The management of stroke patients has evolved with sophisticated treatments capable of reversing brain tissue damage and even preventing future strokes. These advancements bring an evidence based set of medical pathways providing a clear standard of care. Meeting the standard of care and proper treatment of a stroke puts the patient in a position for the best outcome. However, missing a stroke diagnosis can have harrowing consequences of long-term disability potentially leading to a lawsuit. As common a diagnosis as stroke is, it is still misdiagnosed and overlooked.
Take for the example the case I have illustrated below. It’s the true story of a woman who woke up in the middle of the night to go to the bathroom but fell. With weakness in her left leg and a growing sense of numbness she called 911. I present the medical history of the patient, the care that should be provided and the how a deviation from the norm will leave the patient disabled and the doctor open for a law suit. Let’s see how her situation evolved.
Downplaying Serious Neurologic symptoms
A 57-year-old female was brought in by ambulance to the Emergency Department (ED) at 3:30am for numbness in both feet, weakness in her left hand and left lower extremity. She states she woke up to go to the bathroom and fell because she could not stand or walk. She has a history of diabetes, hypertension and hyperlipidemia. However, she was in her normal state of health when she went to bed that night.
Immediately she was evaluated in the ED, her labs were drawn, an EKG was done and a non-contrast head CT was performed. Her labs were unremarkable and her EKG had no acute findings. Her head CT revealed no acute hemorrhage and there was no increase in intracranial pressure. However, there were findings of a recent stroke.
After the results were complete, the Emergency physician gave the diagnosis of diabetic peripheral neuropathy. Because she could not walk she was admitted under observation with monitoring to the medical team. The rehabilitation service was consulted for her inability to walk. It was noted that she could not ambulate with a walker.
While under observation the patient and her family requested to be seen by a neurologist. There were issues with urgent availability of a neurologist; and the neurologist did not evaluate the patient until more than 48 hours after the patient arrived to the ED. When the neurologist evaluated the patient she had a very high suspicion of a stroke. She ordered an MRI of brain tissue and blood vessels of her brain. The MRIs revealed two acute infarcts and blockage of a branch of the vertebral artery of the brain. She was diagnosed with a CVA/stroke and had a regimen of aspirin and clopidogrel started.
In the end, this patient did not have any improvement of strength in her lower extremities and required 24-hour care at home for her activities of daily living. A misdiagnosis of stroke and a delay in evaluation and treatment of significant neurological symptoms by stroke specialists is a breach of the standard of care. It ultimately puts the patient at a disadvantage with chances of permanent disability. This is why stroke the leading cause of long-term disability in the US.
Is This A Medical Diagnostic Error?
In emergency medicine, the most life-threatening diagnosis is considered first for a set of symptoms. Then with evidence or reasoning you can work down to less life threatening diagnosis. However, this is only when the more serious ones are ruled out.
When a patient presents the symptom of sudden weakness on one side of the body and has multiple risk factors for stroke (such as diabetes, hypertension and hyperlipidemia with this patient) a stroke diagnosis should be presumed until proven otherwise. These are classic symptoms of a stroke and do not fit with the presentation of diabetic peripheral neuropathy.
The patient is already a high risk candidate for a stroke and her CT scan revealed an age indeterminate stroke. These facts would put stroke at the top of the differential diagnosis. They would prompt an urgent evaluation by a neurologist for further work up of the patient’s weakness in her legs and arm.
On the contrary, diabetic peripheral neuropathy is a slowly progressive sensory loss; such as numbness, burning and pain that starts in the feet. As the syndrome progresses over months or years mild weakness of the lower legs and hand symptoms may begin. This patient’s presentation of abrupt onset of lower extremity weakness and her inability to walk is worrisome for a stroke. It is not peripheral neuropathy.
Standard of Care Protocol Equals Lowered Risk of Malpractice
These are the elements that must be addressed in order to meet the standard of care for a suspected stroke in this scenario:
In addition to thrombolytics, other immediate treatments to help prevent worsening of the damage include antiplatelet medication, blood pressure and blood glucose control. And in some situations, patients can be candidates for vascular interventions to clear the clot in the brain. This patient’s stroke treatment started two days after arriving to the ED. During this time more irreversible brain tissue damage can occur.
This patient should have been admitted to a stroke unit. Mounting evidence suggests that patients with acute stroke have better outcomes when admitted to a hospital unit that is specialized to the care of patients with all types of strokes. A stroke unit includes a ward with dedicated telemetry beds. These are continuously staffed by a team of physicians, nurses and other personnel who specialize in stroke care. Additionally, prompt availability of specialized neuroimaging by CT, MRI or angiography are components of a stroke unit. Compared with conventional ward care, stroke unit care is associated with reduced probability of death and being disabled.
Just like a “time is of the essence” clause in contracts, in medicine there is a saying of “time is brain”. Therefore, after a stroke occurs, the longer there is decreased blood flow to brain tissue, less and less brain tissue will be left viable leading to increased chances of permanent disability.
