Medical Malpractice Insights: Death Happens

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. Stories of med mal lawsuits can save lives. If you have a story to share click here.

Chuck Pilcher, MD, FACEP

Editor, Medical Malpractice Insights

Editor, Med Mal Insights


Death happens

A bad outcome does not necessarily mean negligence

 

A 36-year-old female presents to a rural ED with a 1 week history of mild dyspnea and dull chest pain, worsening just prior to arrival. She is triaged as a Level 3 and taken immediately to the treatment area.

Timeline:

0:02: VS are normal except for a BP of 169/102. Placed on O2 and cardiac monitor. Physician at bedside. Family history of early heart disease obtained.

0:07: IV is started and labs drawn including a troponin and d-dimer. A quick exam of neck, lungs, heart, abdomen, and extremities is unremarkable. BMI is 39.7.

0:08: EKG is done and ischemia noted.

0:13: CXR is completed and normal.

0:20: Receives prophylactic aspirin for presumptive ACS.

0:32: VS are normal with BP of 138/85.

0:44: Patient reports increasing chest pain.

0:50: Reports extreme SOB.

0:51: Has a grand mal seizure. Monitor shows VF. Labs pending.

0:51-2:07: Resuscitative efforts begin. Labs return about 10 minutes into code (54 minutes after being drawn). The D-dimer is normal but the troponin that was ordered is not resulted anywhere in the record for unknown reasons. CO2 is 19, WBC is 20,330 (48% neutrophils, 44% lymphocytes, no bands). Electrolytes and renal and liver function normal. CPR continues for 1 hour & 16 minutes per ACLS protocols without ROSC.

2:07: Code called.

Post-event: Cause of death is listed as “Ventricular Fibrillation.” No autopsy is performed. An attorney is consulted about her care and the case is reviewed by an ED expert.

Plaintiff Arguments:

  • I was only 36 years old. I shouldn’t have died so young.
  • You knew I had a positive family history of early heart disease.
  • You never gave me a trial of nitroglycerine.
  • I had a heart attack. If you had given me tPA in time, I’d still be alive today.

 

Defense Arguments:

  • Your care was timely and reasonable. We treated you the same as we would treat any other chest pain patient.
  • Yes, you had unexpected ventricular fibrillation and it was probably due to a heart attack, but without an autopsy that’s a presumption, not a fact. We don’t know what caused your death.
  • Yes, we did not give you a trial of NTG. It didn’t matter. 1) If we had given you NTG, your response to NTG is an unknown. 2) If it had helped, it only means that the problem is likely heart related – but not necessarily an MI, given the EKG finding of ischemia only. 3) If it did not help, it could mean that your problem was caused by something else, like a pulmonary embolus or aortic dissection.
  • Until the troponin level returned, we had no reason to give you tPA. And you were in VF before the troponin result would have appeared along with the other lab results. We don’t know what happened to the troponin order and we can’t assume what the result would have been.
  • Once you went into VF and we began CPR, tPA would not likely have made a difference.
  • We are a rural hospital with no cath lab. We transfer patients with an acute MI to a hospital with a cath lab. Once you went into VF, you became too unstable to transfer.
  • Finally, if we had known the troponin, given you tPA, been able to transfer you quickly, you can’t assume that you would not have gone into VF during the transfer.
  • Your care was timely, appropriate to your presentation and within acceptable local community hospital standards.

 

Result: Based on the expert’s review, no lawsuit was filed.

 

Takeaways:

  • Young patients can have MI’s. About 8% are < 45 yo.
  • Any chest pain patient can crump at any time. Remain diligent.
  • Bad things will still happen over which we have no control.
  • A rural hospital with no cath lab is held to a different standard than an urban academic hospital.
  • Good documentation always helps.
  • Was this an MI, a PE, an aortic dissection – or something else? Sometimes we don’t ever learn what we missed.
  • Pain relief of nitroglycerin does not modify the likelihood of ACS. This should not be used to rule in or rule out ACS.
  • We do not know if the cause of the missing troponin level was ever investigated by the hospital. Clearly it should have been.
  • Standard care is defensible. Not every bad outcome results in a lawsuit.

 

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