Summary of Record Review: Ray ******, DOB

Records Reviewed:  J.S. *******, M.D. expert witness report 1/19/2011


  • Ray ******
  • Debra M
  • A.J, M.D.
  • K. T.

Mr. ****** is a 54-year-old male with a history of mild hypertension and hyperlipidemia.

Mr. ****** was admitted to North Central Baptist Hospital, San Antonio, Tx., 7/11/2008 for new onset of atrial fibrillation, with symptoms for 7-10 days previously. He was evaluated by Dr. A. J., a cardiologist, who put Mr. ****** on Coumadin and ASA.

A cardiac catheterization demonstrated dilated cardiomyopathy and reduced ejection fraction below 30%. A defibrillator implantation was recommended for 7/14/2008. In preparation for this Coumadin was discontinued 7/12/2008.

At 4:00 am on 7/14/2008 a nursing check was normal. At 6:00 am a possible facial droop and “some signs of weakness” were noted. The nurse on duty called Dr. J. and reported such. Dr. J. took no action at that time. At 6:40 am the nurse called Dr. J. to inform him that there was a “noticeable increase in right-sided weakness and facial droop.” Dr. J. was informed and ordered a stat CT scan of the brain, which was performed at ~7:56 am which was reported to be normal. Lovenox anticoagulation was started at around 7:45-8:00 am. Mr. ****** subsequently was admitted to the ICU with aphasia, right hemiparesis, and lethargy. CT and MRI of the brain subsequently confirmed multiple infarcts. Mr. ****** was subsequently transferred to a stroke rehab unit.

It is my professional opinion that Mr. ****** was a candidate for treatment with TPA and that timely use of TPA would have prevented the neurologic damage which subsequently developed. Due to his age, Mr. ****** would have fallen into a category of patients whose results from TPA treatment are among the best reported. Additional factors which are predictive of a good response include lack of serious pre-existing medical problems and no evidence of actual infarction at the time of proposed institution of therapy (Archives of Neurology 65(11): 1429-1433, 2008.)

It is my opinion that Dr. J., being given nursing reports of focal neurologic findings at 6:00 am and 6:40 am, should have obtained a consult on an emergency basis from a neurologist or member of a stroke team for the purpose of assessing for and activating a TPA protocol, and that failure to do so was a departure from standard of care for this patient in 2008.

Mr. ****** was at high risk for developing an embolic stroke due to recent onset atrial fibrillation with low ejection fraction and subsequent discontinuance of Coumadin, a preventative medication for embolic stroke. In my opinion, these factors should have made Dr. J. highly suspicious of any symptoms suggestive of a stroke in Mr. ******. Dr. J.’s comment in his deposition that he considered the nurse’s report of facial droop at 6:00 am on 7/14/2008 to be due to the patient sleeping on one side of his face is, in my opinion, inadequate in the context of high stroke risk for this patient. Dr. J.’s additional comment that no neurologist was available to evaluate for or institute TPA treatment is additionally inadequate in the context of a large regional hospital in an urban area, particularly one which at the time apparently advertised its TPA treatment capability to the general public.

I have additionally reviewed the expert opinion provided by the late John S. M., a noted stroke expert, on this case. Dr. M.’s opinion is consistent with and supports my analysis that there were departures from the standard of care in this case.

The above is stated within a reasonable degree of medical certainty.