Medical Malpractice Insights: Teens can have strokes too.

Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

Chuck Pilcher MD FACEP

Editor, Med Mal Insights

Teens can have strokes too.

16-year-old female with sudden unilateral paralysis is partially paralyzed for life. Was cervical artery dissection considered?

Facts: A 16-year-old female presents to the ED only 30 minutes after noticing sudden loss of left sided motor function with “numbness.” Past medical history is remarkable only for occasional headaches and “numbness” in her L arm over the past few weeks. She has an appointment with her PCP in 4 days to address her earlier headaches and numbness. The physical exam states only that “the L arm is tucked to her chest with the hand clenched.” Gait is not documented. A head CT is normal. The patient improves during the visit and is discharged to see her PCP as planned in 4 days. Discharge dx is “”numbness” and “weakness” L side. She suffers a stroke a few hours after discharge due to a carotid artery dissection. She is left with a L hemiplegia and is unable to perform many basic ADL’s. An attorney is consulted and a lawsuit filed against the ED physician. Plaintiff: I was having a major TIA. You didn’t do anything except tell me I did not have a stroke. A normal CT scan does not rule out a stroke OR a TIA, both of which can be caused by a cervical artery dissection. Even a brief paralysis of one side of my body is serious, and you just brushed it off. You didn’t even tell me or my parents that a stroke was anything you were concerned about. You never even considered a TIA in your differential. If you had, you would have realized I needed more tests and should see a neurologist immediately, especially when I’m only 16-year-old. Defense: I thought of a stroke and ruled it out by getting the CT scan. You didn’t complain of neck pain. You had no risk factors. Because you weren’t having a stroke, I didn’t need to consider a dissection. You got better in the ED.

Result: Settled pre-trial for an undisclosed (but likely at least 7 figures) amount.

Takeaways:

• Even teenagers can have a stroke or TIA.
• Sudden onset of unilateral neuro symptoms deserve one’s utmost concern, regardless of age.
• The cost of missing this diagnosis increases the younger the patient because of the “Quality of Life Years” ahead of them.
• Include cervical artery dissection in the differential when considering stroke/TIA.
• A normal CT scan does not rule out a stroke OR TIA (duh).
• Could an assumption that this was a histrionic female teenage have played a role?
• If you can only do ONE neurological test, gait is the simplest and most comprehensive. Walk (“Road Test”) your neuro patients before discharge.

References:

1. emDocs Cervical Vessel Dissection
2. EM Educator Series