The Case
A 61-year-old man presented to the emergency department with a documented chief complaint of chest pain.
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ACEP Now: Vol 41 – No 04 – April 2022The triage nurse documented, “Pt here w/ c/o legs vibrating and abd feels like is going to explode. pt denies chest pain. Pt states he had one episode of loose stools today after eating radishes, tomatoes, eggs and [lox]. Pt also has centrum vitamin. Pt w/multiple complaints.”
His vital signs showed a blood pressure of 169/84, pulse 66 bpm, respirations 18/minute and a temperature of 96.1 degrees F.
After interviewing the patient, the emergency physician documented, “abrupt onset of the sensation that he had a lid of a paint can that began in his epigastrium and slammed up into his jaw and then came down and continues to compress upon his abdomen. It came abruptly after he loaded the car.”
His past medical and surgical history was positive for aortic valve replacement, but he denied coronary artery disease and history of abdominal aortic aneurysm.
His medication list included warfarin, metoprolol, and a multivitamin.
The physical examination was noteworthy for a tender epigastrium, and an aortic pulsation was palpable in his abdomen despite his large body habitus.
Labs were ordered, including a CBC, CMP, troponin, CK, PT and PTT. None of these had any remarkable results. The INR was therapeutic at 2.8.
An ECG was obtained, and the doctor documented, “First-degree AV block, normal axis, T-wave inversions in aVL without prior for comparison.”
As is evident from the history and exam, the doctor was very worried about aortic pathology, especially the possibility of an abdominal aortic aneurysm. However, the patient had a documented anaphylactic allergy to contrast dye. Therefore, a noncontrast CT of the abdomen and pelvis was ordered.
The results are shown here:
The doctor wrote a good note summarizing the findings, concluding, “the patient was admitted given our uncertainty as to the patient’s pain. He was clearly uncomfortable.”
The hospitalist came and saw the patient, writing an admission H&P with essentially the same information and conclusions. She consulted cardiology as well, who saw the patient within a few hours. He felt that the pain was not cardiac but ordered an echocardiogram.
Several hours later, the patient developed severe chest pain and had an episode of bradycardia.
A repeat ECG showed ST changes (however, no specifics were described and no ECG tracing was included in court records), and the interventional cardiologist decided to take him to the cardiac catheterization lab.
In the cath lab, an ascending aortic dissection was discovered. Within several minutes, the patient coded and died.
The Lawsuit
The patient’s wife contacted an attorney, who reviewed the case and offered to take it on contingency.
A lawsuit was filed against the hospital, the emergency physician, the admitting hospitalist and the first cardiologist who saw the patient.
One of the main issues the emergency physician faced was the discrepancy in the chart about the patient’s chest pain. The HPI specifically stated the patient did not have chest pain, but the final admitting diagnosis was “chest pain.” Further, the triage nurse listed “chest pain” as the chief complaint, yet the triage note clearly stated he denied chest pain.
The patient did not have any imaging of his chest, neither an X-ray nor CT scan, during the emergency department stay. The plaintiff’s attorney was very critical that the emergency physician diagnosed “chest pain” but never obtained any chest imaging.
The plaintiff also alleged an EMTALA violation. They felt that the failure to obtain a chest X-ray represented a failure to conduct a medical screening exam. An emergency medicine expert witness opined that this patient’s workup was substantially different than that of other patients presenting with the same documented chief complaint (chest pain) to the same hospital.
The plaintiff’s attorney was able to force the emergency department to turn over records on all chest pain patients who had presented to the emergency department during the four weeks preceding this patient’s death. There were 222 chest pain patients during that period, and 212 had some type of chest imaging. The plaintiff’s EMTALA expert stated that the “[h]ospital, to a reasonable degree of medical certainty, violated EMTALA.”
The defense hired their own emergency medicine expert to counter these claims. He wrote that the patient “repeatedly denied chest pain to each [member of the health care team]. A chest radiograph is NOT part of a medical screening evaluation, specifically in a patient not complaining of chest pain.”
Outcome
Images: Med Mal Reviewer
The defendants and plaintiff ultimately agreed to arbitration. At arbitration, the case is decided by a neutral third party, thereby sparing both sides the time and expense of a trial.
Before arbitration, they reached a high-low agreement, which guarantees the plaintiff a minimum financial recovery but also caps the maximum amount, regardless of outcome.
The arbitrator returned the following decision:
The arbitrator awarded the plaintiff $791,520, paid entirely by the cardiologist’s malpractice insurance. The actual amount paid was $500,000 due to the cap from the high-low agreement.
Discussion
This case embodies an emergency physician’s worst nightmare. The patient had an extremely rare but life-threatening diagnosis. Multiple issues distracted the emergency physician from the diagnosis and necessary workup, including the patient’s insistence that he did not have chest pain and his prior allergy to contrast. However, this case highlights the critical importance of trying to avoid glaring discrepancies in the medical record, which can be easily used to make the physician appear inattentive.
The legal outcome here will also be surprising to many readers. Although it is relieving that the emergency physician did not lose the lawsuit, the fact that the cardiologist took the blame alone seems rather arbitrary and unjust. I would posit that if there is true medical liability in this case, it should have been shared among all parties.
Unfortunately, this case illustrates a pattern that has been identified in many malpractice cases. When a dissection is not diagnosed in the emergency department, the patient is often admitted to a chest pain observation unit or floor bed, where they suddenly decompensate. The true diagnosis eventually becomes identified, whether by echocardiogram or CT scan, but the patient does not ultimately survive to surgery. Reviewing the medical and legal outcomes in cases like these can help emergency physicians take better care of their patients and learn to document in a more effective and protective way.
Read the entire medical record from this case, as well as deposition transcripts from all parties and excerpts from the expert witness opinions.
Dr. Funk is a practicing emergency medicine physician in Springfield, Missouri, and owner of Med Mal Reviewer, LLC. He writes about medical malpractice.
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One Response to “Discrepancies in Patient Information Documentation Spurs Lawsuit”
August 7, 2022
Clayton OvertonThese documentation discrepancies may be due to various limitations in our current system that don’t allow us to appropriately note things as they really are. The triage nurse must choose a triage template to begin charting with, and if the patient noted that the pain “began in his epigastrium and slammed up into his jaw”, Chest Pain would have been a reasonable choice in a 61 y/o male with a Hx of aortic valve replacement, even if the patient then denies chest pain otherwise (and we all know that anatomical boundaries, ie chest vs abdomen, can vary from one patient’s perspective to another, when they point to the location of the pain). Once committed to a CC of “chest pain”, the older systems rarely, if ever, allowed one to add another chief complaint. The ER physician’s final diagnosis of “Chest Pain” may have been simply to get a patient admitted in to the hospital for observation (and to get a second physician’s evaluation/opinion), as to get a non-surgical abdominal pain without any overt metabolical disorder/abnormalities to address, for admission into the hospital is never ever going to happen in this day and age because of lack of reimbursement. The hospitalist who accepts this patient will get into trouble, and by default, so will the ER doc. Then good luck admitting any future gray-zone patients to that same hospitalist. The hospitalist may have even suggested the diagnosis of “chest pain” to facilitate the admission. In the past, the bed police rarely looked beyond the admitting diagnosis for determining reimbursement eligibility, so it didn’t matter what story was documented in the chart (“denies chest pain”). That, unfortunately, is no longer the case, as the bed police have a litany of criteria for observation/admissions these days. The real tragedy is that this ER doctor did not order the CT of the chest. Not because of a triage, or an admitting, diagnosis of chest pain, but because the physician was clearly concerned about the possibility of an aortic aneurysm and/or dissection. We must assume this because he actually went to the trouble of documenting a palpable aortic pulsation on his abdominal exam. If ordering a CT to chase down this concern, you must do a CT of the abdomen and pelvis, plus the chest. The second tragedy, and unspoken at that, is the pervasive problem of the admission momentum placed on autopilot, that we in the ER rarely have an appreciation for. An incorrect admitting diagnosis, an incorrect IV antibiotic started in the ER, a mechanical vent setting not updated upon admission, all tend to follow Newton’s 1st law of physics (a body in motion will stay in motion …) on the hospital floor as a “cut & paste” mentality often occurs on the hospitalist’s end of things, especially when he/she is busy (and, maybe, we haven’t completed our documentation in the chart yet). To our credit in the ED, we are correct enough times to make the hospitalist comfortable with this initial approach, but it does allow things to go unchecked or unchallenged until much farther down the road, or once things begin to fall apart. Such is the case here of a forced square-peg-diagnosis of generic Chest Pain to fit into a round-hole-admission of epigastric abdominal pain of concern. In addition, I’m a little surprised that “the standard of care”, the medical community’s likelihood of making the aortic dissection diagnosis, did not seem to be presented during this trial. When Mel Herbert reviewed this subject a few years ago, the average number of physician encounters was 3, to make the diagnosis of aortic dissection, thus making it “the standard of care” to miss the diagnosis on the initial two physician encounters (if they lived that long). Thus, the odds were heavily stacked against this ER doctor, and the patient, for the correct diagnosis to occur during the patient’s first emergency room visit. Tragically, the diagnostic delay also contributes to the high rate of mortality for this disease.