Allegation:
A failure to obtain or refer the patient to a cardiologist for a pre-operative workup prior to his left knee arthoplasty resulted in his death.
The Case:
The patient, a 55 YOM (6’0”, 246 lbs.), presented to the defendant pulmonologist for a pre-operative history, physical, and medical clearance in anticipation of a left-knee arthroplasty. He had a history of coronary artery disease, HTN, hyperlipidemia, GERD, and peripheral edema that were well-controlled with medications. His surgical history included left and right hip replacements.
Prior to his appointment, the patient provided a list of current medications and a health history form. He denied a history of cardiac disease and any chest pain on the form. The practice obtained records from the patient’s prior cardiac catheterization, cardiac ultrasound, and EKG. A gastroenterologist who had noted the patient was experiencing atypical chest pain likely due to esophageal spasms examined him a week before, and recommended continuing sublingual nitroglycerine.
During his pre-op visit with a nurse practitioner, the patient stated he was experiencing 5/10 knee pain. This achy pain had persisted off and on for 10 years. His knee would also lock intermittently and frequently dislocate. The documented review of the cardiac system was:
“The patient denies DOE, chest pain, palpitations, or edema. He states he has had no chest pain, SOB at rest, or exertion. He underwent cardiac cath two years prior that revealed 20% proximal and medial LAD diffuse disease. RCA is large, dominant, and diffuse with 20% proximal and mid lesions. Overall, non-obstructive coronary artery disease with normal left ventricular function.”
The EKG report revealed NSR with right bundle branch block; HR was 59. The nurse practitioner’s impression was: “Overall non-obstructive coronary artery disease with normal left ventricular systolic function.” She used a “Beta-blocker Pre-Op Assessment Tool” to assist in the evaluation of the patient’s risk for surgery; he obtained a score of 4 based on his history of heart disease, HTN, and high cholesterol. No contraindications to surgery were present. Her recommendation in the assessment was that the chart be reviewed by a physician, and that surgical clearance would be determined at that time. The nurse practitioner also recommended the patient continue Toprol® 50 mg qd in advance of surgery.
The defendant pulmonologist reviewed the chart and the most current EKG later that day. He agreed with the NP’s determination and documented: “Chart reviewed and agree with note and plan as outlined by NP. EKG shows incomplete RBBB and patient denies chest pain symptoms – on beta blocker therapy at this time – OK to proceed with surgery as noted.” He saw nothing in the patient’s reported history or EKG to warrant further cardiac testing.
Another nurse from the hospital contacted the patient for an inpatient health assessment interview by phone. She questioned the patient and documented he was not experiencing any chest pain or SOB. The patient reported he was taking nitroglycerine for reflux pain one to two times a week.
The next week, the patient presented to the hospital for his left total knee arthroplasty. A PA performed a pre-operative history and physical examination of the patient in advance of surgery. The physical exam was unremarkable, and the cardiac assessment noted a regular rhythm and rate. He was evaluated once more in the holding room before the total knee procedure. The patient again denied any chest pain or SOB, and told the NP he occasionally had “GI spasms” that were being treated.
The surgery proceeded as planned and the patient remained stable throughout. Upon arrival to the PACU, his SpO2 on room air was 96%, and vitals were BP 145/85, P 71, and RR 13. The initial EKG looked like possible ventricular tachycardia, and at that time, no pulse was palpable. Staff initiated CPR and called a code. The anesthesiologist and nurse practitioner were present, appropriate medications were given, and the patient was defibrillated as needed. Efforts to resuscitate were unsuccessful, and they pronounced the patient dead within an hour post-op.
An autopsy revealed the cause of death was acute myocardial infarct due to atherosclerosis involving: a) the LAD with 75% and greater calcific stenosis, b) circumflex 50% calcific stenosis, and c) the right coronary 50-80% stenotic by fibrosed fatty atheromatous plaques. The autopsy also noted the presence of cannabinoids and ethanol within the patient. The patient had not disclosed drug use.
The estate alleged the defendant pulmonologist and his group provided clearance for surgery even though the patient had a history of cardiac conditions, which resulted in his death.
Plaintiff experts stated the cardiac clearance should have included contacting his cardiologist. They felt a better evaluation of the patient’s cardiac problems including a nuclear stress test or another cardiac cath would have revealed the significant atherosclerosis that caused his death.
Defense experts were supportive and testified the defendant pulmonologist met the standard of care. Because the patient claimed he was asymptomatic, he did not need further cardiac testing. His wife’s testimony portrayed the decedent as someone who was hiding his chest pain symptoms.
Verdict:
The jury returned a verdict for the defense.
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