Lack of Documentation Equals Indefensible Missed MI Case
In a recent malpractice case, a widow stated that her husband presented with crushing substernal chest pain with shortness of breath, but the emergency physician (EP) testified that the chest pain occurred with cough only.
However, the EP failed to document this in the medical record. "Clearly documenting that the chest pain was only with cough would have saved the EP from having to make a settlement," says John Tafuri,MD, FAAEM, regional director of TeamHealth Cleveland (OH) Clinic and chief of staff at Fairview Hospital in Cleveland.
Tafuri has reviewed many malpractice claims involving disputes between the patient and the EP over what was said or done, with no relevant documentation in the medical record.
"High-risk symptoms need to have specific documentation in the record that supports the EP's decision not to pursue an aggressive path," he says.
According to data from the 2013 edition of the PIAA Risk Management Review for Emergency Medicine, acute myocardial infarction (AMI) was the second most common medical condition in claims alleging errors in diagnosis. Of the 66 closed claims that occurred during that timeframe, 50% closed with an indemnity payment, compared to 33% for all claims involving diagnostic errors.
In a recent malpractice claim, the plaintiff was a young woman in her 20s who presented with substernal chest pain that radiated down her left arm. The patient did not have any other signs or symptoms associated with an MI, and had a normal EKG, chest X-ray, and D-dimer test.
"The physicians discharged the patient and concluded that she had either costochrondritis, in which the pain can mimic a heart attack, or gastroesophageal reflux disease, which can cause burning pain in the chest," says Marcie A. Courtney, JD, an associate with Post & Schell's Professional Liability Defense Practice Group in Philadelphia. Two days after being sent home, the patient suffered a heart attack.
These are common allegations Courtney has seen in claims against EPs involving a failure to diagnose a heart attack:
- the failure to perform a thorough work-up, including obtaining cardiac enzymes, troponin levels, and serial EKGs;
- the failure to admit a patient to the hospital when he or she presents with chest pain radiating down the left arm;
- the failure to order an emergent consult with a cardiologist;
- the improper interpretation of an EKG by a non-cardiologist.
"Cases involving heart attacks which could potentially have been avoided can be challenging to defend," says Courtney. An ED patient who is discharged and subsequently has an MI is likely to sue the EP for the failure to diagnose the heart attack and failure to prevent it from occurring, she says.
"Unfortunately, many of these claims will not be avoided," she says. "While no guarantee, good documentation can help a plaintiff's lawyer decide not to sue or pursue a case against a physician or hospital." Here are some practices that can make claims more defensible:
• EPs should document their rationale for why they didn't believe the patient was having an MI, including the patient's past medical history, lifestyle, and current condition.
This can be used by defense lawyers to help the jury understand why an MI was not higher on the EP's differential; why it was ruled out without the performance of multiple available diagnostic tests; and why the patient was not admitted to the hospital.
• EPs should document the length of time that a patient with chest pain was being assessed by health care providers.
"This can be helpful in defending a plaintiff's claim that the patient should have been admitted to the hospital," says Courtney. For instance, if a patient presents to the ED with chest pain and no other symptoms; is at the hospital for six hours being assessed by multiple health care providers and undergoing multiple tests, which are negative; and the patient's condition does not deteriorate during that time, the defense can argue that the EP's decision to discharge the patient was acceptable under the circumstances.
"This position can be supported by a review of the EKG taken in the ED, and the patient's clinical condition during the six-hour period," she says.
• EPs should review any available past medical records and diagnostic studies.
If an EKG from a previous hospital visit is available, for instance, it should be reviewed and compared with a current EKG. "The fact that no changes were noted between the two studies should be documented in the chart," says Courtney.
• EPs should request a cardiology consult when any questionable abnormalities are seen on an EKG or other pertinent diagnostic studies.
"Document any relevant conversations between the two providers," says Courtney.
• EPs should give clear and understandable instructions regarding future care.
It's not enough for EPs to tell patients return if their chest pain continues, says Courtney — more specific information needs to be provided to the patient.
"Discharge instructions should advise the patient to immediately return to the ED if their condition changes, and if they develop respiratory distress, palpitations, heart rhythm disturbances, edema, nausea, vomiting, increased chest pain, or diaphoresis," she says.
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