Large lawsuit against ER physician for stroke mismanagement

[valianteffort]

$75M Verdict in Med Mal Trial Over Stroke That Profoundly Paralyzed Patient

Jurors handed down a $75 million verdict against a pair of Georgia physicians last week, after finding them responsible for the “locked-in” paralysis one of their patients suffered during a catastrophic stroke.

blog.cvn.com

Locked-In Syndrome Malpractice Case Ends With $75M Verdict

After a chiropractic neck adjustment led to a stroke, the patient's attorney alleged that hospital physicians failed to act swiftly, resulting in locked-in syndrome.

www.medscape.com

Lawsuit just awarded to the plaintiff in GA. Appears that the young patient went to a chiropractor and developed a vertebral artery dissection after neck manipulation. IT appears the ER doc got slammed and the majority of punishment due to him editing his note after realizing what had happened. The neurologist was cleared of any wrongdoing and it appears the radiologist may have also missed some of the imaging. I am wondering why the chiro was not named and charged for actually causing harm to the patient, although it does appear the ER physician was negligent.

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[bravotwozero]

The chiropractor probably doesn’t have pockets as deep as the EP, or hospital.

 

[KaiBuzz]

Caribbean Medical School…..

 

[Jabbed]

The chiropractor settled.

 

[Jabbed]

Some things that make me irate in no particular order:

• Emphasis on the duration of consultant calls as being too short. Seriously?
• Why is the STROKE NEUROLOGIST not held liable for reviewing the perfusion imaging if it is ambiguous and there’s clearly concern for brainstem stroke?
• I’m sure that he mentioned the chiropractic manipulation. We love that sort of ****. Even if he didn’t, what does that matter? If I don’t tell the stroke neurologist about the patient’s history of HLD am I now liable for 60% of 75M since that too is a stroke risk?
• That rads read is some cagey BS. CTA has better visualization than MRA anyway for vessel imaging so this sounds like it was just a rads miss. I like to think that I probably would have called and reviewed this with rads and could have been caught, but who knows.
• So much emphasis is placed on him signing his note the next day when it’s obvious that the initial note was just templated by the scribe.
• Ugh 🤮

 

[EMhawkeye]

Caribbean Medical School…..

And matched and graduated from an american residency program. Your point?
This tells us way more about you than the person in the article. And it isn’t flattering.

 

[RustedFox]

Caribbean Medical School…..

Funny.
The neurointerventional doc at my shop is from a carib school. You don't get that gig without being goddamned good.

 

[WilcoWorld]

So did this patient arrive within 3 hours and not get tPA? I couldn't tell from the articles above what really happened.

 

[CoolDoc1729]

$75M Verdict in Med Mal Trial Over Stroke That Profoundly Paralyzed Patient

Jurors handed down a $75 million verdict against a pair of Georgia physicians last week, after finding them responsible for the “locked-in” paralysis one of their patients suffered during a catastrophic stroke.

blog.cvn.com

Locked-In Syndrome Malpractice Case Ends With $75M Verdict

After a chiropractic neck adjustment led to a stroke, the patient's attorney alleged that hospital physicians failed to act swiftly, resulting in locked-in syndrome.

www.medscape.com

Lawsuit just awarded to the plaintiff in GA. Appears that the young patient went to a chiropractor and developed a vertebral artery dissection after neck manipulation. IT appears the ER doc got slammed and the majority of punishment due to him editing his note after realizing what had happened. The neurologist was cleared of any wrongdoing and it appears the radiologist may have also missed some of the imaging. I am wondering why the chiro was not named and charged for actually causing harm to the patient, although it does appear the ER physician was negligent.

Maybe we should be talking less about banning abortions and more about Chiro manipulations .. how does this keep being allowed?

 

[RustedFox]

Maybe we should be talking less about banning abortions and more about Chiro manipulations .. how does this keep being allowed?

This has already been discussed ad nauseum; it all boils down to: "people like white magic".
The relevant part of the discussion is the med-mal part.

 

[Franzd'Epinay]

I would be really interested in reading the actual notes in this case.

Obviously the chiropractor was fully at fault here, but there was clearly some major miscommunication going on after the patient got to the hospital. These two excerpts together should make everyone go "huh?"

Radiologist Waldschmidt’s attorney, Huff Powell Bailey’s Scott Bailey, told jurors evidence showed his client read Buckelew’s imaging with an eye to answering the specific question of whether one of Buckelew’s arteries was torn. And Bailey argued Waldschmidt properly communicated that tear, which other providers could have linked to a stroke. Reminding jurors of testimony comparing a stroke to a forest fire, Bailey said, “[Waldschmidt's] job is not to go down there and put [the fire] out. His job is to identify the smoke, and he did that.”

Physician assistant Nickum’s attorney, Huff Powell Bailey’s Brian Mathis, argued evidence showed his client treated Buckelew with the justified belief that doctors had ruled out a stroke and that Buckelew likely had meningitis instead.

“You have to ask yourself: were the symptoms that Chris Nickum saw that night consistent with meningitis?” Mathis said. “And the answer is absolutely yes.”

 

[Jabbed]

I would be really interested in reading the actual notes in this case.

Obviously the chiropractor was fully at fault here, but there was clearly some major miscommunication going on after the patient got to the hospital. These two excerpts together should make everyone go "huh?"

The radiology report described the right vertebral artery:

“intermittently identified over its expected course, this may be due to normal congenital variation or a dominant left vertebral system, or may represent the sequelae in an age-indeterminate dissection…. The right vertebral artery does not contribute to the formation of the basilar artery”

 

[evert1de101]

Can anyone find the full radiology report? I wonder if that little "normal variation vs dissection" tidbit was buried in a sentence in the report vs stated clearly in the impressions. Reminds one to always read the full report and not allow vacillating radiology-speak to prevent you from doing your best for the patient.

 

[CoolDoc1729]

Can anyone find the full radiology report? I wonder if that little "normal variation vs dissection" tidbit was buried in a sentence in the report vs stated clearly in the impressions. Reminds one to always read the full report and not allow vacillating radiology-speak to prevent you from doing your best for the patient.

Impression: no acute pathology

 

[evert1de101]

Reminds me of another case from medmalreviewer where PCP ordered MRI for lower extremity weakness, radiologist wrote the following report and didn't call the PCP about it, patient wasn't sent to ER and ended up having decompression surgery too late

“T9-T10 bilateral paracentral disc protrusion superimposed on a circumferential disc bulge, significant mass effect on the thoracic spinal cord. This is considered a moderate to severe stenosis. Questionable faintly increased signal in the substance of the spinal cord, possibility of edema.”

At the end of the day your rads is responsible for looking at a picture and saying some words about it. More words and more hedging is more protection for them. They have zero desire and responsibility to actually call the shots on a life threat.

 

[gro2001]

Some things that make me irate in no particular order:

• Emphasis on the duration of consultant calls as being too short. Seriously?
• Why is the STROKE NEUROLOGIST not held liable for reviewing the perfusion imaging if it is ambiguous and there’s clearly concern for brainstem stroke?
• I’m sure that he mentioned the chiropractic manipulation. We love that sort of ****. Even if he didn’t, what does that matter? If I don’t tell the stroke neurologist about the patient’s history of HLD am I now liable for 60% of 75M since that too is a stroke risk?
• That rads read is some cagey BS. CTA has better visualization than MRA anyway for vessel imaging so this sounds like it was just a rads miss. I like to think that I probably would have called and reviewed this with rads and could have been caught, but who knows.
• So much emphasis is placed on him signing his note the next day when it’s obvious that the initial note was just templated by the scribe.
• Ugh 🤮

Wild case.

Some thoughts as a emergency physician and neurointensivist:

1) I wonder if the neurologist was a stroke specialist or like in many hospitals a random neurologist (like a movement disorder specialist) who happened to be on call. I can't imagine a reasonable stroke neurologist to 1) not ask for a CTA immediately 2) not interpret the images themself. But I can see a non-stroke neurologist who doesn't think about stroke much just shrug their shoulders and mess things up this way.

This is a prime example of why emergency physicians as a specialty should take more ownership of neurologic emergencies. We don't completely outsource our thinking in other areas (cardiac emergencies, trauma, etc). Neurologic emergencies should be even more our core bread and butter as they are everything we use to define ourselves as a specialty:

-time sensitive
-life/limb threatening
-requiring big decisions with limited information

Neurologists don't learn to think this way except when it comes to stroke, but for us it's our core bread and butter. We need the Amal Matu's of stroke in EM to own it.

2) I do think the emergency physician not mentioning the chiropractic manipulation would be a big deal (if they truly didn't mention it), much more so than failing to mention hyperlipidemia. It changes the pretest probability in my mind of a young person having a stroke so much, way more so than them having/not having HLD. Particularly a stroke that would change the level of consciousness (which for ischemic strokes is pretty much basilar or nothing). Ultimately, it's still on the neurologist to look at the relevant images though.

3) Although it is my practice to get a CTP in all stroke codes, it probably would be way less useful in this case than the CTA. CTPs are generally not very useful for brainstem strokes (both because the CTP needs to compare to the contralateral MCA to determine decrease flow/increased transit time for the contrast, which is not really relevant to the brainstem circulation, as well as because it doesn't take a very large perfusion deficit to be devastating in the brainstem). The CTA is critical though.

 

[HemeOncHopeful19]

I like that all these doctors are thrown under the bus for missing a stroke while the PA is allowed to review all of this same information and conclude that there is no stroke.

 

[valianteffort]

As a new attending, I am always worried that a rads missed up a read. At times I pull up the Ct or X-ray but sometimes it is just too busy to look in detail. I’ve always operated on if the imaging was misread that is on the radiologist for mismanagement. We are not CT trained and we don’t claim to be. Whether the story of ‘patient had neck manipulation’ was put into the consult or not shouldn’t matter. This read changes our management and if it changes it to a way where a patient is harmed, should the EP not be thrown out?

 

[rickylafleur]

I like that all these doctors are thrown under the bus for missing a stroke while the PA is allowed to review all of this same information and conclude that there is no stroke.

Yeah the crux of this case was of course the midlevel did it.

 

[HemeOncHopeful19]

Yeah the crux of this case was of course the midlevel did it.

I don’t think the midlevel did it, but it does seem that had the ICU been staffed overnight by the attending that this would have been acted on sooner?

 

[rickylafleur]

I don’t think the midlevel did it, but it does seem that had the ICU been staffed overnight by the attending that this would have been acted on sooner?

Maybe so. Or any of the preceding physicians being better at their jobs. But either way the usual SDN way is to devolve the thread to anti PA or NP and the stars align in a unison hatred.

 

[HemeOncHopeful19]

Maybe so. Or any of the preceding physicians being better at their jobs. But either way the usual SDN way is to devolve the thread to anti PA or NP and the stars align in a unison hatred.

If it makes you feel better I actually think everybody involved from the Chiropractor to the Docs, the PA, the Jury and the state of Georgia probably didn’t do a great job in this case.

As a non-ER doc I have been frustrated multiple times by people in the ER who call me and later document discussions that did not actually take place.

I also think it’s weird how a lot of you guys will basically have a blank note template for hours, and later go in and fill in the blanks often after a patient is admitted. I get that the workflow in the ER is nuts and I’m not saying I know a better way but it always seemed weird medicolegally.

 

[rickylafleur]

If it makes you feel better I actually think everybody involved from the Chiropractor to the Docs, the PA, the Jury and the state of Georgia probably didn’t do a great job in this case.

I agree with that. Just tragic. I’m just fed up with the usual target of these threads eventually going from disarray finally to a consensus that PAs are the root of all evil.

 

[BoardingDoc]

Dad voice: this is an interesting case. Let's continue discussing it. I don't think anyone particularly cares whether the ICU midlevel screwed up in this case. That said, if people have specific issues related to the care that anyone in this case provided, feel free.

 

[HoosierdaddyO]

If it makes you feel better I actually think everybody involved from the Chiropractor to the Docs, the PA, the Jury and the state of Georgia probably didn’t do a great job in this case.

As a non-ER doc I have been frustrated multiple times by people in the ER who call me and later document discussions that did not actually take place.

I also think it’s weird how a lot of you guys will basically have a blank note template for hours, and later go in and fill in the blanks often after a patient is admitted. I get that the workflow in the ER is nuts and I’m not saying I know a better way but it always seemed weird medicolegally.

No disrespect but when you are managing an 8 year that you just intubated and in pressors and anticonvulsants for status, simultaneously reassessing the little bronchiolitic trying to prevent him from going on high flow… to the patient yelling at you because his tooth hurts, to ems just dropping off and 85 year old full code in full on chf exacerbation (and that’s just 1 hour of the shift… we will ignore that it goes one for 9 more like that), ohhh and ancillary staff is asking can you do a peripheral line bc all the travel nurses spent most of their time trying to be tik tok nurse famous as opposed to learning and mastering the one damn skill that matters most. Yea notes take a way way way way way far back in right field priority. Heck I might even do them tomorrow morning (finishing touches at least), when my brain isn’t fried like a piece of crispy chicken at a summer bbq. To be honest it’s a failure on the hospital and healthcare as a system that no other specialty has to do so much in so little time consistently and then expect to be treated like the IM doc who has an hour plus of lunch to sit in the cafeteria. I don’t think there has ever been one single ER doc that took more than 10 min to throw the food down the gullet before getting yelled at by the nurses lol.

And the feeling is sometime mutual to have a consultant who is getting paid to consult makes me feel like I’m the biggest burden in the world, when it comes time to ask him to do their job. So it’s a two way kinda love lol .

 

[Clean7795]

I think the ****ed up part is that the chiropractor was the one who inflicted the stroke, which almost certainly not treatable, yet it's the MDs who fall on the sword.

 

[RustedFox]

No disrespect but when you are managing an 8 year that you just intubated and in pressors and anticonvulsants for status, simultaneously reassessing the little bronchiolitic trying to prevent him from going on high flow… to the patient yelling at you because his tooth hurts, to ems just dropping off and 85 year old full code in full on chf exacerbation (and that’s just 1 hour of the shift… we will ignore that it goes one for 9 more like that), ohhh and ancillary staff is asking can you do a peripheral line bc all the travel nurses spent most of their time trying to be tik tok nurse famous as opposed to learning and mastering the one damn skill that matters most. Yea notes take a way way way way way far back in right field priority. Heck I might even do them tomorrow morning (finishing touches at least), when my brain isn’t fried like a piece of crispy chicken at a summer bbq. To be honest it’s a failure on the hospital and healthcare as a system that no other specialty has to do so much in so little time consistently and then expect to be treated like the IM doc who has an hour plus of lunch to sit in the cafeteria. I don’t think there has ever been one single ER doc that took more than 10 min to throw the food down the gullet before getting yelled at by the nurses lol.

And the feeling is sometime mutual to have a consultant who is getting paid to consult makes me feel like I’m the biggest burden in the world, when it comes time to ask him to do their job. So it’s a two way kinda love lol .

This post goes hard.

 

[johnny_bananas]

No disrespect but when you are managing an 8 year that you just intubated and in pressors and anticonvulsants for status, simultaneously reassessing the little bronchiolitic trying to prevent him from going on high flow… to the patient yelling at you because his tooth hurts, to ems just dropping off and 85 year old full code in full on chf exacerbation (and that’s just 1 hour of the shift… we will ignore that it goes one for 9 more like that), ohhh and ancillary staff is asking can you do a peripheral line bc all the travel nurses spent most of their time trying to be tik tok nurse famous as opposed to learning and mastering the one damn skill that matters most. Yea notes take a way way way way way far back in right field priority. Heck I might even do them tomorrow morning (finishing touches at least), when my brain isn’t fried like a piece of crispy chicken at a summer bbq. To be honest it’s a failure on the hospital and healthcare as a system that no other specialty has to do so much in so little time consistently and then expect to be treated like the IM doc who has an hour plus of lunch to sit in the cafeteria. I don’t think there has ever been one single ER doc that took more than 10 min to throw the food down the gullet before getting yelled at by the nurses lol.

And the feeling is sometime mutual to have a consultant who is getting paid to consult makes me feel like I’m the biggest burden in the world, when it comes time to ask him to do their job. So it’s a two way kinda love lol .

"no other specialty has to do so much in so little time consistently and then expect to be treated like the IM doc who has an hour plus of lunch to sit in the cafeteria"

I enjoy reading comments by ED physicians who think so highly of themselves and so little of their colleagues. You seem to like your job!

 

[johnny_bananas]

I am really surprised that the neurologist shared no culpability in the case. They were consulted by the ED physician and it appears they didn't even examine the patient, collect their own history, review the chart, and images.

I doubt there weren't signs of brainstem dysfunction when examining the patient, and the examination by the neurologist could have played a critical role in suggesting the findings on CT/CTA were acute. An unfortunate case, where it appears the ED physician had minimal support from the neurologist.

 

[HemeOncHopeful19]

I am really surprised that the neurologist shared no culpability in the case. They were consulted by the ED physician and it appears they didn't even examine the patient, collect their own history, review the chart, and images.

I doubt there weren't signs of brainstem dysfunction when examining the patient, and the examination by the neurologist could have played a critical role in suggesting the findings on CT/CTA were acute. An unfortunate case, where it appears the ED physician had minimal support from the neurologist.

This case was discussed elsewhere and if I recall correctly the Neurologist claimed per their phone records that they were called before the CT read was signed out and that they were never told about a CT. It sounded like patient also had fever and a seizure so they recommended an LP for meningitis work-up. I agree with you I’m surprised the neurologist didn’t get burned for not actually seeing the patient but I guess we don’t know exactly what was documented.

The ER doc claimed they had discussed the findings over the phone before the read was time-stamped, but his documentation wasn’t signed until the next morning and I think his physical exam was just a generic template that he may have forgot to update.

 

[Birdstrike]

The details of the case don't matter.

If you can get out of a death or catastrophic injury case with an amount your insurance company is willing to pay, THEN DO IT. Even more so, if the person who caused the death/maiming settles you cannot leave yourself defending the case alone. The jury is left to conclude, "Well, somebody's got to pay for this."

Don't stay in the case. Take the L and GET, OUT. Even though you're 0.1%, or maybe even 0% responsible, you get caught holding the hot potato because you refused to settle. If you don't know exactly what "Joint and Severable Liability" means, educate yourself immediately.

"Pride comes before destruction, and an arrogant spirit before a fall." - Proverbs 16-18

 

[Eigenvector1]

As a new attending, I am always worried that a rads missed up a read. At times I pull up the Ct or X-ray but sometimes it is just too busy to look in detail. I’ve always operated on if the imaging was misread that is on the radiologist for mismanagement. We are not CT trained and we don’t claim to be. Whether the story of ‘patient had neck manipulation’ was put into the consult or not shouldn’t matter. This read changes our management and if it changes it to a way where a patient is harmed, should the EP not be thrown out?

Yes, it is on the radiologist to diagnose a vertebral artery dissection. But, please help us out and mention 'chiropractic neck manipulation' in the indication. That history always makes me go back and take a second look at the vertebral arteries.

 

[johnny_bananas]

This case was discussed elsewhere and if I recall correctly the Neurologist claimed per their phone records that they were called before the CT read was signed out and that they were never told about a CT. It sounded like patient also had fever and a seizure so they recommended an LP for meningitis work-up. I agree with you I’m surprised the neurologist didn’t get burned for not actually seeing the patient but I guess we don’t know exactly what was documented.

The ER doc claimed they had discussed the findings over the phone before the read was time-stamped, but his documentation wasn’t signed until the next morning and I think his physical exam was just a generic template that he may have forgot to update.

Yes, that is my understanding of the case as well. I just don't get how claiming the ED physician gave an incorrect history absolves the neurologist from not taking their own history or reviewing the chart themselves. What kind of specialist trusts what the ED physician tells them over the phone? This is not a jab on the competency of ED physicians, just an understanding that their time devoted to each patient is limited and there may be relevant questions they may not have asked. This is why the fact of the ED physician not telling the neurologist about the chiropractor or CTA for me is irrelevant. I can't tell you how many times the history is completely different from what the ED physician is initially telling me over the phone, and it is the norm rather than the exception for important findings on the neurological examination to be missed.

It is doubtful that the patient had only decreased LOC without any brainstem findings. Why the lack of an in depth neurological examination is where the problems began, the radiological findings were not correlated to the neurological exam and unfortunately assumed to be a congenital variation.

 

[johnny_bananas]

I think the ****ed up part is that the chiropractor was the one who inflicted the stroke, which almost certainly not treatable, yet it's the MDs who fall on the sword.

"stroke, which almost certainly not treatable"

There are acute therapies for stroke: 1.) tPA 2.) endovascular thrombectomy

In this particular case an error by the ED physician was not ordering the CTA stat, they correctly assumed a dissection and therefore a stroke was a possibility - both of the above treatments are time sensitive.

 

[maxxor]

This $75mil case is a mess to discuss unless MedMalReviewer (or anyone else with an account to download court documents) gets some more pieces of the medical record, like the entire the radiology report.

Reminds me of another case from medmalreviewer where PCP ordered MRI for lower extremity weakness, radiologist wrote the following report and didn't call the PCP about it, patient wasn't sent to ER and ended up having decompression surgery too late

“T9-T10 bilateral paracentral disc protrusion superimposed on a circumferential disc bulge, significant mass effect on the thoracic spinal cord. This is considered a moderate to severe stenosis. Questionable faintly increased signal in the substance of the spinal cord, possibility of edema.”

At the end of the day your rads is responsible for looking at a picture and saying some words about it. More words and more hedging is more protection for them. They have zero desire and responsibility to actually call the shots on a life threat.

I remember that case as well from MedMalReviewer. The timing of the imaging was 6+ weeks after ER presentation, likely in an outpatient setting, and who knows if the inpatient/subacute rehab clinical notes were available. That one you are kind of "is it cord edema or myelomalacia?" and without seeing the images, who knows?

 

[GatorCHOMPions]

Are the docs now uninsurable with future malpractice carriers? Where does the money come from with such a large settlement?

 

[forchinet121]

Wait can someone comment on this aspect: typical malpractice policies cover only a few million right…are the doctors on the hook for 75 million!??! Do they have to declare bankruptcy?? Usually there’s a settlement for below the policy limit I thought…

 

[Clean7795]

"stroke, which almost certainly not treatable"

There are acute therapies for stroke: 1.) tPA 2.) endovascular thrombectomy

In this particular case an error by the ED physician was not ordering the CTA stat, they correctly assumed a dissection and therefore a stroke was a possibility - both of the above treatments are time sensitive.

He had brain stem infarcts from a dissected vertebral & basilar arteries, endovascular isn't an option and tPA is unlikely to resolve it. Dissection is very different from emboli.

 

[nikolaite]

I think the ****ed up part is that the chiropractor was the one who inflicted the stroke, which almost certainly not treatable, yet it's the MDs who fall on the sword.

The docs are paying the price of disruptive documentation. Any medico who chooses to litigate rather than settle should know: the only thing a case will hinge on is the record. If a doc keeps an abysmal record with unacknowledged late entries, template drift exams and unattributed alterations…and has the chutzpah to attempt to defend the effects of such unprofessional behavior, then the $75M seems a generous exchange. Sad stuff all around.

 

[WilcoWorld]

"stroke, which almost certainly not treatable"

There are acute therapies for stroke: 1.) tPA 2.) endovascular thrombectomy

In this particular case an error by the ED physician was not ordering the CTA stat, they correctly assumed a dissection and therefore a stroke was a possibility - both of the above treatments are time sensitive.

Basilar artery occlusion has a dismal natural course and the mortality rate is 85% to 95% even with anticoagulant and fibrinolytic therapy if the artery is not recanalized.

 

[Rekt]

Honestly more surprising that it's even a big deal. I've had a few vertebral and cervical dissections and talked to everyone neurosurgery, Neuro, vascular. It's never perfect intra vs extra cranial etc and even then it seems like it doesn't matter. They all just shrug.

This patient was doomed the second some idiot snapped his neck. Need to take the chiro for everything he's worth.

 

[turkeyjerky]

Wait, so we've got both the neuro and the admin who lurk this forum to comment on this case? (Unsurprisingly taking a dump on the EM doc). We just need powerhouse resident to chime in to activate the Troll Triumvirate.

 

[Brigade4Radiant]

Ridiculous so it seems they went with the diagnosis of meningitis then went back and documented the info of a dissection.

The ED doc should have just sticked to what they originally documented

Also it often doesn’t matter what you document if you have a bad outcome and the patient suffers and they are sympathetic it might benefit you to settle.

 

[EMhawkeye]

Caribbean Medical School…..

Didn’t even realize this troll was a premed. Hasn't even gotten into medical school much yet a residency. What are you doing here trolling on the EM forums with the adults?

 

[Brigade4Radiant]

Wait, so we've got both the neuro and the admin who lurk this forum to comment on this case? (Unsurprisingly taking a dump on the EM doc). We just need powerhouse resident to chime in to activate the Troll Triumvirate.

They already trolled the carribean medical school

 

[johnny_bananas]

He had brain stem infarcts from a dissected vertebral & basilar arteries, endovascular isn't an option and tPA is unlikely to resolve it. Dissection is very different from emboli.

This is incorrect, the report suggest there was a basilar thrombus, see quotes below.

For arguments sake, let us say you are correct, and the artery was dissected leading to collapse with severe luminal narrowing of the basilar artery and hemodynamic insufficiency (extremely rare compared to basilar thrombosis) - this would still be an indication for endovascular therapy with stenting of the basilar artery to restore flow. Again, to say this is “certainly not treatable” is incorrect, particularly considering the patient was young, presented early, and with mild symptoms - timely treatment may have made a significant difference.

 

[johnny_bananas]

Basilar artery occlusion has a dismal natural course and the mortality rate is 85% to 95% even with anticoagulant and fibrinolytic therapy if the artery is not recanalized.

I agree with you that the natural history of basilar occlusions is not favourable, more of a reason for rapid treatment to try to recanalize the vessel.
As the two recent RCTs (ATTENSION, BAOCHE) show, endovascular therapy leads to better functional outcomes.

https://www.nejm.org/doi/full/10.1056/NEJMoa2206317

https://www.nejm.org/doi/full/10.1056/NEJMoa2207576

 

[johnny_bananas]

Honestly more surprising that it's even a big deal. I've had a few vertebral and cervical dissections and talked to everyone neurosurgery, Neuro, vascular. It's never perfect intra vs extra cranial etc and even then it seems like it doesn't matter. They all just shrug.

This patient was doomed the second some idiot snapped his neck. Need to take the chiro for everything he's worth.

There is a major difference between an isolated dissection versus one associated with hemodynamic insufficiency or thromboembolism. One may not be a “big deal” and the other is a very “big deal”.

 

[nikolaite]

Ridiculous so it seems they went with the diagnosis of meningitis then went back and documented the info of a dissection.

The ED doc should have just sticked to what they originally documented

Also it often doesn’t matter what you document if you have a bad outcome and the patient suffers and they are sympathetic it might benefit you to settle.

Documentation makes a difference in blocking Med Board reviews that occur in the course of medmal cases. Even if you win or settle a civil case, the state AG office can choose to prosecute on Med Board or DHHS recommendation IF there are allegations of violations of state licensed practice laws and the record meets the standard of evidence. Further, the Med Board could act to control a doc’s license as well.

You’re never going to stop people from suing. It’s always best to settle. But documentation matters when you’re getting checked by your peers in a way that can affect your license.

 

[johnny_bananas]

Wait, so we've got both the neuro and the admin who lurk this forum to comment on this case? (Unsurprisingly taking a dump on the EM doc). We just need powerhouse resident to chime in to activate the Troll Triumvirate.

If you read my posts you would see that I am sympathetic to the ED physician, they appeared to have minimal support from the neurologist or radiologist, and my initial post was regarding the neurologists role. Did the ED physician make mistakes, yes they did, and mentioning those errors is not taking a “dumb” on them but trying to understand how certain small mistakes can add up and may lead to disastrous consequences. Like I alluded before, it is very surprising that the neurologist did not share the lion's share of culpability, the ED physician appropriately consulted the neurologist, who did not even examine the patient and blamed the ED physician for providing incorrect information when they should have taken their own history and reviewed the chart.