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Missed Diagnosis, Follow-Up Leads to Neurologic Brain Damage, and Legal  Settlement

A 52-year-old man was brought to the emergency room after a seizure like episode, loss of consciousness and incontinence. Although he had clear signs that required further investigation into his heart health, his doctors failed to obtain the required examination. Instead, he was sent home without treatment for his heart condition. As a result he suffered a heart attack and brain damage several months later.

The man had a distant history of alcohol and cocaine use, Hepatitis C, and traumatic brain injury (TBI) after falling off a ladder eight years prior. He was an athletic non-smoker with no history of elevated cholesterol. His recorded family history was significant in that his father died at age 42 of a sudden cardiac arrest.

In the ED, his vital signs, a chest X-ray, and brain CT were normal. Several EKGs and biomarkers were done. During this time the patient had another seizure like episode, was treated with Ativan and Dilantin, and was admitted.

At his family’s request, the patient was transferred the next day to a tertiary facility. The transfer summary indicated the diagnosis of new onset seizures and that a new intracranial process should be ruled-out. It also recommended an outpatient stress test and fasting lipid profile because of an elevated troponin level, suggesting underlying coronary artery disease.

After two days, the patient was discharged from the tertiary hospital with instructions to continue the Dilantin and aspirin; there was no record of a cardiac exam or instructions to seek one.

One year later, the patient was readmitted to the tertiary hospital for a fever. He underwent a battery of tests, including an EKG, revealing non-specific T wave abnormalities, suggestive of ischemia. The second-year resident reviewed the results with his senior resident and they agreed that a cardiac consult was not indicated.

Four days later, the patient was discharged. His fever was thought to be due to an allergic reaction to his Dilantin, which was changed to Keppra.

Within 10 months, the patient noted that his stuttering was getting worse, so he was electively admitted to the hospital for long- term video monitoring of his seizure activity.

Upon admission, an EKG showed a new T wave inversion, which is typically a sign of heart attack. Serial isoenzymes were ordered. Nearly 12 hours later, the nurse noted that the patient’s SAO2 or blood oxygenation level, dropped to the dangerous level of 74 percent and that he was unresponsive. During intubation, the patient lost his pulse. After a prolonged effort, the patient was resuscitated and transferred to the ICU.

The patient sued six internal medicine attending and resident physicians, six neurology attending and resident physicians, and one attending ED physician. The primary allegation was that the physicians negligently failed to obtain a cardiology consult when the patient first presented to the ED with evident underlying CAD.

This case settled for more than $1 million against two neurology residents and an attending neurologist.

These factors lead to the successful medical malpractice claim:

• Doctors did not address the EKG changes and elevated troponin, which are signs that further investigation into the man’s heart health was required. The presence of unexplained test results associated with a dangerous illness always calls for seeking more information or considering a consultation.
• The tertiary hospital’s doctors blindly followed the previous diagnosis of seizure disorder. Their failure to reassess the man’s condition and lab results prevented them from making the correct diagnosis. Because they presumed the previous diagnosis was correct, they did not respond properly to the man’s abnormal test results.
• In the transfer from the community hospital, no one followed up on the ED physician’s recommendation for a cardiac work-up, which was based on his elevated troponin level, suggesting underlying coronary artery disease. All providers who hand off or receive a patient (or information about the patient) have an obligation to do so carefully — so that important facts are not missed.
• The patient was not told he needed follow-up testing (outpatient stress test and fasting lipid profile). Patients who are told of abnormal findings can help ensure necessary follow-up with their providers. Recommendations for follow-up should be prominently displayed in the medical record, either on the problem list or in the MD notes, to prompt providers to probe and remind patients about the recommended action.
• When the patient required CPR during his third admission, a delay in treatment resulted from a failure to quickly recognize the situation, promptly notify the code team, and immediately begin ventilation.

For more on patient safety issues, see the library of articles by Daytona Beach medical malpractice attorney.





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