Legal Review & Commentary

Diagnosis delay leads to permanent blindness

$1.8 million verdict rendered

News: A 56-year-old man with complaints of impaired balance and light headedness presented to his local hospital. A resident and attending radiologist interpreted the man's CT scan and read the scan to show old lesions. A physician assistant at the hospital diagnosed the man with vertigo and discharged him with medication. As the symptoms became more severe, the man approached his primary care physician, who completed a more thorough workup. Ultimately, a brain biopsy revealed an intravascular lymphoma. The delayed identification and treatment led to permanent brain damage. The jury entered a verdict against the defendant in the amount of $1.8 million.

Background: Suffering from light headedness and dizziness, an ex-trucker sought treatment at a hospital. A CT scan was ordered, and radiologists reading the scan identified some old lesions. A staff physician's assistant diagnosed the man with vertigo and discharged him with medication and an order to return to his physician for follow-up. Shortly thereafter, the symptoms the man was experiencing became more severe. He went to his primary physician, who ordered an MRI. The MRI revealed that the man had suffered several strokes, and he was subsequently referred to a neurologist for further evaluation.

The man was discharged with an order to seek rehabilitation at a local center. According to the plaintiff's, the neurologist failed to complete a full stroke workup, and the cause of the stroke was not identified at this time.

After presenting to the rehab center, the man's MRI was reviewed again. The man was immediately rushed back to the hospital with an order to test for atypical causes of stroke. During the workup, an intravascular lymphoma was identified. The man was transferred to a larger hospital for treatment, but his charts and slides did not accompany the transfer.

The man allegedly sustained serious and permanent brain damage as a result of the delayed diagnoses. He is now legally blind and unable to walk on his own. Due to the nature of his injuries, the man must reside in a long-term care facility. A lawsuit was filed against the hospital, the radiology group, and various physicians alleging failure to property interpret the CT scan, failure to administer adequate follow-up care, failure to refer the patient to a neurologist, failing to order adequate testing for atypical causes of stroke, failing to obtain brain biopsy, and failing to timely transfer the biopsy results for treatment.

Only claims against the hospital, the radiology group, and the attending radiologist went to the jury. Jurors returned a verdict finding the hospital 100% liable for the man's injuries and awarded damages in the amount of $1.8 million. The judge confirmed the verdict and also ordered the hospital to pay $891,145 in interest.

What this means to you: This case, similar to the other in terms of failure to diagnose or rescue, also led to permanent brain damage in a patient. It involved blindness and the inability to walk independently for a 56-year-old male. The patient, previously employed as a truck driver, is now residing in a long-term care facility for the remainder of his life due to injuries sustained.

Intravascular lymphoma, also known as malignant angioendotheliomatosis is a large cell lymphoma found in the blood cells of the skin and central nervous system. It is known to be rapidly fatal, and the primary treatment for this condition is polychemotherapy.

In the case of this 56-year-old, opportunities existed for an earlier rather than later diagnosis, and those opportunities were missed. Beginning with the initial CT scan following his complaints of impaired balance and lightheadedness, the radiologists identified what they thought to be "old lesions." An opportunity existed to further explore, through the patient's medical history, symptomology, and additional diagnostic studies, the acute or chronic status of the lesions. Instead, a physician assistant (PA) subsequently made the diagnosis of vertigo, prescribed medication, and recommended follow-up with the patient's primary care physician (PCP). There is no indication of an emergency department (ED) physician reviewing or confirming the PA's diagnosis, or of the CT scan results being sent to the patient's PCP. As the patient's symptoms worsened, the PCP ordered an MRI.

The clock is ticking; time is brain. Given the MRI result of the evidence of multiple strokes, the PCP referred his patient to a neurologist. The neurologist allegedly failed to implement a full stroke workup (opportunity missed), and a cause of the lesions and strokes were not identified or questioned. This was another opportunity missed. The clock continues to tick. Rehabilitation for the balance impairment and lightheadedness was ordered, and the patient complied. It was only after presentation to the rehab center that the MRI was again reviewed and recommendations made to test for other possible causes for the strokes. Another opportunity for a more rapid diagnosis also was missed when the charts and slides did not accompany the patient to the larger hospital.

Given the patient's ultimate diagnosis, the prognosis might have remained poor, but the physical complications of blindness and the inability to walk independently might have been averted or postponed through medical management of the appropriate diagnosis. Time, in the form of a missed diagnosis, worked against what could be a reasonably successful or, at minimum, comfortable outcome.

What is interesting in this case is the jury's decision and award. The radiology group and the attending radiologist were included with the hospital as defendants before the jury; however, finding only the hospital liable indicated the jury viewed the total responsibility for the provision and administration of healthcare services to rest solely upon the healthcare organization. In addition to the verdict, the judge ordered the hospital to pay interest. The jury's finding of 100% liability on the part of the hospital implies several possibilities: the radiology group and radiologist were found to be innocent of the claims filed against them, they were considered to be employed by the hospital, the hospital's credentialing process was an issue, or the leadership of the hospital was held accountable for the actions of those who provide care within their organization.

This case also raises the question of culpability of the ED physician, the PA, and the neurologist. It is conceivable the ED physician, PA, and/or the neurologist might have been originally named in the suit. It is possible documentation did not support their role in causing harm to the patient, or they opted to settle prior to trial.

Documentation, as it always is, would be one of the "make-or-break" factors in this case. Dates, times, results, interventions, and quality assurance would provide evidence of thorough and appropriate patient evaluation and treatment. Based on the verdict, the documentation presented in this case did not support evidence of a timely and accurate diagnosis. Based on the verdict, the jury determined there was a duty to provide care with a subsequent breach of that duty, injury was sustained, and causation was established. As a result, a 56-year-old will spend his remaining time blind, lame, and living in a long-term care setting.

Reference

Superior Court of Massachusetts, Worcester County, Case No. Not Provided