Patient With Signs of Acute Stroke Receives Delayed Neurology Consult

This case involves a patient who arrived at the emergency department with acute presentations of stroke. The patient exhibited slurred speech, eye deviation, and facial weakness. A CT scan was completed, however, the patient was not admitted for an extended period of time. In the meantime, the patient deteriorated significantly. The patient did not receive a neurology consult until the following day, at which point they were diagnosed with a massive cerebral infarction and paralysis on one side of their body, warranting a transfer to ICU. An emergency medicine physician was sought to review the patient’s course of emergency care, and whether their symptoms were addressed in a manner to minimize the neurological damage.

Question(s) For Expert Witness

1. Do you routinely manage patients with a history / acute presentations of stroke?

2. When faced with such a case, what are the measures you employ to limit the degree of injury?

Expert Witness Response E-007048

I routinely care for patients with acute presentation of stroke. I am an Associate Professor of Emergency Medicine at a world renown academic medical center. I have been a member of the faculty of this institution since 2009 and also did my residency at this institution. I regularly work clinically in the emergency department. I am Board Certified in Emergency Medicine and Subspecialty Certified in Emergency Medical Services. I work at an inner-city urban academic tertiary care center that is a stroke center. I have lectured on the topic of acute CVA.

When it comes to the management of acute stroke, time is everything. Given the presentation of witnessed onset of neurologic deficit, it is imperative to determine what that new deficit is and to what degree (perform an NIH stroke scale) as well as several key time factors, specifically the time the patient was last normal and the time of the onset of symptoms. This information would determine whether or not the patient required an emergent neurology consult and whether or not they were in the therapeutic window to receive thrombolytic "clot busting" drugs.