Practice of Medicine
Lessons Learned on Neurological Injuries
February 2, 2017
Because of the rise in the number of claims involving neurologic injury, we formed a task force looking at these claims. We examined 22 cases that were closed during the years of 2006 to 2013. The average total incurred costs per claim were 3.33 times higher than the average amount of all other claims over the same time period.
The cases examined were complex and we asked the task force to focus on common principles to improve care. Neurologic examinations, whether performed or documented, were often times inadequate to identify many of the lesions and conditions in which serious adverse outcomes eventually occurred. While we cannot differentiate what was done versus what was documented, we can observe the following:
- Plaintiff attorneys preferentially litigate these cases due to their high damages. Defense counsel repeatedly are faced with the mantra of “did you think about and diagnose or rule out the most dangerous or life threatening condition?” Our liability exposure is greatly determined by what cases are brought and potential damages.
- Neurologic examinations were focused on only a small portion of the functional areas of the brain, predominantly on the anterior circulation. Typical documentation included the motor, sensory, and reflex examinations, posterior circulation findings were either not examined or not documented. These include detailed visual fields, cerebellar examination, coordinated movements, ataxia, nystagmus, gait, proprioception, and subtle behavioral symptoms. We can defend a well-documented examination that describes the entirety of the brain and spinal cord, and a detailed description of the medical decision making. By and large we are not missing anterior distribution cerebrovascular accidents (CVAs) and transient ischemic attacks (TIAs).
- The “tempo” of the workup often did not match the “tempo” of the disease process. This means that a patient received a slower or less urgent evaluation process initially, and then developed deterioration that caused emergent management. This may be inevitable, but to the observing patient and family, the time at which the tempo changes does not correspond to the change in signs or symptoms, and can appear as if the team was poorly communicating or poorly prepared.
- Consideration of relative and absolute contraindications to thrombolytic therapy can be critical to the defense of care. Hypertension, illicit substance use, recent trauma, and familial history are all potential areas in which relative or absolute contraindications may be important in the defense of a given case. Early consultation, consideration of transfer (if limitations are present), and communication to the patient and his or her family of your decisions and the best care pathway are very important. We are sued more for failure to consider thrombolytic therapy than we are for complications resulting from the thrombolytic therapy. This thought process should be well-documented.
- Acute spinal lesions can be difficult to localize. Any discrepancy, or even more importantly, any progression in symptoms such as paresthesia, weakness, numbness, pain, or dysesthesia attributable to spinal lesions needs imaging with liberal thresholds for localization. High to mid-thoracic spine disease is extremely difficult to localize, and the ordered imaging studies often miss the zone of impairment. When evaluating spine disease, often the whole spine needs to be evaluated. Importantly, bilateral extremity symptoms equal a spinal cord lesion until proven otherwise. A sensory level can be very helpful in determining the location of the lesion for imaging purposes.
- Dissection of major arteries is more common than we believed in the past. Ask about family history, recent trauma, unusual neck pain, and consider imaging the neck in a patient with neurologic symptoms. Dissection is not only atherosclerotic in origin, so younger patients or patients without traditional atherosclerotic risk factors are potentially affected.
- ABCD2 score predicts which TIA is more likely to progress to a cerebrovascular accident. This should be documented and discussed with patients. There is controversy about what is a reasonable ED workup before a patient discharge. Many ED physicians admit TIAs for an expedited evaluation, as they have not found the ABCD2 score to be sufficiently sensitive or specific to make them comfortable enough to discharge.
- Beware of labeling in certain patients. Many neurologic presentations are rare but severe. Factitious disorders, personality traits, and pain medication seeking can all cause anchoring bias, preventing the recognition of these rare conditions. Beware of the inherent difficulty in the differential diagnosis of the symptom magnification patient.
- Imaging needs to be expedited and clinical findings should be relayed to the interpreting radiologist. Direct communication should be sought. While not all studies for all conditions can be realistically interpreted emergently, acute neurologic conditions need the most qualified reader with the least delay and the highest amount of communication among the care team.
We need to have a greater awareness of the severity of neurologic illnesses and the difficulty in diagnosis that surrounds acute neurologic disease. We should document thorough neurologic examinations, consult neurology or neurosurgery early, and work up these presentations as soon as possible. Of interest, the most controversial area, stroke thrombolytics, is not the sole area of concern. It is a variety of unusual neurological illnesses with unusual presentations that cause the greatest loss. Medical errors are not the same as preventable patient safety events. Plaintiff attorneys have focused on neurological cases because of the high economic damages. By considering the previous recommendations, we can look at ways to improve care and also recognize the need for education that is unique to these cases.
 A risk assessment tool designed to improve the prediction of short-term stroke risk after a transient ischemic attack
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