The Closing Window: The Patient's Story | Case 7 Episode 1

 A taxi driver finishes his overnight shift and feels something change. He arrives at a major urban emergency department within minutes of the symptoms beginning. Stroke alert is called. CT is clear. The team offers the clot-dissolving medication — and then offers it again, and again, as the window narrows. The patient never says no. He never says yes. The clinical story of an undecided patient, a closing window, and a chart written by four providers who each saw the same conversation differently.

Transcript

SPEAKER_00 1:01

The Charted Defense is an educational program for physicians and clinicians. It is not a law firm, and nothing in this episode constitutes legal advice or medical advice. Laws governing medical practice and malpractice vary by jurisdiction. And physicians should consult qualified legal counsel for guidance specific to their state and situation. Case details discussed are drawn from publicly available court records, published opinions, and peer-reviewed sources. Where appropriate, patient, physician, and institutional identifiers have been anonymized. The views expressed by the host reflect clinical and educational perspective, not advocacy for any party. A middle-aged man is driving his taxi on an overnight shift in a large city. He has a passenger in the car. Part way through the ride, he begins to feel something wrong. Numbness spreading across the right side of his face, his arm, his leg. He tells his passenger. The passenger tells him to get it checked out. That moment, sitting behind the wheel, feeling half his body go numb, is where this case begins. Welcome back to On the Record. A series from the charted defense that breaks down medical malpractice cases from the point of care to the conclusion of the legal case and provides practical takeaways for physicians in practice. This is a shorter case compared to the others we've covered. We'll break it down across two episodes. This one covers the patient's story and the legal battle, and the next will cover the outcome and the learning points.

SPEAKER_04 2:57

This case revolves around a stroke. Stroke and other neurological emergencies represent a significant number of litigated malpractice cases, and are one of the diagnoses that can result in a nuclear verdict. The outcomes can be life-altering for the patient, and regardless of the validity of the malpractice claim, if it gets to a jury, the human component can sway that jury towards a nuclear verdict. Given that, it's very important that we are up to date with stroke guidelines and make sure we are documenting appropriately to protect ourselves and our patients. This case will illustrate some of the important factors for us to consider as we go through our practice. With that being said, Brian, let's go ahead and introduce our patient and his story.

SPEAKER_00 3:48

Our patient is a middle-aged man. He's a husband and a father. He's the provider for his family and works full-time as a taxi driver. He's working night shifts, and on one of these shifts, while he has a customer in the car, he begins to develop symptoms. He complains of numbness on his right side present in his face as well as his arm and leg. In conversation with his customer, he describes these symptoms. The customer tells him he should get this checked out. And once he drops his customer off, the taxi driver seeks the assistance of a friend. He's able to drive himself to his friend's location. He reports that the symptoms started at approximately 0.15. His friend drives him to a pharmacy first, where the patient purchases some aspirin and takes two tablets. The friend then drives him to the emergency room. In the emergency room, the patient is registered and triaged. He is noted to have a last-known well time of 12.15 in the morning, and a stroke alert is called at 1.11 a.m. A neurology resident with the stroke team reports to the bedside at 1.14 a.m. The patient is evaluated, examined, and sent for a CT of the head. He returns to the ER at 1.20 a.m. The neurology resident assigns an NIHSS score of 1 during the initial examination at 1.14 based on right-sided numbness. Upon return from the CT scan, the patient's symptoms have changed. The patient has now developed ataxia symptoms in his right hand. His NIHSS is adjusted to a score of 2. The patient is identified as a candidate for altoplas, commonly known as TPA. The clot-dissolving medication used in acute ischemic stroke. The neurology resident has a discussion with the patient regarding the risks and benefits of TPA administration. This discussion occurs at 1.53. The patient defers and is undecided about whether he wants to receive TPA.

SPEAKER_04 6:15

Let's take a minute and orient ourselves to where we are in this story. We're about 50 minutes into this patient's arrival. The team has moved quickly. Stroke alert, neurology at bedside, CT done, NIHSS scored, and now a TPA discussion. That's solid emergency stroke workflow, but the patient is undecided, and that's where this case starts to get complicated.

SPEAKER_00 6:41

An MRI is then ordered to confirm whether the patient has indeed had a stroke. A nursing note at 224 documents that the patient is medicated with intravenous libetolol and taken to MRI by the neurology team. At 332, a second nursing note documents that the patient has returned from MRI, with two confirmed infarcts identified by neurology, and that the patient remains undecided on whether to consent to TPA. We are now roughly three hours from the patient's last known well time, and still within the window where TPA would be considered. The MRI shows that the patient has a left thalamic ischemic stroke and a punctate stroke in the brainstem. The neurology resident has further discussion regarding the risks and benefits of TPA. The supervising physician for the neurology resident, a neurovascular fellow, also evaluates the patient. The fellow notes that since the patient is right-handed and a taxicab driver, he recommends TPA as a treatment. The patient still declines the intervention or continues to defer the decision. The neurology resident documents at 346 that the initial plan had been to undergo the MRI and MRA together. But given the MRI showing an ischemic infarct, the MRA was deferred and the patient was brought back to the ED for an extensive discussion about TPA before the window closed. When the patient continues to defer, he is sent back to radiology to complete the MRA to rule out any vascular occlusion that might require interventional radiology, especially given the posterior circulation stroke identified on MRI. The results of the MRA are unremarkable. There is no evidence of vascular stenosis or occlusion. At this point, the patient is outside the window for consideration of TPA. He is admitted to the stroke ward and undergoes a routine stroke workup. His echocardiogram is normal. He is evaluated by therapy. There is no evidence of arrhythmia on telemetry to suggest atrial fibrillation that would warrant anticoagulation. Physical therapy and the physical medicine and rehabilitation team are consulted and recommend inpatient rehabilitation. The patient is discharged to inpatient rehab for his stroke deficits. From there, he is discharged home with outpatient occupational therapy and medications for secondary stroke prevention.

SPEAKER_04 9:34

This might sound like a routine case, any of us. In hospital medicine and emergency medicine, see on a near-daily basis. The story seems straightforward, and the care seems appropriate, but somebody didn't think that was the case. Or this wouldn't be the focus of case seven of on the record.

SPEAKER_00 9:55

The patient's wife files, on behalf of the patient, a complaint against the healthcare system that treated her husband. The complaint alleges that the hospital and its medical professionals were negligent, careless, and reckless, and therefore were medically negligent in their treatment of the patient. The complaint goes on to state that the providers failed to properly diagnose, detect, test, medicate, and intervene, leading the patient to suffer permanent brain damage. They failed to administer TPA in a timely manner. They failed to treat his stroke. They deviated from and fell below the standard of care. The complaint argues that this delay and failure to act was the proximate cause of the patient's permanent injury. The complaint also alleges a lack of informed consent. The complaint states that the providers did not disclose the risks, benefits, and alternatives of the different intervention options, thereby depriving the patient of his ability to make an informed decision. The complaint asserts that TPA was a reasonable treatment, and the patient did not receive it because of inadequate informed consent.

SPEAKER_04 11:18

So this complaint starts to provide the framework of this case from the plaintiff's point of view. The focus here seems to center on the allegation that informed consent was inadequate, or didn't occur, or that the patient did not reasonably understand the options he was being offered and therefore was unable to make a reasonable decision. We'll see how this plays out, but for now I want to emphasize how important it is that when we have an informed consent discussion, we always document the specific risks, benefits, and alternatives we discussed with the patient and the outcome of that discussion. That is concrete information frozen in the record that is much easier to anchor a defense to. Compare that to something like risks and benefits discussed with patient, patient declined treatment. One gives a jury something to hold on to, the other gives a plaintiff attorney room to argue the conversation never happened or was insufficient.

SPEAKER_03 12:17

At this point, we have a medical malpractice case coming together. The plaintiff and counsel have filed the initial complaint and served as summons to the relevant parties. The next step is for the defendant's name to provide their answer to each and every allegation brought forth in the complaint.

SPEAKER_00 12:35

The defense denies all claims made in the initial complaint and sets forth six affirmative defenses.

SPEAKER_03 12:43

Let's look at the elements of the plaintiff's case. They first allege that there is a standard of care in stroke management and that the defendants did not meet that standard of care. They then argue that the defendant's breach of the standard of care was the proximate cause of this patient's deficits. Meaning that, based on the evidence, a reasonable person would agree that not receiving TPA was the cause of the patient's injury. As for damages, the claimed damages are the loss of function, loss of ability to work, and loss of companionship from his wife. The defense denies these allegations and will defend the care that was provided. With this, we move into the discovery phase of the case.

SPEAKER_00 13:24

After the defense answers the complaint, they request the plaintiff's bill of particulars.

SPEAKER_03 13:30

The bill of particulars is the formal document that spells out the factual details of the plaintiff's allegations with more precision. It should provide more specific details of the allegations and the evidentiary support for the plaintiff's position.

SPEAKER_00 13:44

The bill of particulars starts with a timeline of the events we've already discussed. The plaintiff asserts that TPA was indicated and was not timely ordered or administered. They allege the defendants were negligent in allowing the treatment window to lapse, that they failed to perform the proper stroke evaluation, and that they failed to adequately inform the patient about TPA while also failing to administer it. The plaintiff alleges that the patient met criteria for TPA and agreed to the treatment, but it was not administered. The bill also alleges that the defendants failed to perform vascular imaging as part of the initial workup. The plaintiff notes that the medical record indicates the MRI was suspended in order to provide intravenous TPA. And yet, the plaintiff alleges the defendants did not administer the medication.

SPEAKER_03 14:44

This is a significant point in the plaintiff's argument. If the medical record itself references suspending imaging for the purpose of administering TPA, that creates a tension the defense will need to address.

SPEAKER_00 14:57

The plaintiff further alleges that the NIHSS was not scored accurately and that the defendants did not heed its significance. They allege that a reasonably prudent person would have consented to TPA if fully informed. And this supports their claim that the defendants did not adequately provide informed consent. The plaintiff objects to the defense's demand for a statement, identifying every person who was negligent. The plaintiff also objects to providing a statement of accepted medical practice and standards, arguing that these requests are beyond the scope of a bill of particulars. The bill names numerous injuries the patient allegedly suffers as a result of the defendant's negligence, including loss of memory, confusion, difficulty concentrating, neurological impairment, deficits in cognitive function, sensory ataxia, difficulty walking, difficulty sleeping, and difficulty with activities of daily living.

SPEAKER_03 16:03

At this stage, the plaintiff may not yet have retained an expert to opine on the specific breach and causation, which could explain why they are not providing the additional detail the defense requested. We do not know.

SPEAKER_00 16:15

Most of the factual information from the clinical timeline is not disputed at this point. The central dispute appears to be forming around the adequacy of informed consent. The defense presents their account of events. The patient presented with stroke symptoms within the window for TPA. He was examined by neurology promptly upon arrival to the emergency room, and he underwent a CT of the head quickly, all within 40 minutes of arrival. Upon the patient's return from CT, the defense contends that TPA was discussed along with its risks and benefits. The patient remained undecided. Since he was undecided, he was sent for MRI and MRA of the brain. The defense contends he was brought back to the ED after the MRI component was complete to discuss TPA again. At this time, the medical records show that the neurology resident, emergency room resident, and emergency room attending are all documenting the ongoing discussion between the neurology resident and the patient. At this point, the progress note entries show that neurology noted two areas of infarct and brought the patient back to the emergency room to discuss TPA further. The supervising physician's note affirms that the patient declined TPA. It further states that TPA would be indicated in part because the patient is right-handed and his symptoms are affecting that side. Since the patient still declined, he was sent for the completion of the MRA to evaluate for large vessel occlusion, especially in the posterior circulation given the MRI evidence of a punctate brainstem infarct. The defense notes that nursing documentation in the emergency room states that the patient continues to decline TPA. The defense retained a medical expert who provided opinions in support of their position. After obtaining depositions from their expert and the treating physicians, the defense filed a motion for summary judgment.

SPEAKER_03 18:30

Summary judgment, as we've seen used in previous cases, is essentially a motion by the defense stating that the plaintiff has not established any claim supported by the material facts, and therefore there is no genuine dispute that requires a jury to decide. In this case, the defense argues that the plaintiff has not produced any evidence contradicting the information documented in the medical record. The defense's position is that the patient received care meeting the standard at every step, from initial screening to discharge, and that the medical record documents at each step that the patient did not consent to TPA. He was treated with evidence-based care and transferred to stroke rehabilitation at discharge. The plaintiff would have an opportunity to respond to this motion. Their response would need to be crafted carefully because the defense has presented a detailed basis for the motion to be granted.

SPEAKER_00 19:28

The plaintiff argues there is a conflict between the experts regarding the material facts, and therefore there are facts that should be decided by a jury. The plaintiff provides as evidence the patient's own testimony, testimony that contradicts the chart documentation from the physicians involved in his care. The patient testifies that after the CT scan, the physician did inform him of options, including using the clot buster. The patient recalls telling the physician, in substance, whatever is good for me.

SPEAKER_04 20:06

So the patient himself testified in deposition that he consented to receiving whatever is good for me. Maybe we have a conflict after all.

SPEAKER_00 20:13

The patient says that after this exchange, he was taken for MRI. He states that he questioned why he was not receiving the drug he was expecting. The plaintiff's timeline asserts that the MRI was complete at 0457. And at that time, the patient was outside the window for TPA. The plaintiff contends that the neurology resident would not have had further discussion with the patient regarding TPA after that point. The plaintiff argues that the patient was only informed of this treatment option once during his hospitalization. A nurse's note states the patient was admitted to the neurology service without receiving TPA. The plaintiff alleges that the defense attempts to minimize the patient's deficits and the potential benefits of TPA. But the plaintiff has retained an expert who will dispute that characterization. The plaintiff's expert is an emergency room physician with extensive experience in initial stroke care, including administering TPA.

SPEAKER_03 21:20

Let's look at what this expert opinion introduces into the case.

SPEAKER_00 21:24

The plaintiff's expert opines that the defendants departed from the good and accepted medical practices of the time. He states that the patient's stroke symptoms continued to progress and that the lack of intervention led to a loss of chance of recovery. This expert disagrees with the defense expert's opinion that, given an NIHSS of two, the benefits of TPA would be minimal. And with the defense expert's broader position, that patients with an NIHSS score of less than five derive Limited benefit from thrombolysis. The plaintiff's expert believes the patient did, in fact, consent after the CT. The expert also notes a significant discrepancy in the record. The nursing notes document the patient returning from MRI at 0332. But the official radiology report lists the MRI exam start time as 0357 and the end time as 0457. The expert argues these cannot both be accurate. The patient could not have returned from a completed MRI at 0332 if the scan did not begin until 0357. The radiology report also contains a note stating that the exam was stopped to provide intravenous TPA infusion, yet no TPA was administered. The expert argues that the likely time of informed consent was reasonably after the CT and that the patient accepted therapy at that time. The plaintiff's expert makes an additional argument. There is no written or signed refusal by the patient anywhere in the chart. There is no documentation from the patient himself, confirming that he refused the treatment. The expert also notes that a rehabilitation physician's note states the patient did not consent until after the window had closed, suggesting the patient did consent at some point. And it would be reasonable to believe that occurred after the CT scan, not after the MRI. Therefore, the plaintiff argues the chart is devoid of important material. And this creates an issue of fact that should preclude the granting of summary judgment.

SPEAKER_04 23:52

So our battle of the experts is lining up like this. The defense expert says that TPA is not proven to significantly benefit a patient with an NHSS less than five, and furthermore, that the patient did not consent to TPA. And the patient was otherwise treated appropriately based on the stroke guidelines in place at that time. The plaintiff's expert says that administering TPA to a patient with an NIHSS of two is in fact the standard of care. The experts are differing on what they believe the standard of care is and that's exactly the kind of dispute that makes summary judgment hard to win.

SPEAKER_00 24:31

The judge, after reviewing the arguments from both sides, rules that there are facts in dispute, and therefore a jury should decide. The defense appeals this ruling. After review, the decision is upheld.

SPEAKER_03 24:48

With summary judgment denied and the appeal exhausted, this case is now headed to trial. Each side will formulate their strongest case for a jury to ultimately decide the facts and determine whether the hospital was liable.

SPEAKER_04 25:02

This is where we'll leave things for this episode. What I want you to sit with between now and next time is the informed consent question at the center of this case. The medical record says the patient declined on more than one occasion and by more than one provider. The patient says he accepted. There's no signed refusal form. There are conflicting timestamps, and the outcome of this entire case may hinge on which version of that conversation a jury believes. That's the power of documentation and the danger of its absence.

SPEAKER_00 25:36

Thank you for joining us for this case. We'll see you next time for the conclusion. The Chartered Defense is an educational program for physicians and clinicians. It is not a law firm, and nothing in this episode constitutes legal advice or medical advice. Laws governing medical practice and malpractice vary by jurisdiction. And physicians should consult qualified legal counsel for guidance specific to their state and situation. Case details discussed are drawn from publicly available court records, published opinions, and peer-reviewed sources. Where appropriate, patient, physician, and institutional identifiers have been anonymized. The views expressed by the host reflect clinical and educational perspective, not advocacy for any party.

SPEAKER_02 28:29

I'm gonna see and gonna see and gonna be tonight and taking time and taking time and taking time and taking time and taking time And the day and the day I'm gonna see tonight I'm gonna see, I'm gonna be