Allegation
Plaintiff alleged defendant cardiologist failed to return plaintiff in a timely manner post-surgery.
Case Details
A 44 YOM (5’8”, 230 lbs.) presented to the ED complaining of chest pain while working. On admission, his pain was 7/10 and radiated down his arms. Vital signs were within normal limits and Troponin I was 0.02 (0.0-0.4). An EKG showed no STEMI. The patient’s history included HTN, hyperlipidemia, obesity, and smoking a pack of cigarettes a day for 30 years.
The defendant cardiologist performed a cardiac cath that showed severe multi-vessel disease with 95% stenosis of the proximal LAD, 95% in the first diagonal, 90% stenosis mid-circumflex, and 90% in the distal RCA. The patient was maintained on heparin overnight, and a CABG was planned for the next day.
The next morning, a CABG x4 was performed and the patient was admitted to the CVICU in stable condition. The post-op EKG revealed sinus tachycardia, low voltage QRS, and an anteroseptal infarct that was possibly acute. The EKG was read as showing a lateral injury pattern consistent with an acute MI/STEMI. The CVICU nurse discussed the findings with the co-defendant surgeon. By late afternoon, the patient’s BP was low and the cardiac index decreased. The co-defendant surgeon ordered a repeat EKG. The defendant cardiologist saw the patient later that evening and found the first EKG consistent with a lateral MI. He noted the repeat EKG was better, and that the patient was stable.
The next morning, the EKG showed anterior Q waves, and the defendant cardiologist ordered an echo to assess the anterior wall. The echo revealed a hypokinetic mid to distal septum and apex. The records show some discussion of the case between the defendant cardiologist and the co-defendant cardiovascular surgeon. Findings on the repeat EKG were sinus tachycardia, low voltage QRS, and incomplete right bundle branch block, indicating an acute MI/STEMI. The defendant cardiologist read and agreed with these findings.
On post-op day five, the defendant cardiologist noted the patient had a perioperative MI with ST elevation, and the echo showed wall motion abnormalities. He planned a cath before discharge to assess the grafts. The EKG showed NSR, rightward axis, low voltage QRS, and incomplete RBBB. The following day, the defendant cardiologist explained the perioperative events to the patient and planned a cardiac cath for the following day.
A hurricane made landfall the next morning and the cath did not take place as planned. The EKG showed frequent PVCs, left atrial enlargement, right axis deviation, and low voltage QRS with incomplete RBBB. This reading was confirmed by the cardiologist. The next day, the cath was canceled because a room was unavailable.
On post-op day nine, hematology was consulted for evaluation regarding coagulopathy. The medical team did not think a clotting disorder was present and thought the present anticoagulants were appropriate. The patient was taken for a cardiac cath to assess graft patency. The EF was 20%. There was a clot found in the proximal LAD and mid-LAD, resulting in 100% stenosis. Angiojet and thrombectomy were done with an extraction catheter. There was also 100% stenosis in the first diagonal and 95% stenosis in the stent in the proximal circumflex. A drug-eluting stent intervention resulted in 0% residual stenosis. Some thrombus was found in the grafts as well, and aspirin and Effient were recommended. Integrillin was started for 48 hours, after which the thrombus burden would be reassessed.
The following day, the defendant cardiologist spoke with the plaintiff and his wife. He discussed the cath findings, and the plan to repeat the cath once the anticoagulants had taken effect. Later that day, the patient began to experience syncopal events, and was unresponsive and incontinent. A brain CT showed no ischemia or hemorrhage. An echo found severely decreased LV EF as before and a LV apical thrombus was noted.
Two days later, the defendant cardiologist noted that based on the occluded grafts, the recent TIA type event, and the apical thrombus and echo findings, the patient needed a life vest and an evaluation for a heart transplant. The next day, the cath was repeated and there was no improvement with the anticoagulants. The following day, the patient was transferred to a transplant center for evaluation. He began to improve slowly and was well enough for discharge 10 days later. He continued to be followed by the defendant cardiologist and the transplant center. Within nine months, his EF had improved to 40% and he was walking 1.5 miles per day. At this point, he was no longer considered a transplant candidate.
Expert Testimony
The plaintiff alleged the defendant cardiologist failed to timely return the plaintiff to the cath lab following surgery when the EKGs demonstrated concerning findings resulting in a reduced ejection fraction. Although defense experts all found decisions they could support, they could not say the standard of care was met by the defendant cardiologist. The lack of documentation of discussions between the defendant cardiologist and co-defendant surgeon stood out, as well as many notes that appeared to have been copied and pasted.
The case was settled for a confidential amount.
Resolution
Due to poor documentation and communication among treating physicians, the support of a defense expert was difficult to obtain and the case was settled.
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