Failure to diagnose myocardial infarction

Presentation and physician action

A 37-year-old patient came to an internal medicine physician reporting chest pain. He was diagnosed with unstable angina and hyperlipidemia, and had a family history of coronary artery disease. A myocardial infarction was ruled out, but a thallium stress test was performed. The results were negative.

Two years later, the patient was driven to an emergency department (ED). He experienced chest pain that radiated to the shoulder while mowing the lawn. When the patient arrived at 8:55 p.m., he reported that two weeks earlier he experienced intermittent chest pain that subsided, so he had not sought medical attention.

The ED nurses triaged the patient as a minor emergency patient. Because of his triage status, the ED physician (the defendant in this case) did not see the patient until 11 p.m.

The patient’s wife gave the hospital staff her husband’s medical history, but she left out his history of cardiovascular disease and high cholesterol. Because of the patient’s lower triage category, the patient was not given the standard work-up protocol for cardiac patients.

At 10 p.m. an EKG was completed and interpreted as normal. The patient underwent another EKG at 10:26 p.m. that showed no ST-T wave changes and was considered normal.

At 10:45 p.m. the patient was placed in an exam room. He denied diaphoresis or shortness of breath. The ED physician saw the patient at 11 p.m., and recorded a history of chest pain with current diaphoresis and shortness of breath. Another EKG was completed and interpreted by the ED physician. He felt the EKG revealed an inferolateral myocardial injury and an acute myocardial infarction.

The patient was moved to a monitored bed at 11:40 p.m. The ED physician ordered sublingual nitroglycerin, aspirin, and intravenous sodium chloride. The patient suffered cardiac arrest at 11:48 p.m. The ED physician successfully resuscitated the patient.

The patient was kept on metoprolol tartrate, a NTG drip, and heparin. Several more EKGs were completed, and the patient was monitored by a cardiologist. Two days later, heart catheterization and angioplasty showed a 90% occlusion of the mid-circumflex artery and a 60-70% occlusion of the right coronary artery. The patient’s ejection fraction was estimated at 40%.

The cardiologist continued to treat the patient. He testified that the patient’s ejection fraction had returned to normal, and he did not have residual effects from the myocardial infarction.

Allegations

A lawsuit was filed against the ED physician, alleging that he failed to timely diagnose myocardial infarction. The plaintiffs also alleged that the patient was improperly triaged.

Legal implications

The plaintiff’s experts claimed that the ED physician should have known about the patient’s presence in the emergency department, despite his low triage status. They were also critical of the physician’s delay in ordering aspirin, sublingual nitroglycerin, and oxygen; the delay in placing the patient immediately in a monitored bed; and the failure to diagnose an impending myocardial infarction.

Defense experts argued that the ED physician was within the standard of care. They stated that the delay in bringing the patient to the treatment area was not the fault of the defendant. The defense claimed that the nurses did not follow the proper protocol for chest pain, resulting in the delay in evaluating and treating the patient.

Disposition

The case was taken to trial and a jury returned a verdict in favor of the defendant.

Risk management considerations

Although the patient reported chest pain, he waited in the ED waiting room for 45 minutes. Had the nurses seen him sooner and triaged him at a higher level, he might have received aspirin, oxygen, and sublingual nitroglycerin earlier. This may have prevented his myocardial infarction.

Challenges posed for the defendant physician included his poor documentation. The documentation was considered especially inadequate when the patient’s condition deteriorated. Standardized forms are often convenient tools and can help expedite documentation; however, care should be used to make sure no areas are left unaddressed. Blanks may be open to conjecture by others reviewing the records.

If areas in the template are irrelevant, a simple “NA” or “not applicable” can be entered. If areas are left consistently blank, the template may need revising to suit the needs of the practice. The standardization of electronic health records in hospitals and emergency settings may allow for physicians and providers to easily pick and choose appropriate elements for inclusion in the progress note. If additional documentation is needed, and standardized forms or templates do not offer space, free text progress notes may be warranted.

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