Medical Malpractice Insights: “You’re not having a heart attack”

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

“You’re not having a heart  attack”

“But doc, what IS causing this pain?”

Facts: A 64 yo hypertensive female smoker (20 pack-years) presents to the ED with chest pain and pressure radiating to her neck and tells the staff “I think I’m having a heart attack.” FH is + for mother and grandmother with CAD < 55 yo. EKG, troponin x 2, and CXR are non-diagnostic. She improves with NTG and 1 mg IV MS, “wants to go home”, and is discharged. Four days later she presents to another ED with persistent sx including CPx made worse by breathing or moving. Lab, EKG, and CXR again are normal and she is discharged on aspirin. Four more days later she is seen again by the same ED physician at the first ED with continued chest pressure radiating to the R back, weakness in L arm, and SOB. BP is 177/111. Troponin is normal, and a CXR is read as “heart size at upper limits of normal.” A CT scan of the cervical and thoracic spine is ordered (apparently to r/o a musculo-skelatal problem) and shows only mild degenerative changes. Four days later she suffers a cardiac arrest at home. The death certificate states she died of a myocardial infarction. No autopsy is done. An attorney is consulted, and records are obtained and reviewed by experts in emergency medicine, radiology, and cardio-thoracic surgery. All agree that the CXR shows clear evidence of a widened mediastinum and the CT shows a dilated aortic arch. A lawsuit is filed.

Plaintiff: You did not document a differential diagnosis. All you did was tell me “You’re not having a heart attack.” There’s no evidence you thought of angina, pulmonary embolus, or aortic dissection. You said that my last CXR showed a large heart, but it was a wide mediastinum. And guess what! My dilated aortic arch even shows up on the CT scan of my T-spine. You missed both of these. And even your own experts agree. I’d be alive today if you’d found the real cause for my chest pain.

Defense: Your symptoms weren’t typical of aortic dissection. Your care was appropriate. Any radiologist could have missed the abnormal aorta. And there’s no guarantee a surgeon would have been able to fix the dissection and save your life.

Result: Pre-trial settlement for an undisclosed amount.

Takeaway: When someone presents with chest pain, we should think of at least 3 things: Pulmonary embolus, aortic dissection, and unstable angina. Why? Because these 3 are the most commonly missed chest pain diagnoses that lead to lawsuits. What about acute MI? Shouldn’t that be in the differential? Yes! But in the typical ED, chest pain patients get an EKG and cardiac enzymes before the doc even knows they’re in the department. If the EKG looks fine and the enzymes are normal, we can’t stop there, or we’ll miss the other 3 killers. Take a good history. Think of other possibilities besides MI. Form a differential diagnosis. Conclude with a simple note stating “I have considered PE, dissection, and unstable angina and am able to rule them out based on…” It is not malpractice to be wrong. It is below the standard of care not to consider likely fatal conditions which could be causing a patient’s symptoms.

Reference/Further Reading:

Aortic Dissection, Medscape eMedicine, Mancini MC et al. Updated Dec 22, 2016

“Plaintiff attorneys are only exposing our medical culture for what it is – overly reliant on fallible humans. Aviation has learned that the best approach to plaintiff lawyers is to starve them. Redesign our processes and change our culture so these mistakes don’t happen.”

 JB, airline pilot and safety officer