Case Archive
Emergency Medicine, Neurosurgery
Ref. # 728301

A 21-year-old man was involved in a physical altercation in front of his home. The EMT's arrived in ten minutes and documented the patient was combative, conscious, alert, oriented, and positive for alcohol and drug use. The patient was transferred to the hospital ER. The complaint noted assault and possible overdose. The ER triage nurse documented toxic-poison/substance abuse. Another triage nurse administered a 5-mg Haldol IV push. Blood pressure was 88/56, pulse 80, respirations 20. Forty minutes later the patient was unresponsive and had a depressed gag reflex with agonal respirations. For the first time he was evaluated by a physician, who intubated him. A CT scan was ordered and a neurosurgery consult followed. The impression was subarachnoid hemorrhage in the absence of any signs of trauma, as well as bilateral herniation with massive cerebral edema, bilateral frontal subdural herniation, right greater than left with some midline shift. The patient was admitted to the medical ICU with a diagnosis of brain death protocol, possible organ donation. Five minutes later his blood pressure was 175/89, pulse 96 and respirations 10. Seventeen minutes later another ER physician evaluated the patient and administered Lasix and Mannitol. The next day a urine toxicology screen was negative for drugs and alcohol. A CT scan showed large bilateral frontal extra-axial fluid collections consistent with subdural hematoma. There was scalp soft tissue swelling in the superior frontal region without evidence of fracture. The patient expired that day. An autopsy listed cause of death as blunt force trauma to the head. The death was classified as a homicide. There was no external injury noted as the patient's hair was very thick. The internal examination revealed diffuse subgaleal hemorrhage in the frontal and parietal areas of the head. A medQuest ER physician and a medQuest neurosurgeon independently found negligence in several areas. The EMT staff failed to obtain an accurate history. In view of the correct history of assault and trauma, the EMT staff should have recognized the patient's mental status and combative behavior as suggestive of possible intercranial trauma. The triage staff failed to immediately obtain a CT scan. Haldol was negligently prescribed without a neurological consult. With appropriate and timely diagnosis the patient may have survived.

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