By Stacey Kusterbeck
Patients who reported dizziness often were discharged home or admitted without anyone diagnosing central nervous system pathology.1 The patients presented to an ED and were diagnosed with migraine, anxiety, benign vertigo, or other conditions. The correct diagnoses only became clear later. The subsequent lawsuits revolved around the first EP missing their diagnosis at the initial ED visit, according to the analysis of 69 malpractice claims.
“Patients presenting with dizziness have long been a challenging group of patients for emergency physicians,” says Rachel A. Lindor, MD, JD, one of the study authors and associate chair of research at Mayo Clinic in Phoenix.
Lindor and colleagues were aware the Society for Academic Emergency Medicine was working on addressing practice guidelines for acute dizziness in the ED. “We thought that better understanding the associated legal risks would complement this work,” Lindor says.
In all the lawsuits included in the analysis, patients presented with dizziness and experienced poor outcomes because of a missed or delayed diagnosis of central nervous system pathology. The cases included other allegations, such as failure to treat or consult with neurology. Plaintiffs also alleged failure to order an MRI or CT scan, or a misreading of an ordered radiology scan.
These patients were relatively young (median age = 45 years). This suggests that among younger patients, EPs might be underestimating risk of serious central nervous system pathology.
Most plaintiffs experienced symptoms for longer than 24 hours before they presented. This suggests EPs might be underappreciating risk for patients with less acute presentations. “These were not elderly patients with acute onset dizziness, who are often the patients we think of as being high-risk,” Lindor notes.
Obtaining neuroimaging did not appear to reduce the risk of a poor legal outcome. Plaintiff attorneys often alleged ED providers should have obtained a CT or MRI to evaluate the patient’s symptoms. “But these cases were no more likely to be successful in court than cases in which providers did obtain neuroimaging during the first evaluation,” Lindor reports.
The cases varied in terms of pathology and patient demographics. “This highlights the difficulties clinicians face in attempting to recognize patients with a dangerous underlying cause for their symptoms,” Lindor observes.
Lindor and colleagues recommended EDs use a standardized approach that incorporates a focused physical exam, neuroimaging, and specialist consultations (when appropriate). “This can help avoid the pitfalls illustrated by the cases in our series,” Lindor suggests.
Dizziness is a problematic complaint in the ED in part because it is tricky to define, according to Martin Huecker, MD, research director in the department of emergency medicine at the University of Louisville (KY).
“The first step in taking a history on these patients is asking them what they mean by dizziness,” Huecker says.
This allows the EP to assign a more precise term for the patient’s symptoms — lightheadedness, vertigo (a spinning sensation) or disequilibrium (feeling off-balance). The differential diagnosis and workup for these three complaints differs. Lightheadedness could mean dehydration; heart issues, including ischemia; low oxygen; anemia; and many other conditions.
“Vertigo makes us more worried about the nervous system, and it is separated into central and peripheral. Peripheral is outside of the brain, central is in the brain. Central is, of course, more serious,” Huecker explains.
Disequilibrium could mean a brain problem, such as a stroke, but also can be toxic ingestion or many other causes. “Once we are moving down one of these pathways, we can be more consistent in ruling out emergencies,” Huecker reports.
In the event of malpractice litigation, Huecker says there is important documentation that can be helpful to the ED defense. For instance, a full history, including medical comorbidities that could put the patient at risk for stroke. Also, a full physical exam with a detailed neurologic exam (including a cerebellar exam) and, especially, the patient’s gait. “Even if the patient is unsteady, we must assess their gait,” Huecker warns.
Plaintiff attorneys will scrutinize the record to see if documentation of the patient history was poor or if the clinician performed an inadequate physical exam. An insufficient differential diagnosis list that perhaps anchors on less serious causes of dizziness could be a red flag. The overall ED workup, and whether the EP explained the rationale for ordering or not ordering certain diagnostic tests, likely will be part of the plaintiff’s discovery process.
As with any malpractice cases, EPs can protect themselves legally with clear documentation, including reasons for the patient to return to the ED and the importance of follow-up. “These are even more important if we do not confirm a diagnosis,” Huecker says.
REFERENCE
1. Ghaith S, Voleti SS, Bellolio F, et al. Dizziness as a missed symptom of central nervous system pathology: A review of malpractice cases. Acad Emerg Med 2022; Nov 10. doi: 10.1111/acem.14627. [Online ahead of print].
After reviewing dozens of malpractice claims, researchers learned patients who reported dizziness often were discharged home or admitted without anyone diagnosing central nervous system pathology. Patients presented to an ED and were diagnosed with migraine or other conditions. The correct diagnoses only became clear later. The subsequent lawsuits revolved around the first emergency physician missing the diagnosis at the initial visit.
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