An article for physicians by physicians
Originally published December 2010
Acute chest pain is a common, chief complaint in both an emergency department and family practice environment. Careful evaluation of the history, physical examination and ECG may provide valuable clues. In some cases, observation and further testing may also be advisable.
Acute coronary syndromes (ACS) are common. Early diagnosis and treatment can reduce subsequent morbidity and mortality. However, establishing the diagnosis may be difficult, regardless of the attending physician's expertise and experience.
A recent review by the CMPA's research staff identified 292 ACS related medico-legal cases (both open and closed) during the time period 2000-2009, of which 163 (56%) have been settled. Common problems identified in the review included: incomplete history, delay in testing, incomplete testing, and misinterpretation of diagnostic tests.
The following case illustrates the often deceptive nature of the diagnosis. In this case, the confounding factor was a proximate musculoskeletal injury in a previously healthy male patient.
Days one and two
On a Monday afternoon (day one), a 45-yearold previously healthy man injured his right shoulder while lifting a stretcher during a first aid drill at work. Despite the injury, he finished his work day and drove home in a vehicle with standard transmission. The following day (day two) he was seen by his family physician who diagnosed a mild rotator cuff injury and suggested NSAIDs and ice.
At 0100 hours, early on Wednesday morning (day three, 36 hours post injury), the patient was awoken from sleep with severe pain in the right upper chest and mild shortness of breath. The patient recalled telling the paramedics (and all subsequent health care providers) that he "was having the big one." They documented "right shoulder pain with radiation to the chest" as the chief compliant. The vital signs were normal aside from a respiratory rate of 25.
On arrival at the emergency department of a community hospital at 0140 hours, the triage nurse elicited a history similar to that provided to the paramedics. The nurse noted the patient was anxious and mildly agitated, with normal vital signs except for mild systolic hypertension and a respiratory rate of 20. He was triaged to a non-monitored bed where he was seen promptly by the emergency physician.
The medical record, in its entirety, read as follows: "On Monday AM was lifting a patient onto a gurney and noted immediate pain right shoulder. Tonite pain a lot worse and breathing ?. O/E moaning ++++, looks a little pale, Tender over R upper chest, good air entry to lung apex, vitals satisfactory. Imp: right shoulder and upper chest pain NYD."
An analgesic and antiemetic were administered intramuscularly at 0205 hours. A shoulder and chest X-ray were read as normal. Nursing notes indicate that the emergency physician reassessed the patient at 0300 hours at which time he was still in distress. An intravenous dose of 10 mg of morphine was administered at 0315 hours.
At 0400 nursing notes indicate a second re-evaluation by the emergency physician at which time the patient was noted to be more comfortable albeit somewhat drowsy. He was discharged at 0415 with a sling and a prescription for oral analgesics. The patient complied with the instruction to see his family physician that morning. The family physician considered the possibility of septic arthritis. Appropriate blood work was ordered and a review of the chest X-ray by a radiologist suggested mild vascular redistribution and early consolidation in the lingula prompting the initiation of antibiotics for a possible pneumonia.
The following morning (Thursday) the patient was referred to an internist because of dyspnea and ongoing pain. The patient was admitted to hospital with a presumptive diagnosis of pneumonia.
An ECG ordered at the time of admission was not performed until the following morning (Friday), 54 hours after the initial emergency visit. The ECG showed qS complexes and ST elevation in V2 through V5, as well as poor R wave progression in the precordial leads, consistent with an anterior infarction of uncertain age.
Repeated blood work showed declining cardiac biomarkers. Due to the delay in diagnosis the patient was eligible for neither PCI (percutaneous coronary intervention) nor thrombolytic therapy. Angiography one week after admission showed a complete occlusion of his LAD (left anterior descending artery). Despite stenting, his clinical course over the next year was complicated by congestive heart failure with an ejection fraction of 35 per cent, recurrent ventricular arrhythmias requiring an ICD (implantable cardiac defibrillator), depression, marital discord, and unemployment.
The emergency physician contacted the CMPA shortly after the event with two concerns. Firstly, that he was "locked into a trauma mindset, and did not initially consider other diagnoses" and secondly, that it was not his usual practice to document reassessments. He was advised to consider adding a dated and timed addendum to the chart and to write a separate narrative. He did neither.
A legal action a year later named the emergency physician and the internist, but not the family physician. Both the defendants and the plaintiff were able to find experts in emergency medicine and cardiology supportive of their respective positions. The internist was dropped from the suit before the trial.
The report of the plaintiff's expert in emergency medicine made the following statements:
"In an otherwise healthy person, the sudden awakening with severe pain would indicate that serious pathology was present."
"In a narcotic naive patient inadequate relief from a reasonable dose of narcotic would prompt a thorough reassessment by a prudent physician."
At trial the physician's defence was compromised by the following line of questioning:
Q: "And with an atypical presentation of a heart attack the pain can occur anywhere in the chest, is that correct?"
A: "Yes, but I have never seen a patient who only had pain confined to the right shoulder and musculature."
Q: "Did you review the ambulance record?"
A: "No, I did not think it necessary."
Q: "Did you ask the patient about the radiation of the pain?"
A: "Yes, I recall it clearly."
Q: "And where is that recorded?"
A: "It is not recorded."
The court ruled in favour of the plaintiff, and the CMPA made a payment on behalf of the emergency physician member.
The judgment was notable in its brevity, clarity and frankness. It commented specifically on standard of care, the medical record and the credibility of witnesses.
The standard of care:
"I have found, as a fact, that the patient presented without chest pain."
"In this case the plaintiff's initial symptoms were wholly explained by his pre-existing shoulder injury. I find that the defendant was not negligent in making a preliminary diagnosis of shoulder pain secondary to injury."
"The defendant was negligent in failing to reconsider his diagnosis after the plaintiff did not respond predictably to narcotics. At this point he failed to formulate a differential diagnosis, evaluate risk factors, and avail himself of other sources of information."
The medical record:
"It seems patently obvious that an accurate and detailed emergency record is a benefit to the doctor in order to avoid relying solely on memory. In addition, it is an obvious benefit to the patient."
"The defendant explained the lack of notes by saying there are time constraints in the emergency department and there is insufficient room on the form to record all that occurred, as the plaintiff's expert stated, if such is the case then get another piece of paper."
The credibility of the plaintiff's emergency expert:
"He gave his evidence in a fair and objective manner and presented himself as a true expert whose role was to assist the court and not to defend his opinion at any cost."
The credibility of the other experts and the defendant physician:
"I place very little weight on their testimony as it was often overtly partisan and unconvincing. In addition, they were self-serving and less than objective in direct testimony and argumentative and confrontational during cross examination. . . ."
The credibility of the patient with respect to his assertion that he communicated his concern of a "heart attack" to all of his health care providers:
"I am unable to accept the evidence of the plaintiff as it cannot be reconciled with that of the other health professionals. . . ."
After reflecting carefully on both the case and the judgment, one should consider the following questions and observations when caring for patients:
Where indicated, has a reassessment been performed and documented?
Is it prudent to reformulate a differential diagnosis after an evaluation of the response to therapy?
Does the medical record capture both the temporal course of care, including reassessments, and the physician's progressive diagnostic reasoning?
A complete medical record is a powerful ally for both the patient and their physician.
Initially, it may not be entirely clear to a plaintiff (and his/her counsel) which physician(s) is/are responsible, and thus physicians are sometimes surprised to be named in a legal action. Many times, as the matter proceeds, peripheral physicians with limited involvement will be dropped from the suit.
A court does not unilaterally or arbitrarily determine a standard of care. The standard of care is determined by a physician's peers through the lens of expert testimony. Ultimately, the court must decide whose evidence is most compelling and credible.
In the eyes of the court, a credible expert should be knowledgeable, insightful and lastly, but importantly, impartial.