Nothing good can result when important information sent between a patient’s care providers is delayed. Including the patient in the communication process is not only the right thing to do, it can also help prevent an adverse event.
A patient with history of low back and neck pain stemming from a diving injury 40 years earlier visited his primary care physician, who referred the gentleman to Dr. N, a neurologist, after x-rays showed diffuse degenerative changes with multiple disc space narrowing and osteophyte formation.
At his first visit with Dr. N, the patient described his longstanding low back pain, right and left sciatic pain, and numbness in his leg. He described an onset four months earlier of low back pain radiating down the leg to the left knee. He also told Dr. N of a single episode of transient left-sided facial numbness spreading to the arm and leg — an event the patient attributed to his use of a statin, which he stopped.
On examination, Dr. N found the cranial nerves normal, mild weakness in the left leg, and no evidence of carotid, ocular, or cranial bruit. Dr. N’s impression was lumbar radiculopathy and neuropathy. Dr. N’s plan was for an EMG of both legs, an MRI of the head, an increase of gabapentin to 600 mg three times daily, and a prescription for pain medication to be used as necessary. A referral by Dr. N dated the next day was for a bilateral carotid artery ultrasound to evaluate “transient cerebral ischemia.”
Dr. N interpreted and EMG/nerve conduction study of the patient’s lower extremities as consistent with peripheral motor and sensory neuropathy and referred him to a neurosurgeon to evaluate treatment options. The brain MRI showed diffuse cortical atrophy and small vessel white matter ischemic changes without evidence of intracranial hemorrhage, mass, or acute infarct.
The neurosurgeon noted the results of the patient’s lumber and lower extremity test results, which in his opinion warranted low back surgery. The surgeon referred the gentleman back to his primary care physician for medical and cardiac clearance for the surgery. A chest x-ray showed “no evidence of active cardiopulmonary disease to preclude surgery” and a cardiologist read the patient’s ECG as abnormal for low voltage QRS, incomplete right bundle branch block, and left anterior fascicular block but cleared the patient as “OK for surgery cardiac wise.”
While Dr. N was out of the country on a three-week vacation (leaving all of his patients under the care of his partner, Dr. N-Partner), the patient underwent the bilateral carotid artery ultrasound ordered by Dr. N some weeks earlier. That study, not read until five days later, noted “(1) severe 70 to 99% stenosis of the right carotid bulb; (2) large calcified plaque in the left carotid bulb without evidence of hemodynamically significant stenosis; (3) antegrade flow in the vertebral arteries and (4) heterogeneous nodular thyroid with pattern consistent with chronic thyroiditis.” Upon receiving the report, Dr. N-Partner wrote on the document: “severe 70-99% stenosis in the right carotid bulb. Refer to vascular surgeon stat.”
Dr. N-Partner did not inform the patient of the ultrasound results and relied on the medical office staff to make the stat referral to the vascular surgeon. Instead, the office made a routine referral, which delayed the vascular consult to after the patient’s low-back surgery. Though the surgeon contacted the primary care physician to confirm the medical and cardiac surgery clearance, he did not contact the neurology group, nor did that group contact him with the carotid ultrasound result.
The lumbar surgery went forth as scheduled without complication, ending at about 4:30 p.m. During physical therapy the next morning, however, the patient was perceived as more altered and with hemiparesis. A stat head CT was negative, and a neurology consultation was ordered. The neurologist suspected a right middle cerebral artery infarct and followed up with a stat CT angiograms of the head and neck. On reviewing those studies, the neurologist assessed a right internal artery occlusion and right middle cerebral artery syndrome. Because of the recent lumbar surgery, the patient was not a candidate for TPA and the neurologist recommended transfer to a higher-level hospital for stroke treatment.
Claiming residual impairment, the patient sued Dr. N’s medical group for failing to properly follow-up on the ultrasound results prior to undergoing the surgery. That dispute resolved informally.
One should never expect that a medical office would fail to properly execute a stat referral. But a physician’s direct involvement in overseeing the referral — and an immediate report to the patient — are appropriate steps to take with urgent test results.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.