Description

A 32-year-old male was diagnosed with acute myocardial infarction after earlier same-day ED evaluation and discharge.

Key Lessons

Clinical Sequence

Allegation

The patient filed a claim against the community hospital and the (first) ED physician for failure to timely diagnose, report, and/or treat acute myocardial infarction. This negligence, he claimed, shortened the patient’s life expectancy and left him permanently disabled and unable to care for his minor twin sons.

Disposition

The case was dismissed after a favorable tribunal session, when the patient failed to present a full order of proof and plaintiff expert opinion.

Analysis

1. The initial ED physician did note the family history of CAD, but did not document the severity or extent of the history. The patient denied cocaine use, at first, but may not have understood the clinical importance of being truthful.
   A thorough clinician-patient initial interview gives providers a better basis for diagnosis and patient management. An incomplete patient and family history can lead to a less aggressive initial workup.
   
   

2. The ED physician did not explain anywhere in the chart why he thought this patient was at such low risk that he could be discharged without serial cardiac enzymes and EKGs or further chest pain workup.
   Documentation in the patient chart is key to communicating the overall picture of the patient, his/her examination and treatment, as well as the provider’s medical decision making. Chest pain, even in young patients, may require longer observation and a more comprehensive diagnostic work up.
   
   

3. The initial ED assessment appears to have stopped at the diagnosis of costochondritis. The patient’s EKG was documented as normal sinus rhythm, without any other (EKG) changes suggestive of acute myocardial infarction. No vital signs, or discharge instructions were reported; a review of systems was not documented.
   Incomplete documentation can negatively impact future care. While most likely diagnoses are usually the common diagnoses—especially in otherwise well appearing and young patients—emergency deparment physicians should document differential diagnoses and their probability (for that patient).
   
   

4. If the patient had initially reported his cocaine use, he would likely have been held for observation in the ED.
   Admitting a patient to rule out an MI, when there is low probability, is difficult to justify. Consideration of a battery of toxic screen blood work may have been warranted but, given that the patient was less than forthcoming, the decision to discharge was not unreasonable.
   
   

5. The patient alleged that inadequate testing was ordered, which prevented his MI from being diagnosed during his initial visit. He said he was not told that there is not a precise way to diagnose an MI, especially a recent one.
   If your concerns don’t match the patient’s, the patient is likely to feel marginalized. If your decision process is not well documented, an allegation of substandard care is difficult to defend. Clarifying the patient’s key concerns and his or her understanding of the diagnostic process can close any gaps between the patient’s expectations and yours.
   
   

6. The ED physician’s medical decision making (e.g., clinical rationale for not drawing serial enzymes) was not well documented.
   Fully appreciating the circumstances surrounding an encounter is, generally, impossible without written evidence. Explaining why certain tests were ordered and not others is instrumental in understanding the disposition of the patient. For example, even though myocardial infarctions are a rare occurrence in this age group, the reasons for not pursuing this possibility should be well explained.
   
   

7. The patient’s statement upon re-presenting to the ED (“I was just discharged and I’m still having chest pain.”) indicates that he did not have a clear understanding of why he had been discharged. Because of the shift change, the physician who saw him earlier in the day was not available to follow up on his concerns.
   This patient was given discharge instructions, including those specific to chest pain, so his contention that he was inappropriately discharged may be debatable. However, recently discharged patients may set the bar higher before they will return to the ED—even in the face of more troublesome symptoms. Patients may return to the ED more willingly if they’ve been properly instructed on how to appropriately respond to various symptoms or circumstances.

8. Jurors and arbitrators are sympathetic to the complaints of a young father with a life-long disability.
   This case has many of the elements that can lead to a claim: dismissed historical factors, unanswered questions, and limited documentation. But, it also had elements that made it defensible, e.g., the first discharge was likely appropriate based on the information provided (or not provided) by the patient to the physician.