Allegation:
The defendant radiologist’s failure to recognize a subdural hematoma resulted in the patient’s death and subsequent settlement of the case.
The Case:
A 77-YOF (5’3”, 185 lbs.) presented to the ED at 8:40 a.m. with a head laceration after a fall. She had also sustained injuries to her left wrist, left shoulder, and left arm. The patient was on the oral anticoagulant, Warfarin® 5 mg.
INR/PT/PTT were drawn at 10:35 a.m. and reported at 6:57 p.m., indicating an INR of 3.2. An INR range of 2.0-3.0 is generally an effective therapeutic range for people taking Warfarin. The patient’s PT was 35.6 (9.0-11.6) and PTT was 35.9 (55-75). X-rays were obtained along with a head CT and a maxillofacial CT scan. The patient reported she was also taking amlodipine 5 mg, lisinopril, mirtazapine 15 mg, simvastatin 80 mg, and zonisamide 50 mg.
The defendant radiologist read the x-rays for the wrist, shoulder, and humerus and identified no acute fractures. The same defendant radiologist read the head CT scan and compared it to one obtained five months earlier. There was no sinus disease or fractures. TM joints were intact and there was no midline shift. The ventricles and sulci were diffusely prominent, indicating diffuse atrophy with no extra-axial collections or intracranial hemorrhage with no mass effects or hydrocephalus. Microangiopathic changes in the periventricular areas were similar to the prior study. The defendant radiologist’s impressions were that current and previous scans showed similar atrophy and microangiopathy type changes with no intracranial hemorrhage found.
The maxillofacial CT scans had no older CT scan for comparison. Similar to the head CT scans, the maxillofacial scans showed atrophy in the brain with globes intact with no retro-orbital hematomas. Soft tissue swelling was also visible over the left cheek and periorbital area with a questionable laceration. The scans showed the cervical spine intact with intact zygoma and TM joints.
The patient was discharged from the ED at 11:29 a.m. with a diagnosis of contusion of the head and wrist. She was given a prescription for Tylenol® No. 3 TID PRN.
The following evening at 11:26 p.m., approximately 36 hours after discharge, the patient experienced projectile vomiting and became unresponsive. EMS intubated the patient and transported her to the same local ED she went to the day before. The patient remained unresponsive on arrival to the ED and was re-intubated.
The head CT obtained and read within 17 minutes of arrival showed that an extensive subdural hematoma over the left hemisphere contributed to marked effacement of the sulci and considerable left to right shift. There was effacement of the suprasellar cistern compatible with uncal herniation. The radiologist also noted a slight amount of central pontine increased density may represent some intraparenchymal hemorrhage. The scan also showed developing dilation of the right lateral ventricle secondary to obstruction of the aqueduct.
A chest x-ray indicated respiratory failure. The family verified the last known awake time for the patient as approximately 12 hours after the initial discharge from the ED, 24 hours prior to being found unresponsive.
The patient was transferred to a tertiary hospital by ambulance the next day. A medical transport flight was requested and denied twice due to adverse weather conditions. The patient was evaluated by a neurosurgeon and noted to be comatose with no response to noxious stimuli or to voice. The vascular neurosurgeon reviewed imaging and declared the patient brain dead and deceased.
A board certified emergency medicine physician stated the ED physician (who was not named in the lawsuit) breached the standard of care when he did not admit the patient for observation of neurological changes and consideration of reversal medications for the anticoagulant Warfarin. The plaintiff retained a board-certified radiologist who alleged the defendant radiologist failed to recognize the subdural hematoma on the original presenting CT. The patient’s subsequent treating physician also agreed to testify on behalf of the plaintiff.
Four board certified radiologists retained by the defense reviewed the case and concluded the subdural hematoma was visible on the first presenting CT read by the defendant radiologist.
Resolution:
The case was settled in mediation.
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