Commentary
Although the patient had an extensive medical history with numerous comorbidities, the case was settled due to a lack of expert support.
Case Details
The patient, a 58 YOWM (5’8”, 200 lbs.), presented to the ED seven days after an ablation. The patient had a medical history significant for cardiac disease including coronary stents and A-fib with cardioversion. He was on Coumadin and was a Type II diabetic with end-stage renal disease requiring hemodialysis. On arrival to the ED, the patient said he had constant chest pain, described as “achy pressure,” and generalized weakness since the ablation.
The patient’s vital signs were HR 144, BP 135/87, and R 18. Heart sounds and peripheral perfusion were normal. An EKG showed sinus tachycardia. No STEMI or acute injury were present. Abnormal labs included WBC 12.58 (4.5-11), HGB 9.6 (14-17.5), and HCT 29.7 (40-52). His INR was critical at >10 (.81-1.2). The patient’s tachycardia improved with medication. The patient’s INR was treated with vitamin K. He was admitted to telemetry on the progressive care unit by the attending physician: a family practice specialist, who ordered a consult with the defendant cardiologist.
That evening, the patient was seen by the defendant cardiologist’s nurse practitioner. His pain was rated 3/10. The patient was in sinus rhythm with a HR of <105 and on a CARDIZEM drip. His heart and lung sounds were normal and his chest x-ray showed an enlarged cardiac silhouette. An echocardiogram was ordered. The nurse practitioner discussed the assessment and plan with the cardiologist.
Four hours later, the patient was nauseous and vomiting with pallor, lightheadedness, and hypotension; he was lethargic. Glucose levels were stable and an EKG was performed; it was unchanged from the prior EKG.
The defendant cardiologist saw the patient the next morning. He was in A-fib with a controlled heart rate. The patient said he had a terrible night with nausea and vomiting, but was currently in no acute distress. His heart sounds were normal and his INR was down to 5.5 after treatment. The patient was also seen by the nephrologist who planned dialysis on MWF.
That afternoon, the hospital nurse called the cardiology office concerning the order for echo since the patient had one a week prior. The office advised that another echo was not needed at this time.
The patient continued to have dry heaves and vomiting the next morning. His HR increased to the 150s. CARDIZEM was increased and Coumadin was restarted at a lower dose. A GI consult was ordered. The patient complained of chest pressure all night. The cardiologist attributed the chest pressure to vomiting. Blood cultures came back growing gram-positive cocci; Zosyn was ordered. An exam revealed no acute cardiopulmonary distress.
Late that day, the patient vomited his Coumadin and an NGT was placed. The patient was made NPO and a low-dose heparin was started. A CT of the abdomen and pelvis revealed that the NGT had coiled in the distal esophagus. A large pericardial effusion was also noted. The cardiologist ordered an echo and felt it was inconclusive for cardiac tamponade and that the pericardial effusion was moderate in size. The patient’s EF was 35-45% with mild to moderate global hypokinesis of the left ventricle. The right ventricle was normal in size and function. The patient’s HR was in the 150-160 range and the CARDIZEM drip was restarted.
The next day, the attending physician noted bilateral jugular vein distention (JVD) and tachycardia. The cardiologist noted no significant changes. The patient’s heart sounds were normal. That evening the patient went into cardiac arrest, but was quickly and successfully resuscitated. The patient was placed on BiPAP and was transferred to the ICU.
The patient did well for several hours, remaining in A-fib with a controlled heart rate. Hemodynamics were stable and no acute EKG changes were noted. He had been doing well prior to the arrest and the etiology of his condition was unclear. The patient spoke to a cardiologist who was covering for the defendant cardiologist who was out of town. She ordered a stat echo and attempted to reach out to the defendant.
The patient became hypotensive. A fluid bolus was given and Levophed was started. The echo revealed the pericardial effusion had increased in size and the EF was down to 10%. The covering cardiologist arranged for interventional cardiology to perform an emergency pericardiocentesis.
Before the procedure could be done, the patient coded again. He was intubated and rushed to the cath lab for the procedure. The pericardiocentesis was performed and a drain was placed that returned 700cc of dark blood. EF increased to 55%.
The following day, the patient’s wife expressed frustration at the lack of communication from the on-call cardiologists. The covering cardiologist had been able to speak with the defendant and they planned to speak with the family. Over the next seven to 10 days, the patient had difficulty being weaned off the ventilator. Two units of packed red blood cells were given. The patient was otherwise stable. He was successfully extubated two days later. Five days later, he was in normal sinus rhythm, on CARDIZEM by mouth, and ready for discharge. He continued dialysis on MWF.
The plaintiff alleged the defendant cardiologist delayed ordering and reading the echo, resulting in the delay in diagnosis and treatment of the pericardial effusion.
Resolution
Attorneys for the defendant cardiologist were unable to obtain expert support, and therefore, the case was settled prior to trial.
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