Medical Malpractice Insights: Bronchitis or myocarditis? A fatal difference
Author: Chuck Pilcher, MD, FACEP (Editor, Med Mal Insights) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) and Brit Long, MD (@long_brit)
Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. The goal of MMI-LFL is to improve patient safety, educate physicians and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.
Chuck Pilcher MD FACEP
Editor, Med Mal Insights
Bronchitis or myocarditis? A fatal difference
Differential diagnosis will reduce chance of lawsuit
Facts: JK, 23, arrives in the ED at 10:56 AM with complaints of chest congestion, fever, sore throat, cough, SOB, muscle aches, and pleuritic pain for 2 days. The triage nurse records tachycardia at 115. He is seen by the ED doc for a total of 5 minutes. A CXR is normal. No differential diagnosis is recorded. He is diagnosed with bronchitis, given an antibiotic and Vicodin, and discharged 29 minutes after arrival. The next morning he is found dead in bed. The autopsy reveals viral myocarditis as the cause of death with bronchitis as a contributing cause.
Plaintiff: The Mayo Clinic and Johns Hopkins websites list the symptoms of myocarditis and I had all of them: fatigue, SOB, rapid heartbeat, fever, chest pain, lung congestion, and myalgias. You only spent 5 minutes with me. You assumed I had bronchitis from the beginning (anchoring bias), and when my CXR was normal, that was the end of your thinking (confirmation bias.) You thought of nothing else and had no differential diagnosis. Because I had chest pain and tachycardia, you should have done an EKG.
Defense: Yes, those are symptoms of myocarditis. They are also symptoms of bronchitis. And yes, the websites say that, but I’d never read them before this trial. The Mayo Clinic and Johns Hopkins websites don’t even list an author. They’re undated and aren’t reliable “expert opinions.” And 5 minutes is all it takes to evaluate a cough like this. Your pleuritic chest pain didn’t warrant an EKG. Viral myocarditis is extremely rare. Your treatment was appropriate.
Result: Jury verdict for $2,925,000. Verdict was appealed on the issue of the admissibility of the website information. The appeals court agreed that the website information was inadmissible hearsay but felt it did not prejudice the defendant because of other evidence presented at trial. Trial court verdict sustained.
Takeaway: This verdict is a bit scary. Simple problems with simple presentations are not always simple diagnoses. Yes, as ED physicians, we must cast a wide net to avoid being lulled by common complaints and must always keep a broad differential diagnosis in mind. Most items in a differential can be eliminated by history alone. Choosing when to get an EKG on a patient with apparent bronchitis with chest pain is a challenge. Simply considering an EKG and DOCUMENTING why you feel it’s unnecessary is sufficient. It’s not malpractice to be wrong, only to be negligent.
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Kace v. Liang et al., Massachusetts Supreme Judicial Court, 2015, SJC-11827 http://caselaw.findlaw.com/ma-supreme-judicial-court/1712851.html
Mayo Clinic Patient Care and Health Information http://www.mayoclinic.org/diseases-conditions/myocarditis/basics/symptoms/con-20027303
Myocarditis, Wilson WH et al., Medscape eMedicine, http://emedicine.medscape.com/article/156330-clinical
“Of course, I think that people are just waiting for that time when I make a mistake and they’re gonna jump on it…. There’s gonna be haters.”