The Closing Window: The Trial and the Lessons | Case 7 Episode 2

  The trial, the verdict, and the lessons. A six-person jury, a two-week trial, a defense verdict on every count, and an appeal that is now pending. How the plaintiff turned vocabulary differences across providers into an argument. How the defense turned timestamps into a defense. And what every hospitalist and emergency physician should write into a  chart the next time a patient says "I don't know" to a treatment with a closing window.

Transcript

SPEAKER_01 1:32

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. Welcome back to On the Record. In the last episode, we followed a middle-aged taxi driver from the moment he felt numbness behind the wheel through the stroke workup, the TPA discussion, and the outcome. Permanent right-sided weakness, cognitive decline, and the loss of his independence. We walked through the complaint, the discovery process, and the battle for summary judgment. The court found triable issues of fact, particularly around the adequacy of informed consent and conflicting expert opinions on the standard of care, and denied the defense's motion. The appeal of that denial was also denied. This case was going to trial. Today we're covering the trial, the verdict, and the lessons this case teaches every physician who manages time-sensitive treatment decisions. Michael is going to walk us through what every hospitalist and emergency physician can take from this case into their next shift.

SPEAKER_02 3:27

Before we get into the trial, I want to set the frame for this episode. The care in this case was good, the stroke workup was fast. The team identified the patient as a TPA candidate within 40 minutes of arrival. Multiple providers documented discussions with the patient about the treatment. This case is a good opportunity to tighten our documentation around informed consent and shared decision making. Not because anyone did anything wrong, but because the case shows how a plaintiff's attorney can pick at the edges of even good documentation when a chart is composed of multiple short entries from different providers. That's the frame for today.

SPEAKER_01 4:12

The trial spanned approximately two weeks. The plaintiff brought three causes of action: medical malpractice and negligence, lack of informed consent, and loss of consortium, which is the spouse's claim for loss of companionship and support.

SPEAKER_00 4:31

Let's orient to the legal landscape. The plaintiff's burden at trial was to establish, by a preponderance of the evidence, that the hospital departed from accepted medical practice, and that the departure was a proximate cause of the patient's injuries. For the informed consent claim, the plaintiff needed to show that a reasonably prudent person in the patient's position would have consented to TPA if fully informed, and that the failure to obtain that consent caused injury. Both claims required expert testimony to establish the standard of care and causation.

SPEAKER_01 5:07

Each side had retained experts who were prepared to testify. The plaintiff disclosed two experts, a neurologist, a fellow of the American Academy of Neurology who had examined the patient, and an emergency medicine physician with experience administering TPA. The defense retained a board-certified neurologist who was a director of vascular neurology and a professor of neurology, and who had provided a detailed affirmation in support of summary judgment and was expected to testify consistently with that affirmation. We do not have the trial transcripts in this case. What we do have is an extensive pre-trial record, expert affirmations, depositions, disclosures, and the post-trial appeal filings that allows us to reconstruct what each side presented and what the central disputes were. Let's walk through what each side brought to the jury.

SPEAKER_02 6:11

That's an important point for our listeners. We're working from the documentary record, not a courtroom transcript. What we can tell you is what each side planned to argue and what the post-trial filings tell us about what actually happened.

SPEAKER_01 6:27

The plaintiff's case rested on several pillars. First, the patient's own testimony. In his deposition, the patient testified that after the CT scan, the physician informed him of his options, including the clot-dissolving medication. He recalled telling the physician, in substance, whatever is good for me. He testified that after this exchange, he was taken for MRI, and that he questioned why he was not receiving the medication he was expecting. He stated that no one discussed the medication with him after the MRI. The plaintiff's emergency medicine expert was prepared to testify that the defendants departed from accepted medical practice. This expert disagreed with the defense expert's position that a patient with an NIHSS of two would not benefit from TPA, and instead opined that such a patient was a good candidate for thrombolysis under the standard of care in 2015. The plaintiff's expert also planned to address a significant discrepancy in the medical record. As we discussed in episode one, nursing notes document the patient returning from MRI at 332 in the morning. But the official radiology report lists the MRI exam start time as 357 and the end time as 457. The expert intended to testify about the significance of this discrepancy and what it suggested about the accuracy of the charting around the consent discussions. Additionally, the plaintiff's expert highlighted the absence of a written refusal form anywhere in the chart. The expert disclosure stated that the expert intended to testify about the significance of the lack of any specific form signed by the plaintiff declining TPA.

SPEAKER_00 8:34

The informed consent claim had a specific structure under the applicable states law. The plaintiff needed to establish that a reasonably prudent person in the patient's position would have undergone the treatment if properly informed. The patient's testimony, whatever is good for me, was the foundation for arguing that he did, in fact, consent, and that the hospital failed to act on that consent.

SPEAKER_01 8:57

The plaintiff's neurologist expert was prepared to testify about the anatomy of the brain and nervous system, and how the stroke and its effects cause the specific deficits the patient now experiences. This expert planned to connect the patient's severe disability, including a diagnosis of infarction-associated dementia and disabling right-sided hemaporesis directly to the specific areas of the brain affected by the stroke, rather than to what the initial NIHSS score might have predicted. The defense's case centered on the documented record and the expert opinion of the defense neurologist. The defense argued that the medical record consistently documents that the patient did not consent to TPA. Multiple providers, the neurology resident, the emergency department resident, the emergency department attending, and a supervising fellow. All documented discussions in which the patient was described as undecided or not consenting. A nursing note documented that the patient continued to decline TPA. The supervising physician's note stated that the patient refused TPA. The defense expert opined, to a reasonable degree of medical certainty, that the defendants did not depart from the standard of care. He testified that the patient was properly and promptly evaluated, stroke alert within minutes, neurology at bedside within three minutes, CT completed within 20 minutes of arrival. He noted that TPA was offered after the CT scan, that the patient did not consent, that TPA was offered again within the treatment window, and that the patient continued to decline on the question of whether TPA would have benefited this patient. The defense expert opined that the benefits of TPA are questionable for a patient presenting with only minor and isolated neurological impairment, including an NIHSS of less than five. He stated that TPA has not been proven to significantly benefit patients with an NIHSS of one, and cited literature suggesting limited benefit for scores less than five. He further noted that the benefit of TPA decreases after the three-hour window, meaning that later offers would have carried even less expected benefit. The defense expert also addressed causation directly. He opined that the fact that the patient was not administered TPA did not cause or contribute to any alleged injury, and that even if TPA had been administered, there was no significant probability that the outcome would have changed given the patient's clinical presentation.

SPEAKER_00 12:04

The defense also made an argument about the refusal form that is worth noting. The defense argued that the standard of care did not require a stroke patient to sign a written refusal form. They went further. They argued that a refusal form would have been inapplicable in this case, because the chart documents the patient as undecided, not as affirmatively refusing. The defense drew a distinction. Undecided is not the same as consent.

SPEAKER_02 12:32

That's an interesting framing. The defense used the undecided characterization as a shield against the refusal form argument, saying you can't expect a refusal form from someone who never formally refused. From a clinical perspective, that same framing raises a fair question for the rest of us. When a patient is undecided about a time-sensitive treatment, what does the plan for getting to a decision look like before the window closes? We'll come back to that. Also, let's think about the other statement from the defense expert for just a minute. He argues that there is no significant probability that the patient would have received a benefit or improvement in outcome if TPA had been administered. This goes to causation. Even if the plaintiff can show that the defendant deviated from the standard of care, would the outcome have been any different? And in this case, the defense's expert says no. This was a lacuna infarct that had likely already completed.

SPEAKER_01 13:31

The trial also presented the jury with the patient's current condition. The patient is no longer working as a taxi driver. He sold his car and stopped driving. He relies on social security disability benefits for income. He requires a home health aid and relies heavily on his wife for assistance with daily activities, including showering, dressing, and remembering to take his medications. His persisting deficits include constant numbness and weakness on his entire right side, a weakened grip, slow and labored gait requiring a cane, severe short-term memory loss, confusion, and forgetfulness. A neurological examination noted bretyphrenia, slowness of thought, and failure to follow three-stage commands. He also experiences severe constant pain in his neck and back, shortness of breath, rapid heartbeat, and dizziness. The plaintiffs claimed damages included estimated loss of earnings of over $800,000 in past and future wages, hospital and physician expenses exceeding $500,000, and claims for pain, suffering, mental anguish, emotional distress, and loss of enjoyment of life. The wife's derivative claim included loss of consortium, loss of services, and loss of emotional support.

SPEAKER_02 15:04

One thing worth flagging here: this patient presented with an NIHSS of two. That is a score that on paper suggests mild impairment. And yet the outcome is alleged to be severe and permanent disability. The disconnect between an admission score in the mild range and the long-term functional picture is an important one to think about, and we'll come back to it later in the episode.

SPEAKER_01 15:29

After approximately two weeks of testimony, the jury returned a verdict in favor of the defendants on all counts. The plaintiff's complaint was dismissed with prejudice, and zero dollars in damages were awarded.

SPEAKER_00 15:44

A defense verdict means the jury concluded that the plaintiff did not meet the burden of proof on at least one essential element of the claims. Given that the verdict was in the defense's favor on all counts, malpractice, informed consent, and loss of consortium, the jury either found no departure from the standard of care, no failure of informed consent, or no proximate cause linking any departure to the patient's injuries. Without the verdict sheet, we cannot determine exactly which element the jury resolved in the defense's favor.

SPEAKER_02 16:16

And that's actually the starting point for what happened next.

SPEAKER_01 16:19

Several months after the verdict, the plaintiff filed a notice of appeal to the state intermediate appellate court. The appeal raises several specific arguments about what occurred at trial. First, the plaintiff argues that the trial court committed reversible error by failing to include two specific questions on the jury verdict sheet. The first missing question, according to the plaintiff, asked whether the defendants departed from accepted medical practice by failing to administer TPA. The second asked whether the plaintiff consented to the administration of TPA. Or whether he was unable to consent.

SPEAKER_00 17:02

The verdict sheet is the document that translates the legal issues into specific questions the jury must answer. In a medical malpractice case, those questions typically address departure from the standard of care, informed consent, proximate causation, and damages, sometimes as separate questions, sometimes combined. The construction of the verdict sheet matters because it determines what the jury is actually deciding. If a question is not on the sheet, the jury never formally answers it. What the plaintiff is arguing here is significant. If the jury was never asked whether the hospital should have administered TPA and was never asked whether the patient consented, then the defense verdict may reflect the jury's answer to a different question, not the core questions in dispute. The appellate court will need to determine whether the trial court's verdict sheet construction was appropriate under the circumstances.

SPEAKER_02 17:53

For our audience, think of it this way: the entire case hinged on two questions. Should this patient have received the clot-dissolving medication? And did he consent to receive it? If the jury was never asked those specific questions, the verdict doesn't necessarily tell us what the jury thought about them.

SPEAKER_01 18:12

The appeal raises additional grounds. The plaintiff alleges that the trial judge committed reversible error by excluding factual and expert testimony that would have supported the plaintiff's case. The appeal also alleges that the judge failed to sustain the plaintiff's objections regarding the defendant's factual and expert testimony. Further, the plaintiff alleges that the judge improperly questioned factual and expert witnesses directly in front of the jury, and improperly interjected comments and statements in front of the jury, creating what the plaintiff describes as improper influence on the jury. The appeal also alleges improper citation and application of the law and an improper standard of proof.

SPEAKER_00 19:03

These are serious allegations on paper. Judicial conduct during trial, particularly questioning witnesses or making comments in front of the jury, can constitute reversible error if the appellate court finds that it influenced the jury's deliberations. The standard on appeal is whether the errors were prejudicial, meaning whether the outcome might have been different without them.

SPEAKER_01 19:23

The appeal is currently pending before the state intermediate appellate court. No decision has been issued as of the time of this recording.

SPEAKER_02 19:33

One thing worth saying clearly here, because I think it can get lost. Most cases that go to trial get appealed by one side or the other. An appeal is part of the normal post-verdict process. The fact that this case was appealed does not by itself signal that something improper happened at trial, or that the verdict was flawed, or that the trial judge did anything wrong. Plaintiffs who lose at trial often appeal. That is how the system works. The appellate court will sort through the specific arguments and decide whether any of them rise to reversible error until they rule we have a defense verdict, an active appeal, and the same set of clinical and documentation lessons either way. That's what we're here to talk about. Here's what I want every hospitalist and emergency physician listening to think about. The initial stroke care was solid. Stroke alert within minutes, neurology at bedside at 114, CT completed, and negative for hemorrhage by 120. NIHSS scored. Patient identified as a TPA candidate. All of that happened within about 40 minutes of the patient walking through the door. That is good emergency stroke workflow. The care was not the problem. The documentation around the consent conversation is the place where this case gives us a learning moment. Mainly a reminder of what we want in our informed consent and shared decision-making notes when the treatment in front of us has a closing window.

SPEAKER_01 21:04

Michael, let's start with what you consider the central lesson.

SPEAKER_02 21:08

Document exactly what was discussed, who was present, and what was decided. That sounds basic. Everyone listening has heard that before, but look at what happened here. Multiple providers documented that the patient was undecided or deferred. The supervising physician wrote that the patient refused. A rehabilitation physician the next day wrote that the patient did not consent until outside the window. And the patient himself testified that he said, whatever is good for me. Read together, those entries tell a coherent story. The team discussed TPA, the patient hesitated, and the window closed. They are not necessarily inconsistent, but even good documentation can be picked at by a plaintiff's attorney when the chart is built from multiple short entries by different providers. When entries get dissected one at a time and held up against each other, vocabulary differences, undecided, deferred, refused, can be framed as contradictions. That framing is the strategy. Tighter, consolidated documentation is the counterweight. Here's what we should consider putting in this kind of note when a treatment has a closing window. First, a single time-stamped entry, not scattered short entries across multiple providers, but one consolidated note that includes the following the patient's capacity to make the decision. In this case, the patient was alert and oriented. Document that affirmatively, then the specific risks and benefits you disclosed. Not risks and benefits discussed, does this itch? That tells a jury nothing. Instead, discussed that TPA is the standard treatment for acute ischemic stroke within the treatment window. Discussed that the primary risk is symptomatic bleeding, including the possibility of intracranial hemorrhage. Discussed that the benefit is a higher likelihood of functional recovery if administered early. Discussed that the benefit decreases with time. Then document the patient's response and use their words. Patient states he is undecided is different from patient states I don't know, which is different from patient declines treatment. Capture what they actually said as close to verbatim as you can, and then document who was present for the discussion by name and role. Discussion held with patient in the presence of the neurology resident, the ED resident, and the ED attending is a sentence that gives the defense three witnesses to the same conversation. That matters when the patient later testifies that the conversation never happened.

SPEAKER_00 23:57

From a legal standpoint, what Michael is describing is the difference between documentation that summarizes and documentation that memorializes. A summary, risks and benefits discussed, invites the question, what was actually said? A memorialized conversation, capturing the specifics, answers that question before it's ever asked. In litigation, the chart is the first and most important witness. If the chart is specific, the defense starts strong. If the chart is vague, the plaintiff has room to fill in the gaps with a different narrative.

SPEAKER_02 24:33

Now let me talk about the informed refusal question because the plaintiff used the absence of a refusal form as one of their pillars in this case. There was no signed refusal form in the chart. No document from the patient himself declining TPA. The defense argued accurately that the standard of care did not require one for TPA specifically. And in the end, the absence of that form did not cost the defense the verdict, but the plaintiff still made an argument out of it. Because the plaintiff used this as part of their strategy, it is worth tightening how we document refusal going forward. There are two reasonable ways to do this. The first is to ask the patient to sign a refusal form when they decline a recommended time-sensitive treatment, even if your institution does not require one. The second, what days and which works just as well in most cases, is to document the refusal explicitly in your own note. Patient was offered TPA, patient declines treatment, discussion witnessed by nurse name and the neurology resident. Either approach creates a record that is hard for a plaintiff to argue around later. And let me be clear, documentation cannot fix a clinical gap. If the workup was inadequate, no amount of charting protects you. But in this case, the workup was appropriate. The clinical decision making was sound. Nothing critical was missing. There are just some places we can tighten the documentation, and that is something every one of us can do differently starting tomorrow.

SPEAKER_01 26:16

Michael, you mentioned earlier that the defense characterized the patient as undecided rather than refusing. Let's talk about what that means clinically.

SPEAKER_02 26:27

This is an important distinction, and I think it's underappreciated. There's a difference between a patient who says no and a patient who says I don't know. A refusing patient has made a decision. An undecided patient has not. And when the treatment has a closing window, the clinical obligation is different for each. In this case, the team handled the undecided patient the way most thoughtful teams do. The neurology resident described the consent process as an ongoing conversation with the team coming in and out to discuss the treatment. They ordered an MRI to confirm the stroke, partly to give the patient more concrete information to make a decision with. When the MRI confirmed the stroke, they brought him back to the emergency department and rediscussed TPA with the confirmation in hand. The fact that the team kept reapproaching the patient strongly suggests they were in favor of giving the medication. They were trying to help him get to a yes or at least be in a more informed situation to make his decision. He simply remained undecided, the window closed, and undecided is not consent, so the medication could not be given. That is a team that did its job. The window did not close because the team gave up. It closed because the patient could not get to a decision in time. I don't fault this team. I think they did a very good job with a hard situation. The reason this case is worth our time is not that the care was deficient, it wasn't. It's that the case illustrates how a plaintiff's attorney can take strong documentation from a thoughtful team and try to frame it against them. It didn't work here. The defense got the verdict. But every one of us should still take note. When we are documenting an informed consent or shared decision-making conversation, the particulars matter. The vocabulary matters. The witnesses matter. Build the note in a way that protects you if the conversation is ever called into question because uh someday it might be. Where I think there is a structural opportunity for any group is to give yourselves a small protocol for the undecided, time-sensitive patient. Set a redecision time. Document each reapproach. Who spoke with the patient, what was said, what the patient's response was, and when you'll come back. If the patient remains undecided as the window narrows, escalate to the attending. Document that escalation and the attending's recommendation. Most hospitals don't have a written protocol like this. I'm not aware of one at the hospitals I've worked at. But the case in front of us today is a good reminder of why one would help.

SPEAKER_01 29:13

Michael. You also wanted to address a teaching point that applies specifically to physicians who find themselves in the defense position.

SPEAKER_02 29:24

Yes. This is about electronic timestamps and knowing the limits of what you can speak to. In this case, there's a discrepancy between the clinical nursing notes and the radiology system's timestamps for the MRI. The clinical notes document the patient being taken for MRI at 224 and returning at 332. The official radiology report lists the MRI exam start time as 357 and the end time as 457. Those cannot both be describing the same event in the same way. There are many possible explanations for that kind of discrepancy. The radiology timestamp might reflect when the radiologist issued the official report, not when the scan was physically acquired. It might reflect when the images were pushed to the system. Hospital imaging workflows have multiple steps, transport, positioning, sequences, reconstruction, reading, and different systems timestamp different steps. The teaching point here is for defendants and for anyone preparing for a deposition. During her deposition, the neurology resident was asked about the MRI timing. She had no independent recollection of when the scan started or stopped. When asked to reconstruct the timeline using the records in front of her, she relied on the radiology report timestamps, bow because those were the documents she was shown. The defense expert, by contrast, relied exclusively on the clinical nursing note times in his affirmation. The lesson: do not give an absolute answer for something that is outside your scope. If you did not operate the MRI machine, you do not know when the scan started. If you are shown a timestamp, you do not recognize, say so. I did not order this report, I did not operate this equipment, and I cannot speak to what this timestamp represents. That is a complete, defensible answer. What gets physicians into trouble is trying to be helpful, trying to reconstruct a timeline from documents they didn't create, and in the process conceding a fact that contradicts their own chart. Think of it as the deposition equivalent of staying in your lane. You know what you documented, you know what you did, you know what you observed, anything beyond that. System-generated timestamps, someone else's note, a report you didn't write. Acknowledge the limits of your knowledge and let your attorney address the discrepancy through the appropriate expert or witness.

SPEAKER_00 31:54

This is a point that defense attorneys emphasize in preparation sessions, and it's worth reinforcing. In a deposition, the opposing attorney's goal is to get you to commit to a fact. Once you commit, they can use that commitment against you, even if you were only guessing. The phrase, I don't know, is not a weakness. It's a boundary, and it's one of the most important boundaries a defendant can maintain.

SPEAKER_01 32:20

The final clinical lesson from this case involves the disconnect between the NIHSS score and the patient's outcome. Michael, walk us through that.

SPEAKER_02 32:33

The patient in this case had an NIHSS of two. To put that in perspective, the NIHSS ranges from 0 to 42. A score of 2 is classified as a minor stroke. The defense experts cited this score as evidence that the benefits of TPA were questionable, opining that TPA has not been proven to significantly benefit patients with a NIHSS of less than 5. And yet the outcome alleged for this patient is severe. He can't work. He uses a cane. He has dementia. He needs help showering and dressing. He can't remember conversations minutes after having them, a score of two on a scale, and a life that is fundamentally and permanently changed. The NIHSS was designed for and validated primarily in anterior circulation strokes, the large territory strokes that produce the dramatic deficits we associate with stroke, facial droop, arm weakness, language deficits. It systematically underscores posterior circulation pathology, ataxia, which this patient had, gets at most one point. Sensory deficits are capped, thalemic strokes, brainstem strokes, these can produce severe and permanent outcomes from lesions that the NIHSS barely registers. The plaintiff's neurologist was prepared to connect the patient's severe disability directly to the anatomy of the stroke, left thalamic and brainstem infarcts, rather than to what the initial NIHSS predicted. That is the plaintiff expert's framing. There is a clinical point in there that is worth taking seriously. The location of the stroke drives the outcome, and the score on a scale is one piece of information among several that we use to make a decision. That is also why the plaintiff's emphasis on the NIHSS does not fit cleanly with what actually happened in this case. The team in this case had already identified the patient as a candidate for TPA. They were in favor of giving the medication. The score of two was not stopping them. The medication was not given because the patient did not consent, and not because the team thought the score was too low to treat. So the lesson here is not about whether to give TPA at a NYCS of two. The lesson is the broader one. The decision to give TPA should incorporate the score along with patient-specific factors. What the deficit is, what the patient's baseline function is, what the deficit means for that patient's life. The 2015 AHA slash ASA guidelines, which were in effect at the time of this patient's care, do not permit exclusion from TPA based on NIHSS alone. A low score is not a contraindication. The guidelines recognize that patients with low NIHSS scores can have disabling deficits that warrant treatment. The team in this case was already working from that framework. They were ready to treat. The reminder for the rest of us is the same. When an NIHSS comes back as one or two, the question to ask is not, is this too low to treat? It's, is this deficit disabling for this patient? And are we still in the window? Document the answer. That documented reasoning is what carries you through if the case is ever reviewed. Let me summarize the NIHSS real quick before we move on. The NIH stroke scale is not a TPA calculator. It's a structured way to measure stroke severity, establish a baseline, communicate clearly between teams, and track whether the patient is improving or worsening. It's been validated as a reliable stroke severity and outcome prediction tool, but it has real limitations. It can underscore posterior circulation strokes. It can miss functionally disabling deficits, and a low NIHSS does not automatically mean a minor stroke. For thrombolysis, the better question is not just what is the score, but is this deficit disabling? And importantly, a lacuner stroke pattern on MRI does not automatically rule out benefit from TPA. If the patient is within the treatment window, has a disabling deficit, and has no contraindication, lacuner stroke can still be treated because the goal is early reperfusion and limiting neurologic injury. Five things. First, and this is the big one, document your consent discussions with specificity, not risks and benefits discussed. Instead, what specific risks did you disclose? What specific benefits? What was the patient's response, in their words? Who was present? What was the plan going forward? One consolidated, time-stamped note that answers every question a plaintiff attorney could ask three years later. Second, when a patient declines a recommended time-sensitive treatment, document the refusal explicitly. That can be assigned refusal form if your institution has one, or it can be a clear note in your own documentation. Patient was offered TPA, patient declines. Discussion witnessed by name and role. The plaintiff in this case used the absence of any refusal documentation as one of their arguments. A clear refusal note, um, a designed form tend to closes that door. Third, when a patient is undecided about a time-sensitive treatment, build a documented plan around the indecision. Set a redecision time. Reapproach the patient with new information when it becomes available, like the team in this case did with the MRI. Document each reapproach and the patient's response at each point. If the patient remains undecided as the window narrows, escalate to the attending and document the escalation. The chart should show a deliberate process, me, not an open-ended conversation that ends when the clock runs out. Fourth, when the NIHSS comes back low for a patient where stroke is still the working diagnosis, do not treat the score as a contraindication. The score is one piece of information. The 2015 AHA slash ASA guidelines do not exclude treatment based on NIHSS alone. The clinical question is whether the deficit is disabling for the patient in front of you. Document the score, document what the deficit actually is, and document the reasoning that ties them to your treatment decision. Fifth, and this one is for any physician who may someday find themselves in a deposition, know the boundaries of your knowledge. If you are shown a document you didn't create, a timestamp from a system you didn't operate, or a note from a colleague, do not reconstruct a timeline from it under oath. State what you know, acknowledge what you don't, and let your attorney handle the rest. The phrase, I don't know, is not an admission of failure. It's an act of discipline. This case ended with a defense verdict. The jury heard the evidence and sided with the hospital. The appeal is pending, which is a normal part of the post-verdict process. Most cases that go to trial are appealed by one side or the other, and the appeal does not, by itself, suggest that anything improper happened at trial. The appellate court will sort through the specific arguments. Whatever they conclude, the clinical and documentation lessons are the same. The care in this case was not reckless. It was not careless. It was emergency stroke management delivered by a team that moved quickly, communicated across disciplines, and kept re-engaging an undecided patient as new information became available. The defense earned the verdict. The teaching value for the rest of us is that even when a team does its job well, a plaintiff's attorney can try to use the chart against them. And the way to make that argument fall apart in advance is to write notes that don't leave room for it. Document like someone is going to read your chart back to a jury, because they might make the consent discussion a conversation that the chart can reconstruct, not one that the chart merely references. And when a patient is undecided about a treatment that has a closing window, treat that indecision as a clinical situation that deserves a documented plan. Before we end, I want to remind everybody of something. These cases are measured against the guidelines in place at the time the care was delivered. The standard of care used in this case was the standard in place at the time this care was rendered. That does not mean that the standard in this case would be the standard for care delivered at this time. In 2015, stroke care was still more altiplace-centered and thrombectomy selection was much narrower, mostly early window, anterior circulation, large vessel occlusions with criteria like NIH SS greater than or equal to six, ASPECTS greater than or equal to six, and treatment initiation within about six hours. That matters because we should not judge a 2015 decision using 2026 hindsight. But for education today, the framework has changed. The 2026 AHA slash ASA guideline is more nuanced. Altoplase and tenectoplase are both endorsed options in the 4.5-hour window. Disabling deficits matter even when the NIHSS is low. Selected wake-up or late presenting strokes may qualify based on advanced imaging. Thrombectomy eligibility is broader, including some large core strokes and bacillar artery occlusions. And minor non-disabling strokes are generally treated with dual anti-platelet therapy rather than thrombolysis. So the teaching point is this guidelines are timestamped. They can protect you when you follow the standard that existed at the time, but they also evolve. And today's risk reduction requires knowing the current framework, not just the one that applied in the case.

SPEAKER_01 43:25

Thank you for joining us for season seven of On the Record. If this case raised questions about your own documentation practices, that's the point. The Charted Defense exists to bring you the cases that teach. So that you can practice with your eyes open. 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 mental practice 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, and then you can't do that.