A 55-year-old male suffered a sudden cardiac arrest, resulting in severe neurologic deficits, following an ED visit, admission, and transfer, in which heart evaluation was recommended but never done.

Clinical Sequence

A 55-year-old male was brought to the ED of a local community hospital after an episode of rigidity, syncope, and incontinence. The patient’s medical history was significant for a distant history of alcohol and cocaine use, Hepatitis C, and traumatic brain injury (TBI) after falling off a ladder eight years prior. He was an athletic non-smoker with no history of elevated cholesterol. His recorded family history was significant in that his father died at age 42 of a sudden cardiac arrest.

In the ED, his vital signs, a chest X-ray, and brain CT were normal. Serial EKGs and biomarkers were done (EKG 1: sinus bradycardia with 1o AV block and troponin level of 0.1; EKG 2: junctional rhythm with retrograde P wave conduction; EKG 3: sinus rhythm with primary AV block and LVH; his troponin level peaked at 0.26.)

During this time the patient had another episode of stiffness and unresponsiveness, was treated with Ativan and Dilantin, and was admitted.

The next day, the patient was transferred to a tertiary facility at the family’s request. The transfer summary indicated the diagnosis of new onset seizures and that a new intracranial process should be ruled-out. It also recommended an outpatient stress test and fasting lipid profile because of an elevated troponin level, suggesting underlying coronary artery disease

After two days, the patient was discharged from the tertiary hospital with instructions to continue the Dilantin and aspirin; there was no record of a cardiac work-up or instructions to seek one.

One year later, the patient was readmitted to the tertiary hospital for a fever. He underwent a battery of tests, including an EKG, revealing non-specific T wave abnormalities, suggestive of ischemia. The second-year resident reviewed the results with his senior resident and they agreed that a cardiac consult was not indicated.

Four days later, the patient was discharged. His fever was thought to be due to an allergic reaction to his Dilantin, which was changed to Keppra.

Within 10 months, the patient noted that his stuttering was getting worse, so he was electively admitted to the hospital for long- term video monitoring of his seizure activity. Upon admission at 4 p.m., an EKG showed 1o AV conduction delay and new T wave inversion. Serial isoenzymes were ordered. At about 3:00 a.m., the nurse noted that the patient’s SAO2 dropped to 74 percent and that he was unresponsive. During intubation, the patient lost his pulse and a code was called. After a prolonged effort, the patient was resuscitated and transferred to the ICU.

Key Lessons

  • Definitively addressing a patient’s abnormal test results reduces the risk of missing or delaying a primary diagnosis.
  • Assuming that the previous diagnosis was correct can result in a narrow diagnostic focus and ultimately lead to a missed or delayed diagnosis.
  • Vigilant follow-up of a documented recommendation for testing protects both patients and clinicians.

Claim Sequence

The patient sued six internal medicine attending and resident physicians, six neurology attending and resident physicians, and one attending ED physician. The primary allegation was that the physicians negligently failed to obtain a cardiology consult when the patient first presented to the ED with evident underlying CAD.


This case settled for more than $1 million against two neurology residents and an attending neurologist.


  1. During his first ED visit, the patient did not present with classic symptoms of cardiac disease, and his only known cardiac risk factor was family history. The clinicians did not definitively address the subtle EKG changes and elevated troponin, which indicated a cardiac referral and work-up.
    An atypical presentation of a medical condition can contribute to a narrow diagnostic focus that fails to timely identify a serious condition. The presence of unexplained test results associated with a dangerous illness calls for seeking more information or considering a consult.

  2. Upon receipt of the transferred patient, the tertiary hospital’s providers followed the previous diagnosis of seizure disorder.
    Failure to reassess clinical indicators and laboratory findings can undermine a timely and accurate diagnosis. A presumptive diagnosis may blur a physician’s response to slightly abnormal findings. It can prevent clinicians from appropriately broadening the diagnostic process as more definitive information is sought. It may be more helpful to consider that any presumptive diagnosis is a flag to broaden the diagnostic process until it can be appropriately narrowed by a confirmed condition.

  3. In the transfer from the community hospital, no one followed up on the ED physician’s recommendation for a cardiac work-up, which was based on his elevated troponin level, suggesting underlying coronary artery disease.
    When a patient is transferred from one hospital to another, communication between the transferring and the accepting care providers often guides the patient’s care. The ideal health care setting, where all disciplines work together in a coordinated fashion, may not always be realistic; yet all providers who hand off or receive a patient (or information about the patient) have an obligation to do so carefully—so that important facts are not missed.

  4. The patient may not have been made aware of the need for follow-up testing (outpatient stress test and fasting lipid profile).
    Patients who are told of abnormal findings and their significance can help ensure necessary follow-up with their providers. Recommendations for follow-up should be prominently displayed in the medical record, either on the problem list or in the MD notes, to prompt providers to probe and remind patients about the recommended action.

  5. When the patient required CPR during his third admission, a delay in treatment resulted from a failure to quickly recognize the situation, promptly notify the code team, and immediately begin ventilation.
    Residents may hesitate to ask questions if they think that by doing so they will be perceived as too dependent, weak, or uninformed. This reticence can generate stress and anxiety, and result in care delays or even patient harm. Residents may also be unaware of their limitations (in skills, knowledge, and expertise around specific clinical situations) and may not know when to ask for help. Supervisors can greatly influence the willingness of trainees to seek appropriate clinical guidance. Making clear that they can’t ask too much—only too little—is empowering for residents and ought to be the culture of every teaching institution.

  6. Although the family met with hospital staff to review the care that was provided to the patient during his cardiac event, they were not satisfied with the information they received. The family was only given a copy of the video after the patient relations department became involved.
    A provider’s ability to communicate effectively with patients and families in a compassionate and thoughtful manner, especially when disclosing information about an incident, is a crucial part of the therapeutic relationship. If it is done well, it can mitigate anxiety and enhance the patient’s and family’s trust in the caregiver, the institution, and the health care system. Volunteering to share information about an incident can engender and preserve trust in the relationship as well. Institutions can prevent misunderstandings about what patients can have access to, by giving providers reminders and updates on a routine basis.

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