ER Failure to Dx and Treat Stroke Leads to Diminished Lifestyle

Case Overview:
Potential med mal claim involving a failure to give TPA in a 62 yo stroke patient at who presented to the ER at with stroke symptoms. TPA was ordered initially, and then the order was cancelled when the pt’s symptoms supposedly improved.

The theory is that the ER staff did not properly evaluate the patient and did not properly score him on the NIHSS. We have a neurologist who has reviewed the case and agrees with that theory. She feels that given the location of the stroke (pons), the patient had to have been exhibiting sensory problems, motor problems affecting the arm and leg, and likely some vision problems. In addition, our neurology expert feels that the patient was a candidate for TPA given that he wasn’t able to walk into the ER.

Case Summary:
Per the client’s wife: She last saw her husband normal at around 14:30. After that, they were on separate levels of the house until about 16:00. At around 16:00, he came upstairs and complained of numbness and tingling. His speech was slurred and he had R-sided weakness. She had him scoot down the steps, because he had difficulty walking. She helped him to the car. They put him on stretcher because he couldn’t stand when they got out of the care. He didn’t complain of dizziness, vertigo, or vision problems. She didn’t notice any drooling or abnormal eye movements. The wife claims that they were in the ER by 19:15. The only time they did a full assessment was when he was initially seen by the PA. After that, 2 nurses came in and did a cursory neuro exam, then said something like “Oh, yea, he’s doing a lot better”. The wife doesn’t feel that his condition significantly improved while he was in the ER and doesn’t know why they felt that it had.

Timeline from the records:

7/22/12 19:53 Triage Time – Complaint: possible stroke. BP 173/80, pulse 71, R.R. 16. O2 sats, 100% RA.

Physician exam (James Jones, M.D. – boarded intern med and ER) was not documented until 21:53, but was presumably done earlier. There is no mention of abnormal eye movements (eye exam WNL), visual deficits, drooling (denied), or complaints of dizziness or vertigo. NIHSS 4 given (1 each for RUE and RLE drift, 1 for minor facial drooping, 1 for dysarthria). It is noted that the wife last saw her husband normal at 16:30 pm, and this is noted several times.

20:05 – Head CT normal

20:20 – TPA (alteplase) .09 mg/kilogram IVP ordered as bolus over one minute. 0.81 mg/kilogram IVPB over one hour, total dose 0.9 mg/kilograms

20:26 – The records indicate that TPA was held because his symptoms were improving (NIHSS 2). It was noted by the attending that the neuro NP determined the NIHS score, but the neuro NP’s note is not included in the records provided. The pt was also seen by a neuro PA , and agreed to hold TPA. By midnight, the patient’s condition was still improving and his speech was “nearly back to normal”.

MRI (completed 22:20 – 00:42) – restricted diffusion L pons

Admitted to the ICU around 2 am.

MRA of the head and neck performed 7/23 showed no arterial stenosis, occlusion, or aneurysm.

7/26 neurology consult note indicates the pt was A&0x3, w/ slight dysarthria but no dysphagia, no CN deficits other than R facial upper motor neuron weakness, visual fields full, RUE 4-4+/5, RLE 4-4+/5, normal reflexes x 4 exts, some clumsiness in RUE on FTN, sensory intact to light touch, vibration, and temp bil.

7/29 DC – Pt was using a rolling walker and required steadying assist or contact guard w/ transfers; also needed steadying assist with stairs. He was DC’d with a home exercise program, PT, and OT project task management software.

Damages:

According to the wife, her husband can’t return to work because he cannot drive. He has residual RLE weakness and RUE weakness. He uses a cane for ambulation outside the home and sometimes needs it while at home. He developed a blood clot and phlebitis in his RLE, which also prevents him from driving. He can’t go anywhere by himself. He used to do all the cooking in the house and can’t do that any longer. His wife has to assist him with dressing and showering (he has a shower chair). He is on 7 different meds now, while he was on no medications before. She didn’t know the names, but they are for bladder incontinence, cholesterol, CHF, and the blood clot in his leg. His speech has almost returned to normal, but he still has some expressive aphasia. He also has a mild facial droop. He also has had mood changes, which she thinks are due to his inability to work and life his life like he used to. He was the manager of a retail store with a $80-100,000/yr gross annual income).

MEDQUEST EXPERT OPINIONS:
The documentation you supplied seems to show last time known to be normal to presentation was 2 hrs and 45 mins if not longer And improving NiH score. These would be things that could possibly support withholding tpa administration. However the neurologist score seems to say otherwise. Need to look at it to be sure.Dr KD – ER

The decision to give tPA is almost always the neurologist’s decision, so if anyone gets sued here, it should be ONLY the NEUROLOGIST consulting, not the ER doc. When I have a stroke pt at yale, I give tPA in consultation with the neurologist. If they say give it, I give it and if they say hold it, I hold it. That is why they are called to the bedside STAT when a stroke pt is en route to the hospital. In addition, the pt presented to the ER more than 3 hours after onset of symptoms. In the 3-4.5hour window, there is a lot of controversy about the indications and safety of giving tPA. There is a greater risk of intracranial hemorrhage AND less chance for positive effect, so unless the stroke score is really high, many pts who present in this window are not given tPA. And realize that he did not present til almost 3.5 hours, then one must take into acct that the initial workup to determine eligibility for tPA will take at least 30 minutes (hx, PE, labs, CT head), so he was going to be pushing even the 4.5 hour window. there was a lot of community education in detroit area about needing to go call 911 IMMEDIATELY if signs of a stroke, bc it is really impt that pts get to the hospital immediately in order to get in and worked up under the 3 hour window that is generally considered safe to give the tPA. Dr KJ – ER

The issue of tPA is always debatable. In this case, there are 2 factors which need addressing.
The first is the time of onset of stroke symptoms. Some hospitals have protocols which stick to a 3 hour window but others will allow a 4.5 hour window under certain circumstances. If we know his stroke symptoms started at 1800 then he was in the time frame to receive tPA within the 3 hour mark. However, if we don’t know the precise time when symptoms started (ie. he awoke from a nap with symptoms), we would have go with the 1630 onset time and this would put out of the 3 hour window and then we would have to know if the hospital protocol had provisions for a 4.5 hour window. The second issue is whether his symptoms improved in the ER. tPA is contra-indicated when the stroke symptoms are improving. If we find documentation of improvement, then it was reasonable not to give tPA.
Overall, this case warrants a close review of the ER notes and knowledge of the tPA protocol being used.
DR G.B – Neurologist