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Miscommunication Between a Radiologist and Emergency Room Physician Leads to Patient Going Blind in One Eye

This was plain to see.

Literally.

Plain to see for a radiologist.

Plain to see for an emergency room physician.

Plain for ANY doctor to see.

Put another way, it was obvious.

Obvious for all to see.

In fact, the radiologist at the hospital DID see it.

He not only saw it, but correctly recognized it.

It was a tumor.

In her brain.

It was a large tumor.

You couldn't miss it.

He didn't.

The radiologist correctly read and interpreted her CAT scan.

He was a board certified radiologist.

Working for a hospital in one of the boroughs of New York City.

He was smart enough to realize this patient had a space-occupying brain tumor.

Was it cancerous?

Who knew?

He didn't know.

He didn't know if it was benign or malignant just by looking at the CAT scan.

She'd need follow up.

She'd need a referral to a neurosurgeon.

She'd likely need surgery.

She was in her 40's.

She didn't have any problem with her head until that day.

She didn't walk into the emergency room either.

She just happened to be passing by.

Literally.

In a van.

She was a home health aide.

She was taking her patient to the doctor in this van.

It was an ordinary day.

Nothing special.

She was sitting in the van with her patient on the way to the doctor's office.

But something happened.

The van got into an accident.

A pretty violent accident.

Coincidentally, the accident happened right in front of the hospital emergency room.

During the accident, she hit her head on the inside of the van.

Now she had a headache.

When she was brought into the emergency room, she was told she'd need a trauma workup.

That included x-rays and a CAT scan of her head.

Other than hitting her head, she only had some scratches and bruises.

They drew her blood.

They made her wait.

Hours and hours went by.

It was a busy day in the emergency room.

She had X-rays done.

Then she had to wait some more.

Finally, she had her CAT scan done.

She wanted to go home.

She felt fine.

She told them that.

The nurses told her she needed to wait to see the results of the X-rays and CAT scan.

"Fine," she said.

Her patient had already left and went home by taxi.

In the intervening hours, the radiologist assigned to read imaging tests from the emergency room finally got around to reading her CAT scan.

The X-ray didn't really show it.

The CAT scan did.

It was a big tumor.

It was taking up a lot of space in her brain.

It didn't look like it was hitting any vital nerves like the optic nerve controlling her eyesight...at least not yet.

(Notice the foreshadowing here?)

The radiologist dictated his findings and observations in a report.

He did that by dialing into a voice dictation system.

He correctly observed her brain tumor.

After he finished his voice dictation, he closed her file and then moved on to the next patient's imaging tests.

This radiologist NEVER communicated his findings to the emergency room doctor.

NEVER.

It had been hours since the patient had her X-rays and CAT scan.

She was antsy to get home.

She asked the ER doctor if she could leave.

He asked her to wait until the imaging tests were read.

She reluctancly agreed.

The ER doctor decided he'd go look at the CAT scan images himself so he could get her on her way.

The ER doctor went into the radiology section in the emergency room.

He looked at the CAT scan images himself.

Alone.

He read them.

He interpreted them.

He concluded she was fine.

He concluded there was no problem at all.

He was totally wrong, and he didn't even know it.

He finally came out to tell the patient about the CAT scan results.

He told her that he personally read the CAT scan.

"Everything is normal," he said.

She is relieved.

She is happy.

Finally, she can go home.

He reassures her that she's Ok.

She has no reason to believe otherwise.

The ER doctor makes no note in the patient's chart about his personal interpretation of this patient's CAT scan.

He makes no notation that he read and reviewed the patient's CAT scan.

The ER doctor discharges her from the emergency room.

Over the next few hours the radiologist finally caught up to the backlog of imaging tests waiting to be read in the emergency room.

He reached the opposite conclusion of what the emergency room doctor "saw."

There's a problem now.

Because the ER doctor didn't communicate with the radiologist, there's a miscommunication.

The radiologist doesn't know that the emergency room doctor read and interpreted this CAT scan.

He also doesn't know that the patient has been discharged from the hospital.

The radiologist, not knowing if the patient was still in the emergency room awaiting his interpretation, simply reads her diagnostic images.

He then dictates a report so that anyone who accesses this patients' record and wants to look at the X-ray and CAT scan results can see what his interpretation is.

This radiologist made no effort to reach out to the emergency room doctor.

This was a violation from hospital protocol.

It was also a violation from the basic standards of medical care.

This was another miscommunication that never should have happened.

The radiologist made no effort to learn whether the patient was still in the hospital at the time he observed her brain tumor on CAT scan.

The radiologist made no effort to send a copy of his report to the emergency room doctor so the patient could take immediate follow-up measures to address her brain tumor.

Let's recap for a moment...

A patient with a history of head trauma comes into the emergency room.

The doctors feel it necessary to take X-rays and a CAT scan of her head to rule out any head injury.

They suspected she suffered an injury to her head because of the violent accident she was in.

The ER doctor reads the CAT scan himself.

He wasn't qualified to read it and had little experience interpreting CAT scans.

Rather than speak to the radiologist, he interprets the CAT scan and decides all is fine.

He then sends the patient home after reassuring her that everything is fine.

It's not.

Now the radiologist gets involved.

His job is to read films.

He does.

He correctly interprets her CAT scan.

He SEES a brain tumor and records in his report that she has a brain tumor.

But then he drops the ball.

HE FAILS TO COMMUNICATE.

HE FAILS TO COMMUNICATE WITH THE EMERGENCY ROOM DOCTOR.

HE FAILS TO COMMUNICATE WITH THE PATIENT.

This series of miscommunications had dire consequences for this patient.

Let me tell you how...

The patient had been reassured by the emergency room physician that everything was fine.

Her blood work was fine.

Her x-rays were 'fine'.

Her CAT scan results were 'fine'.

She was told, upon leaving the emergency room, that if she developed further pain as a result of this car accident, to go to her own physician for follow-up care.

Luckily for her, she did not have any further problems relating to this car accident.

However, over the course of the next nine months, she began to notice problems with one of her eyes.

She was having blurry vision in one eye.

This was a condition that slowly progressed over months.

She didn't really give it much thought.

She thought she was getting older.

Maybe she needed eyeglasses.

It was getting harder to see out of one eye.

One day, as she was passing by an eyeglass store in town, she decided to go in and get her eyes checked.

The optometrist noticed something abnormal during his eye exam.

He immediately sent her to an ophthalmologist; a doctor specializing in eyes.

The eye doctor examined her and tells her that she wants her to have a CAT scan of her head immediately.

She sees something troubling and wants to make sure there's nothing going on.

The patient now goes to have a CAT scan done to see why she's having a problem in that eye.

When she returns to the eye doctor, she is devastated.

The eye doctor tells her that she has a massive brain tumor in her head.

"How can this be? I had a CAT scan 9 months ago and the doctor told me everything was fine!" she exclaims.

The tumor is large and putting pressure on the optic nerve.

That nerve controls her eyesight.

That explains why she's having trouble with her vision.

The eye doctor asks her to tell her about the accident 9 months ago and the CAT scan that was done at the hospital. 

She tells the patient that she needs immediate surgery in an attempt to remove some or all of this brain tumor.

She does not hold out much hope for saving her eyesight.

This tumor does not appear to be cancerous.

However, until surgery is done, she won't know for sure.

"If it's not cancerous, what type of tumor is it?" the patient asks.

"It's likely a space-occupying tumor. It looks like it has put massive pressure on the optic nerve cutting off the blood flow to that nerve and your eye," says the eye doctor. 

If the optic nerve and its blood supply cut off, the patient will lose vision in her eye.

In the meantime, the ophthalmologist requested copies of the x-rays, CAT scans and radiology reports from the emergency room where she was seen nine months earlier.

What she found was shocking.

She found that the brain tumor was plainly visible on CAT scan nine months earlier.

The tumor was in the same location as now.

Except there was one major difference.

The tumor was significantly smaller.

Nine months earlier, the tumor had not yet reached the optic nerve.

There was no pressure on the optic nerve nine months earlier.

This eye doctor could not understand how the radiologist did not communicate with the patient about these OBVIOUS findings.

She could not understand how the emergency room doctor failed to properly read and interpret this obvious finding.

Nor did she understand how no one from the hospital ever communicated these results to her.

EVER. 

Had the patient been told that she had a brain tumor, she would have immediately been referred out to a neurosurgeon for evaluation and surgery.

Had that been done, this tumor never would have grown to compress the optic nerve.

Had that been done, this patient would not have lost total vision in her eye.

When the patient saw a neurosurgeon to see if the tumor could be removed, she was told it could not be removed.

It was too dangerous to remove the whole tumor.

Instead, they'd try and remove part of it.

She would also need radiation therapy to try and reduce the size of the tumor before she had surgery.

She was told that her chances of having her eyesight improve was close to zero.

Nevertheless, she wanted to try.

During surgery, the neurosurgeon confirmed that this tumor was too large to remove without damaging parts of her brain.

The tumor had already encompassed and destroyed her optic nerve.

It was impossible to remove the tumor.

Even if he was able to remove the tumor away from the optic nerve, it was obvious that the optic nerve was already dead.

That means that the patient's vision loss would be permanent.

That meant she would be blind in that eye for the rest of her life.

This patient reached out to me for help because she could not understand how the emergency room doctor sent her home and how he missed the tumor sitting right in front of his eyes.

It was only through this lawsuit I able to learn how a series of miscommunications and medical errors resulted in this patient never being told that she had a massive tumor in her brain.

This series of miscommunications and medical errors led to a nine-month delay in diagnosing this brain tumor.

That delay gave the tumor time to grow and destroy her optic nerve.

That led to her going blind.

To learn more about what happened in this case, I encourage you to watch the quick video below...