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Postpartum Shortness of Breath
A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.
The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.
One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.
The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.
The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.
The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.
Discussion
Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.1
Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.1 Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).
Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.1
Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.
Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.1,2
Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.1 This type of bias also seems to have played a role in this case.
There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.2
The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.
Chest Pain in a Man With Type 2 Diabetes
A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.
An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.
The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.
Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.
This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.
The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.
Discussion
Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.
There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.
Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.1
It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.
Alcohol Detoxification in a Young Man
A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.
Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.
The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.
Discussion
When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.
When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.
Postpartum Shortness of Breath
- Penney FT, Datal AK: Understanding diagnostic error. Hospital Medicine Clinics. 2013;2(2):e292-e303.
- Ely JW, Kaldjian LC, D’Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97.
Chest Pain in a Man With Type 2 Diabetes
- Anantharam V, Lim SH. Treatment of NSTEMI (Non-ST elevation myocardial infarction). Curr Emerg Hosp Med Rep. 2013;1(1):18-28.
Postpartum Shortness of Breath
A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.
The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.
One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.
The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.
The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.
The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.
Discussion
Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.1
Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.1 Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).
Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.1
Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.
Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.1,2
Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.1 This type of bias also seems to have played a role in this case.
There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.2
The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.
Chest Pain in a Man With Type 2 Diabetes
A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.
An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.
The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.
Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.
This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.
The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.
Discussion
Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.
There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.
Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.1
It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.
Alcohol Detoxification in a Young Man
A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.
Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.
The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.
Discussion
When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.
When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.
Postpartum Shortness of Breath
A 35-year-old woman presented to the ED after referral by her obstetrician. Six days prior, the patient had given birth to twins without incident. On postpartum hospital day 2, however, she developed mild shortness of breath, and a chest X-ray was ordered. Since there was concern for possible pneumonia, the patient was prescribed oral antibiotics and discharged home on hospital day 4. She continued to complain of shortness of breath following discharge; at that time, the obstetrician referred the patient to the ED for further evaluation.
The patient was evaluated by the EP, who ordered a chest X-ray. He was also concerned that patient had pneumonia and prescribed a different class of antibiotic before discharging the patient home.
One week later, the patient presented back to the same ED with continued shortness of breath. On this visit, she was seen by a physician assistant (PA). Following the history taking and physical examination, a chest X-ray and rapid flu and rapid strep tests were ordered. Both the PA and supervising EP reviewed the chest X-ray and were concerned for pneumonia; however, both the flu and strep tests were negative. A third class of antibiotic was prescribed, and the patient was discharged home.
The chest X-ray on the second ED visit was not interpreted by a radiologist until 3 days later (The patient was seen on a Friday evening and the films were not read until the following Monday morning). The radiologist’s interpretation was “worsening congestive heart failure” (CHF). Two days later (5 days following the second ED visit), the EP was notified of the interpretation discrepancy and made multiple attempts to contact the patient, which included leaving a voice-mail message on her home phone.
The patient returned the call the following day and spoke with one of the ED nurses, who encouraged her to return immediately to the ED. The patient returned to the ED the next day (1 week after her second ED visit) and was admitted to the hospital for CHF secondary to postpartum cardiomyopathy. Unfortunately, she developed an embolus to her kidney, followed by an ischemic cerebrovascular accident, and died 3 weeks after admission.
The patient’s family filed a malpractice lawsuit against the hospital, the EPs, and the PA for negligent delay in making the correct diagnosis, stating that patient’s subsequent stroke and death were a direct result of this delay. Following deliberations, all of the EPs involved in the case were found free of negligence; the PA and the hospital ED, however, were found guilty.
Discussion
Interestingly, the majority of successful malpractice suits against physicians involve cognitive errors and system issues; this case is no exception. Making the correct diagnosis in a patient is a complex process, involving data gathering and synthesis, intuition, clinical experience, and logical thinking. Unfortunately, biases can occur during this process and result in misdiagnosis or delayed diagnosis. These biases include anchoring bias, confirmation bias, premature closure, and diagnosis momentum.1
Anchoring Bias. This occurs when a physician relies too heavily on the first piece of information or one’s initial impression.1 Despite evidence to the contrary, the physician keeps returning to the initial diagnosis (ie, he or she is “anchored” to it).
Confirmation Bias. Related to anchoring bias, in confirmation bias, the physician ignores or discounts evidence that contradicts one’s initial impression and focuses solely on the evidence supporting it.1
Both anchoring bias and confirmation bias appear to have played a role in this case. The differential diagnosis was never broadened beyond pneumonia, despite the fact that one must also consider pulmonary embolism (ie, a hypercoagulable state) and CHF (ie, postpartum cardiomyopathy) in a patient complaining of dyspnea in the postpartum period.
Premature Closure. This occurs when the physician finds a cause that fits the clinical picture and ceases to search for other diagnostic possibilities.1,2
Diagnosis Momentum. A bias that occurs when the diagnosis considered a possibility by one physician becomes a definitive diagnosis as it is passed from one physician to the next; it then becomes accepted without question by physicians down the line.1 This type of bias also seems to have played a role in this case.
There are a few strategies to help prevent or minimize these types of errors. First, as new data are gathered, one should reconsider and reprioritize the differential diagnosis. When certain data points do not fit neatly with an earlier diagnosis, careful attention must be paid to them. This is especially true for the patient receiving appropriate treatment but not showing clinical improvement. While it is usually helpful to know previous working diagnoses, the clinician must try to keep an open mind and consider alternative diagnoses. At the end of the day, the lesson is the need to develop a broad differential diagnosis.2
The system error in this case involves the lack of timely overread of radiology studies. Emergency medicine is a 24-hour, 7-day-a-week specialty; therefore, support services to the ED need to be similarly available. With today’s teleradiology and dedicated night readers, it is difficult to justify not providing such a service. This situation explains, in part, the negligent verdict against the hospital.
Chest Pain in a Man With Type 2 Diabetes
A 54-year-old man presented to the ED with a several-hour history of chest pain and shortness of breath. His medical history was remarkable for type 2 diabetes mellitus. He denied any associated nausea, vomiting, or diaphoresis. He smoked one pack of cigarettes per day and drank alcohol on occasion. The patient further denied having experienced similar symptoms in the past. All vital signs were normal, and he appeared comfortable and in no acute distress. His physical examination was completely unremarkable.
An electrocardiogram (ECG) revealed Q-waves in the anterior leads, but was otherwise nondiagnostic. The results of a portable chest X-ray were interpreted as normal. Cardiac enzyme testing revealed a positive troponin I, but a normal creatine phosphokinase-MB (CPK-MB). The patient’s complete blood count and coagulation studies were normal, and a basic metabolic profile was remarkable only for a blood sugar of 540 mg/dL; his serum bicarbonate value was normal.
The patient was placed on oxygen via nasal cannula, administered an aspirin (325 mg), and given subcutaneous regular insulin for hyperglycemia. The EP contacted a hospitalist to admit the patient. The hospitalist accepted the patient and admitted him to the telemetry floor.
Upon arrival at telemetry, the patient was examined by a nurse who noted rhonchi bilaterally on lung auscultation. Shortly afterward, he became anxious, and the nurse consulted the hospitalist, who ordered administration of lorazepam. Approximately 20 minutes later, the patient went into cardiac arrest and died.
This patient was never examined by the hospitalist prior to coding. An autopsy revealed evidence of severe coronary artery disease, a previous infarction that was at least a few months old with scarring of the left ventricle, and a recent infarction that had begun at least 12 hours prior to death.
The family sued all of the providers involved in the care of the patient. At trial, there was a factual dispute regarding whether the EP informed the hospitalist of the elevated troponin I level. The defendants argued that the patient had sustained irreversible heart damage prior to his arrival at the hospital, and that nothing any of the defendants could have done would have saved his life. The jury deliberated for approximately 2 hours before delivering a verdict in favor of the defense.
Discussion
Clearly, this verdict could have gone the other way. This patient was experiencing a non-ST segment elevation myocardial infarction (MI). The nondiagnostic ECG, coupled with the elevated troponin I, indicated damage of heart muscle from an acute interruption of coronary blood flow.
There are several problems with the management of this case. First, this patient required a cardiology consult for risk stratification. Several scoring systems could have been used to determine whether this patient was a candidate for early (ie, within 4-48 hours) invasive treatments such as percutaneous intervention or a more conservative approach.
Second, having sustained an MI, this patient was at high risk for complications such as ventricular arrhythmias, heart failure, cardiogenic shock, and other serious adverse events. Patients with acute MI should be admitted to the critical care or intensive care unit. In addition to aspirin, this patient should have received nitroglycerin and anticoagulation therapy. Either heparin or a low molecular weight heparin, such as enoxaparin, would have been appropriate if no contraindications existed. Finally, additional therapy including glycoprotein IIB/IIIA inhibitors, clopidogrel, etc, may have been indicated depending upon the timing of percutaneous intervention.1
It appears that both the EP and the hospitalist either failed to appreciate the significance of the elevated troponin I or overlooked it. This patient had normal renal function, so the only explanation—especially in the setting of a middle-aged man complaining of chest pain—was that myocardial damage had occurred.
Alcohol Detoxification in a Young Man
A young man was brought to the ED by a friend. The patient’s sole complaint was the need for help with his alcohol dependency. In addition to alcohol abuse, his medical history was remarkable only for an admission 1 month prior for suicidal ideation. The patient denied suicidal or homicidal ideations on this presentation. The physical examination revealed stable vital signs, but conjunctival injection, slurred speech, and a strong odor of alcohol. A blood alcohol test showed a concentration level of 0.36 g/dL. The patient, however, was alert and able to ambulate without assistance. He was medically cleared by the EP and arrangements were made to admit him to a local detoxification center.
Approximately 4 hours after his arrival, while waiting for transport to the detoxification center, the patient became impatient with the delay, removed his intravenous line, and told the nurse that he was going home via taxi. The nurse encouraged him to call a friend to take him home, to which to the patient agreed. The nurse left the patient to inform the EP of his desire to go home; when she returned, she discovered that the patient had already left the hospital. The physician notified hospital security but not the police. Approximately 2 hours later, the patient was struck by a car and seriously injured.
The patient sued the EP and the hospital for negligence and medical malpractice. The suit alleged that the physician and the hospital should have prevented the patient from leaving the ED. The physician and the hospital requested a dismissal, arguing that the patient did not exhibit any suicidal or homicidal ideation, presented on his own volition, and, though intoxicated, could still make decisions for himself. An appellate court granted the motion, holding that the defendants “lacked authority to confine the plaintiff upon his departure” from the ED.
Discussion
When a patient attempts to leave the ED against medical advice, the treating physician should make an attempt to convince him or her to remain for treatment. Often, something as simple as offering a cup of coffee will change a patient’s mind. In other instances, the use of chemical or physical restraint may be required. The handling of the case ultimately becomes a question of whether the patient was competent to make decisions and whether he presented a danger to himself or others. The extent of intoxication varies by the degree and does not of itself constitute incapability to make decisions. All practicing EPs have cared for patients with blood alcohol levels above the legal limit for driving, but who were functionally sober and able to make decisions. If a patient is competent and does not present a danger to self or others, he or she can decide to leave the ED without further management. However, it is best to release the patient in the company of friends or family, as was urged by the nurse in this case. Obviously, such a patient should not be allowed to drive himself home.
When a patient does leave against medical advice, the physician and nurse should document in the ED record their conversations urging him or her to stay. Alternatively, when a patient is found incompetent of making decisions or is a danger to self or others, he or she must be prevented from leaving the ED. This includes use of the minimal amount of physical or chemical restraint needed to keep the patient from leaving. When there is doubt that the patient is able to make a competent decision, it is better to err on the side of caution and keep him or her in the ED for his own safety and the safety of others.
Postpartum Shortness of Breath
- Penney FT, Datal AK: Understanding diagnostic error. Hospital Medicine Clinics. 2013;2(2):e292-e303.
- Ely JW, Kaldjian LC, D’Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97.
Chest Pain in a Man With Type 2 Diabetes
- Anantharam V, Lim SH. Treatment of NSTEMI (Non-ST elevation myocardial infarction). Curr Emerg Hosp Med Rep. 2013;1(1):18-28.
Postpartum Shortness of Breath
- Penney FT, Datal AK: Understanding diagnostic error. Hospital Medicine Clinics. 2013;2(2):e292-e303.
- Ely JW, Kaldjian LC, D’Alessandro DM. Diagnostic errors in primary care: lessons learned. J Am Board Fam Med. 2012;25(1):87-97.
Chest Pain in a Man With Type 2 Diabetes
- Anantharam V, Lim SH. Treatment of NSTEMI (Non-ST elevation myocardial infarction). Curr Emerg Hosp Med Rep. 2013;1(1):18-28.