A recent civil suit arose after a 24-year-old woman suffered a major stroke, allegedly resulting from the attending physician’s negligence after she arrived in the emergency department of an Ontario hospital. In Boyd et al. v. Edington et al., the plaintiffs claimed that an error in administering blood pressure medication and a delay in receiving proper care resulted in blockage from blood clots and subsequently caused the woman’s stroke.
The plaintiff, Danielle Boyd had been suffering from headaches and had recently been prescribed medication for high blood pressure. On the evening of Dec 27th, she felt ill and was driven to Hanover Hospital. Upon arrival at 10 p.m., she experienced symptoms of left-sided numbness, garbled speech, unsteadiness on her feet, headache, involuntary eye movement and elevated blood pressure (BP). The emergency physician considered possible diagnosis of hypertensive crisis (HTN), migraine and alcohol use, and decided to keep the patient under observation. He also prescribed medication to lower her BP. At 2:30 a.m., a nurse noted that the woman was dizzy, drowsy and unable to move her left arm, and the nurse advised the attending physician of the patient’s changed condition, but the physician did not reassess the patient until 5:30. At 6:45 a.m., the patient’s condition had worsened, so the physician made arrangements to transfer her to the neurology department at London Health Services Centre (LHSC).
At 12:30, imaging at LHSC indicated a dissection of the right vertebral artery, between her spinal cord and cranium. This meant that the arterial layers had separated and there was bleeding between layers, which could cause narrowing or blockage of the artery, as well as blood clots. The patient was consequently administered an anticoagulant, heparin, to try to prevent blood clot formation, and she remained stable until about midnight on Dec 28th. At that point, she suffered a major stroke which damaged the tissue in her lower brain stem and upper spinal cord.
In Boyd et al., the plaintiffs claimed that the attending physician at Hanover Hospital, Dr. Edington, was negligent in failing to recognize the signs of stoke and in failing to promptly contact LHSC and arrange for the patient’s transfer there. It was also alleged that the physician’s lowering of the plaintiff’s BP exacerbated her minor symptoms and created conditions encouraging blood clot formation. As blockage from the blood clot was the cause of the stroke, it was asserted that, without the lowering of her BP and the eight-hour delay in receiving heparin, the plaintiff would not have sustained a debilitating stroke.
The defendant physician argued that he met the standard of care by treating the plaintiff for high BP and keeping her for observation. He further argued that if the blockage and stroke were caused by a dissection of the artery wall, rather than a blood clot, the action must be dismissed because heparin is not effective in treating a dissection and lowering of BP would not cause a dissection to extend. He also submitted that even if the stroke resulted from a blood clot, the reduction in the plaintiff’s BP at Hanover Hospital did not contribute to blood clot formation. Finally, Dr. Edington stated that, even if one were to assume that the stroke was caused by a blood clot, scientific opinion does not favour using heparin for treating vertebral artery dissection and therefore, any delay in administering a treatment that is not recommended cannot cause damage.
In assessing the standard of care and making a determination of negligence, the Court cited Crits v. Sylvester (1956), where it was stated,
“Every medical practitioner must bring to his task a reasonable degree of skill and knowledge and must exercise a reasonable degree of skill and knowledge and must exercise a reasonable degree of care. He is bound to exercise that degree of care and skill which could reasonably be expected of a normal, prudent practitioner of the same experience and standing.”
It must be noted that a mistaken diagnosis does not, in itself, determine a physician’s liability and doctors are not held to a standard of perfection. Also, one should respect a choice made when there is controversy as to an appropriate treatment. However, as noted in Wade v. Nayernouri, in making a diagnosis, if a physician fails to avail themselves of the means and facilities available to them for collecting the best factual data, does not accurately obtain the patient’s history, fails to refer or consult with specialists when needed, and/or does not perform appropriate tests, the result may constitute negligence rather than an error in judgement. Also, a reasonable doctor should be mindful of a patient’s complaints when treating them, as indicators of a change in their condition.
Justice Sproat heard evidence from several highly-qualified neurologists and experienced emergency room physicians, on behalf of both the plaintiffs and the defendant. It was generally believed that in cases of acute stroke, it is beneficial to maintain BP within a specific range, to avoid increased risk of bleeding and artery rupture associated with extremely high BP, and also, the effects of reduced blood flow to tissue causing infarcts due to very low BP. Based on American Heart Association Stroke Guidelines, BP should not be lowered in the setting of an acute stroke, unless systolic BP exceeds 220 or diastolic BP exceeds 120. However, at 170/112, the plaintiff’s systolic BP was not in the range that required intervention and her diastolic BP was barely in the range, at the time that heparin was administered as per the defendant’s instruction. Also, if LHSC had decided to lower her BP, they would have done so in a controlled and slower rate, with less impact on her blood flow than was experienced at Hanover Hospital. In fact, the plaintiff’s average BP was reduced by about 37 per cent over 3 hours, which is significantly more than the recommended guidelines.
Justice Sproat noted that the lowering of the plaintiff’s BP had an observable and immediate effect, which was her inability to move her left arm, and this likely resulted when reduced blood flow promoted the growth of blood clots. From the plaintiff’s fluctuating symptoms, particularly her inability to move limbs, one could conclude that blood flow and oxygen to her brain and spinal cord cells was tenuous and severely compromised, which would result in cell deterioration. Dr. DePetrillo, who testified on behalf of the plaintiff, submitted that the plaintiff’s signs and symptoms, including numbness on her left side, headache, garbled speech and so on, “should have indicated the possibility of a serious neurological emergency”. Further, it was his opinion that “stroke should have been part of any differential diagnosis” and accordingly, Dr. Edington should have consulted with a neurologist at LHSC after his initial assessment. Dr. DePetrillo stated that to not do so constitutes a breach in standard of care required of an emergency department physician in a rural hospital. Another of the medical experts, similarly noted that Dr. Edington breached the standard of care when he failed to reassess the plaintiff and call LHSC, when her condition deteriorated at 2:45.
In their evidence on standard of care, the medical experts for the defendant used their general emergency department experience in support of the opinion that alcohol was a contributing factor in the plaintiff’s condition. The defence’s experts also submitted that lowering of the plaintiff’s BP did not contribute to, or cause the clotting. However, Justice Sproat did not accept these conclusions and believed that the experts did not adequately focus on the plaintiff’s specific condition. The judge also surmised that their evidence on these issues “suggested partiality or advocacy on their part”. Justice Sproat was satisfied that the lowering of the plaintiff’s BP at Hanover Hospital reduced her blood flow to a ‘trickle’ which in turn promoted blood clot formation and growth, causing her stroke.
One of the issues that was addressed at trial is the fact that Canadian and U.S. guidelines do not recommended using the drug, heparin, under any circumstances. On this basis, an expert witness for the defendant argued that an earlier start to a treatment that is ineffective, does not make any difference. However, evidence revealed that heparin continues to be prescribed by leading stroke experts and would have been administered at LHSC if it was determined that the plaintiff’s BP needed to be lowered. Also, one of the defendant’s own medical experts testified that they would have administered heparin under the same circumstances, and another admitted that there are exceptions to the general rule regarding its use.
Justice Sproat concluded that if Dr. Edington had met the standard of care, the plaintiff’s BP would have been lowered at the same time heparin was given. This would have the effect of lowering her BP to promote clot formation while the heparin inhibited clot formation. Instead, her BP was lowered promoting clot formation but heparin was not administered until about 10 hours later. Considering all the evidence, Justice Sproat concluded “on a balance of probabilities that “but for” the delay in the administration of heparin Ms. Boyd would not have suffered a debilitating stroke”.
Accordingly, the judge found that Dr. Edington breached the standard of care. The plaintiff was awarded damages in the amount of $15 million.
If you or a loved one suffered an injury due to the likely negligence of a medical practitioner or medical facility, you may have legal grounds to seek damages for medical malpractice. Call an experienced medical malpractice lawyer at Kotak Injury Law to discuss the facts of your case and determine the strength of your claim.