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MEDICAL OPINIONS ASSOCIATES, INC.
CASE SUMMARY
THE FOLLOWING SUMARIZES AN ACTUAL MEDICAL MALPRACTICE CASE REVIEWED FOR PLAINTIFF’S ATTORNEY BY MEDICAL OPINIONS ASSOCIATES.
CASE SUMMARY 4 – NOVEMBER 2006
Background
Mr. L (a 39-year old) went to see his family physician with complaints of feeling tired and a ringing in the ears. The treating physician felt that he had an ear infection, but noted that Mr. L had urethra surgery six months earlier and was having difficulty with frequent urination. Mr. L thought he might be diabetic.
About one year later, Mr. L was again seen by the same doctor with reports of both ears bothering him for more than two weeks and a question of an ear infection. He also had a cold and some congestion. He asked his doctor to check for diabetes due to a family history. The doctor did check for diabetes and gave him a prescription for an ear infection.
About one month later, he presented again to the same doctor with reported severe pain in his right lower quadrant for the past few days, with the occasional pain being very sharp. The doctor thought it might be appendicitis and sent him to see a surgeon who had him admitted. The appendectomy was performed and Mr. L felt good for a short period and then began to feel bad again. The surgeon was called and the Mr. L reported having pus in his urine and reported a history of kidney infection. Mr. L was again admitted to the hospital and was diagnosed as having a febrile episode secondary to right pyelonephritis and abscess. He also developed malignant hypothermia during this episode.
The attorney seeks an opinion on behalf of the recovered plaintiff as to whether the treating physicians should have caught the problem earlier and whether or not the problems that manifested at the last hospitalization should have been diagnosed earlier.
Reviewing Expert
The reviewing expert, who is Board-certified in both Internal Medicine and Geriatric Medicine, is in active clinical practice and on the faculty of a Midwestern Hospital.
Conclusions
The physician expert did not find indications of medical negligence in the care rendered.
He notes that Mr. L did in fact experience appendicitis, as confirmed by pathology. Also, the stress of this condition on the system commonly results in minor abnormalities such as a minimal amount of protein in the urine. The earlier urinalyses showed only trace proteinuria and were essentially normal, with no evidence of any infection.
The urinalysis at the last hospitalization clearly showed urinary tract infection that developed between the time of the next to last and last hospital episodes. However, with two unremarkable urinalyses two weeks before, the treating doctor was not in violation of any standard of care by not rechecking, even with some urgency with urination indicated.
CASE SUMMARY 3 – FEBRUARY 2006
Background
The plaintiff in this nursing care case was an elderly man who was being observed for TIA’s (trans ischemic attacks – AKA minor strokes). The claim was against the hospital where observation had been underway. He was confused and told not to travel to the bathroom alone. When he could not reach a nurse during the night to accompany him to the bathroom, he climbed over the rail, fell, and broke his hip. The attorney sought an expert nursing review in support of a nursing malpractice case against the hospital.
Reviewing Expert
The medical records were reviewed by a nursing expert with Medical/Surgical Nurse (MSN), Registered Nurse (RN), and Critical Care Nurse (CCN) clinical qualifications. He is also a nursing educator at an Ohio University.
Findings
Subject to confirmation from review of additional medical records, the nursing expert concluded that the nursing care provided fell below the standard of care required. The expert concluded that the nurses in charge of plaintiff’s care had a duty to assess his physical and mental status, identify his potential risk for injury, and provide for his safety.
Following accepted standards of nursing care would have meant providing and ongoing assessments of his potential for falls, implementing nursing measures to ensure his safety, and evaluating their effectiveness. Because the subject was 81 years old, had a history of TIA’s, and an evolving stroke, the nurses caring for him should have been especially vigilant in protecting him from injury.
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Despite the nursing expert’s finding of negligence, the plaintiff’s attorney decided that damages were not substantial and did not pursue the case further.
CASE SUMMARY 2 - November 2005
BACKGROUND
Mr. S, a male of 39 years, was involved in an altercation and was struck in the back of the head, fell forward, and hit an object on a table. The city fire department ambulance came to the scene and its reports indicated that the patient complained of head pain and on the report section entitled “presumptive diagnosis”, it states “complication from head injury”. The ambulance call report also indicated positive nausea and positive photo phobia with weakness. Importantly, the call report also indicates “possible subdural hematoma” with an indication that even though the patient denies loss of consciousness, witnesses state that there was loss of consciousness.
The face sheet history of the XYZ Hospital Emergency Room states that there was no loss of consciousness and there is no reference to the witnesses' statement that there was loss of consciousness. The examining physician appeared to give little credibility to the extensive nature of the head injury and characterized the injury as “low risk”. The procedures performed involved suturing of the face and head lacerations. After a lengthy delay, the patient left the Emergency Room and the physician’s note indicated the lack of need for follow-up.
Several days later, the patient returned to the XYZ Hospital ER. The ensuing CT scan showed significant brain injury and head injury which resulted in brain death.
The attorney claimed that the ER treatment was inadequate and incomplete. In addition to faulting the ER staff for discounting the ambulance reports and ignoring reports of loss of consciousness, he cited the lack of a CT scan at the first ER visit that might have detected the injury, thus preventing the timely diagnosis that could have resulted in life-saving medical procedures.
REVIEWING EXPERT
The medical records were reviewed by a Board-certified expert in Emergency Medicine who is a practicing ER physician in a major urban hospital.
FINDINGS AND CONCLUSIONS
According to the reviewing expert, the patient presented with the following: history of liver problems; history of recent alcohol ingestion; history of head trauma; laceration of the upper lip and occiput, plus a so-called “coup contra coup” head injury; and EMS history of loss of consciousness documented by witness. The appropriate evaluation of such head trauma requires a good neurological examination. No such examination was performed. A blood alcohol level would have been appropriate along with a period of observation, as was planned.
Further, the intoxicated patient with a history of head trauma, no matter how seemingly trivial, must have a CT scan of the head. The patient gave a history of liver problems. Alcoholics are known to be at high risk for intracranial bleeds from even relatively mild trauma.
The patient died of intracranial hemorrhage as a result of the treating physicians’
• Failure to do an appropriate neurological examination;
• Failure to appreciate that alcoholics are at increased risk for intracranial bleeding;
• Failure to note “coup contra coup” injury, suggesting serious injury to the head;
• Failure to get a CT scan of the brain;
• Failure to call patient’s home and advise return for evaluation;
• Failure to obtain history of witnessed loss of consciousness from EMS record.
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The parties to the litigation reached a negotiated settlement before trial
CASE SUMMARY 1
BACKGROUND
On 3/25/03, while traveling in Michigan, Mr. B developed a right-sided headache and left-sided weakness, with paresthesia (tingling, burning, etc.). There was some ensuing difficulty with spatial orientation such that Mr. B had trouble finding his hotel room. He sought treatment at XYZ Medical Center and was seen by Dr. C. Right-sided headache and left-sided weakness were documented in the chart and a head CT scan was obtained. The scan was normal. A tentative diagnosis of “acute cerebral spasm” was made and Mr. B was treated with Tylenol plus codeine. At discharge from the emergency room, he was given a prescription for Tylenol with codeine.
He returned to his home city and sought further care for persistent headache and worsening left-sided weakness. After a brief evaluation at ABC Hospital, he was admitted on 3/26/03. A neurological consult on 3/26/03 showed 3/5 muscle strength on the left. A dense left homonymous inferior quadrantanopsia developed (focused visual impairment). An evaluation by head MRI/MRA and cerebral angiogram documented a dissection of the right proximal carotid artery and several right frontal and parietal infarcts. Mr. B received anticoagulation with heparin and then coumadin. The left-sided weakness largely resolved, although some left-sided un-coordination and the visual field deficit persisted. There is no careful documentation of the presence or absence of any changes in cognitive performance associated with the strokes.
No further cerebrovascular accidents are reported after 3/26/03, when anticoagulation was initiated. Several months later, follow-up carotid ultrasound showed resolution of the dissection. No cause for the carotid artery dissection was identified.
REVIEWING EXPERT
The physician expert in this case is Board-certified in Neurology, with particular expertise in adult neurology.
FINDINGS AND CONCLUSIONS
In the opinion of the reviewing medical expert, the care Mr. B received at XYZ Medical Center from Dr. C was negligent and fell far below the standard of care appropriate for emergency evaluation of a patient with focal symptoms and headache. In particular, no neurologic consultation was obtained and no diagnostic evaluation of the carotid arteries was completed. Instead, a head CT was obtained and narcotic pain medicine was prescribed.
The appropriate therapy for this carotid dissection, anticoagulation therapy, was not initiated in a timely fashion. The appropriate diagnostic studies were performed at ABC Hospital and the appropriate therapy was initiated there.
The failure of Dr. C and XYZ Medical Center to provide the appropriate care was a significant factor in Mr. B’s injuries. It is more than likely that timely anticoagulation therapy could have prevented the indicated cerebral infarctions between 3/25/03 and 3/26/03.
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