Presentation
At 9:30 a.m., a 43-year-old man came to the emergency department (ED) of a metropolitan hospital. He reported chest pain, dizziness, diaphoresis, shortness of breath, and pain going down his arms. The pain had been intermittent for the last three days, and had increased in intensity over the last few hours.
Physician action
An emergency medicine physician examined the patient and documented that he stated his pain was made worse by movement and relieved by rest. The patient further stated that he had been “lifting at work all day.” The patient was pain free when he came to the ED.
The patient had a history of hypertension and occasional cigar smoking. He had no family history of cardiac disease. Upon exam, his blood pressure was 148/100 mm Hg; his pulse rate was 67 bpm; and he had a normal respiratory rate of 18.
Chest x-ray and EKG results were normal. The CBC was normal with mild hemoconcentration of hemoglobin 18.8 g/dl and hematocrit of 54%. With the exception of an elevated AST level of 51, the results of the complete metabolic panel were normal. Cardiac enzymes were also reported as normal. The emergency medicine physician concluded that the patient had chest wall and neuropathic pain.
The patient was discharged at 12:45 p.m. with instructions to take a daily aspirin and follow up with his primary care physician in one to two days for a stress test. The patient was to return to the ED if his condition worsened. At the time of discharge, the patient reported no pain and his vital signs were “satisfactory.”
Early the next morning, the patient’s wife found him pulseless and apneic in his car. When EMS arrived, the patient was in full arrest. Down time before the arrival of EMS was estimated to be 10 to 15 minutes. Despite resuscitation efforts, the patient remained asystolic until his arrival at the hospital. The same emergency physician treated the patient. Chest compressions and advanced ACLS methods were continued without success. The patient died.
An autopsy revealed cardiomegaly, left ventricular hypertrophy, and 100% stenosis in the left anterior descending coronary artery.
Allegations
The patient’s family filed a lawsuit against the emergency medicine physician. The suit alleged that the patient was misdiagnosed with chest wall and neuropathic pain, and then inappropriately discharged.
According to the allegations, serial EKGs, cardiac enzymes, and a cardiac stress test or coronary angiography could have helped diagnose the patient. The patient was discharged after one EKG and two sets of cardiac enzymes less than two hours apart.
Plaintiffs alleged that the standard of care was breached when: a.) the physician failed to admit the patient to an inpatient monitored unit; b.) a full dose of aspirin was not given to the patient while still in the ED; and c.) a cardiology consult was not obtained before discharge.
Legal implications
Physicians who reviewed this case for the defense had mixed opinions. The majority stated that, given the patient’s initial complaints, he required admission to the hospital for a cardiac workup; serial EKGs should have been performed; and an adult dose of aspirin should have been administered.
Disposition
The case was settled on behalf of the emergency medicine physician.
Risk management considerations
The patient’s chest pain included an atypical feature — sharp pain that became worse with movement. But it was also accompanied with typical signs of cardiac chest pain, namely, chest pain radiating to the arms, diaphoresis, shortness of breath, hypertension, and obesity.
The patient’s combination of symptoms, a normal EKG, and normal cardiac enzymes should have prompted further action on the part of the emergency medicine physician. The need for serial enzymes, serial EKGs, a cardiology consult, and further cardiac testing and monitoring would have required the patient to be admitted to a monitored bed for 24 hours.
EDs assist physicians by implementing detailed, time-sensitive chest pain protocols. While a missed diagnosis of acute coronary ischemia is a common allegation against emergency medicine physicians, protocols have their limits and do not address every possible patient scenario.
Physicians are encouraged to look at the larger perspective and include the patient’s medical history and all reported symptoms. Consider the worst possible outcome in a patient reporting chest pain. In this case, the emergency physician may have been prompted to administer aspirin, order serial EKGs and cardiac enzymes, a cardiology consult, and admit the patient to a monitored unit.
