Between the Triage Note and the Return
A short read on what a defensible review of a missed-SAH case actually examines, and why the work happens in the history.
A 38-year-old woman presents to a community emergency department on a Tuesday afternoon with a severe headache that began suddenly that morning. The triage note records "headache, six hours, no trauma." She is treated with IV fluids and ondansetron (an anti-nausea drug), improves modestly, and is discharged with a diagnosis of migraine and a referral to her primary care doctor. Thirty-six hours later, she is found unresponsive at home. A CT scan (computed tomography, an X-ray-based brain image) shows a large subarachnoid hemorrhage (SAH, bleeding into the space surrounding the brain, most often from a ruptured aneurysm, which is a balloon-like weakening of an artery wall) with intraventricular extension (the blood having spread into the brain's fluid-filled chambers). She survives surgery. She does not return to her prior work.
Both sides will reach for the same record on the way to deposition. The plaintiff's complaint will say the diagnosis was missed. The defense will say the presentation did not classically suggest a ruptured aneurysm. The chart sits in between, and the question this issue takes seriously is what it actually shows, and what its silences carry.
A defensible reconstruction in a missed-SAH case is built from a small set of specific findings, most of them in the documented history rather than the imaging. Was the onset characterized (sudden versus gradual, time to peak intensity), or was the headache reduced to a duration in hours? Was the comparison to prior headaches asked, or assumed away by a chronic-migraine label? Was a sentinel-headache history (a smaller warning leak days to weeks earlier, reported by up to forty percent of SAH patients on retrospective questioning) elicited, or did the chart skip from chief complaint to disposition? When CT was obtained, was it within the six-hour window in which modern scanners, read by attending-level radiologists, approach near-complete sensitivity, or at the eighteen-hour mark, when a negative read no longer rules out the disease? Was a lumbar puncture (LP, a spinal tap that samples cerebrospinal fluid, the clear fluid that bathes the brain and spinal cord) performed when the CT timing demanded it, and if so, was xanthochromia (yellow discoloration of that fluid from hemoglobin breakdown, the most reliable laboratory marker of true SAH) analyzed, or did the interpretation rest on red-cell counts and the traditional heuristic for distinguishing a real bleed from a traumatic tap (blood introduced by the spinal needle itself rather than by a hemorrhage)? If LP was deferred in favor of CT angiography (a CT scan with intravenous dye that maps the brain's arteries), was that decision documented with reasoning, or by default?
The Commentary in this month's Writings walks through the medicine in detail, including the recurring failure modes that lead to missed diagnoses. The point worth carrying into a file review is structural. In missed-SAH cases, the analytical work begins with the documented history and the timing of imaging against symptom onset. Build that first, and the strengths and weaknesses of a given case tend to organize themselves against it. Some files that look strong in the complaint dissolve against a chart that captures a careful onset history and a CT obtained at hour four. Others that look strong on the defense collapse against a chief complaint of "headache" that nobody pressed past, and a scan ordered too late to mean what it was read to mean.
The CT shows the blood. The chart shows whether the question that should have ordered the CT was ever asked. In missed-SAH cases, the second record is the one worth reading first.
Tobias B. Kulik, MD, FAAN, CIME/ABIME, CPPS
CorteXion LLC · Scientia et Veritas
The Commentary in this month's Writings
Missed Subarachnoid Hemorrhage: The Case That Turns on the History — cortexion.co/writings/missed-subarachnoid-hemorrhage
Primary source
Perry JJ, Stiell IG, Sivilotti MLA, et al. Sensitivity of computed tomography performed within six hours of onset of headache for diagnosis of subarachnoid haemorrhage: prospective cohort study. BMJ. 2011;343:d4277. doi:10.1136/bmj.d4277
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