Missed MI Despite Family History

Description

A 42-year-old woman is seen in the ED for chest pain, diagnosed with costochondritis and discharged home with ibuprofen and follow-up instructions. The patient returned four hours later with AMI and ventricular tachycardia, resulting in her death.

Key Lessons

Differential diagnoses were not ruled out
Poor communication led to missed information from patient's family and lack of aligned expectations
The ED lacked a clear chest pain protocol.
Key elements of the care were poorly documented.

Clinical Sequence

A 42-year-old uninsured woman, who had not seen a doctor in 20 years, presented to the emergency department (ED) at 7:50 a.m., complaining of chest pain and trouble breathing. She was accompanied by her husband and her son, who helped interpret because English was her second language. The husband reported that his wife had been experiencing chest pain since 11:00 the prior evening, which she treated with aspirin. In the morning, she had sudden onset of severe chest pain and fainted on her bed.

The patient was first seen by the ED attending and then by a resident. Her initial vital signs were: HR:107, BP:146/99, RR:29. Her chest pain was documented as "sudden onset, right-sided, sharp, under the right breast, started while the patient was lying in bed and worse with inspiration, movement, and palpation." The patient's medical history was documented by the resident as: "fainting spells, no family history of coronary artery disease or clots, father suffered a stroke."

At 8:00 a.m., the patient's initial EKG evidenced changes, which the ED physicians interpreted as non-specific, possibly due to the rapid heart rate. A chest X-ray did not indicate acute cardiopulmonary process. The differential diagnoses included acute costochondritis, pulmonary embolus, and atypical cardiac chest pain. The patient received IV Toradol for pain, which was reduced within an hour. Her labs were significant for elevated glucose, which was noted as potentially stress-related or non-diagnosed diabetes. At 9:30, a second EKG showed continued tachycardia, HR:103; and improvement of the previous ST wave changes (but still some subtle abnormalities). The ED physicians interpreted the second EKG as reassuring.

At 10:30 a.m., while the patient was still being monitored, the son drove his father to his office so he could make arrangements to be with his wife. When the son returned to the ED at 11:00 a.m., his mother was being discharged with a diagnosis of rib pain, with instructions to follow up with a physician at a local clinic the next day, or to return to the ED for worsening symptoms. Her pre-discharge vital signs (documented at 10:15) were: HR:115 and RR:28. Her last recorded blood pressure (taken at 8:45 a.m.) was 140/99.

About four hours post-discharge, the patient's family called for an ambulance because of worsening chest pain. The EKG taken en route to the hospital showed signs of ischemia. Paramedics were unable to auscultate a blood pressure, and the patient died in the ED.

Allegation

The patient's estate file suit alleging that the ED resident and attending negligently failed to diagnose and treat the patient's cardiac condition, resulting in her wrongful death.

Disposition

The case was settled for more than $1 million against the attending.

Analysis

Clinical Perspective

Because the patient did not present with classic symptoms of chest pain for ischemia and had no known cardiac risk factors, the subtle EKG changes were discounted.
The resident noted subtle changes in the first EKG, which the attending attributed to the patient's rapid heart rate. The second EKG was interpreted as non-indicative of ischemia. Upon review, several medical experts noted that, while her chest pain was not classic for ischemia, the pain was also not classic for costochondritis. They also interpreted the EKG results as indicative of acute coronary syndrome. Since she remained tachycardic throughout her first ED stay, even after she appeared more comfortable, a safer approach would have been to admit the patient to rule out a cardiac cause of her chest pain.
Although the resident had listed atypical cardiac chest pain and pulmonary embolism in the differential diagnoses, these were not completely ruled out.
The appropriate tests to rule out a pulmonary embolism or myocardial infarction were not done. This emergency department had no clear chest pain protocol. Protocols for common ED presentations, such as chest pain and abdominal pain, help avoid missed opportunities. \

Family Perspective

We were marginalized.
The husband alleged that the ED doctors did not take the possibility of his wife having a heart problem seriously. The diagnostic process and care plan were unclear to the family. After the first series of tests, the son and husband expected that the patient would be in the hospital for a few days. Communication between the providers and the patient/family is vital to help providers glean clues from the previous medical history and history of present illness. And for the family and patient, being informed about the plan helps greatly to alleviate their anxiety.
We were treated different because we don't have heath insurance.
The family expressed monetary considerations limited the care the patent received. The husband felt the need to tell the doctors, several times, "Please do everything you can; I will pay for it." Patients and families in the midst of a traumatic medical situation need to be reassured-sometimes repeatedly-that the level of care being rendered is unrelated to their insurance situation.

Risk Management Perspective

A clinician's narrow diagnostic focus of an atypical presentation led to a wrong decision.
The patient's complaint, gender, and age were atypical for the presentation of ACS. The attending and resident felt that the clinical presentation and absence of risk factors did not warrant a full cardiac work-up. However, the abnormal EKG changes should have been reconciled.
Inadequate patient assessment led to premature discharge.
The EKGs were only read by the attending and resident prior to discharge. Although the EKG changes were subtle, it was an abnormal EKG in a patient with chest pain. A cardiac consult was not ordered, and providers failed to order cardiac enzymes to rule out an MI. The tachycardia was not really explained and was still present on discharge. Discharge occurred despite the fact that the vital signs were virtually unchanged from the time of initial presentation. In the face of ambiguous findings, the patient would have been better served by being admitted for observation and a cardiac workup.
An interpreter was needed to help this patient give a full account of her symptoms and history.
A patient who speaks and understands some English is a conundrum for emergency clinicians. But, when a patient's medical history is unrecorded, or when subtle symptom information (e.g., the location, duration, or intensity of pain) is important, a trained interpreter reduces the risk of critical information being missed, or misunderstood. For example, during later testimony, the husband described his wife's initial pain as starting on her left side and then moving to the center-typical for ischemia. Quite possibly, an interpreter might have clarified this information during the patient's initial ED examination.
Lack of Documentation
The last set of vital signs was documented 35 minutes prior to discharge…and it was incomplete. The last recorded BP was more than two hours old. Even if a patient is on a monitor, it is important to document the vital signs in the chart, especially prior to discharge.

Legal Defense Perspective

This case had many of the elements that can lead to a claim, and payment: not following up on abnormal findings, unanswered diagnostic questions, limited documentation, and poor communication.
The decision not to pursue unresolved diagnostic questions made the decision not admit this patient difficult to defend. Had the patient's second episode happened in the hospital while she was on a monitor, she would have had a very good chance of survival.