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Failure to confirm echo result leads to cardiac arrest.

SUDDEN ONSET OF CHEST PAIN radiating to the back, which had started during rest, brought a 49-year-old woman to the hospital. The patient also complained of pain radiating to her left jaw and ear, which became worse when she inhaled or moved. She had no shortness of breath, palpitations, diaphoresis, or history of trauma. She did have a history of gastroesophageal reflux disease (GERD), but said that the pain didn't resemble the pain of GERD. While in the triage area, she vomited.

Two electrocardiograms (EKGs) done in the emergency room showed sinus bradycardia and nonspecific T-wave abnormalities. A chest radiograph was reported as normal, but with a note of borderline heart enlargement and a tortuous aorta. A gastrointestinal (GI) cocktail of Nitropaste and Toradol didn't relieve the pain, nor did Ativan. No workup for aortic dissection was done.

After consultation with a doctor covering for the patient's primary care physician, the patient was hospitalized with orders for laboratory studies, a chest radiograph, and an EKG the next morning. The EKG again showed abnormalities, including a nonspecific T-wave abnormality, as did the chest radiograph (moderate cardiomegaly, tortuous aorta, mild prominence of the pulmonary vasculature without evidence of congestive failure, and small left pleural effusion or slight blunting of the left lateral costophrenic angle). But the radiograph wasn't compared to the one taken the night before. A GI consult--by which time the patient's hematocrit had dropped from 32 to 26--attributed the pain to GERD and recommended outpatient esophagogastroduodenoscopy.

The results of a routine echocardiogram--faxed to the patient's floor the same day--were worrisome: a dilated aortic root and ascending aorta accompanied by at least moderately severe aortic insufficiency and normal ventricular function.

The patient's primary care physician saw the patient and discharged her that evening. Fewer than 2 hours later, the patient suffered a cardiac arrest at home and couldn't be resuscitated after transport to the hospital. An autopsy found the cause of death to be cardiac tamponade resulting from dissection of an aortic aneurysm.

PLAINTIFF'S CLAIM: The patient shouldn't have been discharged without clarification of the echocardiogram results.

DOCTOR'S DEFENSE: The primary care physician's understanding was that the cardiologist had ruled out heart-related problems, including aortic dissection, and that the patient had been diagnosed with a stomach illness, which would be followed on an outpatient basis. Even if a diagnosis of aortic dissection had been made, the outcome would have been the same.

VERDICT: $560,000 Massachusetts settlement.

COMMENT: Inadequate follow-up of testing--in this case, an inpatient echocardiogram--can have catastrophic results. Before discharge, each inpatient test should be reviewed and adjudicated, and a clear plan for follow-up delineated.

COMMENTARY PROVIDED BY Jeffrey L, Susman, MD, Editor-in-Chief

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Title Annotation:WHAT'S THE VERDICT? Medical judgments and settlements
Author:Susman, Jeffrey L.
Publication:Journal of Family Practice
Geographic Code:1U1MA
Date:Jan 1, 2009
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