When an atypical presentation is missed
A 50-YEAR-OLD MORBIDLY OBESE MAN went to his family physician with complaints of back pain radiating to the chest, episodic shortness of breath, and diaphoresis. He had a history of uncontrolled high cholesterol. An electrocardiogram showed a Q wave in an inferior lead, which the physician attributed to an old infarct. The doctor didn’t order cardiac enzymes because his office couldn’t do the test.
The physician discharged the patient with a diagnosis of chest pain and a prescription for acetaminophen and hydrocodone. He was scheduled to see a cardiologist in 10 days, but no further cardiology workup was done.
The man died an hour later.
PLAINTIFF’S CLAIM The doctor was negligent in failing to recognize acute coronary syndrome resulting from obstructive coronary artery disease.
THE DEFENSE The patient was discharged in stable condition; cardiac arrest so soon after discharge increased the likelihood that the patient would have suffered sudden cardiac death even if he’d received emergency treatment.
VERDICT $825,000 Virginia settlement.
COMMENT Common, serious problems can present in atypical ways. A high index of suspicion for coronary artery disease in high-risk patients with thoracic pain and shortness of breath—as well as a rapid, thorough evaluation—should keep you out of court (and your patients alive).
Treatment delayed while infection spins out of control
VOMITING, DIARRHEA, AND PAIN AND SWELLING IN THE RIGHT HAND led to an ambulance trip to the emergency department (ED) for a 31-year-old woman. The ED physician diagnosed cellulitis and sepsis. Later that day, the patient was admitted to the intensive care unit, where the admitting physician noted lethargy and confusion, tachycardia, and blueness of the middle and ring fingers on the woman’s right hand. Her medical record suggested that she might have been bitten by a spider.
The patient spent the next 3 days in the ICU in deteriorating condition. She was then transferred to another hospital for treatment of necrotizing fasciitis. She underwent a number of surgeries, including amputation of her right middle and ring fingers, which resulted in significant scarring and deformity of her right hand and forearm.
PLAINTIFF’S CLAIM The defendants were negligent in failing to diagnose necrotizing fasciitis promptly.
THE DEFENSE The defendants who didn’t settle denied any negligence.
VERDICT $80,000 Indiana settlement with the defendant hospital and 1 physician; Indiana defense verdict for the other defendants.
COMMENT When serious infections don’t resolve in a timely manner, expert consultation is imperative.
Inattention to history dooms patient to repeat it
HEADACHES, FEVER, CHILLS, AND JOINT AND MUSCLE PAIN prompted a 42-year-old man to visit his medical group. He told the nurse practitioner (NP) who examined him that his mother had died of a ruptured cerebral aneurysm. The NP diagnosed a viral syndrome, ordered blood tests, and sent the patient home with prescriptions for antibiotics and pain medication. The patient didn’t undergo a neurologic examination.
About 2 weeks later, while continuing to suffer from headaches, the man collapsed and was found unresponsive. A computed tomography scan of his brain showed a subarachnoid hemorrhage and intercerebral hematoma. Further tests revealed a ruptured complex aneurysm, the cause of the hemorrhage. Despite aggressive treatment, the patient fell into a coma and died 3 months later.
PLAINTIFF’S CLAIM The NP should have realized that the patient was at high risk of an aneurysm.
THE DEFENSE No information about the defense is available.
VERDICT $1.5 million New Jersey settlement.
COMMENT I provided expert opinion in a similar case a couple of years ago. The lesson: Pay attention to the family history!