Final Analysis by William Sullivan, MD, JD
These facts are a summary of a Massachusetts medical malpractice case that was taken to trial.

During the trial, the plaintiff’s attorneys argued that the patient’s presenting symptoms suggested the presence of an acute neurologic problem that should have warranted further workup during the patient’s first visit. Had the patient received this extra evaluation, the plaintiff’s attorney argued that the patient would not have suffered his stroke.

Defense attorneys argued that the patient’s symptoms were nonspecific and were consistent with the patient’s previous history of vision problems and headache. In addition, the defense attorneys asserted that the patient’s workup was appropriate under the circumstances and that a carotid artery dissection is a rare condition that can be easily missed.

During trial, the parties reached a $400,000 settlement.

 This case presents two issues regarding the care the patient received:

First, does the standard of care require that an emergency physician diagnose uncommon diseases? The incidence of symptomatic spontaneous carotid artery dissection in the general population is less than 3 cases per 100,000, or .003%. In other words, if we assume that an MRA costs $1,500 per exam, on average, to catch one carotid artery dissection in the general population, we would have to spend more than $50 million. The incidence of positive findings secondary to traumatic carotid dissections is approximately 1-2%.

This patient’s symptoms included runny nose, headache, cough and transient blurry vision. While headache and visual abnormalities are two of the more common presenting symptoms of a carotid artery dissection, they are nonspecific. Many of the patient’s presenting complaints are also symptoms of more common diseases such as sinusitis, a migraine headache, or even a common cold. In fact, the patient’s CT scan showed mucosal thickening in several sinuses. Transient vision changes could just as easily have been due to near-syncopal events from coughing or due to scotoma from a migraine headache.

The standard of care does not require that emergency physicians perform exhaustive testing on every patient to catch the “needle in the haystack.” It is unreasonable to perform angiograms on every patient with atypical chest pain to find the occasional stenotic coronary lesion. No reasonable physician performs MRIs on every patient with a headache to find the one patient in several thousand with a clinically significant lesion. Performing angiograms on every patient with headaches and/or transient visual disturbances cannot be expected during routine emergency department care.

The workup provided for the patient’s symptoms, in addition to the immediate follow up with a specialist were more than what a reasonable physician would have done under the same circumstances. The standard of care was met.

Even if we assume that the diagnosis of carotid artery dissection should have been made, there would still be difficulty proving that the delay in diagnosis caused the patient to have a stroke. The mortality from spontaneous carotid artery dissection is less than five percent. Morbidity is also uncommon, but when present can range from mild transient symptoms to permanent strokes. In this case, the patient was out of the emergency department for 1 hour before his stroke occurred. If further testing was performed would the outcome have changed?

Definitive diagnosis of carotid artery dissection generally requires a magnetic resonance angiogram, a CT angiogram, or a traditional angiogram - depending on the availability of these modalities at the hospital. Once the diagnosis has been confirmed, treatment options include anticoagulants, surgical repair, or endovascular stenting. In this case, even if the diagnosis was suspected and an MRA had been ordered, it is extremely unlikely that the exam would have been completed and a radiologist’s report would have been received before the patient’s stroke occurred.

It is unlikely that the plaintiff would be able to prove that the outcome would have been different even if the diagnosis was made on the first visit. Any potential negligent omissions from the emergency physician could not have caused the patient’s injuries.

Several responses suggested that an ultrasound of this patient might be appropriate, but ultrasound may lack sensitivity. One study by Arnold et al. in Stroke showed that ultrasound can miss a spontaneous internal carotid artery dissection in more than 30% of patients. This study was published in 2008, making it inapplicable to the case presented, but caution should be used when considering whether to rule out a dissection with a normal ultrasound scan.
Continue Next for highlights from reader comments
A record number of readers responded with their insight concerning this case.
Here are some highlights.
alt“...The question, then, is whether the headache and visual disturbance, together with a history of hypertension, CAD and smoking should have led to sufficient suspicion of carotid artery dissection.” -James Cameron, MD

“I have reviewed hundreds of med mal cases and I feel this one has no merit at all. All standards were met.”  -Julie C Georges, RN

alt“I think carotid dissection in a 41-year-old man with no PMH, no trauma to the neck and resolved symptoms is a stretch I would be unlikely to make.”
-Stephen Sample, MD

“In this case the cardiac and hypertensive history tip the scale to extra caution. The patient received immediate eye follow up (obviously very important), but needed prompt neurology follow up also.”
-Bradley Pulver, MD

alt“Even if he got an MRI and even if he consulted a neurologist, I believe the disposition would have been the same. What does the plaintiff argue should have been done with the evidence that was available to the ER doc?” 
-Sonny Sagar, MD

“If the patient had been admitted during the first visit, the outcome likely would have unfortunately been the same for the patient…I see no way the physician could have prevented the progression of this patient’s illness.” 
-Natalie Painter, DO

alt“Bad things happen occasionally to some unfortunate patients and sometimes they just can’t be predicted.”
-David Ross, DO
Colorado Springs, CO

“I guess a discussion on carotid artery dissection should become a topic in upcoming Emergency Physicians Monthly.”
-Jose Dionisio Torres, Jr., MD
Clinical Instructor, Emergency Medicine
New York Hospital Queens

alt“I do not think the EP should be held to diagnosing a dissection on the first visit. This presentation was classic for a migraine.”
-Tom Benzoni, DO
Sioux City, IA




# What about the plaintiff's expert?Jim Mensching, DO 2008-12-03 16:08
I'm fascinated to see that this trial went to a jury. I find it incredible that the plaintiff's expert witness would testify that it is standard of care to make this diagnosis under this clinical setting. Several questions arise - is this physician boarded in EM? What is the expert's current practice setting - community ED vs teaching hospital/tertia ry care center? Was there anything in the testimony that specified if the expert would have his/her testimony reviewed by an outside body such as ACEP or AAEM? This to me strains the boundaries of intellectual honesty.
# Controlling costs and Malpractice ReformJames Cameron 2008-12-03 20:08
The fact that this case went to trial is distressing. Equally troubling is the insurance company's decision to settle, presumably because of uncertainty as to the jury decision. Cases like this serve to mitigate efforts to control costs.

As Greg Henry suggested in the July 2008 issue of EP Monthly: "What we need is a true change in the paradigm of how malpractice is determined and measured." He argues for an "intelligent dispute resolution system." As a new administration attempts to reform the health care system, an integral part of the process should be efforts to change the malpractice system. Without such change, how can we expect to reduce unnecessary services.
# Why did they settle?David Ross 2008-12-03 22:55
After all of the pertinent discussion by Dr. Sullivan and the readers, I find it amazing that the defendant settled for $400,000. Was the physician forced to settle? If so, it would appear that the malpractice carrier did the physician very wrong. And settlements like this only embolden plaintiffs to file weak, long-shot suits like this one - because they pay off anyway.
# Natalie Painter 2008-12-04 11:35
It is unfortunate to realize that cases like this are settled. The illness' progression couldn't have been halted even if the physician had ordered an MRI or CTA. Where is the fault for the outcome, and how is this physician responsible for the progression of this patient's illness?
# Stroke GuidelinesJoseph Soler, MD 2008-12-17 13:57
It is commonly asserted in articles and textbooks that the treatment for carotid artery dissection is heparin followed by coumadin. It would be extremely helpful for your readers to know that the American Stroke Association in their published guidelines, Stroke 2006:37:577-617 , state the following:

“Although it is often stated that treatment with intravenous heparin, followed by 3 to 6 months of therapy with Coumadin, is routine care for patients with a carotid or vertebral dissection (with or without an ischemic stroke), there are no data from prospective randomized studies supporting such an approach.” Page 595

“A case series of 116 consecutive patients treated with anticoagulation (n=71) and antiplatelet agents (n=23) found no significant differences in outcomes (e.g. TIA, stroke or death) of 8.3 % versus 12.4%, respectively. Meta-analyses comparing rates of death and disability have not found any significant differences between treatment with anticoagulants and antiplatelet agents.” Page 595

The Guidelines Recommendations state “For patients with ischemic stroke or TIA and extracranial arterial dissection, use of warfarin for 3 to 6 months or use of antiplatelet agent is reasonable. (Class IIa, Level of Evidence B), Page 596. “Aspirin (50 to 325 mg/day), the combination of aspirin and extended-releas e dipyridamole are all acceptable options for initial therapy.” (Class IIa, Level of Evidence A), Page 595.

The national organizations supporting/affi rming these guidelines are impressive and should dissuade many “experts” from the unfounded repetition of recommendations for which no data exists supporting such an approach.

“Guidelines for Prevention of Stroke in Patients With Ischemic Stroke or Transient Ischemic Attack: A Statement for Healthcare Professionals From the American Heart Association/Ame rican Stroke Association Council on Stroke” Co-Sponsored by the Council on Cardiovascular Radiology and Intervention: The American Academy of Neurology affirms the value of this guidelines.” Stroke 2006:37:577-617 .

Thank you for the excellent work that you do in behalf of Emergency Physicians.

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