News: A woman suffered a stroke and was admitted to a hospital for treatment. The hospital physician sought a consultation with a telemedicine company. A neurologist assigned by the company determined treatment with tPA, a medication that breaks up blood clots and restores blood flow, was appropriate. The patient consented and received the treatment, but ultimately suffered a hemorrhage and died.
The patient’s husband filed a malpractice suit, claiming the care providers delayed treatment — which took more than two hours after the patient’s admission — and requesting a consultation. However, experts testified the risk of hemorrhage was prevalent even if treatment had been provided earlier. The trial court granted the defendants’ summary judgment, which was upheld on appeal.
Background: In July 2014, a woman was taken to the ED around 11:00 a.m. after her friend noticed she could not speak. Nurses alerted the physician of the possibility of an ischemic stroke. The physician examined the patient and ordered a CT scan and lab work before requesting a neurology consult with a telemedicine company that provides on-call specialists to help determine whether the patient is a candidate for tPA. The physician requested the consult at 1:07 p.m.
A nurse at the telemedicine company reviewed the patient’s information, spoke with the physician at the hospital, and sent the patient into a queue to await lab and CT results before assigning a neurologist. The nurse prioritized the patient as “intermediate” rather than “high” because the physician noted the patient was improving and could speak.
The attending physician received lab work and CT scan results around 1:50 p.m. and provided those to the telemedicine company. However, over the next half hour, the patient’s condition worsened, her ability to speak diminished, and she became more confused. The physician hospital nurse followed up with the telemedicine company, and a neurologist was assigned at 2:56 p.m. The neurologist determined tPA was appropriate, and informed the patient and her husband of the risks, including the possibility of hemorrhage.
The patient and her husband consented to treatment, and the hospital staff administered tPA at 3:17 p.m., which was within the 4.5-hour treatment window advised for the medication. The patient ultimately suffered a hemorrhage and did not survive.
The patient’s husband sued the telemedicine company and the hospital, claiming the defendants delayed in providing treatment, which resulted in a loss of opportunity to benefit from tPA. The plaintiff provided a statement from an expert who claimed the failure to timely treat resulted in a less favorable outcome. However, during deposition, the expert admitted tPA can be administered up to 4.5 hours after the onset of symptoms, and that hemorrhage is the most common risk. The expert further noted the chance of hemorrhaging was present even if the patient received tPA early, given her hypertension.
The defendants’ expert noted the risk of hemorrhage only increased by 0.1% when tPA is administered at the 4.5-hour mark compared to the three-hour mark. The expert also explained this was not a clinically significant difference, and a delay did not affect the risk of hemorrhaging.
The trial court granted summary judgment for the defendants, finding no evidence the delay in obtaining the consultation and treatment caused the hemorrhage. The patient’s husband appealed, but the appellate court upheld the judgment.
What this means to you: This case confirms the importance of timely treatment and how providers can defend against claims of failure to provide such treatment. Frequently, a patient’s condition requires time-sensitive treatment, and the failure to do so may constitute medical malpractice if a similar physician under such circumstances would provide that timely care. Depending on the provider’s specialty, these concerns may be even more prevalent. That was the case here, as the providers were an attending ED physician and on-call neurologist.
Fortunately for the providers in this case, any delay in treating the patient was deemed immaterial based on known medical standards. In a malpractice suit, the injured patient is required to prove causation as a necessary element. If the patient cannot prove that, the case necessarily fails.
There are several methods for challenging causation. In this case, the defendants successfully demonstrated the delay did not cause the patient’s injury by providing expert testimony confirming hemorrhages are a known risk of tPA treatment — and, more importantly, the risk does not increase if the patient is treated at the three-hour mark or at the 4.5-hour mark. Even the patient’s expert agreed to these medical facts, concurring with the defendants’ expert.
The court found it did not matter if the patient received the tPA treatment sooner because the risk of hemorrhage was the same. Thus, it was impossible for an expert to state the patient would not have suffered the hemorrhage if the tPA treatment had been administered sooner. Since the plaintiff did not prove this necessary element, the case was defective as a matter of law, and judgment was proper for the defendants.
When faced with a malpractice action, providers should evaluate this cause-and-effect relationship the patient alleges. If a patient claims some specific action or inaction caused the injury, other intervening or superseding causes might be responsible. If a provider can demonstrate his or her actions did not cause the harm, or the harm would have occurred regardless of the provider’s actions, then there can be no malpractice liability. These are critical aspects of a case to explore in depth in discovery and to challenge if there is any doubt as to causation.
If a defendant presents such a strong defense that unequivocally confirms the plaintiff’s case is defective, procedures are in place to allow early adjudication. This is commonly known as summary judgment, whereby one party can request the court determines as a matter of law based on undisputed facts the party is entitled to judgment. A jury is not used for this process since there is no factual dispute, and the court is capable of ruling based solely on the law.
Here, both experts agreed on the medical facts related to tPA administration, timing, and hemorrhage risk, so the court was not required to make any determination of such issues. Rather, the court merely had to apply those facts to the law and found the defendants were entitled to prevail. These circumstances do not occur in every malpractice action because it is quite common for fundamental, factual disputes about what happened, or when certain events happened, that affect adjudication.
However, when there is no dispute about the facts, or about a small but critical subset of those facts, it may be possible for care providers to successfully prove their defense without the need for a jury. If available, this option can be significant as it confirms the lack of liability, cuts off expensive legal fees and costs, and prevents the need for a trial and jury, which are inherently unpredictable. In this case, the defendants successfully proved their actions did not harm the patient, and did so before putting the issues in front of a jury, representing a complete and early victory.
REFERENCE
- Decided Aug. 25, 2022, in the Court of Appeals of Georgia, Case Number A22A0960.
This case confirms the importance of timely treatment and how providers can defend against claims of failure to provide such treatment. Frequently, a patient’s condition requires time-sensitive treatment, and the failure to do so may constitute medical malpractice if a similar physician under such circumstances would provide that timely care.
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