The Verdict Is In

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10:30 am: An otherwise healthy 28 y/o developed a mild headache, right arm numbness and difficulty speaking. His wife called 911 at 10:45 am. EMS activated a stroke alert, and the pt was assessed immediately upon arrival in the ambulance bay by the ED physician. Right arm numbness/weakness resolved before arrival. He was awake, alert, oriented and able to move and feel all extremities. He has a slight facial droop and expressive aphagia. No slurred speech. A Code Stroke was called at 11:17. NIHSS score by ED MD was 2 because of difficulty speaking and slight facial droop. He was sent immediately to CT from the ambulance bay. Per the suggestion of the nurse, a CTA was also entered as this was part of this hospital’s stroke protocol/checklist when 2 or more symptoms are present.

The radiologist called the ED MD and said the CT head was negative asking if they still wanted the CTA. With his low NIHSS score of 2, the ED MD deferred this decision to the neurologist who was just arriving to evaluate the pt. The ED MD entered the order to cancel the CTA because on exam there was no sign of large vessel occlusion. The neurologist evaluated the pt and indicated the symptoms were mild and he was not sure if the symptoms were due to a stroke. He ordered an MRI and carotid u/s. Pt was evaluated by the hospitalist in the ED at 13:00 who admitted the pt with "stroke protocol orders" to the stepdown unit. At this time pt was noted to have expressive aphagia, slurred speech, facial droop, drooling and difficulty swallowing his saliva.

Pt in the stepdown unit by 14:00. Symptoms progressed ….. delay in the MRI and despite being changed to STAT, the pt did not go for MRI until 1900. Pt was now only responsive to noxious stimuli. He returned from MRI obtunded without movement or response. He was intubated, and they initiated transfer to a higher level of care. Transfer receiving facility requested CTA prior to accepting the pt which showed total occlusion of the basilar artery shortly after its origination. After transfer the clot was successfully removed by thrombectomy, but the pt’s neurologic status did not improve. He suffered from locked-in syndrome and eventually the family chose to withdraw care.

Acute basilar artery occlusion (BAO) is an easily missed true neurological emergency. Early diagnosis and treatment are essential to prevent brainstem infarct and death.

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Survey Questions

1. In this case, the pt did not present with typical symptoms of BAO. What makes the diagnosis of BAO so difficult?

  1. The symptoms can be fluctuating
  2. The symptoms can mimic other non-stroke conditions
  3. They may have a long prodrome
  4. Assessment of the posterior fossa by non-contrast CT is difficult
  5. It is an uncommon condition representing only 1-4% of all ischemic strokes
  6. All the above

2. When a lawsuit happens, it is typical for everyone involved to be named. The hospital settled leaving the ED physician, radiologist, neurologist, and hospitalist as defendants. In this case, the ED physician relied upon the specialized opinions of the radiologist and neurologist. What were the plaintiff's experts critical of when reviewing the care of the ED physician?

  1. Delay in calling a Code Stroke
  2. Deferring from the hospital protocol and cancelling the CTA
  3. Nothing. The ER physician was dismissed

3. The Mutual is seeing more stroke related malpractice claims in young patients than we did 5-10 years. Why is this?

  1. More young people are having strokes
  2. Diet
  3. The public now expects we have a treatment (tPA) to "cure" stroke symptoms. This was not the case 10 years ago

The Previous "Verdict Is In"

The results of the prior installment of "The Verdict Is In" are below. The case can be viewed here. Congratulations to Dr. Renee Brown from Sutter Davis (Davis, CA) who won last quarter's raffle!

1. ED Expert opinions were supportive but felt there would be challenges to the defense. The records from both visits were templated and therefore the expert felt their documents did not reflect the reality of the true physical exam. ED visit 1 does not document a motor and sensory exam. ED visit 2 also had a limited neuro exam. Neither chart had a good MDM. What else in the documentation was a problem for the defense?

  1. It was never documented the patient demonstrated ability to walk. In every back pain case, it is important to document either in the exam and/or the ED course the patient can ambulate.
  2. The discrepancy between the physician and nursing note on visit #2. It is wise to read nursing notes and if there is a discrepancy it should be addressed.
  3. Both of the above.

2. Upwards of 90% of low back pain presentations in the ED are due to benign causes. However, there are several important life/limb threatening diagnoses we must consider in the low back pain patient, and some of these diagnoses are easy to miss. There are numerous red flags of back pain and we encourage you to refresh yourselves on them. What red flag should have triggered the physician on the second visit to consider imaging?

  1. Age < 18 or > 60.
  2. Symptoms of or history of cancer.
  3. IVDU, previous spinal interventions, recent infections.
  4. Hx of trauma or coagulopathy.
  5. GU dysfunction, saddle paresthesia.
  6. Bilateral leg symptoms.
  7. Fever.

3. Anchoring bias is the term used to describe the mental error of maintaining one's initial impression despite evidence pointing to the contrary. (Wellerby C. Flaws in clinical reasoning: a common cause of diagnostic error. Am Fam Physician. 2011;84(9):1042-1048). In this case, the providers heard “worker’s comp injury”, “prior back pain”, “chronic pain” and anchored. They neglected to address this was different and associated with difficulty walking, weakness, and (on the 2nd visit) numbness. How do we combat anchoring bias?

  1. Limit words that introduce bias such as frequent flyer, crazy, drug-seeker, malingerer.
  2. Take a cognitive pause when the clinical exam does not correlate with other data.
  3. Force yourself to think of alternative diagnoses when you gather new information.
  4. Understand that unexpected returns are high risk and warrant extra time to think of what might have been overlooked.
  5. All the above