Allegation
The cardiologist failed to order the necessary tests to rule out a dissecting aortic aneurysm that resulted in the patient’s death.
Case Details
A 66 YOF (5’6”, 260 lbs.) arrived at the ED at 09:17 via EMS. She complained she woke up with chest pain that emanated from the bottom of her neck through the chest and abdomen, and that the pain was sharp and severe for 2-3 minutes. She had heavy sweating and dyspnea. Pain was 8/10 with heart rate at 104 and BP at 152/85. The patient’s history included HTN, cardiomegaly, CHF, COPD, diabetes, lupus, gout, stroke, bipolar disorder, depression, and a 20-pack-year history of smoking.
The ED physician ordered an EKG, 2-D Echo, CTA, chest x-ray, CK-MB, troponin, and D-dimer. He interpreted the EKG as tachycardia, T-wave normal and non-specific ST changes. That night, the EKG was read by a cardiologist as ST, nonspecific T-wave abnormality, minimal ST elevation inferior leads and inferior Q-waves, possible inferior infarct, age undetermined, clinical correlation advised. Labs were normal including CK-MB <0.5, and Trop 1 <0.015. The patient was given morphine 2 mg for pain 8/10 and NTG 2% topical at 11:00. Another ED physician charted differential diagnosis as CHF, PE, MI, and GERD. At 11:32, the radiologist read the chest x-ray as enlarged cardiac silhouette and tortuous aorta with calcification in the aortic arch. There were no acute changes from previous film done the year before.
Later, the D-dimer came back elevated at 0.89 (0-0.5). A chest CT angiography with contrast was ordered due to chest pain, SOB, and elevated D-dimer. It was interpreted as showing no evidence of PE, aortic dissection or aneurysm, although contrast opacification was suboptimal. Cardiomegaly with moderate pericardial effusion was confirmed. An order was written to admit her to telemetry under the care of the defendant cardiologist.
The patient’s chest pain continued throughout the evening. At times the pain was described as aching; at other times, sharp. A resident performed a history and physical at 08:00. She noted blurred vision and minimal SOB, and negative pericardial friction rub. Her impression was moderate pericardial effusion, CHF, possibly from SLE, and possibly infectious. COPD was not in exacerbation. The patient had an uneventful night, and only experienced chest pain a couple of times.
The next morning, the patient complained of pain with squeezing and heaviness. She was treated for 8/10 pain. By mid-morning, an intern described the pain as positional. The ESR was 38 (0-15) and C- reactive protein 1.11 (0-0.3). The assessment was chest pain due to pericarditis. An Echo indicated minimal pericardial effusion, hemodynamically insignificant. Ibuprofen was added to medications. The defendant cardiologist saw the patient with the intern. He recorded that although the patient still complained of chest pain, it was less severe and there was less SOB. The defendant felt the pericarditis was due to lupus. He dictated the echo report as: EF 60%, moderate left ventricular hypertrophy with evidence of decreased left ventricular compliance; aortic and tricuspid regurgitation 1+ and small pericardial effusion.
Through the afternoon until the next morning, the patient’s chest pain ranged from 3-7/10. She received morphine as ordered. The next morning (hospital day three), there was CV tenderness to palpation and a systolic ejection murmur. Prednisone 60 mg was added since pain was not well-controlled; it was noted that the hospital considered discharge the following day. An EKG that afternoon indicated sinus rhythm with first degree AV block with occasional supraventricular premature complexes, and inferior myocardial infarction of indeterminate age. Later that afternoon, a discharge summary was dictated by a resident with diagnosis of chest pain due to pericarditis versus acute coronary syndrome. The patient was evaluated for acute coronary syndrome, which was ruled out. Later that afternoon and through the night, the patient again experienced chest pain as much as 7/10. Morphine and SL NTG were given.
The pain was much less the next morning (hospital day four), and at times, recorded as 0. The plan was to monitor another 24 hours with continued ibuprofen and prednisone. The defendant cardiologist recorded that his impression remained acute pericarditis. The patient continued to have episodes of chest pain as much as 7/10 and periods of no pain.
The next morning (hospital day five) at 03:00, a nurse found the patient unresponsive. CPR was started and a code was called. All efforts were unsuccessful and the patient was pronounced dead at 04:00.
The autopsy indicated the cause of death was a dissecting hematoma of the aorta with rupture into the pericardium with 377 grams of clotted blood within the pericardium. Rupture of the aortic base originated 2.4 cm above the aortic root with aortic dilation of 6 cm; progression of the dissection extended 7 cm into the thoracic aorta.
Three adult children of the deceased filed a suit. They alleged failure to timely diagnose and treat the dissecting aneurysm that led to the patient’s death four days after presenting with chest pain and SOB.
Expert Testimony
Plaintiff experts testified the chest x-ray was not normal, and that calcification in the aortic arch and an enlarged tortuous aorta required aortic dissection be placed higher on the differential. The experts stated the defendant cardiologist should have been aware the CTA was performed under a PE protocol, and should have concluded the CTA was not diagnostic to rule out an aortic dissection. They further testified he should have reordered a CTA or done a TEE focusing on the aorta.
The defense experts agreed that pericarditis was an appropriate diagnosis with the CTA interpreted as showing no evidence of aortic dissection. They further stated the patient’s symptomatology was consistent throughout her admission.
Verdict
The case was settled with agreement from the defendant cardiologist.
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