Shortly after noon on a Christmas Eve, paramedics brought to the hospital a young lady who was found on the floor of her residence, verbally unresponsive. Her mother explained the daughter had apparently received an upsetting text message in the bathroom and while en route, the 18-year-old patient nodded in agreement when asked if she was emotional about something.
At the emergency department, staff could not determine her medications, allergies, or medical history because of her silence. When a social worker asked the woman if she felt like hurting herself or others, she shook her head no. The social worker noted the mother’s report that her daughter’s prior treating physicians felt that she may have MS because she had been losing her balance and coordination.
According to the psychiatric emergency team, the young patient did not meet the criteria for a hold, and later that Thursday afternoon, Dr. EM, an emergency medicine physician, evaluated her. Dr. EM noted that the patient had received a text and thereafter refused to speak. According to her family and a friend of the woman, she had done this often in the past. The patient denied a headache, was able to shake her head, and though cooperative during the exam, she did not try to speak the entire time. Her mental status did not appear altered. Eye and ears were normal, as were motor strength and reflexes. (Dr. EM did not learn from the social worker the mother’s mention of the daughter’s possible MS.)
Dr. EM presumed a hysterical conversion reaction and explained to the mother that her daughter showed no stroke-like symptoms. Dr. EM discussed a CT scan but said unless new symptoms showed up, she did not want to subject the patient to the significant radiation of a scan. The ER team attempted to contact the young lady’s PCP for more than hour, without success. Dr. EM cleared the patient medically and noted the family’s comfort in taking her home. Dr. EM wrote that the mother understood if her daughter showed any new symptoms or confusion, she should bring her back immediately for a CT scan. Otherwise, she should follow up with a referred local physician Monday morning.
The next day, Christmas, the patient was found shaking and vomiting and was taken to a children’s hospital. A brain CT showed a large area of encephalomalacia. A later MRI showed an acute left middle cerebral artery infarction and an older, smaller infarction on the right side.
The patient sued Dr. EM and her various health care providers for neurologic injuries.
It turned out that in May of the year before, the teenager visited a local hospital for mild left leg tingling. An abnormal ECG showed a normal sinus rhythm but an inferior and possible anterolateral infarct of an undetermined age. A year later, she visited a regional center ER crying, dizzy, and complaining of numbness in her arms and legs. A radiologist interpreted a brain CT as negative. Two more visits to that ER — one just five weeks before the Christmas Eve event — noted continued tingling and complaints of dizziness.
At trial, an emergency medicine expert testified that Dr. EM fell below the standard of care by not getting a CT scan, not getting a neurologist involved, not starting heparin, not diagnosing a stroke, and not getting an adequate history. On direct examination by the plaintiff’s attorney, Dr. EM explained her consideration of a CT scan, her rationale for not ordering it, and her discussion with the mother about it. She testified on her examination and on the lack of any focal neurological deficit. Dr. EM also testified that all those who saw her thought that the patient was choosing not to talk, as opposed to not being able to talk. An expert testifying on Dr. EM’s behalf told the jury that had the doctor learned about the MS issue from the social worker, it would only support her decision not to call in a neurologist as the patient had a neurology appointment coming up and MS is not an emergent condition. Testimony from vascular neurologists said that heparin was not called for.
The vote was close, but the jury found its own voice and returned a verdict in favor of Dr. EM.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc.(CAP).
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