Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
A Kansas woman, age 41, presented to an ED on Christmas Day with cough, congestion, difficulty breathing, and a two-week history of flu-like symptoms (chest tightness and body aches); this, she had attributed to previously diagnosed fibromyalgia.
In the ED, the patient was seen by the defendant physician assistant, who made a diagnosis of sinusitis with a flare-up of her fibromyalgia. Medication was prescribed, and she was discharged after about two hours.
On the way home, the woman experienced cardiac arrest. She was returned to the hospital and pronounced dead less than two hours after discharge.
The plaintiff alleged negligence in the PA’s failure to order an ECG. The defendant denied that an ECG was indicated and claimed that the treatment provided was reasonable.
Plaintiff settled with the hospital for an undisclosed amount prior to trial. A defense verdict was returned.
In this case, we don’t know the reproducibility or magnitude of the patient’s chest pain. Her history of fibromyalgia and flu-like symptoms may have blurred the presentation, which included “chest tightness”—especially considering that fibromyalgia can cause tender points over the anterior chest wall. Further, because 6% to 15% of patients with acute MI will exhibit some degree of reproducible chest tenderness, tenderness on exam can be misleading. Additionally, women with acute coronary syndrome (ACS) commonly present with subtle and nonspecific findings, including dyspnea, fatigue, and weakness. Frank chest pain is often absent.
During litigation, a plaintiff’s attorney will commonly argue that a “five-minute” test (such as an ECG) would have saved a patient. Here, the attorney likely offered expert testimony that ACS presentation can be subtle and atypical and that reasonably prudent clinicians should know this. Jurors familiar with ECGs as quick and noninvasive could reach the conclusion that a complaint of chest tightness in a 41-year-old woman requires that ACS be considered, regardless of her own opinion of the cause. It is important to have an index of suspicion for ACS, even without classic symptoms. It is also important to voice respect for the patient’s self-diagnosis, yet resist our temptation to hastily agree with any patient’s diagnostic assessment. —DML