Failure to diagnose aortic rupture in a timely manner

by Rachel Pollock, Marketing and Brand Specialist, and
Ariana Gutierrez, MSN, RN, Risk Management Representative
 
Presentation and physician action
A 60-year-old woman came to the emergency department (ED) of a large hospital center on February 22 with chest pain and pressure and tightness in the center of her chest. The patient reported that the pain began 20 hours earlier and had become severe. 
 
The ED physician ordered an electrocardiogram (EKG) which revealed a first-degree intraventricular (AV) block, intra-atrial conduction delay, slight atrioventricular (AV) conduction delay, very pronounced left ventricular geometry (LVG), and marked high lateral depolarization disturbance. Labs showed a normal troponin level. The patient was treated with aspirin and nitroglycerin and was admitted to the hospital.  
 
During a second exam, the patient reported that she was still experiencing tightness in her chest and that pain had spread to her jaw and ears. The patient’s blood pressure was 148/64 and her pulse was 56. A second EKG indicated signs of sinus bradycardia with first-degree AV block, left ventricular hypertrophy, and repolarization abnormality. A cardiac consult was requested.
 
 
Physician action
The cardiologist examined the patient and noted that the patient’s chest pain was retrosternal, left sided, and pleuritic. Her blood pressure was 135/63 and her pulse was 62. The cardiologist determined the patient had atypical chest pain and ordered a CT without contrast. The patient was treated with atorvastatin and aspirin. 
 
The next morning, on February 23, the cardiologist was notified that the patient had developed atrial fibrillation. Additionally, an EKG showed her to have rapid ventricular response, voltage criteria for left ventricular hypertrophy, ST&T wave abnormality and to consider lateral ischemia. Rivaroxaban was initiated. By 8 a.m. her blood pressure was 143/75 and her pulse was 109.
 
A CT scan performed at 8:57 a.m. revealed slightly dense pericardial effusion measuring 17mm in thickness, possibly due to complex fluid. The CT scan also suggested dilation of the aortic root 5 cm, although this was poorly assessed without contrast, and wedge-shaped, pleural-based pulmonary opacity in the right lower lobe suggestive of pneumonia, scarring, or volume loss.  
 
The cardiologist ordered a STAT surgical consult after receiving the CT scan information, which she believed showed an aortic root aneurysm. 
 
On February 24 at 7:14 a.m. the cardiologist noted an echocardiogram (echo) performed the day before on February 23 showed ventricle enlargement and increased concentric left ventricular wall hypertrophy. At 9:45 a.m., the patient’s blood pressure was 87/46 and her pulse was 90. 
 
At 11:24 a.m., the patient’s heart stopped. Life-saving measures were administered, but the patient died. The cause of death was listed as cardiac arrest due to aortic rupture. 
 
 
Allegations
A lawsuit was filed against the cardiologist for failure to timely diagnose the aortic rupture, resulting in the patient’s death. 
 
 
Legal implications
Consultants for the defense were not supportive of the cardiologist. An emergency medicine consultant stated that the failure to recognize the patient’s “impressive” heart murmur during the initial ED exam was a significant issue. If the murmur had been recognized, the patient could have received a STAT echocardiogram, which could have diagnosed the aortic root dissection. Then, the patient could have been taken to surgery immediately. Unfortunately, the murmur was not recognized. 
 
In a statement, the cardiologist said that once she suspected the aortic root dissection on February 23, she ordered an urgent surgical consult. The cardiologist also stated that she asked a nurse to follow up with the surgeon on February 24, when she learned the patient had not been seen. 
 
One consultant stated the cardiologist should have contacted the surgeon directly instead of relying on the nurse, especially since the consult was emergent.
 
Another weakness in the patient’s care occurred when the patient was prescribed anticoagulants after developing atrial fibrillation. A cardiology consultant stated anticoagulation was contraindicated due to the patient requiring emergent surgery.
 
Unfortunately, the cardiologist did not maintain adequate documentation on this patient. It was unclear from the records when the cardiothoracic surgeon consult was ordered. Many of the cardiologist’s notes on this patient were added to the record on February 25, a day after the patient died. 
 
 
Disposition
The case was settled on behalf of the cardiologist.
 
 
Risk management considerations
This lawsuit was filed against the cardiologist alleging failure to timely diagnose. The patient experienced a delay in receiving an echocardiogram, which led to an inappropriate anticoagulation prescription. The anticoagulant therapy exacerbated the effusion that ultimately resulted in the patient’s death.
 
As this case illustrates, a delayed diagnosis can occur when a lab, imaging, or diagnostic study is not ordered in a timely manner. This delay could be from misdiagnosis, misunderstanding of the disease, or failure to treat. A significant delay can reduce treatment options going forward, depending on the severity of the disease.
 
Consultants for the case were also critical of the cardiologist’s delegation to nursing staff to contact the cardiothoracic surgeon. Consulting another physician during an urgent or emergent situation is the responsibility of the ordering physician. In this case, the cardiologist should have communicated the severity of the findings and the urgency of the consult to the surgeon directly. 
 
Tools for better managing consultations have been developed in recent years. A tool called the “5 Cs of Consultation” has been shown to improve patient outcomes by promoting clear and direct communication between treating physicians. The “5 Cs of Consultation” are as follows.

1. Contact: Consulting physician reaches out to consultant physicians and makes “contact.” 
2. Communicate: Consulting physician provides information to consultant physician and asks questions based on patient condition or case.
3. Core Question: The consulting physician asks a specific question or makes a specific request of the consultant. Agree to a reasonable timeframe for consultation. 
4. Collaborate: This step refers to treatment discussions, including any changes or further testing.
5. Close the Loop: Both physicians agree on treatment plan and maintain clear, proper communication about the patient’s status. (1)

Those consultants reviewing this case were also critical of the cardiologist’s documentation, especially for not completing her entries until after the patient’s death. The documentation also lacked information about the cardiothoracic consult. It was unclear when the consult was ordered or if communication between the two physicians occurred. 
 
The Texas Administrative Code states that the “written plan for care should include, when appropriate, any referrals and consultations” and “include a summary or documentation memorializing communications transmitted or received by the physician about which a medical decision is made regarding the patient.” (2)
 
Documentation must also be complete, contemporaneous, and legible. It is imperative to document all applicable aspects of the rule. While documentation can be time-consuming, finding time should be a priority to ensure that the care provided and its rationale are included in the chart. Documentation completed in a timely manner is especially important in a case with a poor outcome, such as a patient death.
 
If you practice outside of Texas, it is important to refer to your state’s medical board on documentation rules.
 
 
Sources
 

1. Kessler, CS, Afshar, Y, Sardar, G, et. al. A Prospective, Randomized, Controlled Study Demonstrating a Novel, Effective Model of Transfer of Care between Physicians: The 5 Cs of Consultation. Academic Emergency Medicine. Volume 19, Issue 8, August 2012. Society for Academic Emergency Medicine. Available at https://onlinelibrary.wiley.com/doi/full/10.1111/j.1553-2712.2012.01412.x.
   Accessed November 30, 2022.
2. Texas Administrative Code. Chapter 165. Rule 165.1. Medical Records. Amended November 10, 2019. Available at https://texreg.sos.state.tx.us/public/readtac$ext.TacPage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=22&pt=9&ch=165&rl=1.
   Accessed November 30, 2022.

 
  
Rachel Pollock can be reached at Rachel-pollock@tmlt.org. 
 
Ariana Gutierrez can be reached at ariana-gutierrez@tmlt.org.