Medical Malpractice Insights: How did this MI get missed?

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.

Missed MI’s are becoming a rare occurrence, but here’s one with some interesting twists.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

How did this MI get missed?

 Could “anchoring bias” have played a role? 

Facts: A 53-year-old male with a history of mild pulmonary fibrosis presents to the ED with a 2 days of new onset exertional chest tightness radiating to both shoulders and relieved by rest. He has dyspnea but feels that it is no worse than usual. He denies nausea or diaphoresis. An EKG shows only non-diagnostic abnormalities, and troponin is within normal limits. The patient is diagnosed with an exacerbation of his pulmonary fibrosis [anchoring bias?/cp] and discharged, but advised to “have your heart checked.” The patient calls his primary care the next morning and is immediately referred to a cardiologist for a stress echo. This is done late the following afternoon, and the result is placed in a pile of routine studies to be read by the cardiologist the next morning. Upon returning home after the stress test, the patient experiences more chest tightness and sweating. He calls 911 and returns to the same ED and sees the same ED physician. An EKG and troponin are repeated and are again non-diagnostic. The EP makes no effort to contact the cardiologist (or the PCP who ordered the test) about the stress echo done only a few hours before. The patient is again discharged without any mention of nitroglycerine or aspirin therapy for acute coronary syndrome (ACS). The next morning the cardiologist checks the patient’s “routine” stress test, finds it abnormal and schedules the patient for a follow-up visit the following day. When the patient shows up in the office the next morning, his symptoms are so severe that he is sent by EMS directly to the cath lab. He is found to have an acute MI and is stented. He develops cardiomyopathy that prevents him from working and files a lawsuit against the ED physician, his primary care, and cardiologist.

Plaintiff: I had classic symptoms of unstable angina, both at rest and with exertion. You just focused on my lung problem and didn’t listen. I may not have had an MI when you saw me, but I clearly had ACS. You never even offered me NTG or an aspirin. You let my crescendo angina continue until I had a major heart attack, and now I can’t work. Oh, and why didn’t you and my PCP and my cardiologist talk to each other? This could all have been avoided with just a couple phone calls.

Defense: Our care was reasonable if not perfect. You would have had to have stents anyway. The delay didn’t change anything.

Result: Undisclosed settlement with the ED physician after 5 years of litigation. Outcomes against other defendants are unknown.

Takeaways:

• A normal EKG and troponin does not rule out other forms of ACS.
• In addition to MI, angina and ACS should be in every chest pain differential. Always consider the life threats (PETMAC – PE, esophageal rupture, tension pneumothorax, MI, aortic dissection, cardiac tamponade).
• When ACS is a possibility, ASA and NTG should be considered and/or given.
• For patients with classic symptoms of ACS, a coronary angiogram – not just a stress test – is often an appropriate first choice, especially in a young person facing a lifetime of worrying about the cause of his chest pain.
• If a patient has just had a stress test, find out what the result was before discharging the patient, especially when a primary care is so concerned as to order one urgently after you missed the diagnosis on a prior visit.
• Don’t get “anchored” to a diagnosis based on a prior history (e.g., pulmonary fibrosis).

References:

• Hickam’s Dictum (A patient may have as many problems as he damn well pleases)
• Occam’s Razor (The simplest answer is often the best)

Diagnostic Error: A diagnosis that was delayed or wrong that occurs when all the clinician needed to make the diagnosis was potentially there, but because either the clinician or the system or both wasn’t functioning at the level of which they’re capable, the diagnosis wasn’t made.

Bob Trowbridge, MD, Director, Internal Medicine, Maine Medical Center