There but for the grace of god went I

In yesterdays paper on the front page was a story about how a court had recently given a $900,000 settlement against a general practitioner who had "missed a heart attack".

According to the paper, the patient, a 45 year old smoker, arrived in the ER at a small country hospital clutching his chest, sweaty etc. He was, curiously, not however complaining of chest pain. The EKG was normal. The paper didn't say what blood work was done, or for that matter what bloodwork would have been available on a STAT basis in that hospital at that time of the day.

The GP examined the patient, asked the appropriate questions and admitted the patient to hospital overnight, asking the nurses to observe for any chest pain. The patient had no further chest pain overnight; however in the am, the cardiogram showed that sometime between admission to hospital and the morning, the patient had had an infarct which was now too late for thrombolyis, assuming it was available at that hospital.

The court presumbably acting on the testimony of experts found that this was negligent and assessed damages of $900K to the patient who is now a cardiac cripple. (Of course I would suspect in a smoker who has ischemic heart disease in the 40s it is merely a question of when he becomes a cardiac cripple, nothwithstanding the fact that the odd patient stops smoking, modifies his lifestyle and runs marathons.)


Here's where I started thinking there but for the grace of god....

I was in general practice for 3 years and did a great deal of call during that time. It was not unusual for patients to present with chest pain and a normal EKG. Depending on where you worked you could or could not get cardiac enzymes on a STAT basis. So if we were really suspicious we did what this poor GP did, we admitted them to hospital, asked the nurses to watch for chest pain, get a EKG if they had chest pain and we got an EKG in the morning. Now EKGs were usually sent out to be read by a cardiologist which meant that when you missed something, if you were lucky the cardiologist phoned you; usually you got a dictated report a week later. I know I sent at least one patient home with what proved to be an inferior MI, another patient had been transferred to a different hospital by the time I got the report.

Part of my anaesthetic training involved 6 months of internal medicine during which time I was on call for cardiology consults in the ER. I know for a fact that on at least one occasion the cardiologist and I sent a patient home with what proved to be a MI. There may have been other cases that we never found out about. On another occasion, we did just what the GP did; admitted the patient to the CCU for observation, did a EKG in the morning which showed a completed infarct that it was too late to do anything about. (Worse for me,this was the father of a staff anaesthesiologist who I really liked.)

Further, EKGs are notoriously hard to read. Inferior MIs can be missed easily, in addition anterior MIs frequently present with what we can "poor R wave progression" which unless you have an old EKG to compare it with you may miss. I remember as a resident standing in the ER with a very competent internist trying to figure out whether the EKG we were looking at showed poor R-wave progression in which case we needed to give a thrombolytic which is not an innocuous therapy. Fortunately we decided that was what he had, we gave the thrombolytic, he did well and cardiac cath did show a critical lesion.

Of course the other factor in this case was that the GP in question had been on call by himself for the previous 3 weeks and according to the paper, working from 0800 to 2100 (not including the innevitable night visits and phone calls).