Risk Management

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.