Allegation:
Communication between providers and physicians can be a challenge, but ultimately it is very important in assimilating comprehensive, timely care for patients.
The Case:
A 65 YOM (5’9”, 279 lbs.) presented to the ER around 6:41 a.m. with chest and back pain for a period of 12 hours after shoveling snow. His pain improved if sitting up and worsened with movement, coughing, and breathing. An EKG revealed nonspecific sinus tachycardia (ST) and T wave changes with a prolonged QT interval; lab tests revealed D-Dimer 0.69 (<60), troponin I 0.042 (0.000-0.034), BUN 34 (9-20), creatinine 2.00 (0.66-1.25), total CK 1104 (55-170), and CKMB 14.1 (0.0-2.4), with a BP of 204/114. The defendant radiologist assessed no acute infiltrates or vascular decompensation in a single view portable chest x-ray (CXR), and low probability for PE on a ventilation-perfusion (VQ) scan.
When the patient’s BP rose to 215/111, the emergency medicine (EM) physician ordered a stat CTA. Because the patient had decreased kidney function, the test was cancelled due to a standard radiology protocol. A STAT echocardiogram was also ordered along with hydralazine 10 mg STAT and NTG ointment. The patient continued with mild mid-thoracic and lower chest pain. The EM physician reviewed the EKG and VQ scan diagnostics, and admitted the patient under routine admission orders with a STAT cardiology consult.
The cardiologist diagnosed the patient with unstable angina, improved uncontrolled HTN, borderline troponin, an EKG suggesting myocardial ischemia, and history of mild renal dysfunction. The patient’s second set of labs were troponin 0.028, CK 1010, and CKMB 11.0, with BP readings of up to 173/98. The cardiologist recommended a cardiac catheterization after hydration, and started Norvasc® and Lopressor® for HTN. He also noted that aortic dissection seemed less likely given the EKG changes of anterior ST and T wave changes.
The patient underwent a cardiac catheterization via right radial artery, but the cardiologist encountered extreme tortuosity in the ascending aorta and had to gain access via a right femoral approach. The cardiologist also had difficulty in the aortic arch due to anatomy and the angulation of the arch, so he used a GLIDEWIRE® to get into the ascending aorta. He found no significant disease and placed routine post-catheterization orders.
The patient continued to have increasing BP through the evening and was found unresponsive. A code was called and, despite emergency efforts, the patient was declared dead. An autopsy of the chest was performed and confirmed a tear and dissection of the proximal descending aorta with 1,950 cc of blood in the chest cavity. The treating cardiologist reviewed the autopsy findings with the family. He indicated the autopsy suggested a subacute Type III dissection; based on the amount of blood behind the aorta, the cardiologist felt the dissection appeared to have been going on for a week or so.
The allegations made against the defendant radiologist involved a failure to identify and diagnose abnormalities associated with a dissecting thoracic aorta, via interpretation of a portable CXR, resulting in the patient’s death.
Plaintiff’s experts were critical of the defendant radiologist’s interpretation of the portable CXR; some stated there was a mediastinal widening and tracheal deviation with left main stem bronchus depression. Emergency medicine experts were critical of the EM physician for failing to override the CTA canceled per radiology protocol, as well as for failing to rule out ruptured esophagus or aortic dissection as a part of the differential diagnosis. Experts were also critical with the lack of communication from the EM physician to the defendant radiologist; such communication may have provided information that would have guided the EM physician to order an alternate diagnostic test or override the CTA cancellation.
Defense experts were critical of the cardiologist’s decision to perform a cardiac catheterization, and felt he should have performed an aortogram. The defense experts felt the cardiologist may have caused the perforation with the GLIDEWIRE. They were also critical that the cardiologist did not manage the patient’s elevated BP aggressively. The defense experts unanimously agreed with the defendant radiologist’s interpretation of the CXR that there was no evidence pointing to a dissection.
Resolution:
The defendant radiologist was dismissed with prejudice right after the jury was sworn in but before opening statements. The co-defendant cardiologist went on to ultimately agree to a settlement. The co-defendant EM physician received a defense verdict.
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