In this month’s case, we cover a classic high-risk medicolegal topic: chest pain. There has been extensive research on this topic in pursuit of identifying low-risk patients who can be discharged safely. This case occurred in 2011, so bear in mind that we have made significant strides over the past 10 years.

The Case

A 58-year-old woman presented to a small emergency department with chest pain. The patient and her husband lived in a different state and were visiting his parents. They were helping with some tasks around their house; she had been outside washing a Jeep. She had developed a slight sunburn on her back prior to noticing chest pain.

When she presented to the emergency department, the chest pain had been present for two to three hours. She described it at one point as a burning pain and at another point as a “raw” sensation. She had taken a Lortab with no improvement and also had vomited once.

In the emergency department, her vitals showed a blood pressure of 116/57, pulse of 94 bpm, respiratory rate of 24 per minute, temperature of 97.0 ºF, and an oxygen saturation of 90 percent on room air.

The physician did not have access to any previous medical records as this was her first time visiting this health system. However, he did note that she smoked a pack of cigarettes each day and had hypercholesterolemia, Crohn’s disease, hypothyroidism, and anxiety. The physical exam did not reveal any abnormalities.

The physician ordered an ECG, complete blood count, comprehensive metabolic panel, magnesium test, creatine kinase-MB, and troponin.

The patient was given nitroglycerin 0.4 mg sublingual, with no change in her pain. A 500-mL bolus of normal saline was given. After 30 mg of Toradol IV, she stated she felt “maybe a little better.”

The results of her tests showed a mild leukocytosis (14.4), slight hyperglycemia (118), and slight hypokalemia (3.3). The troponin was 0.06, within the normal limits of 0.0–0.10. The creatine kinase-MB was also normal. Her ECG was read as “normal sinus rhythm” by the physician.

The court documents had a poor copy of the ECG that would not appear well in print but is available for review at www.medmalreviewer.com/ekg.

The physician reasoned that the patient had a negative troponin, no ST-segment elevation myocardial infarction on ECG, and no relief of pain with nitroglycerin. The patient was discharged home.

The following morning, the patient was in the kitchen with her in-laws, making coffee. She suddenly collapsed and became unresponsive. They called 911. When EMS arrived, she was in ventricular fibrillation. She was defibrillated six times and finally had return of spontaneous circulation.

She was taken back to the same emergency department, arriving at 7:08 a.m. During the next 50 minutes, she lost pulses several times, and the physician caring for her placed her on a dopamine drip.

The process to transfer her to another facility started around 7:49 a.m. An EMS helicopter landed at 8:29 a.m. to whisk her to the receiving facility. During the flight, she briefly lost pulses, but return of spontaneous circulation was achieved again. By 9:04 a.m., she was in the catheterization lab at a university medical center. She was found to have a 100 percent occlusion of her right coronary artery, and a stent was placed (see Figure 1).