Blindness Results After Woman is Denied Adequate Care

This case takes place in Iowa and involves a female patient who initially presented to a physician assistant complaining of chronic headaches. Five days later, the patient presented to the ER with a severe headache, which she described as feeling like her head was in a vice grip. The patient also had scotoma, blurred vision and photophobia. Five days later, the patient was seen at the ER again by another physician assistant. This time, elevated intracranial pressure was suspected and the patient was sent for a CT scan, however the scan was interpreted as within the normal limits. The patient was seen later that day complaining of difficulty balancing. The patient was discharged with Topomax and oxygen and told to follow-up in a week. One week later, the patient presented to the ER again with headache and loss of vision in the right eye, and blurred vision in the left. A CT scan was again normal. The patient was recommended for neurology and ophthalmology consultation at that point, however she was not seen by either. The patient visited the ER several times more with no resolution. After a month had passed, the patient was finally seen by a neurologist at an out-patient facility. A lumbar puncture was ordered which revealed elevated pressure, and the diagnosis of pseudotumor cerebri was made. A shunt was placed, however it was too late and the patient was left blind in both eyes.

Question(s) For Expert Witness

1. Do you treat patients with elevated intracranial pressure? If so, how often?

2. What is the standard work up for patient's presenting with these symptoms?

3. Should the patient have been discharged without treatment so many times?

Expert Witness Response E-006207

My initial thoughts, without seeing the rest of the chart, would be that the initial ER visit involved the patient complaining of a HA with symptoms that could be seen in migraine or a host of other things (not sure what the diagnosis was then). The second visit to the ED involved a PA "suspecting" elevated ICP (did he/she write that in the chart? I'd like to know what else they wrote). A CT scan is part of an evaluation for someone suspected to have elevated ICP, but another important test should be included. That would be a pressure measurement of some sort; usually a lumbar puncture (spinal tap) with an opening pressure measurement. I would like to know if one was done. That second visit the same day for "imbalance" is alarming to me on first glance. I would like to know what they were treating with the Topamax, unless that was for migraine prophylaxis which is sometimes done by a neurologist. Surprised an ED provider would initiate something like that. It's a seizure drug too, but there is no mention of that. On first glance, I think if there is suspicion of elevated ICP, a lumbar puncture should be done. If that pressure is high, it warrants an immediate/urgent neurology consult. I think a week is too long in someone with active, and worsening (new imbalance) symptoms. I am surprised there were so many visits without even a call to a specialist.