Missed MIs Still "Loss Leaders" for EDs — and Atypical Presentations Aren’t Always to Blame
Many malpractice claims involve chief complaint of chest pain
In one case, a 45-year-old mother of four who spoke limited English was awakened by severe chest pain. Her teenage son, who acted as the interpreter, told the emergency physician (EP) that his mother had fainted when she tried to get up that morning, and that she had complained of chest pain prior to going to bed.
"The pain was worse with inspiration, movement, and palpation," says Jeanie Taylor, RN, BSN, MS, vice president of risk services for Emergency Physicians Insurance Company in Auburn, CA. The patient rated her pain as 10, but the EP’s documentation described "histrionics" in relation to the patient’s reaction to the pain.
The patient’s heart rate was 116, and vital signs were otherwise within normal range. The family history and past medical history were benign, and illicit drug use was denied.
"The patient was overweight and a smoker. The initial — and only — EKG showed some subtle ST wave changes which were attributed to the tachycardia," says Taylor. "Her pain resolved after a single dose of IV morphine."
The patient was diagnosed with "rib pain" and discharged with instructions to follow up with her primary care physician in two or three days if the pain continued, and to return to the ED if the pain worsened.
"Her pain continued at home, but the family did not return to the ED, as they felt reassured by the ED evaluation and trusted that the pain was not cardiac or significant," says Taylor. When the pain became very severe, emergency medical services was called. "The woman experienced a cardiac arrest en route, and could not be resuscitated," says Taylor.
In the resulting malpractice case, the plaintiff’s experts opined that even though the patient’s EKG changes were subtle, they indicated the need for a further evaluation. They also argued that while the symptoms were not typical for an acute myocardial infarction (AMI), they were not typical for costochondritis either; observation and a more thorough work-up was indicated.3 "The case settled for a large undisclosed amount," says Taylor.
Chest Pain: Cardiac Until Ruled Out
Missed AMI and chest pain cases "have been the loss leaders in medical malpractice claims for years — no, make that decades," says Taylor. "They account for approximately 25% of indemnity dollars paid."1
Even though patients who present with "crushing chest pain" are not likely to be missed, patients who attribute their pain to reflux or heartburn might be, says Taylor. EPs need to be diligent in not allowing patients to lead them to a non-cardiac diagnosis without an appropriate work-up.
"We often hear physicians lamenting about atypical presentations, which, of course, is a concern," says Taylor. "But many of the claims and incidents the Emergency Physicians Insurance Company reviews involve a chief complaint of chest pain."
EDs are challenged with throughput and patient wait times, says Taylor, and at some facilities, patients with chest pain wait for care once they perform an EKG and show it to an EP, who reads the EKG as normal.
"However, a single EKG on arrival is only a snapshot," says Taylor. A 2010 study reported that it is safe, in some circumstances, to have a stable patient with chest pain and a normal EKG remain in the waiting room, as long as an evaluation is taking place while they wait.2
"Chest pain is cardiac until ruled out," emphasizes Taylor. "The chest pain bundle — serial biomarkers, serial EKGs, and provocative testing — remains constant," she says. She says that another "constant" involves these risks associated with treatment of patients with chest pain:
• Mistaking acute coronary syndrome (ACS) for a gastrointestinal problem or chest wall pain.
• Ruling out AMI but failing to rule out ACS.
• Overlooking other life-threatening conditions, such as pulmonary embolism, esophageal rupture, cocaine use, or aortic aneurysm. "Sometimes providers anchor on AMI and CAD [coronary artery disease], and fail to consider these potentially deadly diagnoses," says Taylor.3
EDs should collaborate with radiology, cardiology, and internal medicine providers to facilitate agreement on treatment protocols, she advises.
"Emergency departments that do not employ CT imaging to evaluate coronary arteries must arrange for same or next day testing for intermediate- or high-risk patients and outpatient testing of low-risk patients," adds Taylor.
Failure to Consider Diagnosis
The most common allegation in missed MI cases is failure to consider the diagnosis, says Terrence W. Brown, MD, JD, FACEP, chairman of the Department of Emergency Medicine at Banner Estrella Medical Center in Phoenix, AZ. Brown is also counsel for the Emergency Physician Insurance Program.
Most cases of missed AMI result from atypical presentations, according to Brown. "As EPs, I think we are getting better at risk stratifying patients appropriately who present with chest pain, sending low-risk patients home, and bringing in higher risk patients for observations or provocative testing," he says.
However, the challenge is for EPs to do the same kind of risk stratification on patients who present without chest pain. Patients may present with indigestion, nausea, trouble breathing, dizziness, and other vague or nonspecific symptoms.
"This is particularly important in patients with diabetes, the elderly, and women," says Brown. "There is a good amount of literature at a plaintiff’s attorney’s disposal to show that consideration of a cardiac cause is required when they present with atypical symptoms."
Most of these patients — and many who present with chest pain as a chief complaint — can be safely sent home, however, says Brown, assuming that an appropriate initial ED workup is done which matches the patients’ risk of a cardiac event.
"I don’t think we have reached a point where juries expect EPs to catch every atypical presentation for impending MI," says Brown.
Some Missed MIs Are Defensible
There is a lot of room to defend a missed MI that was discharged from the ED, says Brown, if the EP can show that the diagnosis was considered, and that the patient was advised of the possibility.
"What makes these cases hard to defend is where the EP anchored on a non-cardiac etiology, or the chart seems to read in retrospect like blind reassurance was given to a patient that his/her symptoms were benign," says Brown.
Sending a patient home with discharge instructions for "GERD" after successful treatment of indigestion with a GI cocktail is not unreasonable, says Brown, if the EP can show that the possible diagnosis of MI was entertained by the EP in the initial workup, discussed with the patient, and return precautions given.
"The alternative is to risk an allegation that the EP failed to act with the care expected — not just to diagnose a benign condition, but to carefully consider life threats — which plaintiff’s attorneys and juries feel is the particular duty of the emergency room," says Brown.
Equally challenging are cases in which the EP did, in fact, entertain a cardiac etiology, but failed in the initial workup. "These are equally attractive to plaintiff’s attorneys," says Brown. "They can take advantage of the EP’s ability to think of the diagnosis as a way to focus criticism on the evaluation or treatment." He says these factors make cases difficult to defend:
• Sending one set of troponins;
• Discharging patients with abnormal EKGs without cardiology consultation;
• Discharging patients with inappropriate follow-up timeframes.
"In these cases, the argument is not about the potential diagnosis, but how to engage in a basic workup once the right’ diagnosis is entertained, which is harder to sympathize with in the eyes of the jury," explains Brown.
It’s easier for juries to sympathize with the complexities of making a difficult diagnosis, says Brown.
"They are less likely to let off the practitioner for not doing what the plaintiff will argue is the basics’ of treating a known condition," he says. "These cases are very hard to settle." n
References
- PIAA Risk Management Review, 2011 Edition, Emergency Medicine.
- Scheuermeyer F, Christenson J, Innes G, et al. Safety of assessment of patients with potential ischemic chest pain in an emergency department waiting room: A prospective comparative cohort study. Ann Emerg Med. 2010;56(5):455-462.
- Colucciellio S, Bitterman R, Taylor J. EPIC Principles: Chest Pain. Emergency Physicians Insurance Company, 2011.
SOURCES
• Terrence W. Brown, MD, JD, FACEP, Chairman, Department of Emergency Medicine, Banner Estrella Medical Center, Phoenix, AZ. Phone: (602)
839-6968. E-mail: [email protected].
• Jeanie Taylor, RN, BSN, MS, Vice President, Risk Services, Emergency Physicians Insurance Company, Auburn, CA. Phone: (530) 401-8103. E-mail: [email protected].
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