Medical Malpractice Insights: Chest tightness and cough – EKG, CXR, or both?

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.

Last month’s case was an example of a missed MI due to anchoring bias based on the patient’s prior history of pulmonary fibrosis. In this month’s brief summary, we are reminded that myocarditis is another cause of chest pain that must be considered, especially in younger patients.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights

Chest tightness and cough: EKG, CXR, or both?

Would including myocarditis in the differential have avoided a $4.8 million jury verdict?

Facts: A 23-year-old male presents with chest tightness, cough, and fever. The record indicates a very brief physician encounter with the patient. A chest x-ray is normal. The patient is discharged with a diagnosis of bronchitis and prescribed an antibiotic plus hydrocodone for cough and chest pain. The next morning he is found dead. Autopsy reveals cause of death to be viral myocarditis.

Plaintiff: You only paid attention to the cough, not the chest pain. You should have obtained an EKG. If you had, you would have made the diagnosis. His death was 100% preventable.

Defense: An EKG was unnecessary with typical symptoms of bronchitis. Bronchitis can cause chest pain. There’s no guarantee the EKG would have been abnormal anyway. And even if we had made the diagnosis of viral myocarditis, there isn’t any treatment that guarantees the patient won’t develop complications and die.

Result: Jury verdict for $4.9 million; unsuccessfully appealed to the state Supreme Court.

Takeaways:

• We rarely miss an MI, so always consider the most common and the less common causes of chest pain: ACS, aortic dissection, pneumothorax, tamponade, esophageal rupture, PE, and myocarditis.
• Juries can be unpredictable.
• Spend enough time with the patient to take at least a full problem-focused history and exam.
• Focus on the chest pain, not the cough.
• Myocarditis exists, more often in children, but you have to think about it and include it in your differential.
• Plaintiff lawyers love cases where a single test, if ordered, would have made the diagnosis – even though other docs (most other docs?) – might also have missed it.

References: Myocarditis. Tang WHW. Medscape eMedicine, Updated Dec 19, 2016. https://emedicine.medscape.com/article/156330-overview

It is always better to get the treadmill test the day BEFORE the cardiac arrest rather than the day AFTER the cardiac arrest.

Greg Moore MD FACEP