A 15-Year-Old's Headache: When Documentation and Bias Collide

On September 11, 2001, a 15-year-old girl named Peggy developed a headache and neck pain after a coughing spell. Her grandmother couldn't get her into the car, so she called 911. Paramedics documented "sudden onset of neck and head pain this AM after coughing." In the emergency department, the triage nurse noted stiff neck, nausea, vomiting of thin fluids, and a pain score of five out of ten. The patient was so uncomfortable she couldn't get onto the stretcher and was examined in a wheelchair.

The emergency physician documented something different: throbbing frontal headache for a few hours, no nausea or vomiting, no photophobia, no fever, and that "this is not the worst headache of life." The physical exam noted a supple neck and normal neurologic exam. Blood pressure was 174/94. She received ibuprofen, a soft collar, and ice packs. The diagnosis on the chart was simply "headache." No imaging was performed. No reassessment was documented. No differential diagnosis was recorded. She was told to return if worse.

Four days later, she saw her primary care physician for neck pain and received muscle relaxants. Three weeks after the initial ED visit, her grandmother found her unresponsive. The autopsy revealed a ruptured berry aneurysm with massive intracranial hemorrhage and no evidence of prior bleed.