Physician Legal Review & Commentary: Hospital's missed total arterial blockage results in jury verdict of $6.4 million
Hospital's missed total arterial blockage results in jury verdict of $6.4 million
By Jonathan D. Rubin, Esq.
Partner
Kaufman Borgeest & Ryan
New York, NY
Philip Nash
Law Clerk
Kaufman Borgeest & Ryan
Garden City, NY
Carol Gulinello, RN, MS, CPHRM
Vice President, Risk Management
Lutheran Medical Center
Brooklyn, NY
News: A 37-year-old man was transported to the emergency department complaining of chest and shoulder pain after playing basketball earlier in the day. EMS workers noted the man experienced atrial fibrillation en route to the hospital. At the hospital, he was given ibuprofen and azithromycin, diagnosed with having pneumonia and syncope, and released. Three months later, the man passed out during a game of basketball, suffered a seizure, and was taken again to the emergency department. He was diagnosed with an acute heart attack with cardiac arrest as a result of a total arterial blockage to the left anterior descending coronary artery. He suffered anoxic brain injury and required the use of a ventilator. The man died in a long-term care facility two months later. The estate administrator brought a lawsuit on behalf of the surviving children against the treating physicians and the hospital and alleged negligent care and wrongful death resulting from the first emergency department visit. The jury returned a verdict of $6.4 million.
Background: A 37-year-old man was transported to the emergency department on May 31, 2009, and was complaining of chest and shoulder pain. He first began to experience the pain during a game of basketball earlier in the day. En route to the hospital, EMTs reported the man experienced atrial fibrillation. Once at the hospital, the man told a nurse that chest pain was radiating down his right arm. An EKG was ordered, which indicated early myocardial infarction. The man's white blood cell count also was elevated. One of the treating physicians noted the man reported chest and shoulder pain and that he showed signs of acute coronary syndrome. However, the treating physicians diagnosed the man with pneumonia and syncope, gave him ibuprofen and azithromycin, and released him several hours after he first presented at the emergency department.
On Aug. 30, 2009, three months after his release from the emergency department, the man collapsed while playing basketball and suffered a seizure. EMTs arrived and found the man vomiting, spitting, and coughing before going into shock and needing to be resuscitated. The man was brought to the same hospital as on May 31. He was found to have total arterial blockage to the left anterior descending coronary artery and suffered a heart attack with cardiac arrest and anoxic brain injury. Now ventilator-dependent, the man was placed into a medically induced coma. He was transferred to a long-term care facility on Oct. 7 where he died on Nov. 12, 2009.
A lawsuit was filed against two emergency department physicians and the hospital by the estate administrator on behalf of the five surviving children. Plaintiff argued the defendants violated the standard of care when the man was first brought to the emergency department on May 31, 2009, and that the hospital's guidelines were not followed. Plaintiff claimed the defendants failed to admit their patient for a full cardiac work-up and order cardiac biomarkers and a lipid panel after the results of his EKG. Plaintiff claimed the patient's symptoms were clearly related to a heart condition, not pneumonia, and that this condition was treatable had the patient been properly diagnosed.
In support of the hospital and physicians, the defense argued that the treatment received in the emergency department and diagnosis of pneumonia was consistent with the symptoms exhibited by the patient. The defense also argued that if the patient were truly suffering from early myocardial infarction when he first presented to the emergency department on May 31, he would have exhibited other symptoms or complaints between the time of his discharge in May and collapse playing basketball on Aug. 30. The defense argued that the record did not indicate any such complaints by the patient between his two emergency department visits. The defense also referenced the patient's criminal record and statement to hospital workers that he had smoked marijuana earlier in the day on May 31, which seemingly was an attempt to limit the jury's damage calculation for the children's loss of guidance and moral upbringing.
After a weeklong trial, the jury returned a verdict of $6.4 million for the damages sustained by the patient. The two emergency department physicians were found 98% negligent, and the hospital was determined to be 2% negligent. The defense has filed an appeal.
What this means to you: Literature has shown that although coronary artery disease (CAD) can develop in young adults and might be more prevalent than one might think, it still might not be the first consideration by the treating physician when a young patient comes into an emergency department setting with complaints of chest pain. This scenario is especially relevant if there has been no prior history of a cardiac event or other related symptoms. Although this patient had a history of atrial fibrillation while en route to the hospital and classic symptoms of a cardiac event — chest pain radiating down the arm and positive EKG in the ED — the ED physician's thought process was swayed by an increased white blood cell count and other "consistent" symptoms of pneumonia. It seems that he/she did not at all consider a cardiac event and, in fact, ignored blatant cardiac symptoms.
Clearly this patient was denied the benefit of a full cardiac workup which, at a minimum, should have included an overnight admission, performance of two cardiac biomarkers (troponin levels and creatine phosphokinase [CPK]), serial EKGs and, possibly, a stress test. If the results of this cardiac workup proved negative for a cardiac diagnosis, then a diagnosis of pneumonia should be considered, but not until then.
The defense argued that that if the patient were suffering from a myocardial infarction when he first presented to the emergency department in May, he would have exhibited other symptoms between the time of his discharge and collapse in August. The defense based this argument on the fact that the patient did not mention any suspicious complaints in the time between the two emergency department visits. This defies logic. CAD can be an insidious disease and without appropriate treatment, his condition was likely to deteriorate over time. Additionally, based on his overall condition upon arrival to the emergency department in August, he would likely be a poor historian as it related to prior symptoms.
Unfortunately, according to the case study, there was no documentation by the treating physician articulating his/her clinical thought process while providing evidence to substantiate one diagnosis versus another upon discharge.
From a risk management perspective, this case is one of a knowledge deficit on the part of the emergency department physician treating this patient. A corrective action plan would include a significant educational component with subsequent monitoring of performance.
An educational curriculum would include; a review of a chest pain protocol; a review of EKG interpretations with a focus on diagnosis of myocardial infarctions; a review of symptoms of low-, intermediate-, and high-risk cardiac patients with respective appropriate testing modalities; and review of appropriateness of documentation including discharge summaries and follow-up treatment plan.
In addition to the education for the emergency department treating physician, I would recommend a focused random concurrent review of his/her charts of all patients presenting with complaints of a cardiac nature and who have an EKG performed during their visit.
The lack of documentation, poor clinical judgment, and overall knowledge deficit made this case indefensible.
Reference
Court of Common Pleas of Philadelphia County, Pennsylvania. Case No. 091203310.
News: A 37-year-old man was transported to the emergency department complaining of chest and shoulder pain after playing basketball earlier in the day. EMS workers noted the man experienced atrial fibrillation en route to the hospital.Subscribe Now for Access
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