ER folks - what to think? (some RO)

My friend told this story yesterday. Her mom wasn’t feeling well over the weekend a few weeks ago but her husband thought she looked OK and so she didn’t seek help. A couple of days later (I think) she said no, something’s really wrong and he needed to take her to the hospital. She goes in saying she thinks she is having a stroke, so they say they will give her an MRI. There isn’t a bed available so they park her in the corner. At this point she has full use of her body. Her husband has to leave to meet workers at their house so he isn’t there for part of the time.

By the time they come back to her (20 hours later according to my friend) she has lost the use of her right side. She’s now in rehab for the rest of the month re-learning eveything on that side.

Part of me is outraged because early intervention may have mitigated the effects. Did they not believe her? This is a rural hospital but it is a major one for the area so they do get the bigger traumas and transports in from other hospitals. Maybe they were swamped. But we’re not talking a huge urban ER here. Maybe she should have been louder and more forceful…?

This is just upsetting all around, if there’s something that could have been done for her.

Call a lawyer. Patient comes in with possible stroke, doesn’t get treated for 20 hours? Get ye an attorney posthaste.

20 hours waiting in a hospital ER is ridiculous no matter what the ailment. But it seems particularly outrageous given the stated concern. Was she able to enunciate what it was that made her think she was having a stroke despite having full physical function at the time?

… Or rather, your friend’s mother should get a lawyer. It isn’t really your case.

Your story has some missing and/or contradictory information. If she had full use of her body on initial presentation why did she think she was having a stroke? If she had no neurological deficits on exam why would they do an MRI?

If she had been having symptoms for a couple of days she was outside the window for any emergent intervention. The exception to this would be a TIA (transient ischemic attack). It’s what people call a mini-stroke, although I really dislike that term. What happens is the bloodflow to part of your brain gets cut off for long to cause stroke symptoms but not long enough to cause permanent damage. So when the bloodflow is restored the symptoms resolve. But it’s a major warning sign that you’re at risk for a true stroke. So if she had focal weakness over the previous couple of days which resolved by the time she presented to the ED and then had a stroke while she was there that would be plausible. So lets say she was neurologically normal when she came in and then developed R sided paralysis while there. You would still need to know more about the specifics of the stroke and her personal medical history to determine whether she was even a candidate for the clot-busting drugs we sometimes give.

In short you don’t have enough information to say whether her treatment was malpractice, OK but not great or completely appropriate.

Also, I have worked in a crappy, overcrowded, under-resourced urban ED and even there patients didn’t sit for 20 hours without anyone looking at them. If nothing else there would have been a change of nursing shift and they’re supposed to document a nursing assessment on each patient. Was she boarding in the ED - admitted to the hospital but physically sitting in the ED because there were no inpatient beds available?

She probably should sue her husband as well, since he told her she looked okay so she didn’t seek help. And then he left her at the hospital for 20 hours sitting in the corner while he headed home.


A significant portion of my job has been reviewing care given based on patient complaints. More than half the time, I find that the story I get from patient/family is quite different from that which is documented in the medical record.

Sometimes the failing is in informing the patient/family just what’s going on and why. Sometimes patients/families are upset by what’s going on and won’t be happy with anything except restoration to their normal routine. Sometimes the medical staff fucked up too. But as a rule, the medical providers generally are found to have made a reasonable and acceptable effort to meet the patient’s legitimate needs.

I agree with this. Anyone in a hospital needs an advocate.

I also think there’s more to the story. During my cancer clusterfuck last year, I was in the EDs* of three different hospitals multiple times. They were all swamped, all super-busy, and I was checked on at least every 15 minutes.

  • For some reason, they’re Emergency Departments now. I’d have no issue with this as it more accurately describes them except that most civilians are more familiar with that acronym as something else! It diminishes emergency departments, IMO.

As I have said many times before, I worked as CT/MRI Tech for a number of years in both small/large rural and large major hospitals in several States. I cannot remember once where a patient who stated they thought they were having a stroke was not whisked off to Radiology for at least a CT of brain to start with (r/o aneurysm at minimum as stated reason for exam). Done plenty of emergent MRI’S also.

NEVER have I come across a patient who waited 20 hours, let alone an hour or more (for the most part) if there was any reasonable suspicion of even a possible TIA or such. Just patient saying they felt ‘weird’ was more than enough to get 'em scanned appropriately - unless they were known diabetics or had other type of pre-existing thing. Many times, as I was in middle of a scheduled/routine exam, I’d have ER-staff come into control-room and tell me they have a suspected-stroke patient awaiting outside of scan room. THAT person was next to be scanned (ASAP) - period. In the Trauma Level 1 places, it was not unusual for the radiologist and/or neuro Docs to sit there and watch as the images came up, fwiw.

20 hours of waiting, for most any complaint, is bullshit - unless this person was a frequent-flyer on ED visits for ‘feeling weird or whatever’ and staff got used to her being a ‘whacko’ seeking attention medically when uncalled for (some Docs/Nurses called it ‘lonely old lady syndrome’, IME). Not saying this is/was the case above, but I’ve seen such type persons (not often, though). Those types can slip through the cracks at times when something is actually wrong - seen it happen, unfortunately. But the wait to eval/re-eval them periodically was never on the excessive side by any means.

As an aside, this reminds me of a TED talk by Jill Bolte Taylor who experienced a massive stroke and remembers the feelings of its onset, etc and speaks of it in personal detail. Quite interesting for those who want to know more about strokes and effects.

A smallish TIA (or repeated infrequently ones) would not (necessarily) cause such largely somewhat-immediately noticeable effects such as described by her (a brain researcher to boot), such as pendgren states (and I agree with totality of that post). But if OP’s subject did have what would be routine periodic medical charting of worsening sx’s on re-evals over those 20 hours, then there’s a serious issue somewhere, IMHO and experience(s).

Really? Your wife might be having a stroke and you can’t cancel the workmen and stay at the hospital?

And it takes you 20 hours to come back?

I know, I am getting the story third hand. As my friend told it, they had been told she would be getting an MRI, and she told him to go home. I don’t think he was away for the whole time.

Her being told she would be getting an MRI makes me think the ER folks recognized what they needed to do, and the patient would assume they would be doing it within the required time. But that’s us throwing a lot of assumptions out there!

I don’t know about the first part, but I do know they said they would be giving her an MRI, so something made them think that was the next step.

This is the part that confuses me the most. If someone comes in with acute neurological deficits and I’m trying to figure out whether they’re a candidate for intervention I start with a CT, not MRI. It’s much faster and time is brain. If they appear to have had a TIA they get a CT angiogram to assess the blood vessels to the brain and admission to neurology for monitoring, MRI and probably a cardiac echo. That’s at my current institution. At the previously mentioned large urban ED neuro would sometimes try to get their MRI from the ED so they could avoid the admission. If someone comes in with a completed stroke well outside the interventional window I may call neurology and discuss whether they want to skip the CT and go straight to MRI. So starting with MRI suggests to me that she may have been beyond the point where they could do anything but that conflicts with the report that she had full use of her right side on arrival.

Did your friend tell you whether his mom got a clot buster drug (tPa) or procedure to try and remove the clot from her brain? Because that would mean she had an acute stroke that was diagnosed within a few hours of onset and treated. In which case the bit where she sat in the ED for 20 hours without anyone doing anything is wrong.

I’m a deficient witness here :slight_smile: From what she said, they didn’t do anything – she didn’t mention any meds. Of course she was having a hard time talking about it.

I guess I just need to assume there is more to the story!

Having spent an enormous amount of time in emergency departments, I find the story as told pretty implausible.

Given the 20 hours seems like made up nonsense it’s quite possible your friend is giving you a wildly dramatized and inaccurate version of events viewed through the lens of their emotional state.

I agree in one sense. In another, she went where you’re supposed to go to get help, and she had full function when she went in. She left with her right side disabled. Is there something that could have been done that wasn’t, based on those facts?

Those are pretty scant facts. Perhaps if they hadn’t intervened, she’d be comatose from a massive brain bleed, or dead, rather than with some weakness amenable to therapy. Maybe they did what they could, but it was too late, as she did complain of feeling like she was having a stroke before she went there. Often, by the time symptoms appear, it’s too late to reverse things, or even keep them from going further.

Not all bad outcomes are preventable. Everybody dies eventually. Medical professionals try to help where we can and often make huge differences. But failure to have a good outcome is NOT automatic evidence of someone making a mistake.

I can think of one scenario that fits all of the information in the OP:

The patient comes in with stroke-like symptoms that have resolved. Gets a typical ED workup including labs, EKG and a CT Head (many patients confuse CT and MRI, but as mentioned above CT will be first test in >99% of cases). Everything comes back normal, they decide to admit her for further evaluation of possible TIA (which would include MRI). She gets seen by a hospital doctor and has admission orders placed (including neuro checks every 2 hours). But there are no beds available in the hospital so she is boarded in the ED for an extended time (20 hours is long but not unheard of for a Monday night-Tuesday morning). The ED is good at a lot of things, but doing inpatient nursing tasks (like scheduled meds and neuro checks) is not one of them.

It’s possible her stoke-like symptoms returned during her ED stay and no one noticed (even the patient) until it was too late to intervene. There is a 3-6 hour window (depending on the institution) where ‘clot-busting’ drugs like tPA can be helpful for acute strokes. If she had onset of symptoms after falling asleep on her stretcher and then no one came around and checked her for a few hours it would be too late at that point.

This is exactly the procedure I went through when I suspected a TIA (turned out to be symptoms from an ocular migraine). No questions asked, just whisked me into a room and started hooking shit up. In quick succession, I saw a nurse, the ER doc, and a neurologist (they found a couple of small aneurysms). The people who check you in at an ER are usually very well trained in triage.

That was my first thought as well.

Jesus, my FRIENDS would cancel the workmen and stay with me if needed!