Allegation:
Failure to timely assess and administer tPA resulted in ischemic stroke with residual deficits
The Case:
A 60 YOF (5’4”, 150 lbs.) presented to the ED at 20:43 with complaints of right upper arm weakness, difficulty standing and walking, and impaired speech. Her BP upon presentation was 190/115. Her past medical history was significant for HTN, TIA, uterine sarcoma stage I with lung metastasis, and lobectomy with radiation therapy.
The ED physician’s exam revealed weak muscle strength of all four extremities, bilateral upper extremity drift, and abnormal sensation to the right side of her face. The patient was alert, oriented, and ambulated without a device. Her speech was impaired. A head CT without contrast noted mild volume loss, and small vessel white matter ischemic changes; no intracranial hemorrhage was detected. Her repeat BP 15 minutes after presenting was 178/105, and she was given IV Labetalol. Forty-five minutes later, the ED physician noted her upper extremity strength was slightly better since she was able to raise her arm, but the drift remained. His initial clinical impression was CVA/stroke.
The ED physician discussed the case with the defendant neurologist and the hospitalist. The hospitalist’s exam revealed improved symptoms, and that the patient’s speech was almost back to normal. The patient was able to move all extremities. Her BP remained at 163/98. Another dose of IV Labetalol was given along with Plavix®.
The patient was admitted to the neurology floor with stroke protocol orders, which included carotid Doppler, MRI of the brain, and echocardiogram. The hospitalist, as the attending physician, signed off on Ischemic Stroke Admission Orders-no tPA. These orders included a form titled Reasons for Not Administering IV tPA, to which the hospitalist checked the box marked SBP>185 or DBP>110 mmHg despite treatment. Nursing orders included vital signs and neuro checks every two hours for 24 hours. At 23:20, nursing noted neuro signs were intact, and that the patient could lift her right arm and make a fist. Her speech was clear and vision was normal; BP was 157/104.
At 01:00, the nurse documented that the patient was holding her right leg in a bent position and complaining of leg cramping. The patient could move her right upper extremity, and stated she felt very tired. Her speech was still clear; BP 163/95. Two hours later, the patient reported she could not move her right hand or arm on command. She could lift her right leg but it drifted back to the bed. There was obvious drift of the right upper extremity. Her BP was now 158/100. Nursing notified the defendant neurologist of the symptoms. He did not provide any new orders.
The defendant neurologist examined the patient at 07:00, and noted the patient had no movement of the right arm with decreased tone. The patient’s right toes had minimal movement. She had slightly decreased reflexes on the right compared to the left. He documented her diagnosis as probable small vessel lacunar infarction on the left. The MRI of the brain noted some chronic small vessel disease but no evidence of hemorrhage or acute abnormality. By the next day, the defendant neurologist made a final diagnosis of acute subcortical left frontal infarct. Treatment focused on control of HTN, PT, OT, and ST.
By day five, the patient’s right facial droop was almost resolved; she was able to move her right arm and leg off a chair and hold for several seconds. She was discharged to an inpatient rehabilitation facility prior to returning home. Over the next several years, her treatment course included outpatient rehabilitation, and BOTOX® injections for right hand and leg spasticity. Eventually, she progressed to using an ankle-foot orthotic (AFO), and ambulating without a device. She sued the defendant neurologist for failure to timely institute tPA, which resulted in ischemic stroke and residual deficits.
The plaintiff’s expert, a board certified neurologist, testified the patient was a candidate for tPA since she did not have a complete return to baseline of her symptoms. He also stated the standard of care required one-hour neuro checks. He was critical of the defendant neurologist for not seeing the patient in the ED, and at 03:00 when nursing notified him of the changes in the patient’s condition.
The defense argued that when the patient presented to the ED she was not a candidate for IV thrombolytic therapy because her symptoms were improving rapidly and significantly, and she had presented with minimal deficits. The defendant neurologist and hospitalist testified that the decision to not provide tPA occurred in the ED when her symptoms were resolving, and elevated BP had responded to IV Labetalol.
Verdict:
The case went to the jury and they returned a defense verdict.
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