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Critical Care

• Head injury patient given anticoagulation (blood thinner) for heart attack concern; develops cerebral hemorrhage, coma, and dies.

Head injury patient given anticoagulation (blood thinner) for heart attack concern; develops cerebral hemorrhage, coma, and dies.

The basic standard of care in medicine requires the doctor to take an adequate medical history, perform a reasonable physical examination and create a "differential diagnosis," a list of probable diagnoses based on the history and physical. This differential diagnosis is the fundamental basis of all medical and surgical care, and is taught to every third-year medical student. They then have to rule them out and not endanger their patient.

In this case, a 65-year-old diabetic man (for 25 years) had a history of coronary artery heart disease for which he had a coronary artery bypass graft (CABG) operation two years before and amputation of both legs because of severe artery disease that did not respond to vascular surgery.

He was taken by ambulance to the emergency room on April 24 complaining of "tightness in the chest and shortness of breath (SOB) for a couple of hours with vomiting and dizziness."

He told the Emergency Room Triage Nurse, "Two days ago fell out of wheelchair and struck back of head on concrete. Last p.m. onset of SOB plus vomiting x 3, followed by chest pain and continued SOB." At that time (0625), he "denies any chest pain. Complains of SOB…" The lungs had "fine rales," which are wet breath sounds consistent with congestive heart failure, also confirmed by a chest x-ray.

Just before he was admitted to the Coronary Care Unit, the emergency room nurse's note begins with, "…History of (H/O) fall out of wheelchair, striking back of head on concrete."

The nurses admitting physical examination form states under "skin": "abrasion (scrape) noted back of head from recent fall, tender to touch. Nurse #1."

Dr. #1, his regular physician, saw him and failed to note anything about him falling and striking his head on concrete. One of the causes of vomiting is a head injury, especially where there is bleeding or swelling involving the brain. The failure to obtain that relevant "present illness" medical history (or to simply read the emergency room record where it is recorded in two places) is a departure from the accepted standards of care.

Dr. #1 also performed an inadequate physical examination because under "HEENT (head, eyes, ears, nose and throat)" he noted, "hearing aids, normal fundi (retina: back of the inside of his eyes, which is unlikely in an insulin dependent diabetic of 25 years duration, since they develop multiple areas of small blood vessel [artery] disease) and thyroid normal…." Not one word about the tender abrasion on his scalp.

Having failed to obtain (or read) the relevant head injury history, or note the head injury with his physical examination (both negligent), he jumped to the conclusion that he may be sustaining a heart attack. The EKG (electrocardiogram) was not supportive of that diagnosis. The cardiac enzymes (CK-MB: creatine phospho-kinase myocardial band fraction), which are proteins released into the blood from oxygen starved and dying heart muscle showed "slight elevations of the CK-MB fraction." (Normal is 0-5.0. At 7:05 a.m. in the Emergency Room it was 7.09 and at noon it was 6.91.) This is questionable and it did not rise, even more questionable.

If there is any reasonable potential for a head injury that caused bleeding within the skull (brain), a CT scan done as an emergency is the proper standard of care before any anticoagulation ("blood thinner") is started. Dr. #1 failed to obtain a CT scan because of his negligence in his differential diagnosis, noted above. He ordered STAT (now) grains V (one adult 325 milligram aspirin) and it was given at 0855. Aspirin will damage all the platelets (clotting particles produced by the bone marrow) and will have its effect for up to one week, until the body makes enough healthy undamaged new platelets, or they are given by transfusion.

To make matters even worse, he ordered the very potent injectable anticoagulant, heparin, to be given intravenously (IV) as 5,000 units immediately and then 1,000 units IV every hour. He ordered the blood coagulation test for monitoring its "therapeutic" effectiveness, the PTT (Partial Thromboplastin Time). At 1040 on April 24 the PTT was 23.2 with the normal range of 25-35 seconds, but at 2100 it was 51.6 and on April 25 at 0600 it was 46.3. It was working.

By 1430 on April 24, he had already received the 5000 units of heparin and was getting the 1000 units per hour. He was "awake/alert/oriented." At 2300 he had "fleeting nausea without emesis. Medicated with Tylenol for headache and leg pain...." Dr. #1 was made aware of all the laboratory results but the failure of the nurse to advise him of the patient's headache, considering all of the above, was a departure from their accepted standards of care.

At 2300 he was found "lethargic, diaphoretic (sweating), BP (blood pressure) 170/100 (elevated even for him and it rises as the pressure in the brain rises). C/o (complains of) severe frontal headache." They also noted a change in his sensorium, "disoriented to time and place…follows commands but stares blankly when asked where he is - only verbalizes re: my head hurts very badly - Dr. #1 called - advised regarding patient's complaint of pain, headache, increased BP (blood pressure), neuro (neurological) status - apparent confusion - orders received for Tylenol with codeine (a narcotic) for headache to be administered. Nurse #1."

He is grossly negligent. His patient receiving therapeutic doses of a "blood thinner" had a severe headache and significant neurological change. Even if he never knew of the head injury, the standard of care demands that the heparin be stopped, the antidote, Protamine, be given, a physical examination by some doctor (him, a Neurology or Neurosurgeon consultant, or even the Emergency Room Doctor) be done without any delay, and an emergency CT scan be done. It would have shown early bleeding into his brain and had a reasonable chance of not bleeding further with his clotting mechanism impaired by the heparin anticoagulant all night long, if he was treated with the antidote. He may not have had any significant defect and would not have died.

The Nurse was negligent for not going to her supervisor (up the hospital "chain of command") to protect her/their patient from obvious (to a nurse) negligence (even if she did not know of the head injury in the nurse's notes in the chart in front of her).

At 0030, "Patient complained of headache (c/o HA) - medicated with Tylenol with codeine grain ? (15 milligrams)." The heparin was running well at 1000 units per hour. During that 11 p.m. to 7 a.m. shift, "Patient lethargic but arousable (illegible words)."

By 8 a.m. he was "not responsive" and the heparin was turned off, but no antidote given to immediately stop its lingering effect for a few hours. Further negligence.

At 9:20 a.m. on April 25 he was transported for the CT scan of his brain which showed blood on both sides of its surface and within its flesh. A neurologist and neurosurgeon were called to see the patient and gave proper care. There was no localized area of blood (hematoma) to operate on and drain. The next day it was somewhat more as blood degenerates and increases in its volume and damage to his brain. He was comatose. They tried to decrease the swelling with a potent steroid medication (Decadron) and diuretic that pulls water out of the brain (Mannitol), but he died in a deep coma on April 28.

Because of initial findings of congestive heart failure (CHF), Dr. #1 correctly ordered the very potent diuretic Lasix. However, it helped to somewhat dehydrate the patient and caused a reversible type of kidney failure (pre-renal azotemia). That part of the care was not negligent, but the cause of death on the death certificate assigned by Dr. #1 as, "Part 1 (A) Immediate cause: Acute renal (kidney) failure; due to or as a consequence of: (B) Chronic renal failure; due to or as a consequence of: (C) Diabetes mellitus; other significant conditions contributing to death but not related to cause given in Part 1 (A): Heart failure, ASHD (arteriosclerotic heart disease), cerebral hemorrhage," it is negligent and a cover-up.

That is grossly wrong and a falsification of the death certificate. He died as a direct effect of the unchecked cerebral hemorrhage markedly worsened by Dr. #1's negligent beginning anticoagulant therapy and not stopping it promptly when the nurse told him of all the factors that would lead any prudent physician to stop the heparin and intercede as I noted in detail above!

Dr. #1 and the Nurses (therefore the Hospital) were negligent as I noted, and their negligence was the proximate premature cause of the death of this patient.

In this case I suggest you authorize us to obtain the services of Experts in Neurosurgery, Neurology, the same specialty of Dr. #1 (what is his Board Certification and how does he advertise his services in the Yellow Pages?) and a Nurse.

The Defense will contend that he did not come to the Emergency Room complaining of a headache. He complained of tightness in his chest, the CPK-MB enzymes were "slightly elevated" and the chest x-ray was very consistent with congestive heart failure. However, he failed to take a recent medical history or even read what the nurses wrote. He was then called at night with all the information that a third-year medical student would be able to conclude: Rule out cerebral hemorrhage in a patient receiving therapeutic doses of a potent anticoagulant. He failed to act responsibly causing the death of his patient, which he covered up by falsifying the death certificate!

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