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ARTICLE ID 193555

$________ – HOSPITAL NEGLIGENCE – SEVERAL DAY FAILURE TO CONDUCT TESTING TO LOCATE SOURCE OF CNS BLEEDING IN 14-MONTH-OLD AFTER FINDING OF BLOOD IN SPINAL FLUID – ARTERIAL-VENOUS MALFORMATION (AVM) IN LOWER SPINAL AREA HEMORRHAGES, CAUSING PARPARESIS OF BOTH LEGS

Albany County, NY

The plaintiff contended that the defendant hospital and its staff negligently failed to conduct appropriate and timely testing to locate the source of bleeding noted in the child’s cerebrospinal fluid (CSF), and thereby, negligently failed to determine that an AVM was present in the lower spine. The plaintiff maintained that the AVM was surgically obliterated only after a devastating hemorrhage had occurred several days after blood was first noted in the CSF at two different levels of the central nervous system (CNS). The plaintiff contended that surgery, prior to the hemorrhage, would very likely have been successful and the ultimate permanent neurological compromise avoided.



The evidence disclosed that the parents brought the child to the defendant’s Emergency Department early Monday morning, on September 24, ________ and provided a history that she had been seen two days earlier at a different local E.R., was not taking much by mouth, was irritable, was sleeping more than usual, and had a fever at home of 100º. The plaintiff pointed out that throughout that first day, during which she was only in the Emergency Department, she was noted to be moving all four extremities spontaneously and had good tone and strength.



A spinal tap was ordered. but first, a CT of the brain was ordered to make sure no space occupying lesion was present which might cause herniation of the brain when the tap was done. An Emergency Department Attending took charge of the infant plaintiff’s care after she came on duty at about 4 :00 p.m. The CT was done by 5:40 p.m.. and the E.D. attending, an E.D. resident and the attending pediatric infectious disease specialist reviewed the CT study together. The CT showed blood in the CSF in one ventricle in the brain. but no sign or source of bleeding in the tissues of the brain itself.



After the E.D. resident failed twice, in attempts to perform the lumbar puncture, the E.D attending physician did the spinal tap. The plaintiff established that the four tubes of CSF withdrawn from the spine consisted almost entirely of blood. The plaintiff maintained that since the Cerebral Nervous System (CNS) is a closed system, consisting of the brain and the spinal cord, it was clear that since blood had been found in the CSF at two levels the source of the bleeding had to be either in the brain or the spinal cord. The attending infectious disease physician wrote in an emphatically emphasized note at approximately 7:00 p.m., shortly after the lumbar puncture was completed, the critical importance of the findings from both, the CT scan and the lumbar puncture, and that those findings had dramatically changed the picture as to what the child s problems were, essentially ruling out encephalitis or meningitis.

The physician stated that the problem was almost certainly bleeding in the central nervous system, that an MRI was needed; that the child was presenting urgent signs and symptoms, specifically the blood in her ventricle and spine and pain on leg raising, a sign of possible spinal cord irritation. The physician’s note also reflected that urgent steps were required to relieve the increased intracranial pressure caused by the blood in the CSF, and to find the source of the bleeding. A resident-neurosurgeon saw the child in the E.R. and wrote out and faxed a requisition for a stat MRl/MRA (Magnetic Resonance Imaging/Magnetic Resonance Angiogram) of the brain and the vessels supplying it from the neck up, to try and determine the etiology of the bleeding in the central nervous system. The neurosurgeon performed a ventriculostomy in the E.R. before 11 p.m ., inserting a tube into the ventricle to allow drainage of CSF.

The MRl/MRA test was never performed that day. The child was transferred to the Pediatric ICU just after midnight on Monday/Tuesday, and the transfer note listed a differential diagnosis created before the CT and lumbar puncture results had been obtained. That differential did not mandate any pursuit of the source of the blood in the central nervous system. The Attending Pediatrician on duty when the infant plaintiff was admitted to the PICU, saw her in the PICU sometime between that admission to the unit at 12:10 a.m. and 8:00 a.m., and made no entries in the chart, formulated no differential diagnosis, made no plan for treatment , made no attempt and ordered no tests to try to find the source of the bleeding in the central nervous system.

At 6:10 a.m. a second order was written and faxed to radiology for a stat MRl/MRA of the brain, but the study was not performed until around 4 p.m. that day, and the radiologist’s report was not posted until around 1 p.m., Wednesday, which was the following day.

On Thursday morning, another Attending Pediatrician who had been involved in the PICU care from Tuesday on, noted that the infant plaintiff’s neurological status was fine. However, he was called to see her again in the early afternoon when it was discovered that she was not moving her legs. At that point, an MRI of the spine was ordered stat, and was performed promptly. It revealed a spinal arteriovenous malformation (AVM ) in her lower spine. An AVM is a congenital, unnatural connection between arteries and veins. The infant plaintiff had suffered a massive hemorrhage of the AVM. The infant was taken to the operating room that evening and spine surgery was performed to relieve pressure in the spinal column. The next morning, Friday, a vascular neurosurgeon performed further surgery, and wrote in his post-operative note, “cured AVM,” stating that he had achieved “excellent obliteration of AVM.” He testified at deposition that the hemorrhage occurred on Thursday afternoon and had caused injury to the spinal cord, causing paralysis of her legs. He also testified that had he been asked on Tuesday, Wednesday, or Thursday before the hemorrhage occurred, to perform the same procedure to obliterate the AVM, there was at least a substantial probability that the child would not have been paralyzed.



The plaintiff contended that the child will permanently suffer paraparesis. The plaintiff also contended that she will permanently suffer bowel difficulties and severe urinary difficulties, requiring frequent catheterization. The plaintiff contended that the costs of future care are extensive. The plaintiff’s experts would have concluded that her life expectancy was essentially normal, to age 78.



The plaintiff would have also argued that the pain and suffering will be especially severe, and lifelong.The case settled prior to trial for a present value of $________. A portion of the case was used to fund a Supplemental Needs Trust.

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