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Cardiology
40 Year Old Obese Male
With Chest Pain Not Correctly Diagnosed Because Of Delays In Testing And
Consultations, Subsequently Dies From A Pulmonary Embolus (Blood Clot To
His Heart/Lung Circuit).
This patient was 40-years when he was first seen and
evaluated at Hospital #1's Emergency Room for an upper respiratory tract
infection beginning on or about July 7. He was treated and released,
and details of this patient encounter are not fully available.
On July 4, the patient was readmitted to the
emergency room where the diagnosis of congestive heart failure was made. He
was treated for congestive heart failure as well as being given a prescription
of Cephalexin antiboitic for reasons that appear somewhat obscure. In addition, he was
told to see his internal medicine physician for further followup, and indeed
this was done through Dr. #1 who ordered several studies in addition to
treatment for this patient. For example, on July 25, an EKG was performed,
and the patient was begun on Robitussin for his cough, as well as Lasix and an
aerosolized inhaler.
The patient's wife maintains that on July 28th, she placed
a call to a Dr. #2 and this call was never returned. On July 30th, the patient
presented again to the Hospital #1's Emergency Ward and was cared for by the ward's
physicians, including Dr. #3, Dr. #4 and Dr. #5. The patient's wife maintains that
none of these physicians had sufficient expertise to be caring for such a seriously
ill cardiac patient, but the qualifications of these individuals is not available
for my review; nor is any of their medical management from the Emergency Room, per
se, negligent.
The patient's hospital course can be described as one in which
he was evaluated for an idiopathic (i.e., cause unknown) cardiomyopathy, a disorder
of impaired heart contractility.
It should also be mentioned that this patient had a history of
Hodgkin's disease treated with radiation therapy back in 1984, and was also being treated
for thyroid dysfunction in the past.
The patient had undergone a cardiac MUGA scan which revealed
decreased contractility. He also had, as mentioned a baseline abnormal EKG prior to
his July 30th Hospital #1 presentation. In addition, this patient also suffered from
morbid obesity.
It is clear from the foregoing that this patient being 40
years old did not have a typical medical presentation with a straightforward diagnosis.
In fact, heart failure in this age group with such severely impaired heart contractility,
as was shown on this patient's MUGA scan, is distinctly unusual and calls for an urgent
cardiac evaluation. It is clear that this patient never had the benefit of such a
cardiologist's consultation throughout his emergency room and ICU course. The treatment
for congestive heart failure, because it is caused by many different etiologies, differs
depending on the etiologies. For example, when heart failure is caused by high output
states such as sepsis, treatment for that infection generally is indicated in addition
to diuretics and a host of other conventional treatment modalities. When cardiac failure
is caused by a lack of blood flow to the heart, the treatment, in addition to diuretics,
must include modalities to improve heart blood vessel circulation, such as angioplasty.
Clearly, the diagnosis of congestive heart failure by itself is
insufficient to optimally treat such patients. Indeed, the patient received very generic
types of treatment for his congestive heart failure, including nitrates, pre- and after-load
reducing agents and oxygen. In addition, he appears to have had prolonged bed rest as was
noted in the discharge summary by Dr. #6 who cared for this patient.
On the evening of August 1st as well as August 2nd, the patient was
observed to have had nocturnal blood oxygen desaturation, and this was felt to represent
sleep apnea and the patient was scheduled for a sleep study. The patient appeared to be
improved on August 2nd and was receiving oxygen with assistance without chest comfort,
although chest comfort did return on the afternoon of August 2nd. The patient, at that
time, received sublingual (under the tongue) nitroglycerin and the pain lasted less than
a minute.
On August 3, the patient no longer had atypical chest pain,
and ambulation was again attempted. At that time, the patient was walking to the elevators
with the assistance of oxygen, but became diaphoretic (sweaty), and profoundly short of breath.
He was noted to be in sinus tachycardia at a rate of about 130 with a respiratory rate in
the 70s and an oxygen saturation in the 70s. The patient soon required a full cardiac
arrest to be called, and he eventually expired on that same date.
Prior to the patient's acute decompensation on August 3rd, discussions
were held between Dr. #6 and Dr. #7, the latter a Cardiologist. There is no documentation
of this cardiovascular consultation that I have been able to uncover other than the
reference in Dr. #6's note in the discharge summary. According to that discharge summary,
Dr. #7 felt that unless the patient's thallium scan was markedly positive, the patient
should be further evaluated at a transplant center via right heart catheterization following
congestive heart failure therapy being maximized. The case was also discussed allegedly
with a Dr. #8 at the Hospital #2 who supposedly agreed with the workup and management by
Dr. #6. It was also mentioned in this discharge summary notation that Dr. #8 agreed to
the see the patient sooner if she became acutely worse.
An autopsy performed on this patient reveals that the proximate
cause of his death was a pulmonary embolus. A pulmonary embolus or blood clot is an
often fatal condition that is overlooked in the workup and treatment of patients who
have a number of underlying risks, such as was seen in the case of the patient. He
indeed had many risk factors for pulmonary emboli, including his morbid obesity, his
hypercoagulable state which would be due to his Hodgkin's disease, as well as a reference
in the chart that he may have had recent travel. The diagnosis of pulmonary embolism must
be kept in the forefront of a treating physician's mind in order not to allow such a treatable
condition to claim a patient's life, as occurred in this case. Pulmonary emboli or clots in
the lungs can be readily managed by a variety of medical and surgical techniques, including
blood thinners, the use of pulmonary arterial system filters, such as the umbrella and vena
cava filters, as well as other modalities.
It is well known that the condition of multiple pulmonary emboli can
cause the right side of the heart strain, worsening congestive heart failure symptoms,
sinus tachycardia, intermittent chest pain which may or may not be relieved with nitroglycerin,
as well as poor cardiac contractility.
It is my opinion based on a review of these records that the lack of
cardiology consultation with direct evaluation and examination of this patient was a departure
from the standard of care. It can be grossly misleading for a cardiologist to evaluate a
patient by such a telephone-type format. An adequate examination of a patient begins with
an adequate history as well as a first-hand examination, and both of these steps were denied
this patient, to his detriment. In addition, it is inappropriate and a deviation from the
standard of care, for a cardiologist to offer his services "if the patient deteriorates." The role of a cardiologist should not only be therapeutic but preventative, and the
preventative role in the management of pulmonary emboli is well established.
In addition, it is reported in the discharge summary of Dr. #6
that the patient had a guaiac- (blood) positive stool and an anemia which prevented
the use of full intravenous (anticoagulant: blood thinner) heparin. Although
guaiac-positive
stools represent blood loss from the gastrointestinal tract, such blood loss is at most a
relative contraindication to the blood thinner intravenous therapy. As a compromise, it
appears that Dr. #6 was willing to give this patient subcutaneous heparin. Heparin, as a
blood thinner, can be very useful in preventing blood clots, but has a very limited role
when given by the subcutaneous route in treating established blood clots. For this reason,
the standard of care regarding pulmonary embolus therapy remains either intravenous
anticoagulants, such as heparin, or similar medications.
Although the presence of anemia with gastrointestinal bleeding
would have made blood thinner medication a somewhat risky form of therapy, this again
is a relative contraindication, and it is far easier in general to treat gastrointestinal
bleeding than it is pulmonary emboli. Furthermore, this patient never had the benefit of
a scan to rule out pulmonary emboli or an ultrasound to rule out the precursors of pulmonary
embolic disease; i.e., deep venous thrombosis of the lower extremities.
The lack of performance of a V/Q scan by either the emergency room
or the Intensive Care Unit physicians represented serious departures from the standard of
care regarding patients such as the patient in whom a search for pulmonary emboli can be
life saving. Furthermore, as mentioned in Dr. #6's note, a right heart catheterization
could have given very useful information, and the lack of performance of this procedure
represents another departure from the standard of care, which likely contributed to this
patient's adverse outcome.
In addition, it seems very paradoxical for the discharge summary to
document that a cardiologist agreed that this patient was sick enough to be evaluated by a
transplant service team but whose illness did not appear to be of sufficient gravity to
warrant an inpatient expeditious cardiac authorization.
The Hospital #1 and several of its personnel may indeed also be
negligent in a similar fashion.
Expert reports are available. In this particular case, the input
of a Cardiologist and possibly an Intensive Care Unit Specialist would be very valuable.
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Hypertensive young smoking patient
with family history of heart disease has no cholesteral testing or therapy, had chest and
shoulder pain but negative EKG and cardiac enzyme blood tests. Sent home and dies a few
hours later.
In 1994, at age 37, this patient was hypertensive, had a family
history of heart disease and complained of chest pain. His family physician, Dr. #1,
referred him to a cardiologist, Dr. #2, who performed an echocardiogram (sound x-ray-like
study) and noted his heart to be normal. The coronary artery patency was tested by a
stress test but was "inconclusive" because he could not exercise enough to raise his
heart rate above 92. It was no where near the target rate.
I found no blood testing for a lipid panel, which includes
cholesterol and triglycerides. The failure to do such a test by either doctor is a
departure from the standards of care, even in 1994. Proper long-term cholesterol-lowering
therapy reduces the risk of developing a heart attack. Also, I found no documentation
that a low-fat / low-cholesterol diet was recommended. His aunt died of a heart attack
at age 43 and these blood tests needed to be done. His hypertension was treated,
although he did not always take his medication due to the cost, yet he continued to
buy and consume one to three packs of cigarettes per day which shortens life by 48
minutes per cigarette.
On August 17, 1999, he was seen at the Clinic #1and his blood
pressure was elevated to 180/98. They reasonably decided to recheck it in three days.
They prescribed medication for his left shoulder, which was painful to touch. He
had no chest pain radiating (projecting into) his shoulder, often seen with a heart
attack. And it was "tender' to touch, consistent with their diagnosis and therapy.
When they rechecked him on (?) August 20, his blood pressure
was borderline elevated at 140/90 and his left shoulder still was "tender."
On August 20 he arrived at the Emergency Room with a history of
severe chest pain (10 out of 10) and a blood pressure of 164/90 and repeated as 170/100.
The chest x-ray was normal, as was the EKG. Also, most significantly the cardiac enzymes
(proteins that enter the blood stream from dying heart muscle cells, the CK-MB)
were normal at 0.
Except for 30 seconds of chest pain while in the X-ray Department,
he had no chest pain, the cardiac monitor was normal and his prerelease blood pressure
at 1555 (3:55 p.m.) was 145/90 (borderline and required no treatment).
He died after he arrived home, most likely from a heart attack.
No autopsy was done.
Even if the cholesterol test would have been done on August 17, 1999,
prescribing cholesterol-lowering medication on that date would make no difference
to his survival, compared to 1994.
His cigarette smoking significantly contributed to his demise and
you may want to file a claim against the cigarette manufacturer of his brand.
For all the reasons noted above, I do not find negligence against
his health care providers. At age 42 and with his family history and chest pains, some
physicians may have admitted him to the coronary care unit of the hospital for a one-day
stay and monitoring. If that had happened, his death most likely would have been
prevented by the use of anti-arrhythmic drugs and electrical shock therapy. But he had
significant coronary artery disease of an unknown amount. Without an autopsy, I can only
assume by statistical probability that more likely than not, he would have been amenable
to angioplasty (balloon artery dilatation) or CABG (coronary artery bypass graft) surgery.
Then with an intense antismoking therapy program, cholesterol-lowering drug therapy and a
strict vegetarian diet, he may have had added years to his life.
The defense will contend all I noted above, plus the fact that he was
disabled. Therefore, the "economic value" of his life was very limited and he had real
shoulder pain, which would, to some degree, confuse his cardiac diagnosis which had a
normal EKG and a cardiac enzymes (which rise within a few hours of a heart attack),
and the fact that his chest pain went away.
You may want us to send these records to a cardiologist and/or
Emergency Room Expert for their independent opinions, regarding negligence causation
and/or longevity issues. Please advise us if you want to pursue the product liability
(cigarette) aspect of this case.
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