A woman in her early 60s was referred to a cardiologist for chest pain and dyspnea on exertion. The patient reported a history of hypertension, high cholesterol, and diabetes. She had also been a smoker for 40 years.
Upon physical examination, the cardiologist noted bilateral carotid bruits, a 2/6 systolic murmur suggesting mild to moderate aortic stenosis, and decreased dorsalis pedis and posterior tibialis pulses in both lower extremities. An EKG performed in the office showed sinus bradycardia with nonspecific ST-T wave changes.
The cardiologist ordered lab work, a chest x-ray, a treadmill nuclear stress test, a carotid Doppler study, cardiac ultrasound, and a CTA of the abdominal aorta and lower extremities.
The patient completed her lab work and chest x-ray the same day as the initial visit. The lab work showed she had high cholesterol and the chest x-ray revealed COPD.
The patient began the treadmill nuclear stress test at the cardiologist’s office four days later. She completed two stages of the Bruce Protocol and developed significant ST-T wave changes. The test was stopped and the patient sat in a chair to rest. While resting, the patient went into ventricular tachycardia and ventricular fibrillation. She tried to stand, but collapsed to the floor and struck her head on the ground. The patient was resuscitated with a defibrillator and EMS was called.
The patient was transported to the hospital with fixed, dilated pupils. A CT-scan showed a linear skull fracture with acute right subdural and epidural hematomas with midline shift. The patient underwent an emergent decompressive craniectomy and evacuation of the hematoma. The patient arrested and died on the operating table.
A lawsuit was filed against the cardiologist and the cardiology group. The allegations were:
- negligence in administering the treadmill stress test;
- failure to properly advise the patient regarding the increase in treadmill speed;
- failure to properly supervise the treadmill to prevent the patient from falling off; and
- failure to carefully monitor the patient.
The lawsuit stated that the patient fell off of the treadmill during the test and that the cardiologist was not present during the exam “as required by medical standards.” The plaintiff alleged that the patient was not warned of possible dangers associated with the test. The plaintiff also alleged that a stress test was contraindicated in a patient with severe aortic stenosis. The patient should have undergone cardiac catheterization instead.
The cardiologist and the nuclear medicine technologist who administered the stress test did not document anything in the chart about the fall, leading the plaintiff to incorrectly state the facts of the incident in the lawsuit.
Two cardiologists reviewed this case for the defense. The reviewing physicians were not supportive of the care given. One stated that based on the patient’s symptoms and EKG results, a stress test was contraindicated. Both felt that the patient should have been more closely monitored to prevent the fall. There was not adequate documentation in the medical record about the incident.
Due to the nature of the incident and negative consultant reviews, this case was settled on behalf of the cardiologist.
Risk management considerations
A written informed consent form should be obtained for tests or procedures performed in the office. There was no informed consent form found in the patient’s chart. Without it, there was no evidence that the patient was informed about the risks of the stress test, that the patient was advised to notify the technologist if she was feeling unwell during the test, or that the test could be stopped at any time.
Practices should have written protocols to follow in case of an adverse event during a stress test and what to do in case of an emergency. In this scenario, the patient should have been made to lie down instead of sit down to reduce the risk of a fall. A physician should have been notified of the patient’s cardiac irregularities immediately, and the patient should have been closely monitored until a physician arrived. As there was no documentation, there was no indication that the technologist took measure to prevent a fall. Having a written protocol in place can ensure that all staff members are taking the same precautions and performing to the physician’s standards.
There was some documentation in the chart about the cardiac events that required termination of the stress test and the need for CPR, but there was no documentation about the patient falling and hitting her head.
Any kind of injury that occurs in the office needs to be thoroughly documented on an incident report form. The incident report should be completed as soon after the event as possible. It should objectively describe the details of the event and what actions were taken to obtain help. The completed report should not be filed in the medical record, but in a separate file.
The documentation of the stress test gave no indication of who performed the test. The Texas Medical Board rules require a legible identity of the observer when documenting a medical record.
This case highlights the importance of having emergency equipment on site where stress tests are performed. Many practices simply rely on calling EMS to handle medical emergencies. While the patient’s skull fracture was not known at the time, the fact that the physician attempted to resuscitate the patient with CPR and a defibrillator was helpful in the settlement discussion.
It is impossible to prevent all accidents. However, taking steps to prevent them, being prepared when they do happen, and good documentation will assist in the defense of a claim.
These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.