Med Mal Mondays - Killer Headaches, “Sentinel Bleeds,” and the importance of the nursing notes

One of my aims in doing these weekly posts is to teach my attorney clients some of the secret medical “Power Words” to watch out for in charts and case histories. These are things that are non-obvious if you’re not in the trade, but they are some of the most important red flags to watch out for when reviewing your cases. I believe that everybody wins when docs and attorneys understand each other's jargon better. Now hopefully my ER colleagues won’t have me killed for spilling these secrets…

On this week’s Med Mal Monday, we’ll be discussing a missed aneurysmal head bleed in a young woman with significant damages. This was a strange case from the very start in that what was documented in the physician’s note was completely different from what the woman later told me. Sure, sometimes a client can revise their story in a self-serving fashion after the fact, but when I interviewed her later I really wasn’t getting that vibe from her at all. So who to believe? Well in this case the nursing notes completely agreed with the client’s account and contradicted the physician’s note. Oops.?

The Case?

If you were to take the physician’s note at face value, this was a case of a 36-year-old woman who had experienced several days of diarrhea which progressed to nausea and vomiting on the day of her ER visit. That’s pretty much it. There was also a brief mention in passing that she’d had a headache on the day of presentation. A minimal workup was done including labs which were normal. No CT scans were done. The patient was given medication for pain and nausea. A later note states that her “pain was resolved” and she was discharged home with prescriptions for meds intended to treat nausea and headache.?

When I interviewed the client a year later though, she told me a completely different story. In her account, she had been taking a shower when she developed a very severe headache and visual changes. The onset of this headache was extremely fast (over seconds), and it caused her to collapse to the floor. She confirmed that she’d had diarrhea for a few days, but only after the onset of this terrible headache did she develop the nausea and vomiting. When she arrived in the ER, her nurse documented this history, noting that her headache was her most bothersome symptom. The nurse went on to chart that the client was struggling to answer basic questions because of the severity of the headache. The nurse also documented that her pain was still “7 out of 10” after receiving the drugs and that light was bothering her eyes even when she was being discharged from the ER.?

I bet that you guys can guess where this whole story is going: 48 hours later, while at dinner with her family, this young woman had another sudden severe headache, but this time she also became paralyzed on the left side of her body and was very confused. She was rushed by ambulance to a large university hospital where she was found to have a ruptured cerebral aneurysm. After emergency brain surgery and extensive care, she ultimately survived but still has partial paralysis on her left side as well as seizures.?

Sentinel Bleeds

To this day, I have no idea why the doctor’s initial history was so far off the mark. If he had just read and addressed the nurse’s documentation, he might not have missed this one. In fact, if he had gotten an accurate history, it is “Textbook”. Cerebral aneurysms can often present just like this: an initial small leak of the aneurysm causes sudden pain, nausea, sometimes a stiff neck and photophobia, but then it temporarily seals off for days to weeks before fully rupturing and causing tremendous damage. This first phase is called a “sentinel bleed”, and it is a golden opportunity for an alert clinician to diagnose the aneurysm with CT and other testing. If found at this stage, the neurosurgeons or interventional radiologists can fix them with a minimally invasive technique before any harm is done. An accurate history from this patient showed almost all of the red flags for a sentinel bleed: A sudden “thunderclap” headache with onset over seconds, the “worst headache of her life”, simultaneous visual changes, etc.?

It was a bad miss.?

The Takeaways?

1. Timely diagnosis of a sentinel bleed is critical. Patients presenting with symptoms of a sentinel bleed require immediate imaging, starting with a noncontrast head CT. If the CT is unremarkable but symptoms are still consistent with a bleed, the patient requires a lumbar puncture. Deviation from this represents a well established breach of the standard of care.?
2. In cases of missed diagnosis, it’s critical to look at every note written on the client to see if they tell the same story. Most providers don’t “tell on themselves” right in their notes, look carefully at the nursing notes as well.