The Clinical Alarm Was Ringing — No One Listened
How Adriana Smith’s fatal headache reveals the cost of dismissal, delay, and missed judgment in maternal care
There are patterns clinicians are trained to recognize.
And there are moments we’re trained not to ignore.
A pregnant patient with a headache is one of those moments.
Not because every headache is dangerous—but because when something doesn’t fit, you have to stay curious.
You have to listen.
You have to know when it’s time to stop looking for reassurance and start looking for the rare thing that could kill her.
That’s what clinical judgment is.
And it’s what Adriana Smith didn’t get.
🚪 The First Visit Should Be a Door—Not a Dead End
Most pregnancy headaches are benign—tension, hormones, dehydration. But when the pain is new, intense, and unrelenting? That’s not routine.
Unrelenting Pain Needs More Than Tylenol
(And why trusting your neuro exam might not be enough)
When a patient walks into the ER with a severe headache, the first thing I assess is the pain—but not through a 1–10 scale.
Pain scores flatten what we need to expand.
Instead, I ask:
When did you last eat?
If someone hasn’t eaten in over 24 hours, that’s not routine—it’s a sign that the pain is intense enough to override basic drives.
What did you do while waiting?
If they say, “I sat stiff as a board, afraid to move,” or “I couldn’t even look at my phone—it hurt too much,”
That tells me we’re not dealing with garden-variety tension or migraine pain. Something more serious may be unfolding.
🧠 In the Setting of Headache, Neuro Exam Is Key—But Imperfect
Once I’ve registered that the pain is severe and out of proportion, I move to the neurological exam. Because the question now is:
Could this headache be the first sign of something catastrophic?
But here’s the catch:
As a non-neurologist, how much do I trust my own neuro exam?
Subtle early deficits are hard to detect. They hide behind normal reflexes, vague complaints, or fatigue. And by the time deficits are obvious—you don’t need an exam. You just need eyeballs.
That’s why the neuro exam isn’t a final answer. It’s a tool.
And if the tool is giving you uncertain signals while the patient is screaming in pain—you escalate.
🚨 Adriana Smith Didn’t Get Escalation. She Got Tylenol.
She came in with a severe headache while pregnant.
No imaging. No neuro consult. No admission.
Just Tylenol.
And then she was sent home.
She was later declared brain-dead.
If you’re not sure, act like this is her only shot—because it might be.
In too many hospitals, neurology isn’t readily available. That means we need to get better at recognizing when something doesn’t feel right—even if we can’t name it.
🔁 When They Come Back, Everything Changes
Adriana returned the next day. That, alone, should have changed everything.
Returning to the ER—especially in pregnancy—is never normal. It means the pain was too much to manage. It means the patient didn’t feel safe. It means we missed something.
When someone comes back, I ask:
What did we do last time?
Did we image her?
Did anything improve?
If the answer is “nothing changed,” then everything has to change.
We don’t double down on dismissal. We widen the differential.
We don’t reach for more reassurance. We reach for a CT scanner.
🧠 No One Goes Home With the Same Headache They Came In With
Here’s the clinical rule I live by:
If I’ve tried two or three treatments and she still has pain that has not improved, I scan.
The “headache cocktail” is a standard first step: IV fluids, magnesium, Tylenol, Reglan, Benadryl. Maybe Toradol or caffeine if she’s not in the third trimester. But if her pain hasn’t resolved—if I still don’t have an explanation—I need to image her brain.
I’m no longer treating a headache.
I’m ruling out stroke, hemorrhage, cerebral venous thrombosis.
That’s how lives are saved.
That’s how Adriana’s life might have been saved.
🗣️ Ask Her: “Do You Feel Safe Going Home?”
Before I discharge anyone, I ask two questions:
“Do you feel safe going home?”
“Are you comfortable with this plan?”
You’d be surprised how often that changes the course of care.
Because patients know when something is wrong—even if we don’t see it yet.
If Adriana had been asked that—really asked, and heard—maybe she would’ve had her scan.
Maybe her clots would’ve been caught.
Maybe she would still be here.
🧬 The Case That Could Have Gone Differently
Not long ago, I had a pregnant patient in her third trimester.
She had persistent abdominal pain requiring narcotic pain medications—nothing on labs, nothing on imaging. If a pregnant patient has a new narcotic requirement, I will always recommend admission until the pain either improves or an underlying cause is identified.
In this patient’s case, during her prior visits she was told it was just pregnancy. She was “fine.”
But she wasn’t improving. She kept coming back.
I repeated tests and imaging—and still, nothing.
I told her:
“I don’t know what’s causing your pain. Everything has come back normal. I rarely send pregnant women home with narcotic prescriptions without a diagnosis.”
So here are our options:
“Do you think you can manage the pain at home?”
“No.”
“Okay—then I recommend transferring you to a tertiary care center, where you can get further imaging, like an MRI.”
She said:
“I want to know what’s causing this pain.”
So I transferred her.
Not because I had a diagnosis. But because I had reached my limits—and she hadn’t gotten better.
She ended up having a pheochromocytoma—a rare tumor of the adrenal gland that secretes excessive catecholamines (like adrenaline). In pregnancy, it’s exceptionally dangerous.
The classic symptoms—severe abdominal pain, headaches, palpitations, high blood pressure, and sweating—can easily be misattributed to common pregnancy complaints.
But if undiagnosed, pheochromocytoma can trigger life-threatening hypertensive crises, arrhythmias, stroke, and even maternal or fetal death—especially during labor or anesthesia.
It’s rare, but when it’s missed, it’s catastrophic.
We caught it because we listened.
Because we stayed curious.
Because we didn’t accept “normal tests” as the end of the story.
She—and her baby—survived.
An aside on why this was missed:
Our radiologist missed it on the scan. This happens. Unlike tertiary care facilities, in small hospitals, you have one radiologist working alone, so if there is something challenging, there are no colleagues readily available to consult. In a large hospital, there are teams of radiologists specializing in different imaging modalities. They take challenging cases to conference for a group to study in detail. It’s important to understand it’s not about the individual doctor (because often doctors work at multiple hospitals supporting both large and small facilities). It’s about the system.
Two Missed Opportunities. One Devastating Outcome.
By the time Adriana Smith was declared brain-dead, she had passed through the doors of two different hospitals—neither of which managed to escalate her care appropriately.
At the first hospital, Adriana presented with severe headache and was discharged with Tylenol.
No imaging.
No escalation.
No neurology consult.
Despite being pregnant—despite being in visible pain.
When she returned to a second hospital in worse condition, her deterioration continued without meaningful intervention until she was found unresponsive. By then, it was too late.
This wasn’t just a tragic outcome.
It was a clinical failure—a systems failure—and a predictable failure.
What Adriana’s Symptoms Could Have Signaled
Adriana’s headache, light sensitivity, and neurological decline were consistent with cerebral venous sinus thrombosis (CVST)—a rare but well-documented neurologic complication of pregnancy.
📌 CVST is more likely in pregnant and postpartum people, especially in the presence of dehydration, elevated estrogen levels, or prothrombotic conditions.
📌 Early signs often include persistent headache, visual disturbances, and confusion—all of which can progress rapidly to seizures, coma, and death if not treated.
📌 Diagnosis requires brain imaging (MRI/MRV or CT venogram), not just clinical observation.
Even if CVST wasn’t the ultimate cause, her symptoms warranted a full neurological workup—and she never got one.
Diagnostic Dismissal Is a Pattern—Not an Exception
According to the 2023 AP investigation, Black patients are less likely than white patients to be diagnosed early for serious conditions like stroke, appendicitis, and sepsis—even when presenting with textbook symptoms.
The data show that Black patients:
Receive less imaging in the ER
Wait longer for pain medication
Are more likely to have their symptoms dismissed as non-urgent or psychiatric in origin
Adriana was a pregnant Black woman in visible pain. And instead of getting a workup, she got instructions to go home and rest.
As SisterSong powerfully put it:
“She should’ve been listened to first. That’s why we say, Trust Black women.”
The Burden of “Proving” You’re in Crisis
In healthcare, Black women are too often expected to perform their pain in a way that convinces others they are suffering enough to deserve care.
Even while in the third trimester.
Even while neurologically compromised.
Even while dying.
⚠️ What Adriana Smith’s Case Reveals
We don’t have access to her full chart.
But here’s what we do know:
She had a severe, persistent headache.
She was pregnant.
She was discharged—twice.
She returned.
She didn’t improve.
She died of cerebral blood clots the next day.
That’s not a mystery.
That’s a failure—of systems, of clinical culture, and of urgency.
What Could Have Changed This?
A basic neurological exam
A CT or MRI
A consult from neurology or maternal-fetal medicine
A provider who paused and said, “This doesn’t feel right”
None of these are obscure interventions.
They’re standard care.
But Adriana didn’t get standard care.
Because in this country, Black women are systemically denied it.
And So—The Pattern Continues
Adriana’s death is not an outlier. It is part of a repeatable, traceable, and preventable pattern of diagnostic inequity.
Until the pattern is broken—
Until every Black woman is listened to—
Until escalation is the default, not the exception—
This will keep happening.
Let Adriana be the last.
🩺 Quick Aside - Clinical Judgment Is the Safety Net
This isn’t about defensive medicine or over-testing.
It’s about having the humility to say: “Something’s not right here.”
It’s about understanding that pregnancy doesn’t protect people from dangerous diagnoses—it can actually increase the risk of them.
And it’s about knowing when unresolved pain is a red flag—not just an inconvenience.
Sometimes we scan.
Sometimes we transfer.
Sometimes we just stop and listen one more time.
And sometimes, that’s the difference between dismissal and diagnosis.
✅ What This Means for You
If you’re pregnant and experiencing a severe or persistent headache:
Ask directly: “Could this be something dangerous?”
Insist on answers. If you don’t feel heard, go back—or go elsewhere.
Before leaving, ask: “Do you know what’s causing this? Are you sure it’s not something serious?”
If you’re a provider:
Don’t discharge patients with unresolved symptoms—especially neurological ones.
Escalate when the clinical picture doesn’t make sense.
Ask: “Do you feel safe going home?” and trust the answer.
Next Up: What the Law Took Away
In the next post, we’ll move from medicine to law.
Because after Adriana Smith was declared brain dead, her story wasn’t over.
Her body was kept alive—not for her, but for the fetus inside her.
Her family had no say. Her prior wishes didn’t matter.
That’s what happens when fetal personhood laws meet brain death.
And that’s where we go next.