Echocardiography Not Available on Weekends
One Friday evening in late October, a 58-year-old man presented to the emergency department (ED) of a rural hospital with complaints of jaw pain, chest pain, arm and leg numbness, and difficulty speaking. Within 15 minutes of his arrival, the man’s symptoms resolved spontaneously. Results of testing performed in the ED were consistent with coronary artery disease.
The patient was transferred late that night to another hospital for specialized cardiac care. His condition at the time of admission was stable, and he had no complaints other than the unusual 15-minute episode he had experienced earlier that day. This information was presented to a resident, who examined the patient and ordered an echocardiogram for the next morning (Saturday). The hospital’s echocardiography laboratory was not routinely open on the weekend.
The man was seen by a cardiologist that Saturday morning. It was noted that his heart monitoring had shown abnormalities, and blood work had revealed abnormally elevated cardiac enzyme levels. The cardiologist recommended that the patient remain on high-dose heparin until angiography could be performed on Monday.
The cardiologist also noted that he detected a slight diastolic heart murmur near the left sternal border. He informed the man and his wife that there might be a bacterial infection affecting the aortic valve, which would explain the murmur. The cardiologist ordered an echocardiogram for Monday to rule out the possibility of aortic incompetence due to aneurysm of dissection. The man died that night before testing could be performed.
The cardiologist claimed that the man’s death was the result of a sudden heart attack secondary to coronary artery disease. No autopsy was performed at the time. The body was exhumed 18 months later, however, and a postmortem examination revealed the cause of death to be aortic dissection.
The plaintiff claimed that the ED physician, the resident, and the cardiologist were all negligent in failing to make a diagnosis of aortic dissection and that emergent chest CT should have been performed. The plaintiff also argued that if echocardiography had been performed on Saturday morning as ordered by the resident, the dissection could have been detected in time to perform lifesaving surgery. The plaintiff further claimed that the cardiologist was negligent for recognizing the possibility of a dissection and doing nothing to confirm or rule out the diagnosis, despite the high mortality rate associated with aortic dissection.
The defendants maintained that the decedent’s signs and symptoms were not typical for aortic dissection and were more consistent with coronary artery disease. The defendants also argued that even if the correct diagnosis had been made, the decedent would not have survived surgery.
A settlement of $2 million was reached.
Viral Syndrome—or Lupus?
A 34-year-old woman presented to the defendant hospital ED complaining of chills, fever, and blood in her urine. She underwent laboratory testing and was given IV fluids and antibiotics. She was discharged with a prescription for ciprofloxacin for a urinary tract infection and was given instructions to follow up with her primary care physician or return to the ED if her symptoms worsened.
Two days later, the patient returned to the ED twice and was ultimately admitted with fever, chills, shortness of breath, and a cough. The next day, she suffered a grand mal seizure and was transferred to another hospital, where she died a few days later.
The plaintiff claimed that the decedent had systemic lupus erythematosus and that she should have been transferred to the second hospital immediately.
The defendants claimed that the decedent had a viral syndrome, that her seizure was completely unpredictable, and that nothing could have been done during her ED visits to have changed the outcome.
According to a published report, a defense verdict was returned.
Advanced Heart Disease Recognized, Treated Late
In April 2003, a 47-year-old woman underwent aortic valve repair and mitral valve replacement in an attempt to correct problems with blood flow to and from her heart.
After the surgery, it was discovered that the left ventricle was pumping out a dangerously low amount of blood. She was taken to the ICU in Dr. A.’s care. At midnight, Dr. C. assumed her care.
The following morning, Dr. C. installed an intra-aortic balloon pump (IABP), which required several attempts. The patient was then transferred to another hospital for a possible heart transplant. She experienced cardiac arrest and died the following day.
The plaintiff claimed that Dr. A. and Dr. C. failed to perform appropriate preoperative testing and to administer the proper medication in the hours immediately following surgery. During this time, the decedent suffered multiple myocardial infarctions due to lack of oxygen to the heart. The plaintiff also claimed that the IABP should have been installed earlier.
The defendants argued that the decedent was in extremely poor health before the surgery as a result of advanced heart disease, which they claimed had been misdiagnosed as asthma since 1996.
According to a published account, a jury found no negligence by the hospital or Dr. C. The jury found Dr. A. negligent, but they did not find his negligence to have caused the woman’s death. A defense verdict was entered. Posttrial motions were pending.
Sinus Infection Leads to Brain Abscess
A woman in her 50s presented to a hospital ED complaining of severe headaches for several days. An ED physician made a diagnosis of tension headache and prescribed muscle relaxants and pain medication. Two days later, at her primary care physician’s office, she still had a headache, but it was less severe; she also had nasal discharge, swollen eyes, red sinuses, and nausea. The patient was examined by a PA, who diagnosed an allergic reaction. Steroids were prescribed, and a sinus x-ray and blood work were ordered.
Five days later, the woman developed stroke-like symptoms, including facial drooping and disorientation. She was transported to the same hospital, where CT revealed a brain abscess. She was airlifted to a second hospital for emergency brain surgery, which required part of her skull to be removed and replaced with plastic.
After surgery, the patient experienced respiratory failure and was placed on a ventilator. Following additional brain surgeries, she was left with loss of vision in her left eye and cognitive impairment that could increase her likelihood of developing dementia. She also needed two months of rehabilitation.
The plaintiff alleged negligence by both the ED physician and the PA for their failure to diagnose a sinus infection and to prescribe appropriate antibiotics. She maintained that tests should have been ordered on an urgent basis and that timely diagnosis and treatment would have prevented the abscess. The plaintiff further charged that the PA’s supervising physicians failed to review her chart or consult with the PA regarding her case.
The defendant primary care provider argued that the plaintiff was properly treated. The remaining defendants claimed that the plaintiff was at fault for not undergoing diagnostic testing immediately following the PA’s examination.
According to a published report, a jury found the primary care provider and the PA negligent and awarded the plaintiff $3 million. The ED physician and the first hospital were found not at fault.