Medical-Legal Review, Inc.

Case Studies

Medical-Legal Review, Inc

Medical-Legal Review, Inc. has found that in most meritorious medical negligence cases the mistake is not one of commission, but one of omission. Usually it is a case of not proceeding aggressively enough to find a diagnosis, thus delaying treatment and causing irreparable damage to the patient.

Case Study

A 37-year-old female with a long history of classic migraine headaches was seen in the emergency room of a large community hospital at 11:30 in the evening complaining of “the worst headache I have ever had”. Further, she stated that this particular headache, which had come on rather suddenly, was not similar to the pain of the previously diagnosed migraine headaches. This particular headache had come on about a half hour prior to her emergency room visit. She was brought in by her husband and waited approximately one hour and a half in the waiting room before being brought into a room and examined by an ER physician.

She gave a history of the sudden onset of a generalized headache, more severe than any previous headaches, but she had no other symptoms: no photophobia, no difficulty with cognitive function and no nausea or vomiting.

Examination showed no neurologic deficit. There was some mild nuchal rigidity, but no pain on anterior flexion of the cervical spine.

The examination was concluded at approximately 2 o’clock in the morning, and the patient was admitted with a diagnosis of headache of unknown cause, possible subarachnoid hemorrhage, and a CT scan was ordered for the morning.

The CT scan was carried out at approximately 2:30 in the afternoon, and interpreted by the radiologist at 4 p.m. He felt that the patient’s CT showed evidence of subarachnoid hemorrhage and called the patient’s internist to whose service she had been admitted. The internist then contacted a neurological surgeon who saw the patient at approximately 5:30 and ordered four-vessel angiography.

At approximately 6:30, the patient was on her way to the angiographic suite when she suffered another episode of severe headache and, within minutes, her condition rapidly deteriorated to the point that she was unresponsive to verbal stimuli and showed posturing in response to painful stimuli. Her pupils were dilated and fixed. Prior to the onset of the last episode of headache, she was a Hunt-Hess Grade 1, and after the episode was a Hunt-Hess Grade 5.

Nonetheless, the angiogram was carried out and communicating artery aneurysm with massive subarachnoid hemorrhage and rupture into the anterior ventricular system. There was thought to be some extravasation of dye from the aneurysm, although this could not be confirmed.

The patient had been intubated prior to the angiogram and, subsequently, was placed on an aggressive program of conservative care including appropriate doses of Mannitol and intraventricular drainage (the opening ventricular pressure was 20).

She expired at 10:30 on the day after admission.

Why did the Medical-Legal Review panel find this case to be meritorious? There was absolutely an unacceptable delay in the diagnosis of a subarachnoid hemorrhage in this case. As soon as such a diagnosis was entertained, either a spinal fluid examination or a CT scan should have been done immediately. The subarachnoid hemorrhage from the first episode would have been found. At that time, an angiogram would have been done, the aneurysm found and surgical intervention carried out. The surgical mortality for a Grade 1 aneurysm is less than 15%. This is compared to the mortality of a second aneurysmal subarachnoid hemorrhage which is over 50%.

This case went to trial and the jury returned a verdict against both the ER physician and the internist, who was the patient’s personal physician onto whose service she was admitted.