Failure to Diagnose an Occipital Aneurysm

Digest, Spring, 1994

Allegation

Insured ophthalmologist allegedly failed to diagnose an occipital aneurysm. Additionally, there were allegations of failure to diagnose and treat plaintiff’s headache disorder, which resulted in a left hemisensory deficit.

Disposition

Dismissed.

Background

Sometimes the initial discovery phase of a lawsuit can be the most productive. When the facts are clear and the evidence is persuasive, a plaintiff often can be educated in the pathophysiology of the case and dissuaded from pursuing a suit that has little chance of success. The following case is an example of how the OMIC defense team worked with the plaintiff’s attorney to obtain a dismissal.

Case Summary

The patient was a 79-year-old woman who had been a patient of the insured for four years. She was examined for complaints of difficulty with night vision, frontal headaches and URI. The decreased night vision was consistent with the previously diagnosed cataract formation in the eye. There was no mention of double vision and the pupils were equal and reactive to light. An extraocular exam was normal. The optic nerve was examined stereoscopically, and no papilledema was found. A visual field exam was not performed. A prescription change was made in the patient’s glasses and the patient left the office.

Two months later, the patient suffered a stroke due to an occipital aneurysm. She claimed that the insured ophthalmologist was negligent in failing to order a CT scan to evaluate her headaches at her previous visit.

Outcome

When the medical experts reviewed this case, they were able to defend the insured because he had carefully documented the office exam as well as the history presented by the patient. Each expert who reviewed the case came to the same conclusion: there was no indication to order a CT scan for this patient.

These reviews enabled defense counsel to discuss the case frankly with the plaintiff attorney and convince the attorney that the insured was not an appropriate defendant in this case. The plaintiff attorney persuaded her client to dismiss the case against the insured ophthalmologist based largely on the clearly written notes in the office record, which correlated with the standard of care as stated by defense experts. It was later discovered that the plaintiff attorney was unable to find an expert witness who would testify against the insured based on the facts in the record.

Risk Management Principlesand Commentary

In this age of managed care and cost cutting, physicians frequently may have to decide whether the diagnostic value of a given test justifies its cost. Medical tests always will be essential to accurate diagnosis. The guideline for whether they are indicated must continue to be based on sound medical judgment, even in the face of budget cuts and increasing pressure to keep costs down. Not every test may be needed to make a diagnosis, but if a diagnosis is missed because a necessary test was omitted, the cost of the test will not provide a convincing defense.

At times it may seem a precarious balance between the cost of additional testing and the benefit of the test to the patient. Medically sound decisions supported by clear and proper documentation provide the best defense if a claim is filed. Ultimately, one hopes the goals of physicians and utilization reviewers will coincide: to provide safe, competent and cost-effective patient care.

Failure to Diagnose Toxic Optic Neuropathy

Digest, Winter, 1995

Allegation

Insured ophthalmologist allegedly failed to diagnose ethambutol toxicity.

Disposition

Lawsuit was settled on behalf of the insured ophthalmologist. Co-defendant pulmonologist also settled for an undisclosed amount.

Background

Ophthalmologists should be alert to the potential visual side effects of the non-ophthalmic medications their patients use and be prepared to include even rare toxic conditions in their differential diagnoses.

Case Summary

The plaintiff was a 67-year-old male with a long-standing history of bronchiectasis and non-tuberculosis mycobacterial infection. In 1991, the patient’s pulmonologist added 1000 mg. per day of ethambutol to the medication regimen. Although ethambutol is associated with liver damage and ophthalmic toxicity, the pulmonologist only screened the patient for liver complications. He did not perform any ophthalmic testing or refer the plaintiff to an ophthalmologist for monitoring.

Approximately six months after the plaintiff had started on ethambutol, he presented to the insured ophthalmologist complaining of a heavy feeling in his eyes, diplopia, and esophoria. Visual acuity was measured at 20/25 +/- OU with pinhole at 20- and 20. Mild cataracts OU were noted. The insured indicated in his notes that the plaintiff might need a prism if the double vision increased. A medication history was recorded and included ethambutol.

Four months later, the plaintiff returned to the insured’s office with continued complaints of heaviness in the right corner of his right eye, blurry vision, and occasional horizontal diplopia. At this visit, the plaintiff’s visual acuity was 20/25 OU. The insured noted 1-2+ cataracts bilaterally. Media clarity was documented as 20/25. The diagnosis was possible ptosis and cataracts, and the plaintiff was advised to return in three weeks for further evaluation. When the plaintiff returned as instructed, visual acuity OD had decreased to 20/40, and he continued to complain of infrequent diplopia at night. The insured recommended cataract removal. Over the next several weeks, the plaintiff’s vision deteriorated rapidly to 20/200 OD. Cataract surgery was performed in late 1992 without complication. Postoperatively, the plaintiff’s visual acuity OD was count fingers. The insured documented in his notes that he did not understand why the plaintiff did not have better vision. A month after the surgery, the plaintiff was demonstrating visual loss in the left eye as well. Concerned about the continued vision loss in the left eye, the insured ordered an MRI. The results were normal. At this point, the insured referred the plaintiff to a neuro-ophthalmologist.

The neuro-ophthalmologist suspected toxic optic neuropathy resulting from ethambutol and recommended that the pulmonologist immediately take the plaintiff off the drug. The plaintiff continued to be treated by the neuro-ophthalmologist. Over time, his visual acuity improved to 20/200 OD and 20/50 OS, and his central scotomas and much of his color vision problems were resolved.

Analysis

Defense experts identified several issues that made defense of the case difficult. First, the medical records did not clearly reflect a recognition of the potential for ethambutol to cause toxic optic neuropathy. Second, there was no visual field testing performed. Even if visual fields do not assist in specifically diagnosing ethambutol toxicity, abnormal results might suggest the need for further evaluation or referral to a specialist. Third, the inconsistency between the degree of visual loss and the severity of the cataracts suggests looking for an alternative explanation for the patient’s problems.

Defense experts who consulted on the case did point out, however, that ethambutol toxic optic neuropathy is a very rare phenomenon and not one typically seen in a general ophthalmologist’s practice. This allowed the defense to argue during settlement negotiations that the insured was justified in pursuing more common explanations for the plaintiff’s visual problems (i.e., cataracts) before considering unusual conditions.

Risk Management Principlesand Commentary

An ophthalmologist’s vigilance concerning medications should extend beyond the prevention of classic medication errors that can arise in clinical settings. It should extend to evaluating the impact of medications prescribed by other treating physicians on the health of the patient’s eyes. General ophthalmologists serving an elderly population are so accustomed to cataracts being the major cause of visual problems among their patients that they may forget to document the possibility of other explanations, such as drug toxicity, in their differential diagnosis. If a lawsuit ensues, the lack of such documentation makes it difficult to argue that the physician was proceeding in an orderly fashion to rule out possible causes of the patient’s visual deterioration.

Failure to Diagnose Temporal Arteritis

By Stacey Meyer
OMIC Claims/Litigation Associate

Digest, Winter 1998

ALLEGATION

Delayed diagnosis and treatment of temporal arteritis.

DISPOSITION

Claim settled on behalf of insured ophthalmologist.

Case Summary

A 70-year-old male was referred by his family practitioner for an eye exam. He was seen by one of the insured’s ophthalmic technicians, who noted the patient’s complaints of waking up in the morning with a history of headaches and difficulty with reading. Following the technician’s work-up, the insured performed a complete eye exam on the patient. Visual field testing and mobility were within normal limits. Funduscopic examination revealed spontaneous venous pulsation and a normal optic disc. The insured’s impression was conjunctivitis sicca and early cataracts. He noted that the patient’s headaches were most probably related to sinus problems and referred the patient back to his family practitioner.

The following week, the patient presented to his family practitioner with complaints of sporadic headaches during the previous three weeks, jaw pain and loss of appetite. The family practitioner diagnosed headaches secondary to sinusitis, polyuria and polydipsia.

The patient returned to the insured six weeks later with complaints of shutter type vision and blank veils of vision in his left eye. An examination revealed count finger vision. To rule out temporal arteritis and/or anterior ischemic optic neuropathy, the insured ordered a SED rate, which returned as 79. The patient was immediately started on 50 mg of Prednisone. A temporal biopsy two days later confirmed temporal arteritis.

The patient’s present visual acuity is no light perception OS and an altitudinal field defect OD with visual loss in the upper half and a small ring scotoma in the far peripheral field inferiorly.

Analysis

The patient alleged that the insured failed to obtain an adequate history and order appropriate testing, thereby resulting in delayed diagnosis and treatment of temporal arteritis. More specifically, the plaintiff attorney argued that the insured should have diagnosed temporal arteritits on the first visit, claiming that when an elderly patient presents with new headache complaints, temporal arteritis should always be part of the differential diagnosis. Because the insured took no steps to rule out temporal arteritis, the disease was allowed to progress, and the patient lost all vision OS and suffered a significant altitudinal vision defect OD. At the very least, the plaintiff maintained, the insured should have asked the patient questions about his headache complaints and any associated symptoms.

Defense experts pointed out that the insured did not chart any follow-up regarding the patient’s new onset of headaches. In light of the patient’s age, questions should have been asked to rule out giant cell arteritis and to elicit whether he was suffering from any other symptoms associated with this disease. The experts opined that while the complaints of headache alone may not be enough to warrant extensive neurological work-up, the do warrant asking the patient related questions and documenting pertinent negatives. Through discovery, it was apparent that while the insured did address the patient’s headache complaints, he did not record the relevant questions and responses in the medical record. Defense counsel was therefore unable to use the medical record to dispute the plaintiff’s argument that the diagnosis should have been made earlier.

Risk Management Principles

When failure to diagnose is alleged, any physician in the chain of events will be brought into the suit. In this case, both the family practitioner and the ophthalmologist were parties to the suit and each contributed to the settlement of the claim. That is why it is imperative to thoroughly explore and address any complaints described by a patient and to record all relevant questions and responses in the medical record. While it may be impractical to order a sedimentation rate for each older person presenting with a headache, it is a simple matter to question the patient about other symptoms that might indicate temporal arteritis. Finally, when referring at-risk patients to a primary care physician or specialist, do so promptly and follow up with a request for exam and test results.

Trauma Cases: Risky to Treat, Difficult to Defend

By Jennifer Takeman, JD

Digest, Spring 2003

ALLEGATION  Failure to refer trauma patient to ER for neurological exam delayed diagnosis of brain hemorrhage.

DISPOSITION  Defense verdict on behalf of insured oph- thalmologist and subsequent treating neurologist.

Case Summary

A16-year-old male was struck in the right cheek when he pulled a wire hanger serving as a radio antenna from the hood of his car. He complained of pain and immediate blindness in the right eye lasting for approximately 20 minutes before gradually recovering sight. The boy’s father called the insured ophthalmologist who came in from home to examine him approximately 80 minutes after the accident. The patient had by then developed a severe headache.

Examination revealed VA 20/25 OD, 20/30 OS. Pupils were four millimeters and reactive to light with positive escape on the right. There was a small puncture wound beneath the right eye. Motility and confrontational visual fields were normal and the right globe was intact with a pressure of 17 mm Hg. Slit lamp examination was entirely within normal limits and direct ophthalmoscopy through an undilated pupil revealed sharp disc margins and positive venous pulsations. The insured did not dilate the right fundus because he wanted to preserve the pupillary reactions for subsequent treaters. He charted a right affer- ent pupillary defect and “ ? scan to r/o bleed.”

The insured called a nearby neurologist and advised the office staff that the patient needed to be seen immediately due to an afferent pupillary defect and headache complaints. The neurologist examined the patient less than half an hour later and documented that the exam seemed normal. There was no mention of an afferent pupillary defect. He sched- uled the patient for an MRI two days later.

Back at home, the patient blew his nose, immediately complained of an excruciating headache, and became diaphoretic. He was rushed to the ER where a CT scan revealed a large right thalamic and intraventricular hemorrhage. Due to the hemorrhage location, surgery was extremely risky and the prognosis was poor even if the patient survived it. The family rejected surgical intervention and the patient died the next day. The insured ophthalmologist was sued along with the neurologist.

Analysis

The plaintiff’s expert opined that the patient should have been referred directly to the hospital for neurological examination or, failing that, referred once the insured detected an abnormal pupillary reaction. The expert was critical of the insured for not communicating his findings to the neurologist directly. He maintained that the negligence of both doctors resulted in a three-hour delay in diagnosing the hemorrhage.

The defense expert countered that the history relayed by the patient’s father when he called the insured suggested a perforated globe, and since the finding of an afferent pupillary defect was indicative only of trauma to the optic nerve, not a brain injury, it was his opinion that referring the patient to the neurologist, not the ER, was appropriate. Further, he explained, it is not unusual to leave details of a patient’s condition with office personnel as it is often impossible for physicians to speak directly with one another in a timely manner.

The jury returned a verdict in favor of both the insured ophthalmologist and the neurologist.

Risk Management Principles

The decedent’s parents were sympathetic plaintiffs and might have won on that basis alone. Fortunately, the jury listened to the facts and understood that the insured’s care and treat- ment met the standard of care. However, had it not been for the insured’s prompt examina- tion of the patient, immediate referral to the neurologist, and thorough documentation of his findings, the jury might easily have found for the plaintiffs. One additional precaution that the insured might have taken would have been to fax a copy of his chart notes to the consulting neurologist, thereby alerting the neurologist to his concern about a possible bleed. In general, a faxed copy of the chart notes, including the referring physician’s differential diagnosis and questions for the consultant, will ensure that the consultant has all of the pertinent information to evaluate the patient. In this case, it might even have precluded the insured’s involvement in the lawsuit.

Ms. Takeman has defended physicians, nurses, and hospitals in medical malpractice cases. She has worked in hospital risk management and as a claims representative for an insurance company.

Watch for Warning Signs of a Missed Diagnosis

By Anne M. Menke, RN, PhD OMIC Risk Manager

Digest, Spring 2004

ALLEGATION  Failure to diagnose optic glioma, resulting in delay in surgical removal and blindness in right eye.

DISPOSITION  Settled on behalf of defendant ophthalmologist.

Case Summary

A three-year-old was referred to the insured ophthalmologist with a complaint of headaches. The mother reported an out-turning right eye and said the child needed to sit directly in front of the TV to see. The ophthalmologist noted nystagmus, diagnosed hyperopia OU and exotropia, issued a prescription for a full cycloplegic refraction, and instructed the mother to bring the child back in three months or sooner if headaches and/or blurred vision persisted. Four months later, the ophthalmologist noted resolution of the headache, stable exotropia and hyperopia, slow-beating nystagmus, and stable gaze. The patient was to continue wearing the glasses and return in six months. Three months later, the mother brought the child in when he failed his school eye examination and reported trouble with the glasses. VA was felt to be unreliable but measured 20/30 OD, 20/70 OS. A low-grade allergic conjunctivitis was noted and treated. When he returned as requested for a refraction the following month, the child was failing the school eye exam with and without glasses. Refraction was performed with a mild hyper- opic correction; optic pallor was noted on the fundus examination OD. A trial of patching was planned, after which the child was to return for evaluation. When the mother reported problems with the patching exercise a week later, the ophthalmologist referred her to the local children’s hospital. A work-up there revealed HM to LP only, with marked divergent drift and pale optic disc OD. Neuro- imaging studies revealed an optic glioma, which was treated with surgery, radiation, and chemotherapy.

Analysis

In order to prove malpractice, the care rendered must deviate from the standard and be the cause of the patient’s alleged damages. Experts criticized the insured’s failure to refer the child to a specialist for nystagmus, found on the initial exam, and optic pallor, noted seven months later. The validity of the visual acuity measurement was also challenged, given the precipitous change over a one-week period. Defense experts noted, however, that the patient did benefit from the treatment for exotropia and, more importantly, that earlier diagnosis of this slow-growing tumor would not have affected the treatment or the out- come. The insured ophthalmologist agreed with the defense attorney that these shared concerns, coupled with the child’s poor outcome, could lead to a substantial jury verdict. A decision was therefore reached to settle the case.

Risk Management Principles

“Failure to diagnose” claims are common and account for half of OMIC’s top ten indemnity payments. From both a patient safety and liability perspective, it is important to rule out the worst possible diagnosis as part of the diagnostic process. One of the simplest for- mulations of this axiom is the “witty” or “WIT-D” approach.1 Include the worst thing (W) the patient could have in the differential diagnosis; collect the information (I) needed to rule it in or out; tell (T) the patient and other members of the health care team of your differential diagnosis, planned treat- ment, and any symptoms that should be reported to you; and document (D) your care, decision-making process, and instructions. In this case, nystagmus should have prompted a referral (I) to a neuro-ophthalmologist to rule out a CNS process (W); the optic pallor also required further work-up. There are usually many warning signs of a missed diagnosis. These include repeated, ongoing, or worsening complaints (worsening visual acuity); treatment that does not resolve complaints (kept failing school eye exams); and a diagnosis that does not account for the symptoms (neither the nystagmus nor the optic pallor could be attrib- uted to the hyperopia or exotropia). Such warning signs should prompt the physician to start over by reviewing all chart notes, using the WIT-D approach, accounting for all symp- toms, and seeking a consultation or referral.