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Heart Attack Fatal For Patient Discharged From Emergency Room | Volusia County Medical Malpractice Attorney

Heart Attack Fatal For Patient Discharged From Emergency Room

When a patient arrives at a hospital complaining of chest pain, the most obvious of diagnoses – a heart attack – should be ruled out before he is discharged.

This did not happen for one man and he died 10 days later as a result. Autopsy results revealed that the patient died of a fatal cardiac arrhythmia, that he had coronary artery disease with 80-90 percent stenosis, and that he had had a heart attack — probably 7-10 days prior to his death.

The patient’s family sued the emergency room physician, alleging failure to diagnose the patient’s cardiac condition, which led to his death 10 days later. The case was settled for more than $1 million.

This case has many of the elements that can lead to medical malpractice: narrow diagnostic focus, not following up on abnormal findings, unanswered diagnostic questions and poor communication between providers.

The 51-year-old man began to experience chest pain and weakness while driving out of state as part of his job. He went to a nearby emergency room and complained of a dull ache in his left arm and chest for about seven hours, numbness in the left arm, and some weakness when closing his car door.

He did not complain of shortness of breath, diaphoresis, or nausea. His past medical conditions included GERD (the date of onset was unclear – but he was taking Zantac), and in the prior 18 months: appendectomy, and a dislocated shoulder. He was a non-smoker and had no known history of coronary artery disease, CAD.

Upon admission to the ER at 11:30 a.m., the patient’s vital signs were: blood pressure 135/96, heart rate 130, and respiratory rate 20. Findings on EKG revealed sinus tachycardia or a rapid heart beat at 114 with anterior hemi block. General laboratory tests were ordered to rule out myocardial infarction, and at approximately noon the patient received nitroglycerin under his tongue.

His pain level at that time was 4/10. Twenty-five minutes later, his pain level was 2/10, and a second nitroglycerin tablet was given. Vital signs at that time were blood pressure 100/75, heart rate 128, and respiratory rate 20.

At 1:10 p.m., the patient’s pain level was zero and vitals were 133/89, HR 114, and RR 20. While awaiting the Troponin results, the ED physician ordered an exercise stress test (without imaging). A cardiologist administered the test, which lasted only three minutes due to patient fatigue. Results of the stress test were reported back to the ED physician as within normal limits; the patient experienced no chest pain.

An hour later, all of the laboratory findings were back and the lab slip stated: recommend clinical correlation and repeat in 3-6 hours). Enzymes were done once and reported as normal.

The patient was discharged at 3:30 with a diagnosis of recurrent GERD. His discharge instructions included: maintain diet (avoid caffeine and continue low fat diet), take Prilosec as ordered, and follow-up with his physician.

Ten days later, while watching TV at home with his family, the patient died.

Doctors failed to maintain the standard of care for this patient by discharging him without further evaluation. They should not have ordered a stress test prior to knowing the results of the patient’s Troponin level, which can indicate heart disorders. And they should have expanded their narrow diagnostic focus.

The patient’s estate argued that the underlying coronary artery disease was evident when he presented to the ED and that the physician should have assessed the patient more thoroughly.

When a patient arrives in an ED with chest pain and related symptoms, the most obvious of diagnoses (heart attack) must be ruled out before he is discharged. This process should include studies such as serial cardiac enzymes, Troponin levels, EKGs, and possibly extended observation.

Based on a patient’s age, gender, symptoms, vital signs, test results, and the patient’s response to medications, physicians should have expanded their differential diagnoses to include possible underlying diseases. This allows them to consider that the patient may be experiencing a new, but related event (like a heart attack).

With inconclusive test results, physicians should consider observing patients longer while performing additional tests. The patient’s responses to medications should be noted.

A physician’s assessment of a patient may be skewed by relying on a patient’s previous history, such as GERD, or by the fact that many of the patient’s test results are reported as being within normal limits. This can be avoided with a fresh assessment of basics, such as patient’s age, gender, past medical history, current complaint(s), vital signs, test results and response to medications when establishing the differential diagnosis.

The cardiologist admitted he had not been made aware that a Troponin level had been drawn and that the results were pending. He stated that had he known the results were elevated (even only slightly elevated) he would not have performed the stress test at that time and would have recommended continued observation and testing.

The failure to pursue unresolved diagnostic questions (persistent tachycardia, elevated Troponin level, response to nitroglycerin, etc.) made the decision to discharge this patient difficult to defend.

For more on medical malpractice issues, see the library of articles by Daytona Beach medical malpractice attorney.

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