A PA’s misdiagnosis of labyrinthitis raises questions about her examination technique.

Ms. L, age 42, was a certified physician assistant who had worked in several clinics since her graduation 12 years before, but she enjoyed her latest job in a rural emergency room best. Sometimes, when the ER was busy, she handled cases on her own and told the supervising physician about them later.

This did not pose a problem until a patient came in with apparent labyrinthitis — or was it a stroke?The patient was a 61-year-old man who loved the outdoors and often went camping in the area with his wife. The ER was very busy when she brought him in because of a multicar collision on the nearby freeway, so Ms. L saw him alone.

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On arrival, the man described a sudden onset of vomiting that led to collapse. He recovered a bit in the ER but still felt dizzy with nausea and a headache. Ms. L was rather puzzled at his sudden prostration. She suspected a viral infection and was aware of several recent cases of labyrinthitis in the ER. As part of her customary thoroughness, Ms. L took a full history, reviewed his medications (only amlodipine [Norvasc] for high BP), and did her usual physical examination, including neurologic tests.

The adequacy of this neurologic exam and how it was administered were a subject of contention in the lawsuit that followed. Ms. L testified that, as a physician assistant, she performed only a “screening exam,” including visual fields. The test consisted of asking the patient to stare at her nose, while she wiggled her forefingers at the outer limits of the expected visual fields. The patient was then to tell her “when the finger moved.” This was how she had been taught to perform the test, and it had worked well for her in the past. Its weakness was that it relied on the patient to say whether he could see the finger moving or not. In this sense, the test was subjective. This was to be a key point in the defense.

After completing the physical exam and identifying only some loss of coordination and balance —consistent, she thought, with labyrinthitis—Ms. L gave the patient a prescription for meclizine [Antivert] and discharged him to be followed up by his family physician in his hometown, some two hours away.

During their trip home, the couple had to stop several times so the man could vomit at the roadside, a point emphasized to the jury at trial. Once home, he went to bed. The following day, he suffered a stroke, which produced a visual-field deficit in the lateral field of the left eye. MRI scanning showed this to be an occipital lobe lesion, with multiple small defects.

The patient tolerated his loss of visual field for a while, even trying to compensate with “prism lenses” fitted by his ophthalmologist. Frustrated by his diminished quality of life, he decided to sue and made an appointment with a plaintiff’s lawyer, who had represented members of his family in several auto accidents and in a supermarket “slip-and-fall” case. The lawyer called for the chart and had it reviewed by an expert emergency physician, who returned a favorable report. With a 40% fee agreement in hand, the lawyer then filed suit against Ms. L and her supervising physician.

The case proceeded through paper discovery for some six months before the depositions started. The patient went first, describing in detail his crisis of vomiting and collapse while camping, his discharge from the ER and his subsequent stroke. He minimized Ms. L’s exam, saying that “she took about five minutes to do a few things like blood pressure [measurements],” and went on to describe the subsequent course of his disability.

Ms. L was next, working her way through her notes to reconstruct the ER visit and backing up her conclusions with data from the medical record. When the plaintiff’s lawyer reached her examination of visual fields, he challenged the methodology. “Is that medically adequate?” he asked. “It’s the norm for physician assistants. It’s called a screening neuro examination,” Ms. L smoothly replied. The plaintiff’s lawyer grunted and remarked: “It wasn’t successful for my client, that’s for sure.” Ms. L ignored this provocative comment and settled down to the rest of the deposition.

The supervising physician, the director of the ER, and expert witnesses for each side were deposed next, but they added little to the mix.

The case went to trial about two years after the lawsuit was filed. The experts appeared via videotape, while Ms. L, her supervising physician and the patient appeared in person for the proceedings, which lasted a week.

The patient testified first, describing his disabilities to the jury and how they had affected his life. The defense lawyer challenged the man’s account on cross-examination by trying to show that he was ignoring available remediation. He was not wearing the prism lenses that the ophthalmologist had prescribed. “Well, they never helped me, so I stopped wearing them,” the patient spluttered.

Later, when he presented the defense’s case, the lawyer put the ophthalmologist on the stand and elicited testimony that prism lenses help more than 50% of patients with similar problems.

The defense expert testified that a “screening neuro exam” was all that was required of physician assistants, not the full neurologic exam a physician might perform. Ms. L then took her turn, testifying according to the chart entries as she reconstructed the visit step-by-step. When she described her screening test for visual fields, the defense lawyer’s questioning stressed that her method required patient cooperation and thus was partly subjective.

The jury deliberated for 12 hours and came back with a verdict for Ms. L.

Legal background

Juries vary in the amount of responsibility they require of a patient. In a recent trend, some juries, mainly in urban areas, have transferred duties traditionally assigned to the patient, such as follow-up visits or making appointments for consultations with specialists, to the provider and her staff.

In this case, the jury accepted the defense argument that although the visual-field defect was missed during the screening neurologic exam, its failure could not be attributed unequivocally to Ms. L, because the technique depended on the patient’s interpretation.

Protecting yourself

This case illustrates one jury which did not accept the typical plaintiff’s lawyer’s argument that patients bear no responsibility for their own medical management. However, there is a disturbing trend toward expecting providers to do many of the things that patients have traditionally taken care of, such as arranging appointments.

Because of this trend, providers need to individualize patient management, taking the initiative with certain patients to make follow-up appointments and arrange specialty consultations. This “special treatment” policy is most appropriate when the patient seems particularly helpless or disorganized and the follow-up needed is particularly important, such as the incidental discovery of a breast mass or an abnormal x-ray result that needs further investigation.