Stroke centers, treatment, and medical malpractice
May is National Stroke Awareness Month: Learn stroke symptoms and how to increase your odds of a good outcome
May 2018 is National Stroke Awareness Month. Stroke is the fifth leading cause of death in the United States, with someone having a stroke every 40 seconds.
This year, stroke experts are using this designated month to highlight both the symptoms of stroke that everyone should know, as well as the 10 modifiable risk factors that cause 90% of strokes.
What is a stroke?
A stroke is a condition that disrupts blood flow to the brain. There are two major types of stroke. First, ischemic stroke is caused by a blood clot blocking artery. Second, hemorrhagic stroke occurs in conjunction with a brain aneurysm, which is when a blood vessel in the brain bursts open.
The classic symptoms of stroke include muscle weakness on one side of the body, including a one-sided facial droop, and difficulty speaking. Other symptoms include visual changes (blurriness, brief blindness, or double vision); a severe, new, or changed headache; confusion or memory loss; vertigo (sensation that your surroundings are spending) and dizziness; burning or tingling sensations; clumsiness and coordination issues; temporary memory problems; difficulty reading or writing; and confusion or memory loss.
Stroke healthcare providers have come up with the acronym of FAST to make it easy to remember the telltale signs of stroke.
F Face Drooping
A Arm Weakness
S Speech Difficulty
T Time to Call 911
Stroke risk factors
According to the National Stroke Association, the following is how much stroke would be reduced if each of the top 10 stroke risk factors were eliminated:
Physical inactivity: 35.8%
High blood fats/lipids: 26.8%
Poor diet: 23.2%
Heart causes: 9.1%
Alcohol intake: 5.8%
This weekend, I watched an interesting special report on Houston’s ABC Channel 13, which was sponsored by Memorial Hermann and its Mischer Neuroscience Institute.
What really caught my attention is the hospital’s mobile stroke unit ambulance, which was made possible by a generous contribution from Jim “Mattress Mack” McIngvale. This specialized ambulance travels with a neurologist, CT scanner, and clot-busting medication tPA, among other tools.
As a Houston, Texas medical malpractice lawyer, I was happy to see this type of cutting-edge innovation—the first mobile stroke unit in America. At the same time, I was mindful of how I have seen healthcare providers at stroke center hospitals dropped the ball, botch a straightforward stroke diagnosis, and cause significant injury to patients.
Before getting into a few examples, we should first discuss what a stroke center is.
Memorial Hermann—Texas Medical Center is certified by the Joint Commission as a Comprehensive Stroke Center. Other hospitals in the Memorial Hermann system, like Memorial Hermann Northeast Hospital, in Humble, Texas, are accredited as a Primary Stroke Center.
Houston Methodist Hospital, in the Texas Medical Center, also holds certification as a Comprehensive Stroke Center, but from a different accrediting agency, called DNV.
I bet that most people do not even know that there are different types of stroke centers, let alone what the differences are. I think the medical director of the Houston Methodist Stroke Center gave a great explanation.
David Chiu, M.D., said, “Patients rightfully expect that wherever the ambulance takes them for a stroke, there should be a basic level of quality care. They should also be aware that some hospitals have comprehensive stroke center capabilities to treat even the sickest stroke patients, other hospitals are primary stroke centers able to provide good quality care for the average stroke patient, and still others are not equipped to give emergency stroke treatment at all.”
Quality of care concerns
In 2009, the State of Texas adopted a regulation detailing a three-tier stroke designation program, requiring stroke certification through The Joint Commission or similar body.
Under Texas Administrative Code Rule 157.133(t)(3)(G), emergency medical technician (EMT) ambulance crews must follow a bypass protocol for stroke patients who fall within the timeframe approved by the Food and Drug Administration (FDA) for stroke care therapies, including tPA. Under the bypass protocol, ambulances must transport such patients to the highest state-designated stroke center nearby.
This mandate is confusing to many patients, who may prefer to be transported by ambulance to a different hospital. Quite often, these concerns are at least somewhat relieved when EMTs explain that they are being taken to a certified stroke center.
In my experience, though, the arrival of stroke center does not mean it is safe to let your guard down. Two medical malpractice lawsuits that I have handled illustrate how the diagnosis of stroke can be missed at a comprehensive or primary stroke center.
A few years ago, I resolved a case involving a young woman who arrived by ambulance to Houston Methodist Hospital, in the Texas Medical Center, less than one hour after her boyfriend suspected she had a stroke. She had the textbook signs of stroke, including motor weakness on one side, facial droop on one side, and slurred or garbled speech.
This patient was seen by a second-year neurology resident who was only two years out of medical school and not finished with his training. Although this Comprehensive Stroke Center Hospital had top-notch attending physician neurologists, none of them saw the patient. Instead, the resident jumped to the irrational conclusion that her symptoms were psychogenic (meaning all in her mind) and discharged her. Two days later, she went to another hospital and was immediately diagnosed with a massive stroke. By then, it was too late for tPA clot-busting therapy; thus, she will live with her stroke symptoms for the rest of her life.
I am currently working on a lawsuit involving botched stroke care at Memorial Hermann Northeast Hospital. The young male patient went to the hospital emergency room (ER) complaining of the worst headache of his life, nausea, vomiting, and visual disturbance. He had been to the ER for the two previous days with similar complaints. On each of the three dates, he was discharged with the hospital after treatment for hypertension (high blood pressure) and headache pain. On the third ER visit, a neurologist—the head of the hospitals stroke’ team—cleared him for discharge after making a “working diagnosis” of migraine headache. Within a few hours of discharge, he had a massive stroke caused by a cerebral artery dissection.
In both cases, the patients were taken by ambulance to certified stroke centers. In both cases, the patients were discharged without treatment to address their stroke symptoms. In both cases, the patients had massive strokes.
The take-home lesson here is to ask questions and politely push-back if the ER physician or neurologist discounts stroke symptoms or jumps to a seemingly irrational diagnosis. Be sure to share with each doctor and nurse a complete history, beginning with your baseline health status, and detailing your symptoms, including how they started. Ask questions about test results, including lab work and CT or MRI scans. Ask what other potential diagnoses were considered by the physicians. Ask if any other tests are available that can allow for a definitive, rather than working diagnosis. Finally, consider asking for a second opinion from a fully-trained attending stroke team member or neurologist.
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Robert Painter is a medical malpractice attorney at Painter Law Firm PLLC, in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits against hospitals, physicians, surgeons, anesthesiologists, and other healthcare providers. In 2017, H Texas magazine named him one of Houston’s top lawyers. In May 2018, the Better Business Bureau recognized Painter Law Firm PLLC with its Award of Distinction.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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Published in the July/August 2018 edition of "The Houston Lawyer" magazine