The initial story was a guy with a headache that thought he heard a "pop". The stroke symptoms came later, as was pointed out earlier in this thread. If the "pop" was from a vessel bursting then there would have been blood on one of the CT's. Sounds like he ended up with an ischemic event, not a hemmorhagic one. It might not have even been related to his headache. The LP would likely have been normal.
In my opinion, if a youngish man with no prior headache history presents with an instant-onset headache with confusion, dizziness, NV, and diplopia, then its a hemorrhagic insult until proven otherwise.I disagree that it sounded like ischemia on first presentation, since he was not expressing focal signs.
Non-contrast enhanced CTs may not show hemorrhage if done within the first one or two days, although it should show up within 72hours 95% of the time. However, with SAH, that's far too long to wait for a CT to show blood.
If the CT is negative and your suspicion is high, an LP is the next step. Blood would be present since the SA space communicates with the spinal canal. Even if it were negative, a prudent physician would monitor the guy for at least 6 more hours to repeat the LP and look for xanthochromia.
And how do you know they didn't look in his eyes? If they did, it was probably normal because ICP increases AFTER the acute event.
You have a good point here: you wouldn't expect to see papilledema so soon after the SAH. However, a regular Cranial nerve exam would perhaps reveal some deficits - not unreasonable considering the diplopia.
Oh, and I agree with you on more pay, less rush, and no midlevels except in fast track.
Midlevels should be relegated to the paperwork. The medicine should be done by the doctors. Even on fast track, I've seen people come in with fairly mundane complaints that, upon further investigation, were actually true pathology: mild vertigo is a vestibular schwannoma; mild chronic back pain that does not respond to NSAIDs as usual is MI secondary to triple-vessel occlusion; old guy with "functional decline" has infective endocarditis. A midlevel does not possess the knowledge to effectively diagnose these conditions when they present insidiously.
The truth is that doctors are overworked and cannot afford to take the time to pay strict attention to details, hence the hiring of the midlevels. This is a horrible solution. What should happen is the hospital should hire more doctors and have more working at any given time, and pay them more to do it. It's a crucial job that
nobody else can do right, especially midlevels.
Maybe I'm missing something, but the whole midlevel thing seems really unfair to me. The midlevels I've worked with see their own patients, sign their own charts, and rarely talk with the EP unless they have something that was mis-triaged or they have a question (this is in the private world, academics is different). And then we're supposed to be responsible for their mistakes? If their going to see patients, then they should take responsibility for them - good outcomes or bad.
They shouldn't be seeing patients at all. They should be doing the paperwork and that's it!
I think PA's should just see the fast track, low acuity patients and carry their own malpractice. It's not because I think PA's aren't capable, but because if there's a mistake made I want to have only one person to blame. And no-one who bounces back should be seen by a PA
Unfortunately, the onus falls on the supervising physician if a midlevel screws up. What's the point of a midlevel if they have no authority to definitively diagnose and treat patients? I fail to see it other than as a cost-cutting measure for hospitals to use: you can hire 6 midlevels for the price of one physician.
