Neurological Misdiagnosis in ED: Uncommon, but Suit Likely

Approximately 5% of patients presenting to EDs have neurological symptoms such as headache, dizziness, back pain, weakness, and seizure disorder, but little is known about the factors that led to misdiagnoses of neurological emergencies in the ED, according to a 2012 review of studies.1

“Neurological emergencies tend to be more complicated than a lot of things that we see,” says Jonathan Edlow, MD, co-author of the study and vice-chair/director of quality in the Department of Emergency Medicine at Beth Israel Deaconess Medical Center in Boston.

“The approach to chest pain, belly pain, or vaginal bleeding tends to be more algorithmic in people’s minds,” says Edlow. “Before leaving the room, the emergency physician [EP] pretty much has an idea of what the next steps are.”

Less than 20% of emergency medicine residencies require a neurology rotation.2 “This knowledge gap is fixable by individual EPs, in the short term, by boning up on neurology,” says Edlow, such as by attending a course or conferences, or reviewing films with neuroradiologists. “While individual physician education is very important, it won’t solve the systems issues.”

Headaches indicating a neurological emergency, stroke, and subarachnoid hemorrhage (SAH) are all likely to result in malpractice lawsuits if these are missed in the ED, says Joseph Shiber, MD, FACEP, FACP, FCCM, associate professor of emergency medicine and critical care at University of Florida College of Medicine – Jacksonville. Consider these risk-reducing strategies to prevent misdiagnosis of neurological emergencies:

• Take the time to do a thorough history and physical examination.

Patients with neurological emergencies often present with extremely common symptoms such as dizziness and headache, notes Edlow. “This is an area where the history and the physical exam are very important,” he says. “I don’t think EPs are as comfortable with their neurological exams as they are with their heart or lung or abdominal exams.”

“And if you miss a problem with a neurological emergency, the stakes are high. Stroke, a bleed, or cord compression are major life-altering events for the patient,” warns Edlow.

From a defense lawyer’s perspective, the best evidence to support the EP’s decision-making is a well-documented medical chart that delineates the medical management of the patient, from the history and physical exam to the ordering of medications, tests, and consultations, says James P. Donohue, Jr., Esq., an attorney with Diedrich & Donohue, LLP, in Boston, MA.

Failing to do a thorough history and examination might prevent EPs from including a neurological condition in their differential, says Shiber. If patients have a cardiac condition such as decompensated heart failure or atrial fibrillation, they are more likely to have a embolic stroke, for instance, he explains.

Similarly, if a patient complains of back pain and the EP doesn’t obtain a history of the patient’s intravenous drug use, “not realizing they are at risk for an epidural abscess is obviously a huge miss,” Shiber says.

• Keep in mind that the patient might be presenting early or with a mild presentation.

Most patients with SAHs that were missed at the time of the initial ED presentation had small amounts of bleeding and initial normal mental status and neurological examinations, according to a 2007 study.3

“The only complaint they had was headache, and it might have been mild. That’s the difficulty,” says Shiber. “If someone still looks well and does not have physical examination findings that push the EP to consider a serious and dangerous condition, it may be missed during the initial contact.”

• Recognize the limitations of diagnostic tests.

Assuming the history and physical examination point the EP in the direction of a possible neurological diagnosis, appropriate neurological testing and consultations should be ordered, says Donohue, adding that initiation of medical management might be indicated while awaiting the results.

EPs don’t always consider the limitations of diagnostic tests when neurological conditions are a possibility, however, says Edlow. “Although the CT is a fabulous test, it has limitations. Certainly in the first six to eight hours, it’s limited in terms of diagnosing or excluding acute stroke,” he says. “It is very limited with respect to cerebellar stroke.”4

Magnetic resonance imaging (MRI) isn’t available off-hours in many EDs. “It’s not a test that you can order and an hour later you’ve got the result. So the best test is a slow test when we get it, and is often not available,” says Edlow. “That’s a systems issue. But we should still remember that a negative CT does not mean there is not a problem.”

EPs who wouldn’t think of sending a chest pain patient home based solely on an initial negative troponin result might not have the same skepticism about a negative CT scan in a dizzy patient. “They don’t have that same reflex to say, ‘This could be a false-negative CT, so I need to examine the patient more carefully or observe them, or get an MRI to be sure this is peripheral and not central,’” says Edlow.

• Have an alternative approach for when real-time neurological consults are unavailable off-hours, such as transferring a patient to get an MRI or obtaining a teleconsult with a neurologist.

If MRI is not available and the EP is concerned about spinal cord compression, “getting the patient transferred rapidly is necessary,” says Shiber.

If systems problems exist, “you are not going to fix it tonight in the ED,” says Edlow. “But you can sit down Monday morning and work with hospital administration.”

• Ensure that appropriate tests are ordered and correctly interpreted.

In a 2010 study on missed SAHs in the ED, failure to order a CT scan was the most common underlying reason for the misdiagnosis.4

The EP might have ordered and performed the appropriate tests, but failed to interpret them correctly, such as attributing red blood cells in the initial lumbar puncture sample to capillary bleeding and missing an SAH, notes Shiber.

• If a patient is discharged, be sure the chart indicates why the EP didn’t think the patient was at risk.

This makes a missed diagnosis case more defensible, according to Shiber. For instance, charting, “The headache was not acute thunderclap onset,” or “patient’s symptoms improved with mild analgesics” shows that the EP considered SAH. “If you documented that you thought about it, evaluated the patient, and the process led you away from a serious condition, that’s hard to argue with,” says Shiber.

• Document a full neurological examination, including the patient’s level of alertness, mental status, a motor strength exam, and a sensory exam.

“It doesn’t have to include all the modalities of sensation, but at least touch. Also, evaluate the patient’s ambulation and gait. Some people forget that, and only examine the patient in bed,” Shiber says. “If that’s all done and is all normal, it’s quite reassuring.”

• Keep the patient long enough to do a reassessment, even if the patient appears well and has a relatively reassuring presentation.

“It’s very difficult to get a full picture of what’s happening with a snapshot in time,” says Shiber. “It doesn’t need to be necessarily six to 12 hours, but should be more than one initial contact.” The EP can then document, “On reassessment, the patient continues to have a normal examination,” and that the complaint the patient came in with is resolved.

“It’s hard to discharge someone when they are still complaining of the same exact symptoms,” says Shiber. “It’s always good to have more than one set of vital signs, with nursing documentation in agreement with your physician documentation.”

• Document that a rectal examination was done, especially if patients report bowel or bladder complaints.

If the patient reporting back pain doesn’t have risk factors, has a normal neurological exam, normal strength and sensation of legs, and normal bowel and bladder function, “then the back pain typically can be treated as such, but otherwise you must pursue it,” says Shiber. “It’s been shown that a delay in surgery of decompression of the spinal cord is associated with a favorable verdict against the provider.”

References

1. Pope JV, Edlow JA. Avoiding misdiagnosis in patients with neurological emergencies. Emerg Med Int. 2012; 949275. Epub 2012 Jul 25.

2. Stettler BA, Jauch EC, Kissela B, et al. Neurologic education in emergency medicine training programs. Acad Emerg Med 2005;12(9):909–911.

3. Vermeulen MJ, Schull MJ. Missed diagnosis of subarachnoid hemorrhage in the emergency department. Stroke 2007;38(4):1216-1221.

4. Schellinger PD, Bryan RN, Caplan LR, et al. Evidence-based guideline: The role of diffusion and perfusion MRI for the diagnosis of acute ischemic stroke: Report of the Therapeutics and Technology Assessment Subcommittee of the American Academy of Neurology. Neurology 2010;75:177-185.

Sources

For more information, contact:

  • James P. Donohue, Jr., Esq., Diedrich & Donohue, LLP, Boston, MA. Phone: (617) 367-0233. E-mail: jdonohue@ddcounsel.com.
  • Jonathan Edlow, MD, Vice-chair & Director of Quality, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA. Phone: (617) 754-2329. E-mail: jedlow@bidmc.harvard.edu.
  • Joseph Shiber, MD, FACEP, FACP, FCCM, Associate Professor of Emergency Medicine and Critical Care, University of Florida College of Medicine – Jacksonville. E-mail: joseph.shiber@jax.ufl.edu.