Case Study
Delayed Heart Care Due to Lack of Expertise, Hospital Capability
Description
A 71-year-old female developed a pericardial effusion and cardiac tamponade three days after implantation of a cardiac pacemaker.
Key Lessons
- When a patient’s status deteriorates and a more worrisome condition is added to the differential diagnosis, the urgency of ruling out the new potential cause should match the seriousness of the potential outcome.
- Relying on another physician’s assessment in an area that is not his or her specialty can be risky, especially over the phone.
- Well-informed patients and families are more likely to regard providers as partners in care.
- The management of a complicated patient at a smaller hospital with fewer resources warrants a clear contingency plan of what will be done and when if the patient’s condition deteriorates.
Clinical Sequence
A 74-year-old female with a cardiac history underwent placement of a cardiac pacemaker at her community hospital due to sick sinus syndrome. The day after being discharged home (a Saturday), she returned to the hospital by ambulance, complaining of severe substernal chest pain at rest radiating from shoulder to shoulder, accompanied by mild shortness of breath and lightheadedness. She was given nitroglycerine sublingual with some improvement, and she became pain free after IV morphine. The on-call cardiologist (a moonlighting Cardiology fellow who was reached by phone at another hospital) recommended admission to the ICU and treatment for unstable angina, including aspirin, heparin, and nitroglycerine.
Approximately four hours later, the covering cardiologist saw the patient. Her vital signs had stabilized, and labs were normal. The chest X-ray suggested hypertrophic non-obstructive cardiomyopathy. The differential diagnoses included unstable angina and aortic dissection. The plan called for an echocardiogram in the morning due to findings on the chest X-ray. The hospital had no echocardiogram facilities after hours. The possibility of transfer to a tertiary hospital was discussed—but decided against, as the patient appeared stable and her primary cardiologist was at this hospital.
Later that night the patient was found writhing in bed with difficulty breathing. She was speaking in Portuguese, which her family said indicated she was in severe pain. Upon exam by the covering physician, the differential diagnoses now included: pericardial effusion (due to complication from pacemaker insertion); aortic dissection; ischemia; congestive heart failure; and pulmonary embolism. The Heparin and Plavix were discontinued, and repeat tests (chest X-ray, arterial blood gas) were reassuring. A CT scan was ordered but not done stat because the patient appeared to be more stable and was resting comfortably.
A moonlighting Infectious Disease fellow covering the ICU performed a limited echocardiogram that he thought might show a small effusion, but he was not expert in this procedure. On the phone with the on-call cardiologist, he reviewed all possible diagnoses, including pericardial effusion. The patient was not tachycardic and did not have pulsus paradox — both symptoms that would have suggested tamponade. It is unclear if the Infectious Disease fellow told the cardiologist that he did a limited echocardiogram. The cardiologist still considered aortic dissection; he planned to come in and do another echocardiogram early in the morning.
Approximately two hours later, the patient was found restless and moaning in Portuguese again, with worrisome vitals. The covering cardiologist came and performed an echocardiogram, which revealed a pericardial effusion. A discrepancy between the patient’s blood pressure in her right and left arms led the cardiologist to still suspect aortic dissection. He felt that, if the patient was having a dissection, then a tap for the effusion could result in death. He wanted to have back up surgeons available and to do the procedure in a cardiac cath lab—neither of which were available at this hospital.
The patient was eventually transferred to a tertiary care facility, where an emergency pericardiocentesis removed one liter of blood. Subsequently, she had a cardiac arrest; developed diffuse anoxia of the brain, went into a coma, and died four days later.
Allegation
The patient’s family sued the two moonlighting physicians, alleging that they failed to diagnose and appropriately treat the cardiac tamponade that resulted in the patient’s death
Disposition
After unsupportive reviews, the case was settled in the medium range ($100,000-$499,999)
Analysis
Clinical Perspective
- With the recent pacemaker insertion, a perforation and tamponade should have been strongly considered and ruled out or treated.
Over reliance on negative findings, such as physical exam, despite continued signs or symptoms can result in a delay in diagnosis and a poor outcome. Initial success may lead to overconfidence that blinds a clinician to signs of continued symptomatology. When a patient’s status deteriorates and a more worrisome condition is added to the differential diagnosis, the urgency of ruling out the new potential cause should match the seriousness of the potential outcome. Unavailability of back-up personnel and proper facilities should not be allowed to hamper the effort to rule out or treat a potentially worrisome cause.
- Although the covering cardiologist agreed with the assessment of a possible pericardial effusion, he did not come to the hospital to see the patient and perform an echocardiogram himself.
Good collaboration requires awareness of each provider’s capabilities. When working with other providers, duly consider their area of expertise. A specialist who assumes that a provider not in that specialty matches his or her level of knowledge is taking an ill-advised risk that could lead to a delay in diagnosis and treatment and ultimately a poor outcome. At the same time, a clinician practicing in an area outside of his or her area of expertise must routinely self-assess if the care is moving outside their appropriate scope of practice. Supervision of residents and fellows at off-site settings can be difficult. Supervisory physicians must be available to evaluate and support resident decision-making, and residents must be able to recognize when they need help and feel comfortable asking for assistance.
Patient Perspective
- The family was upset about how long it took for the cardiologist to come to the hospital to evaluate the patient when she was first admitted. They felt that no one had an idea of what they were treating or how to treat it.
Ongoing communication with the patient and the family about the treatment plan will help to allay their anxieties and foster confidence in the treating team. Patients and families are more likely to tolerate delays when they are routinely updated on the situation. Well-informed patients and families are more likely to regard providers as partners in care.
- The family felt that the possibility of a complication of the pacemaker insertion was not promptly addressed.
When the patient or a family member voices a concern; a sincere acknowledgment of that concern can help clear the way to a more factual discussion. Especially when a patient is unable to communicate directly, the family often takes the role as the voice for the patient. Listening to the patient and/or family and clearly acknowledging their input will help to build a more trusting relationship. They can often help to clarify the recent course of events. If they feel that their input is valued, they will be more likely to listen to the provider and trust their judgment.
Risk Management Perspective
- Transfer to a tertiary hospital may have been initiated too late.
Moonlighting physicians need to be aware of their “temporary environment” (e.g., what services are available at a smaller community hospital after hours). The management of a complicated patient at a smaller hospital with fewer resources warrants a clear contingency plan of what will be done and when if the patient’s condition deteriorates. It may be more prudent to have a lower threshold for when to transfer a patient to a tertiary hospital if the patient’s status is unstable.
- Although the ICU physician contacted the covering cardiologist during the night to discuss the patient’s condition, it is unclear if the covering cardiologist knew the Infectious Disease fellow covering the ICU had done an echocardiogram and what his findings were.
Clear communication between the providers is crucial. If a patient’s condition deteriorates despite receiving appropriate care, it’s time to step back and reassess the situation. Clinical information that is shared between providers should include all pertinent findings from all caregiver’s observations (physicians, nurses, therapists, etc.).
Legal Defense Perspective
- Two opportunities to improve the outcome were missed: when pericardial effusion was added to the differential diagnoses, and when it was actually identified. Some of the elements that led to payment in this case were: incomplete communication between providers, lack of timely assessment by the covering specialist, and delay in treatment.
The jury would want an answer as to why a specialist did not come to the hospital to assess a patient whose condition worsened overnight. The plaintiff will argue that, had the condition had been properly diagnosed and treated in a timely manner, the chance of survival would have been good. A settlement becomes more likely in the face of such an allegation, when expert reviewers cannot support the care.
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