Malpractice Counsel
The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.
Chest Pain in a Man With Type 2 Diabetes
A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.
An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.
The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.
Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.
This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.
The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.
Discussion
Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.
There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.
Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.1
It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.
Alcohol Detoxification in a Young Man
A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.
