and potential stroke presentations are fundamental components of emergency practice. I routinely manage hypertensive emergencies and evaluate suspected stroke cases on virtually every clinical shift. The timing of presentation, recognition of symptoms, and proper diagnostic evaluation is crucial.
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