Mr. R, 58, was looking forward to a coffee break at the construction site where he worked when he experienced blurry vision and began to feel ill.

The foreman agreed that he definitely looked unwell and asked a coworker to drive Mr. R a few blocks to a nearby clinic.

As he came through the clinic door, the receptionist noticed Mr. R’s unsteady gait and unusually flushed appearance. She ushered him into an exam room immediately. A few minutes later, Ms. E entered the room. At age 44, she had more than 15 years’ experience as an NP.

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Mr. R told her he felt dizzy and had double vision. Finding his BP was 200/95 mm Hg, she  performed a quick neurologic exam, which she recorded as normal. Then she checked his BP twice more, noting little change.

Ms. E diagnosed a hypertensive crisis. She gave the patient a few samples of telmisartan (Micardis) 40 mg,  a prescription for more, told him to rest for a few days and scheduled a follow-up in two weeks to recheck his BP.

“But make sure you come back tomorrow if you don’t feel better,” she warned. “Don’t wait the two weeks. Your blood pressure is extremely high, and that could be dangerous.”

Mr. R then left to go to the pharmacy next door, and Ms. E went on to her next patient. But a few minutes later, the receptionist stopped her.

“I just saw Mr. R out by the pharmacy,” she reported. “He looked very sick. He was walking like he was  dizzy or drunk.”

Ms. E went outside and found Mr. R sitting on the ground, leaning against a wall.

“I’m very concerned about your blood pressure and the vertigo,” she told him. “This could be the sign of something serious—like a stroke. You should either go to the emergency department at the hospital up the street right away, or go home and have your wife take you there if you don’t feel better after you’ve rested a while.”

The patient chose the latter course. Ms. E then gave him a prescription for meclizine (Antivert) to ease the vertigo and watched as Mr. R’s coworker arrived  to drive him home. When she returned to the clinic, she recorded the second prescription in his chart and made an additional note: “Patient declined going to ED now.”

Mr. R continued to feel dizzy and experience double vision on the ride home. His wife rushed to meet him at the door and helped him up the stairs to lie down. When she checked on him a short while later, she found him on the floor. At that point she decided to drive him directly to the ED.

Once at the hospital, Mr. R was admitted for stroke. Despite rehabilitation, he ultimately suffered from permanent impairments of speech, vision, mobility, and balance, and he required ongoing medical management to prevent a recurrence.

Mr. R and his wife then consulted a plaintiffs’ attorney who advised them to sue Ms. E and the clinic for negligence.

“She should have recognized the signs of a stroke and sent you to the ED immediately,” the lawyer asserted.

The case proceeded slowly through the discovery and deposition phases. At trial, the plaintiffs’ attorney called an expert emergency medicine physician as his first witness.

That doctor listed the signs of stroke: vertigo, loss of balance, lack of coordination, and impaired vision—all symptoms that Mr. R exhibited at the clinic. The expert physician then explained the importance of immediate treatment to avoid permanent damage.

Mr. R testified next. He did not recall Ms. E’s telling him to go to the hospital immediately nor that he might be having a stroke. Instead, he stated, she gave him a choice between going home to his wife and resting, or getting checked out at the ED.

“I felt much more comfortable going home to my wife,” he explained. “I thought it would be better to explain the situation to her and see if I improved later on.”

But when Ms. E took the stand, her testimony had a different perspective.

“I was really concerned about his elevated blood pressure,” Ms. E told the jury as she described her initial exam.  “I said to him, ‘Your blood pressure is elevated and that could mean several things. It could be that you’re having a stroke, so you really need to go to the ED for evaluation.’ ”

“And what was Mr. R’s response?” asked the defense attorney.

“His response was nothing,” she replied. “He didn’t say anything at that time. When I saw him outside the pharmacy and realized he was dizzy, I said ‘Mr. R, I’m really, really concerned about you. I saw the way you are walking, and I feel you probably should go to the emergency room. But he kept saying, ‘Well, I just called my wife, and she’s probably going to be home by the time I get there.’”

On cross-examination, the plaintiffs’ lawyer asked, “Didn’t you in fact offer Mr. R the option of going home and lying down and having his wife take him to the ED rather than going immediately?”

“Well, I thought he should go to the hospital…”

“But you gave him the option of going home?”

“Yes, I gave him that option.”

The jury returned a verdict in favor of Mr. R and awarded him $250,000.

Legal background

Sometimes the salient issue in a malpractice case is not so much what happened but how actions and advice are interpreted. In this case, the parties more or less agreed about the events. The question was, how forceful was Ms. E’s demeanor and how successfully had she conveyed the urgency of the situation.

The jury clearly believed Ms. E failed on both counts, especially by suggesting Mr. R might go home before reporting to the ED. That failure constituted the negligence charged.

Protecting yourself

While Mr. R made a mistake by not going to the ED right away, the jury found he could not be faulted because his clinician had offered him an alternative.

A patient who may be having a stroke needs to get to an ED right away. Period. Going home to await developments is not an acceptable choice.

Ms. E should have clearly and forcefully explained the potential severity of his situation to Mr. R. If his coworker was not available to drive him to the ED, she should have called an ambulance and notified the patient’s wife.

Ms. E’s chart notations were also inadequate. She should have recorded that she had told Mr. R he might be having a stroke and that she had urged him to go to the ED. When he declined, noting that fact alone was not enough. She should have added that he had been warned about the consequences of delaying treatment.

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.