Case: The plaintiff, age fifty-two, went to the emergency department of the hosp
ID: 127837 • Letter: C
Question
Case:
The plaintiff, age fifty-two, went to the emergency department of the hospital in March 2005. He had experienced transient episodes of blurred vision and also had a numb right hand. He was examined by a doctor and nurse “A”. The plaintiff’s symptoms quickly resolved and a CT scan did not reveal abnormalities.
The doctor diagnosed a transient ischemic attack and contacted the plaintiff’s treating physician. The plaintiff’s treating physician arranged transfer to the hospital’s telemetric monitoring area and requested neurological evaluation. Before the transfer occurred, the doctor and nurse “A” reassessed the plaintiff and detected no neurological abnormalities.
About twenty minutes later the plaintiff was examined by another nurse, “B”, who noted slurred speech, confusion and weakness on the right side. The symptoms were reported to the emergency department and Nurse “B” was told that these symptoms had not been present in the examinations by the doctor and nurse “A”.
Nurse “B” then contacted the doctor who then requested an immediate neurological consultation by a neurologist. The neurologist examined the plaintiff over an hour later. The neurologist considered the use of tPA, but the plaintiff had been at the hospital for over six hours at that time and the neurologist determined that the three-hour time for administration of tPA had passed. Further observation was recommended.
The plaintiff’s symptoms worsened. By the next day it was determined that the plaintiff had suffered a full stroke. The plaintiff was transferred to another hospital and was hospitalized for several weeks. He achieved significant recovery, but continued to have partial paralysis of his right arm, aphasia, mild impairment of cognitive functions, and foot drop of the right foot. He requires a cane, but can independently perform most of his everyday activities.
The plaintiff alleged negligence in the failure to timely diagnose and treat the stroke. The plaintiff claimed that the stroke was caused by a clot which traveled to the brain and could have been treated with tPA.
The defendants claimed that tPA would not have provided any benefit to the plaintiff. Additionally, the neurologist claimed that Nurse “B” could not accurately determine the time of the onset of the symptoms and that the first two examinations by the doctor had been concluded more than four hours earlier.
Nurse “B”, however, claimed that she reported to the neurologist that the symptoms had begun less than three hours prior to the examination.
The doctor claimed that her order for an immediate neurological evaluation was all she was required to do. The defendants also claimed that the stroke was due to circulatory obstruction caused by a dissection of the left internal carotid artery, which was confirmed by angiography.
Decision Making Case Analysis. From the following case please provide me with your assessment as to what was wrong and who was or was not at fault in the case. More specifically I am looking for you to provide discussion on what the problem is, alternative identification of issues within the case, your analysis and evaluation of the situation within the case, and your solution to the problems and alternative issues you have provided. DISCUSS, NOT SIMPLY BULLET POINTS.
Explanation / Answer
What went wrong?
Significant delay in diagnosis. The time between transfer from plaintaffs doctor to ER in hospital has also contributed to delay in tPA treatment introduction. The time between nurse B evaluation and neurologist examination which was over an hour has also made matters worse. However this cannot be called as negligence as nurse A had examined patient and found no neurological symptoms. Onset of theses symptoms were delayed and presented only after 20 minutes when nurse B was evaluating patient. The neurologist however stated that it was well over 3 hours to introduce tPA. so in his capacity he is also not at fault. In this scenario, the only problem is transfer time from one clinic to hospital which is where delay in treament has occured and is unfortunate. Also delayed onset paralysis has also contributed to the confusion.
Other issues: why was an emerengy angiogram not performed for brain and coronary arteries to check for blocks?. This could have been initiated during CT, and an additional MRI with angiography could have been done to exclude clots. This missed test has significantly altered therapy. Another issue is delay in introducing tPA, when symptoms where first discovered. IT took 1 hour for neurologist examination which is not ideal in ER rooms. A prompt response is required here and nurse B could have alerted emergency doctors who are authorized to introduce tPA without neurological consultation.
Solution: it is essential to document all symptoms. Close monitoring of all TIA patients is necessary. No investigations should be skipped and patient should not have to wait for neurological examination.