Commentary
Despite criticism surrounding the lack of referral for follow-up care, including a cardiac stress test, the jury returned a verdict in favor of the defendants.
Case Details
A 58 YOWM (6’, 238 lbs.) presented to the ED after being awakened with dizziness, lightheadedness, tingling, and some speech difficulty. His history was significant for borderline HTN, hyperlipidemia, GERD, and diabetes. He was not taking any medications. Vital signs on admission included BP 148/99, HR 80, T-97.4, RR 18, and glucose 230 (65-99). The EKG was normal and head CT was negative for bleeding, masses, acute ischemic stroke, and acute changes.
A hospitalist admitted the patient for transient ischemic attack and diabetes mellitus. On hospital day three, the admitting hospitalist consulted a neurologist whose exam revealed that the patient was oriented x3 with mild articulation and difficulty finding words. An MRA of the head and neck was normal. An MRI revealed acute infarction in left basal ganglia of moderate size, and acute ischemia in white matter in the right frontal lobe. The patient was a good candidate for rehab and the admitting hospitalist placed him on Aggrenox, an ACE inhibitor, and a statin.
The next day—hospital day four—the admitting hospitalist dictated a discharge summary believing that the patient was ready for transfer to rehab. On hospital day five, the neurologist consulted the defendant cardiologist to rule out a cardiac source of embolism. A 2D echo showed an EF of 60% with normal LV function and no LV hypertrophy. The patient told the defendant cardiologist he had a recent onset of exertional chest discomfort with no radiation and some shortness of breath. The symptoms sometimes occurred after eating and usually resolved within a few minutes. The patient thought it might be related to his GERD.
The cardiologist ordered a TEE which was interpreted by his partner as normal with no evidence of clots. In his consult report, the cardiologist noted that once the patient recovered from the CVA, the patient would need a thallium stress test to rule out CAD. His dictated consult report included copies to both the admitting and primary care physicians. The admitting hospitalist signed off on the report because he had a partner with a name similar to the defendant cardiologist.
On hospital day eight, the patient was discharged to a rehab facility under the care of the neurologist. The admitting hospitalist did not dictate an amended discharge summary to include the cardiologist’s report. Three days later, the patient was discharged home and instructed to follow up with the neurologist and his PCP. One month later, the patient saw the neurologist who noted he had made a good recovery with only some mild deficits in his right hand. The next month, he had coagulation studies which revealed only a single abnormality not requiring anti-coagulation. The hematologist sent a letter to the neurologist and the PCP with results and noted that anti-platelet therapy was reasonable; and treatment to minimize arterial sclerosis and increasing folic acid in his diet was recommended. An EEG in January was normal.
Two months later, the EMS was called to the patient’s home. On arrival, the patient reported he had severe abdominal pain which had moved to his chest. He was weak and diaphoretic. A 12-lead EKG showed SR with elevated ST segments in leads II and III. He was given aspirin and two nitroglycerin tablets which did not relieve the pain. He was placed on oxygen and transported to the ED. On arrival, he complained of severe chest pain and suddenly arrested. Resuscitation was unsuccessful and he was pronounced dead. Autopsy revealed cardiomegaly, no evidence of myocardial infarction, 80% blockage of the LAD, and 50% blockage of the left circumflex. Immediate cause of death was listed as myocardial ischemia and ventricular fibrillation with the underlying cause listed as severe atherosclerotic vascular disease.
The plaintiff alleged the defendants were negligent for failing to order cardiac stress testing to diagnose and treat atherosclerotic heart disease. As a result, the patient died four months later from myocardial ischemia. Defendants included the hospital, admitting hospitalist, and the cardiologist.
Expert Testimony
The plaintiff’s experts agreed the patient had multiple risk factors for sudden cardiac death. The patient had stabilized after his stroke and the stress test should have been ordered prior to transfer.
Defense experts argued the patient’s CAD was stable when he was discharged to rehab, and the standard of care for this is medical management. The most common cause of death from ventricular fibrillation is abnormal ventricles or LV dysfunction secondary to cardiomegaly. The death was not the result of CAD as there was no scarring in the heart.
The admitting hospitalist testified when he dictated his discharge summary on day four, the patient was stable enough for discharge to rehab although it did not actually take place until day eight. He acknowledged the discharge summary was incomplete since it did not include the cardiology consult or TEE procedure. He said he would have expected medical records to call this to his attention and to request the summary be amended; he did not know why that was not done in this case. The admitting hospitalist was questioned concerning his H&P, specifically that he included that a copy was sent to the patient’s PCP, but the wrong name was listed. He denied dictating the incorrect name.
Resolution
The hospital settled for a confidential amount. The physicians went to trial and the jury returned a defense verdict.
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