Discharged from ED Before MI Death

Description

A 51-year-old male died from a heart attack 10 days after an ED presentation with left-sided chest pain and weakness and a diagnosis of gastro esophageal reflux disease (GERD).

Key Lessons

A presumptive diagnosis may blur a physician’s response to slightly abnormal findings.
Inadequate communication between providers can lead to inappropriate testing and misinterpretations of the findings.
Discharging a patient without a definitive diagnosis or ruling out the most serious potential cause of symptoms places everyone at higher risk.

Clinical Sequence

A 51-year-old traveling salesman began to experience chest pain and weakness while driving out of state. He presented to a nearby ED with complaints of a dull ache in his left arm and chest for about seven hours, numbness in the left arm, as well as some weakness when closing his car door. He did not complain of shortness of breath, diaphoresis, or nausea. His medical history included GERD (the date of onset was unclear – but he was taking Zantac), and in the prior 18 months: hernia repair, appendectomy, and a dislocated shoulder. He was a non-smoker and had no known history of coronary artery disease (CAD).

Upon presentation to the ED at 11:30 a.m., the patient’s vital signs were: BP 135/96, HR 130, and RR 20. Findings on EKG revealed sinus tachycardia at 114 with anterior hemi block. General laboratory tests were ordered to rule out myocardial infarction, and at approximately noon the patient received nitroglycerin sublingually. His pain level at that time was 4/10. Twenty-five minutes later, his pain level was 2/10, and a second nitroglycerin tablet was given. Vital signs at that time were BP 100/75, HR 128, and RR 20.

At 1:10 p.m., the patient’s pain level was zero and vitals were 133/89, HR 114, and RR 20. While awaiting the Troponin results, the ED physician ordered an exercise stress test (without imaging). A cardiologist administered the test, which lasted only three minutes secondary to patient fatigue. Results of the stress test were reported back to the ED physician as within normal limits; the patient experienced no chest pain and there were no ST/T changes noted.

An hour later, all of the laboratory findings were back and included: CBC wnl, lytes sl low, BS 113 (↑), BUN 119 (↑), HGOT 14 (sl ↓), and Troponin .33 (↑ - lab slip stated: recommend clinical correlation and repeat in 3-6 hours). Enzymes were done once and reported as normal.

The patient was discharged at 3:30 with a diagnosis of recurrent GERD. His discharge instructions included: maintain diet (avoid caffeine and continue low fat diet), take Prilosec as ordered, and follow-up with his (home-state) PCP.

Ten days later, while watching TV at home with his family, the patient died. Autopsy results revealed that the patient died of a fatal cardiac arrhythmia, that he had CAD with 80-90 percent stenosis, and that he had had an MI—probably 7-10 days prior to his death.

Allegation

The patient’s family sued the ED physician, alleging failure to diagnose the patient’s cardiac condition, which led to his death 10 days later.

Disposition

This case was settled for more than $1 million.

Analysis

Clinical Perspective

Experts agreed that the standard of care was not met when the patient was discharged home without further evaluation regarding the cause of his chest pain, weakness and tachycardia.
Based on a patient’s age, gender, presenting symptoms, vital signs, test results, and the patient’s response to medications, ED physicians should expand their differential diagnoses to include possible underlying diseases (e.g. CAD). This allows them to consider that the patient may be experiencing a new, but related event (e.g. cardiac ischemia – MI). With inconclusive test results, physicians should consider observing patients longer while performing additional tests (e.g., serial cardiac enzymes and EKGs). The patient’s responses to medications should be noted.

An exercise stress test should not have been ordered prior to knowing the results of the patient’s Troponin level.
When a physician refers a patient for a diagnostic test, he/she should provide pertinent medical information to the provider performing the test, such as differential diagnoses, the reason for the test, and pertinent test results or pending results. It is customary to wait until the Troponin level results are known prior to ordering a stress test. Tests done without imaging are much less sensitive and provide a high degree of false negative results. The degree of accurate results is low for tests lasting three minutes or less.

Patient Perspective

The patient’s estate argued that the underlying CAD was evident when he presented to the ED and that the physician should have assessed the patient more thoroughly.
When a patient arrives in an ED with chest pain and related symptoms, the most obvious of diagnoses (cardiac event such as MI) must be ruled out. This process should include studies such as serial cardiac enzymes, Troponin levels, EKGs, and possibly extended observation. Administration of certain prophylactic medications, e.g., ASA, beta-blockers, nitrates and anticoagulants should also be considered. A patient should not be a candidate for discharge until such diagnoses can be excluded.

Risk Management Perspective

The providers, assuming that previous diagnoses were correct, followed a narrow diagnostic focus.
A physician’s assessment of a patient may be skewed by relying on a patient’s previous history, such as GERD, or by the fact that many of the patient’s test results are reported as being within normal limits. This can be avoided with a fresh assessment of basics, such as patient’s age, gender, past medical history, current complaint(s), vital signs, test results and response to medications when establishing the differential diagnosis.

Inadequate patient assessment led to premature discharge.
If a patient continues to experience abnormal symptoms despite treatment, further observation and testing should be considered. If the symptoms are thought not to be life-threatening and the patient is discharged, the physician should communicate to the patient his or her findings and their importance. A clear follow-up plan should be agreed upon.

The cardiologist admitted he had not been made aware that a Troponin level had been drawn and that the results were pending. He stated that had he known the results were elevated (even only slightly elevated) he would not have performed the stress test at that time and would have recommended continued observation and testing.
Effective communication between a primary care provider and a consulting provider is critical in providing effective quality patient care. In order to make informed decisions and conclusions, the consultant needs adequate relevant medical information from the PCP about the patient, such as the reason for the referral, any pertinent or outstanding test results (e.g., Troponin level), and abnormal vital signs (e.g., tachycardia).

Legal Defense Perspective

The failure to pursue unresolved diagnostic questions (e.g., persistent tachycardia, elevated Troponin level, response to nitroglycerin, etc.) made the decision to discharge this patient difficult to defend.
This case has many of the elements that can lead to a claim and payment: narrow diagnostic focus, not following up on abnormal findings, unanswered diagnostic questions and poor communication between providers.

Written by Debbie LaValley, CRICO/RMF (2006)