Texas Spinal Tap

[timwgrisham]

I was admitted to a Texas hospital in April 2009 for stroke symptoms and was given blood thinners then a lumbar puncture that was later diagnosed after an MRI to have caused bleeding into my spine, causing excruciating painful mussel cramps and spasms in every mussel of both legs.

I rember lying in bed for days under high levels of pain medication but even though I was in excruciating pain and rember that about every six hours or so I would notice that I had lost fifteen or twenty minuets due to sleep and that was the only relief I ever rember during those days.

I was released from the Hospital after the full diagnoses but could not walk and was bedridden and still in excruciating pain with all my leg muscles cramping and spasms for almost a full month.

1.) Should the Doctor have given me the spinal tap knowing that I was treated with blood thinners?

2.) Shouldn't I have been informed that I may have a full month of unbearable pain before I received the procedure?

This seems like a no-brainer malpractice case to me !

Thanks,
houstontwg @ hotmail

[Proserpina]

Originally Posted by timwgrisham

I was admitted to a Texas hospital in April 2009 for stroke symptoms and was given blood thinners then a lumbar puncture that was later diagnosed after an MRI to have caused bleeding into my spine, causing excruciating painful mussel cramps and spasms in every mussel of both legs.

I rember lying in bed for days under high levels of pain medication but even though I was in excruciating pain and rember that about every six hours or so I would notice that I had lost fifteen or twenty minuets due to sleep and that was the only relief I ever rember during those days.

I was released from the Hospital after the full diagnoses but could not walk and was bedridden and still in excruciating pain with all my leg muscles cramping and spasms for almost a full month.

1.) Should the Doctor have given me the spinal tap knowing that I was treated with blood thinners?

2.) Shouldn't I have been informed that I may have a full month of unbearable pain before I received the procedure?

This seems like a no-brainer malpractice case to me !

Thanks,
houstontwg @ hotmail

What was your diagnosis at discharge? Do you have lasting damage from the procedure?

(While there is an increased risk of bleeding in patients taking blood thinners, this isn't by itself an absolute contraindication)

[ecmst12]

Negative outcome does not automatically indicate malpractice. If the lumbar puncture was necessary, it would have been malpractice to NOT perform it.

[lealea1005]

Originally Posted by timwgrisham

This seems like a no-brainer malpractice case to me !

You're wrong. The treating Physician (the one actually examining you) felt the LP was necessary to properly diagnose your symtpoms. There will be documentation on your medical record. Your presenting symptoms, previous history, lab work, etc., warranted the procedure.

The informed consent you signed before having the LP indicate the risks and possible, including rare, adverse reactions.

Please answer Dogmatique's question regarding your diagnosis at discharge. Also, how old are you?

[LAWMED]

Originally Posted by lealea1005

You're wrong. The treating Physician (the one actually examining you) felt the LP was necessary to properly diagnose your symtpoms. There will be documentation on your medical record. Your presenting symptoms, previous history, lab work, etc., warranted the procedure.

The informed consent you signed before having the LP indicate the risks and possible, including rare, adverse reactions.

WOW...lot's of assumptions here. The fact of the matter is: There is NO patient who has just been administered an anticoagulant such as (heparin, LMWH, coumadin, etc.) who should then have a lumbar puncture, unless they are told that there is a significant, VERY significant chance that they will develop and epidural hematoma compressing on the spinal cord, at the level of the puncture, which would likely require surgical evacuation and would pose a significant risk of permanent spinal cord injury. In other words, the lumbar puncture would have to be immediately necessary to save the patient's life and THEY would have to make an informed decision. EVERY attempt should be made to postpone the LP, the med be held, until lab values show a subtherapeutic effect (coags are acceptable). Otherwise the procedure should only be entered into with the assumption that spinal cord injury is being traded for life.

If the 'blood thinner' was a thrombolytic administered to 'clot bust' a cereberal embolism ..stroke..(i.e. streptokynase), then the absence of a post LP epidural hematoma would be a miracle.

Possibly in error, I am assuming that you were misdiagnosed for a stroke, treated for it with a thrombolytic before confirmation via radiological studies, the error was determined, and the next possible diagnosis entertained was meningitis or other cerebral spinal fluid abnormality requiring a sample for lab evaluation for a diagnosis. But at that point you had been given a blood thinner. The likelihood of negligence and malpractice here FAR outweighs the contention that your treatment was appropriate....the ORDER in which things were done is the problem. You DEFINITELY have a case which merits further investigation by a medical malpractice attorney.

[ecmst12]

Well NOW look who's making assumptions...

[LAWMED]

GUILTY!

However I began with the caveat i could be assuming in error.

[cbg]

Just out of curiousity, Lawmed, has there EVER been a thread on this board where you did not take the position that the poster had a case for malpractice?

[ecmst12]

I don't think he bothers responding to threads where he doesn't think there's a case.

Personally, I was waiting for OP to come back and provide more information before makeing any assumptions myself. And since OP hasn't come back, he must have lost interest anyway.

[lealea1005]

Originally Posted by LAWMED

WOW...lot's of assumptions here.

I addressed OP's assumption that their situation was a "no brainer malpractice case".

NONE of us were present to actually examine OP and make medical recommendations. NONE of us know the actual order of events and are relying upon OP's recollection while s/he was having "stroke symptoms".

Obviously, the treating Physician....the person looking at the whole picture after physical exam, previous medical history, review of diagnostic imaging and/or bloodwork, review of current medications, etc. found it necessary, in their MEDICAL opinion, to order the LP.

In any case, OP has not returned to answer questions asked earlier in this thread.

Now go have a beer and relax.

[lealea1005]

Originally Posted by ecmst12

I don't think he bothers responding to threads where he doesn't think there's a case.

Personally, I was waiting for OP to come back and provide more information before makeing any assumptions myself. And since OP hasn't come back, he must have lost interest anyway.

I tend to agree with you on both points.

Have a fun 4th!

[LAWMED]

Originally Posted by timwgrisham

I was admitted to a Texas hospital in April 2009 for stroke symptoms and was given blood thinners then a lumbar puncture that was later diagnosed after an MRI to have caused bleeding into my spine, causing excruciating painful mussel cramps and spasms in every mussel of both legs.l

Any knowledgeable and competent medical professional familiar with the acute treatment of strokes, the differential diagnosis for stroke-like changes in the nervous system, and the indications, cautions and contraindications for lumbar puncture in the face of anticoagulant administration, upon reading the above sentence must be suspicious of inappropriate care. The scenario I proposed is the only one which makes any sense based on the information OP provided. As should be clear by now, none of us will ever see medical records or have any facts to rely on other than those posted by individuals who may be emotional, angry and unlikely to have medical training.

Perhaps we should just post an announcement that 'Obviously, the treating Physician....the person looking at the whole picture after physical exam, previous medical history, review of diagnostic imaging and/or bloodwork, review of current medications, etc. found it necessary, in their MEDICAL opinion, to' do whatever you are complaining about. After that ridiculous announcement greets each OP, no further need for discussion is apparent since apparently all treating physicians do what they are supposed to, and only what is necessary.

Are you guys for real??? I confess that in fact since my specialty is anesthesia and I am confronted by the patient on an anticoagulant who required a spinal, epidural or lumbar puncture on a regular basis I have an unfair advantage. However, LP while anticoagulant is a HUGE freaking deal and you better have a VERY VERY good explanation for performing one...
Medically, the sequence of events, as related, are very odd and make little medical sense viewed from a treatment perspective.

From a medical malpractice perspective, this scenario is SO undesirable from a treatment perspective that proceeding with the LP should scare the **** out of you and make you very aware that you have to justify what you are about to do based on solid medical reasoning. What that would be in this case is a bit hard to fathom.

I would agree that I am more likely to respond to an OP when I think there is a malpractice issue....there is usually no need to add to the number of responses already rejecting malpractice claims. That said, YES there have been threads where i thought no malpractice existed AND to which i responded.

My consulting practice reviewing cases for med mal attorneys is about 50% defense and 50% plaintiff and I only take cases which i think have merit....so 50% of the time I generally find malpractice absent.

If anyone sees a flaw in the scenario I presented in this case, or, a more likely scenario, I am all ears. Try not to forget that 'possibly in error, I am assuming..' appeared first.....so none of this 'we don't have the medical record, we were not there BS'. For all we know the physician mixed up the charts, was high as a kite, and screwed everything up from the moment he walked in. Stick to the facts presented.

[Proserpina]

Originally Posted by LAWMED

WOW...lot's of assumptions here. The fact of the matter is: There is NO patient who has just been administered an anticoagulant such as (heparin, LMWH, coumadin, etc.) who should then have a lumbar puncture, unless they are told that there is a significant, VERY significant chance that they will develop and epidural hematoma compressing on the spinal cord, at the level of the puncture, which would likely require surgical evacuation and would pose a significant risk of permanent spinal cord injury. In other words, the lumbar puncture would have to be immediately necessary to save the patient's life and THEY would have to make an informed decision. EVERY attempt should be made to postpone the LP, the med be held, until lab values show a subtherapeutic effect (coags are acceptable). Otherwise the procedure should only be entered into with the assumption that spinal cord injury is being traded for life.

If the 'blood thinner' was a thrombolytic administered to 'clot bust' a cereberal embolism ..stroke..(i.e. streptokynase), then the absence of a post LP epidural hematoma would be a miracle.

Possibly in error, I am assuming that you were misdiagnosed for a stroke, treated for it with a thrombolytic before confirmation via radiological studies, the error was determined, and the next possible diagnosis entertained was meningitis or other cerebral spinal fluid abnormality requiring a sample for lab evaluation for a diagnosis. But at that point you had been given a blood thinner. The likelihood of negligence and malpractice here FAR outweighs the contention that your treatment was appropriate....the ORDER in which things were done is the problem. You DEFINITELY have a case which merits further investigation by a medical malpractice attorney.

Treating something before a diagnosis is determined is not automatically malpractice.

If the patient presents in the ER with signs of a stroke there's a good chance he will be given a blood thinner. Do we want to prevent possible further damage, or wait until the diagnosis is confirmed and risk a much worse outcome which may have been lessened or avoided if the blood thinner had been given in time to halt the progress (or at least attempt such).

I can actually see a patient's family suing for not administering a potentially life-saving drug when the patient was showing signs of a stroke.

[lealea1005]

Originally Posted by LAWMED

Any knowledgeable and competent medical professional familiar with the acute treatment of strokes, the differential diagnosis for stroke-like changes in the nervous system, and the indications, cautions and contraindications for lumbar puncture in the face of anticoagulant administration, upon reading the above sentence must be suspicious of inappropriate care. The scenario I proposed is the only one which makes any sense based on the information OP provided. As should be clear by now, none of us will ever see medical records or have any facts to rely on other than those posted by individuals who may be emotional, angry and unlikely to have medical training.

Perhaps we should just post an announcement that 'Obviously, the treating Physician....the person looking at the whole picture after physical exam, previous medical history, review of diagnostic imaging and/or bloodwork, review of current medications, etc. found it necessary, in their MEDICAL opinion, to' do whatever you are complaining about. After that ridiculous announcement greets each OP, no further need for discussion is apparent since apparently all treating physicians do what they are supposed to, and only what is necessary.

Are you guys for real??? I confess that in fact since my specialty is anesthesia and I am confronted by the patient on an anticoagulant who required a spinal, epidural or lumbar puncture on a regular basis I have an unfair advantage. However, LP while anticoagulant is a HUGE freaking deal and you better have a VERY VERY good explanation for performing one...
Medically, the sequence of events, as related, are very odd and make little medical sense viewed from a treatment perspective.

From a medical malpractice perspective, this scenario is SO undesirable from a treatment perspective that proceeding with the LP should scare the **** out of you and make you very aware that you have to justify what you are about to do based on solid medical reasoning. What that would be in this case is a bit hard to fathom.

I would agree that I am more likely to respond to an OP when I think there is a malpractice issue....there is usually no need to add to the number of responses already rejecting malpractice claims. That said, YES there have been threads where i thought no malpractice existed AND to which i responded.

My consulting practice reviewing cases for med mal attorneys is about 50% defense and 50% plaintiff and I only take cases which i think have merit....so 50% of the time I generally find malpractice absent.

If anyone sees a flaw in the scenario I presented in this case, or, a more likely scenario, I am all ears. Try not to forget that 'possibly in error, I am assuming..' appeared first.....so none of this 'we don't have the medical record, we were not there BS'. For all we know the physician mixed up the charts, was high as a kite, and screwed everything up from the moment he walked in. Stick to the facts presented.

Gee Lawmed, I would have guessed, in your infinite wisdom, you already knew LP after anticoagulants is a relative contraindication, not an absolute contraindication. Again, NONE OF US were there to examine the patient or interpret any testing/documentation. Yes, I do give the examining PHYSICIAN the benefit of the doubt. I don't really give a flying fig whether you agree with that or not.

You do realize an LP can be performed on a anticoagulated patient when medically necessary, right?. One does not bleed while on anticoagulant therapy unless there's already a bleeding source. The goal is to find the source of the bleed, correct? Have you entertained the possibility that OP may have already had a CNS bleed which can be diagnosed (the easiest way) via LP? OP states they were having "stroke symptoms". Hindsight in medicine is the problem with litigious patients. Diagnosing is not as straight-forward as you are attempting to convince us. Hindsight is always 20/20.

Again I will reiterate that the patient, no doubt, signed a consent for the LP and probably the anticoagulants, as well.

Make that a couple of beers and a deep breath.

[LAWMED]

Originally Posted by lealea1005

Gee Lawmed, I would have guessed, in your infinite wisdom, you already knew LP after anticoagulants is a relative contraindication, not an absolute contraindication. Again, NONE OF US were there to examine the patient or interpret any testing/documentation. Yes, I do give the examining PHYSICIAN the benefit of the doubt. I don't really give a flying fig whether you agree with that or not.

You do realize an LP can be performed on a anticoagulated patient when medically necessary, right?. One does not bleed while on anticoagulant therapy unless there's already a bleeding source. The goal is to find the source of the bleed, correct? Have you entertained the possibility that OP may have already had a CNS bleed which can be diagnosed (the easiest way) via LP? OP states they were having "stroke symptoms". Hindsight in medicine is the problem with litigious patients. Diagnosing is not as straight-forward as you are attempting to convince us. Hindsight is always 20/20.

Again I will reiterate that the patient, no doubt, signed a consent for the LP and probably the anticoagulants, as well.

Make that a couple of beers and a deep breath.

Let me see if I can help you understand why everything you have just said is medically dead wrong. And i am actually a bit surprised since you have never posted anything so stupid.

One would hope EVERY LP performed would be medically necessary. An LP performed on a patient on anticoagulants is malpractice unless the benefit of the LP outweighs the high risk of epidural spinal hematoma and paralysis. The LP must be necessary to save life and limb in this situation otherwise any spinal cord damage from hemorrhage is indefensible malpractice...PERIOD.

You do not understand the etiology of a spinal hematoma after LP in the patient receiving anticoagulants. The needle as it performs the lumbar puncture, is the source of the bleeding...it is the cause of the spinal hematoma secondary to the inability of even the most minor of bleeding to clot due to the medication.

The next thing you have no grasp of is the etiologies of stroke and the role of thrombolitics in treatment of stroke, nor do you seem to be aware of the utter inappropriateness of LP in determining hemorrhagic stroke and its treatment. Strokes come in two types: embolism and hemorrhage. Embolism is a clot in a blood vessel of the brain, while hemorrhagic is due to the rupture of a blood vessel in the brain. Both cause similar symptoms as they both disrupt blood flow in the brain. The treatment of each is very very different. Thrombolytic drugs are administered, within a certain time from onset of symptoms, for embolic stokes ONLY. Administering them to a hemmorhagic stroke patient would be 100% fatal, 100% of the time. So, pay attention now, the administration of a thrombolytic agent to a suspected stroke patient BEFORE obtaining a CT scan to rule out cerebral hemorrhage is malpractice. Administration of the drug before performing an archaic and unreliable procedure almost certain to cause bleeding around the spinal cord, in order to attempt a diagnosis so that a decision can be made whether to administer the drug you already gave negligently is malpractice 100% of the time...and just plain stupid and incompetent bordering criminal. So no, the LP could not be for determining whether there is blood in the cerebral spinal fluid absent having already committed gross malpractice.

In fact, the diagnosis of stroke is quite straight forward, technologically advanced, well defined and agreed upon, and not at all consistent with the facts as the OP presents them. Your suggestions make no sense medically.

Evaluating a plaintiff medical malpractice question in the context of the result determining whether the elements have been met for a lawsuit cannot be done appropriately if 'the benefit of the doubt' is part of the process. Medical malpractice is NEVER about 'the benefit of the doubt' and this is a medical malpractice forum. I say again that there is no appropriate treatment scenario where the events could have been in the order the OP
described.