In past issues, I have discussed the medical and legal issues surrounding aortic dissection and pulmonary emboli, but it's time to consider the malpractice issues of “the big one:” acute coronary syndromes and acute myocardial infarction.
Many members of the public consider chest pain and heart pain to be equivalent. I have treated countless patients who cannot believe that anything other than the heart could ever be the source of chest discomfort or pain, despite the fact that the majority of patients hospitalized for chest pain are never documented to have any organic cardiac disease.
This is clearly a major issue wherever one practices emergency medicine because approximately seven million annual visits to U.S. EDs are for chest pain. (National Ambulatory Care Survey: 1997 Emergency Department Summary: Advance Data from Vital and Health Statistics, No. 304, Hyattsville, MD. 1999.) Figures from a 1993 report of closed claims against emergency physicians indicated that eight percent of claims and 21 percent of total indemnity were related to chest pain (Ann Emerg Med 1993;22:553), though recent figures are generally higher.
At any rate, when dealing with an entity that accounts for 10 percent of claims and 30 percent of dollars paid out, this topic will require more than one installment to do it justice. Throw in the fact that patients are frequently in the prime of life (middle-aged male breadwinners), and the stakes for misdiagnosis and treatment errors are increased exponentially.
If ever defensive medicine is practiced in emergency medicine, it is for chest pain. One recent article detailed how physicians with a higher malpractice fear were more likely to order troponins and chest x-rays and more likely to hospitalize patients than physicians with a lower malpractice fear. (Ann Emerg Med 2005;46:525.) The malpractice fear was rated according to physician self-assessments: whether they were ordering tests or consultations with the thought they might be sued, whether they thought relying on clinical judgment as opposed to laboratory testing was risky, whether he feels pressured in the day-to-day practice of medicine by the threat of malpractice litigation, and concern about whether he will be involved in malpractice litigation sometime in the next 10 years.
In the evaluation of chest pain, it may be riskier to order laboratory tests than to order none at all. After all, one cannot rule out a myocardial infarction with one negative cardiac marker. Perhaps it is safer not to order any lab testing, and document from the history and physical alone that the patient does not have a cardiac etiology.
Those who would claim that any missed diagnosis of MI constitutes malpractice are, quite simply, wrong. A commonly quoted figure is that from two percent to three percent of acute MI patients in the United States are discharged home from the emergency department. (N Engl J Med 2000;342:1163.) Myocardial infarction has presented as abdominal pain, dizziness (whatever that is), shortness of breath, and abdominal pain. In one report, only 53 percent of patients subsequently shown to have sustained a myocardial infarction had chest pain as a chief complaint. (Ann Emerg Med 2002;40:180.) The authors in another report concluded that chest pain was an insensitive marker for myocardial infarction. (JAMA 2000;283:3223.) If so, then perhaps descriptions of pain are somewhat irrelevant as well.
The majority of patients hospitalized for chest pain are never found to have any organic cardiac disease
What Goes Wrong?
Whenever malpractice comes up, there are broad categories of things that can go wrong. The first is the failure to diagnose. It is difficult to imagine a case of chest pain in an adult in which the treating physician does not consider myocardial ischemia. When the chief complaint is alteration of mental status, generalized weakness, or abdominal pain, however, it is not infrequent that a cardiac work-up is not pursued or is considered only after other considerations take precedence.
In someone with history of stroke, claudication, or abdominal aortic aneurysm, it is safe to assume that his coronary arteries are at risk as well. In someone with prior MI, any listing of risk factors is pretty much irrelevant from a care perspective. Perhaps an EKG is misinterpreted or perhaps it is normal or nondiagnostic, and the emergency physician attached inappropriate significance to this.
Failure to provide treatment in a timely manner also can lead to a malpractice claim. There is a delay in giving thrombolytic therapy or a delay in getting the patient to the catheterization lab. The patient lives, with an ejection fraction of 20%, and has to quit his job as an electrician because he cannot walk across a room without becoming dyspneic.
Complications of treatment also lead to malpractice in some cases. The patient is given some sort of heparinization and thrombolysis, but develops an intracerebral hemorrhage. The patient lives, has a normal ejection fraction, and presents aphasic in a wheelchair in court.
Finally, reliance on aspects of the visit, history, or physical examination that provided a false sense of security can land a physician in court. Physicians may discharge a patient because he has no pain or felt better after some sort of GI cocktail. The patient may have pain when someone presses forcefully on his chest, and I have seen physicians diagnose musculoskeletal chest pain in patients after they pressed so hard they made me wince. The admitting attending also may not be convinced over the phone that the patient warrants hospitalization or intervention.
The Bottom Line
Although I have not touched on the use of cardiac markers yet, it is clear from the diagnosis of myocardial infarction that it takes time to rule out a myocardial infarction. Emergency physicians had better be good at giving their admitting attending and cardiology staff a good story to access observation or telemetry beds and the catheterization lab. Collectively, we have reduced missed MIs down to the low single digits. Whether it is feasible to lower this further is unclear.
What Goes Wrong? Malpractice Causes in MI
▪ Failure to Diagnose
▪ Failure to Provide Timely Treatment
▪ Complications of Treatment
▪ Reliance on History or Examination Provides False Sense of Security