This month’s monster case involves a 60-year-old man who developed chest pain while at home with his wife. After his wife called 911, an ambulance brought the man to the emergency department, where he was seen promptly by the emergency physician. The patient complained of substernal burning chest pain and nausea. The symptoms started at rest and lasted about 30 minutes, but there was no shortness of breath or diaphoresis. The paramedics administered aspirin and nitroglycerin prior to the patient’s arrival, and he was pain-free once he reached the emergency department. The patient had a history of hypertension, but he was otherwise in good health. His vital signs and physical exam were unremarkable.

An ECG was performed within minutes of the patient’s arrival, and showed a sinus rhythm with no ST elevation and some slight nonspecific ST wave changes. His laboratory evaluation showed a normal CBC, CMP, and CXR. When he arrived in the ER, the patient’s initial troponin was 0.03.

The emergency physician was concerned about the patient and contacted the cardiologist on call to admit the patient. The emergency physician documented that the cardiologist advised him to discharge the patient and have the patient call the cardiologist’s office to get a stress test.

The patient was discharged, but never called the cardiologist’s office and suffered a cardiac arrest at home five days later. The coroner determined that the patient died of coronary artery disease and had an occluded LAD.

The patient’s family sued the cardiologist and the emergency physician.

In his deposition, the cardiologist claimed that he had never received a phone call from the emergency physician, and if he had, he would have ordered admission and further testing for the patient and would not have sent him home.

Defense counsel argued that the chart reflected the emergency physician’s discussion with the cardiologist, and that this documentation established that the discussion had occurred. The defense also argued that the emergency physician recommended admission and the patient left the hospital against medical advice. The contention was that the patient was also negligent for not returning to the hospital when he felt chest pains the next day.

The case went to trial. The jury found that the cardiologist was not negligent, the emergency physician was nearly 75% negligent, and the patient was approximately 25% negligent. The plaintiffs were awarded over $4,000,000, which was ultimately reduced to just over $3,000,000. This monster case demonstrates that an emergency physician can do just about everything correctly and still be found liable for millions of dollars.

Despite technological advances and specialized medical training, missed myocardial infarction remains the leading cause of high-dollar U.S. malpractice awards. In fact, missed MIs account for nearly 30 percent of all dollars paid out by emergency physicians. Correct diagnoses are complicated by the fact that chest pain is one of the most frequent complaints from adult emergency room patients. Furthermore, there are many more cardiac patients who present without chest pain, but with silent presentations of ischemia with general fatigue, dyspnea, abdominal pain, nausea, or vomiting instead. Pressured to avoid unnecessary admissions, emergency physicians only admit about one of every three or four patients with potential angina or myocardial infarction. Despite the fear of missing an MI, targeted education, and advanced testing, it’s estimated that emergency physicians still miss 2-6% of myocardial infarctions. This number has remained relatively constant over the past two decades and is similar to numbers seen in other developed countries.

To put this in perspective, if an emergency physician cares for about 2.5 patients per hour and works 1,600 hours/year, he/she will see 4,000 ED patients each year. Around 250-400 patients (5-8%) will have chest pain, 40 patients (1%) will have MIs, and he/she will, on average, discharge at least one and likely several patients with myocardial infarction ever year. These patients can have a 10-20% mortality rate.

In addition to the numbers and odds of missed myocardial infarction cases, we can learn several lessons from this case.

  1. Single troponins for short episodes are not always helpful if negative.
  2. Many patients tend to minimize symptoms and request to be discharged, yet the families are frequently the ones that sue. Therefore, communications with family members can be extremely important.
  3. Phone conversations between physicians are problematic.
  4. Discharge instructions are very important.

The most concerning aspect of this case was the telephone conversation. Over the past ten years, communication has changed dramatically, moving from emails to texts and from paper to electronic medical records. Nevertheless, telephone calls are still the most widely used communication tool between physicians.

Telephone conversations can be inherently problematic, particularly after hours. Most consulting physicians never record the occurrence of conversations with other physicians, let alone their content. Similarly, emergency physicians rarely document phone calls with consultants. In a medical malpractice case, this can lead to disagreements over the existence and content of a call. The use of verbal orders has been identified as a potential contributor to poor quality and medical errors. As a result, Joint Commission (2005), Institute of Medicine (2001), Leapfrog Group, and other organizations have recommended limiting or eliminating verbal orders altogether.

Discharge instructions and documentation of the patient’s understanding of those discharge instructions are also crucial. In medical malpractice cases involving missed myocardial infarction, the patient may have died and cannot testify in the case. Therefore, solid and consistent written documentation and the physician’s and nurse’s notes are critical in the defense of a medical malpractice claim.

Missed myocardial infarctions are inevitable even for the best physicians. Thorough and clear documentation is essential in the defense of medical malpractice cases.

The Monster Claim is the nightmare, $1,000,000 plus settlement or judgment (not including defense costs) that could happen to any unsuspecting physician or medical care provider. As in most cases in emergency medicine, it is a case of failure to suspect the diagnosis and involves a series of unfortunate events. We believe that it is important that all emergency providers become aware of these claims so they won’t repeat the same mistakes in the future.

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