Allegation
A failure to appropriately follow Lovenox protocol, administering too high of a dose, and starting the dose too early resulted in a subdural hematoma that led to a patient’s permanent disability.
Case Details
A 58 YOF (5’ 2”, 144 lbs.) presented to the defendant cardiologist with a history of hyperlipidemia and HTN, upon referral by her PCP. Her surgical history included ventricular septal defect (VSD) repair at age 6, repairs of ascending thoracic aortic aneurysm, and aortic valve replacement with a mechanical valve at age 42.
The patient presented with atypical chest discomfort. A baseline EKG demonstrated sinus rhythm at 65 beats per minute and a right bundle branch block. Cardiac risk factors noted obesity, a sedentary lifestyle, and postmenopausal female, but her BP was 130/80 and SaO2 99%. The defendant cardiologist recommended a noninvasive assessment, including an echocardiogram and a pharmacologic stress test with a follow-up visit after these tests.
Six days later, the patient underwent a nuclear chemical stress myocardial perfusion study with SPECT ordered for abnormal EKG. The conclusions noted small, predominantly fixed, apical defect suggestive of scar or apical artifact. There was ST segment depression in the infero lateral leads, 0.5-1.0 mm, septal dyskinesis, and ejection fraction 65%.
Two days after the myocardial perfusion study, the patient underwent an echocardiogram and the interpretation noted VSD repair. There was mild concentric left ventricular hypertrophy. Septal motion was consistent with postoperative state. Ejection fraction was 60-65%. The left ventricle was normal in size, and the right ventricle was normal in size and function.
The defendant cardiologist saw the patient one month after the initial visit, noting the stress test demonstrated an area of predominantly fixed perfusion defect in the apical territory that suggested a scar or apical defect. The EKG potion of the test was abnormal under pharmacological stimulation with 1 mm of ST segment depression. The patient was having episodes of chest discomfort highly suggestive for angina pectoris. The defendant recommended a cardiac catheterization and angiography. The patient was instructed to manage her anticoagulation with Lovenox 100 mg/mL subcutaneous syringe with one syringe two times daily. The defendant discussed indications, contraindications, and alternatives, and the patient agreed with the recommendation.
Later that month, the patient presented to the hospital for cardiac catheterization and angiography. She complained of head pain of 5/10 due to nausea that began the day before. There were no complications noted, and the patient had a normal sinus EKG post-procedure. The procedure report noted non-obstructive CAD, mid- to distal-LAD myocardial bridging. The patient added a low-dose beta-blocker to her medications.
The defendant ordered strict bed rest for two hours along with checking vitals frequently. The patient’s prescriptions included Lovenox and Coumadin; however, the note appeared to be incomplete. Throughout the morning, the patient reported moderate head pain and bilateral aching. A CRNP noted the patient complained of headache that began one day prior with nausea.
The patient’s pain continued to increase from 6/10 to 7/10. She had a STAT CT of her head. The results suggested a small acute subdural hematoma in right frontal and temporal lobe that was reported to the defendant as a critical value. Axial CT images of brain showed artifact requiring a repeat study. A comparison with a prior CT showed subtle loss of sulci in the right frontal lobe and increased density peripherally in right frontal and temporal lobes extending to anterior cranial fossa. There was no evidence of mid-line shift, or mass effect on the ventricular system.
By the afternoon, the defendant cardiologist certified the patient was stable for transport; her pain was 2/10 with bilateral aching. The patient was air transported to another hospital that evening with no changes to her neurological status. The next day, she had a repeat head CT showing no significant interval change in the supratentorial and infratentorial subdural hematomas. An MRI of the brain and an MRI angiogram of head indicated late acute to subacute subdural hematoma along the right cerebral hemisphere in the right posterior fossa with regional mass effect without hydrocephalus; other indications were scattered punctate microhemorrhages in the bilateral cerebral hemispheres and posterior fossa.
The patient was discharged the following day. In the discharge summary, the neurosurgeon noted he related the microhemorrhages on MRI brain and angiogram to a combination of amyloid angiopathy and/or HTN despite patient’s age. Four days later, a head CT noted very small focus of residual subdural hemorrhage overlying the inferior right frontal convexity. Mild asymmetric density along the right cerebellar tentorium likely represented redistribution of subdural blood product, but no evidence of new or active bleeding, mid-line shift, or mass effect.
The patient followed up with her PCP a few days later. His impression indicated the subdural hematoma was resolving. The patient followed up three weeks later and reported intermittent headaches, sleep disruption, and increased anxiety. She was diagnosed with PTSD and insomnia.
One month after the initial CT, an updated head CT indicated the right subdural collection seen previously had resolved. The patient reported emotional issues, exhaustion from return to work, and improved headaches. The PCP’s assessment included traumatic and/or non-traumatic brain injury. The patient continued to report headaches, insomnia, and fatigue at her regular visits.
Expert Testimony
Plaintiff experts believed the defendant cardiologist prescribed an excessive dose of Lovenox that led to subdural hematomas. However, the defense experts believed the patient was a good candidate for the catheterization and the treatment was reasonable. Further defense testimony illustrated that there was no medical literature to support that a lower level of Lovenox would have resulted in the patient not having a bleed.
Resolution
The jury returned a defense verdict in favor of the cardiologist.
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