When a patient comes to an Emergency Room complaining of chest pain, the Emergency Physician is faced with complex and difficult decisions. Chest pain is a key issue in many medical malpractice actions, and is a facet in medical legal case evaluation that is poorly understood. The physician must decide whether a major diagnostic or therapeutic intervention should be used and then must decide whether the patient is to be admitted or sent home. choosing wrong may result in catastrophic consequences for the patient making the evaluation of chest pain on of the most challenging and studied presenting medical problems, from both the clinical and risk management point of view.
For attorneys involved in litigation concerning misdiagnosed chest pain, it is essential that the complexity of its evaluation be understood and appreciated.
Physicians work form a differential diagnosis by weighing the frequency of specific diagnoses in different patient groups, associating clinical findings with common illnesses, and applying available ancillary tests to diagnose and triage adults with acute chest pain. This process, however, is extremely difficult in a brief ER visit with limited access to historical information. The ERMD will attempt to quickly establish and document an adequate database, estimate the rusk of life-threatening disease, use history and physical examination to evaluate the risk analysis, determine the role and interpretation of available ancillary tests, and then document the reasoning viewed for clinical decisions regarding disposition of therapy.
Any patient who has unstable vital signs or who requires resuscitation should be promptly admitted to the critical care unit and the appropriate consultants should be accessed in a timely manner. Patients with "classic" presentations of life-threatening diseases such as acute myocardial infarction or dissecting thoracic aneurysms also require admission and immediate stabilization. Well-trained emergency physicians should not have any difficulty recognizing acute situations.
But how should the physician approach the patient with an atypical or confusing clinical picture and what should the criteria be for admission versus discharge? In general, patients who have clinical presentations clearly indicative of benign or non-life threatening diseases may be sent home. This would include, for example, a young patient with a mild, sharp chest pain which increases with deep breathing and movement who has no risk factors for pulmonary embolism or cardiac disease and has a normal electrocardiogram, chest x-ray and blood gas. This patient can be sent home even though a clear diagnosis may not be indentified in the ER. Of course, the patient must be instructed to follow up with his private MD sooner if worse, within 24-48 hours.
On the other hand, older patients whose chest pain increases with palpation of the chest wall may not only have benign chest wall pain particularly if their history, physical exam or ancillary studies suggest a cardiac or pulmonary problem. The same holds true for patients who have a history of stomach ulcers or esophageal reflux and who gain some relief with anti-ulcer/reflux medications. The physician should be careful no to overlook symptoms, signs or other clues which may point to an underlying co-existing cardiac or pulmonary life-threatening illness.
Physicians should not rely too heavily on the electrocardiograms or cardiac enzymes in the ER. The medical literature is replete with studies demonstrating prior acute AMIs in patients with normal electrocardiograms. This phenomena occurs in from 5% to 20% of patients depending upon the study. Cardiac enzymes may be normal in the emergency room too but become elevated hours later because elevated levels are not detected until 4 to 8 hours after the heart muscle is damaged. Therefore, a normal or non-diagnostic ECG and normal cardiac enzymes can not rule out acute cardiac disease or negate the decision to admit a patient with a possible AMI.
The quality and quantity of pain itself is highly variable and in some situations may be totally absent and yet an AMI be in progress. Blunted pain responses commonly seen with underlying chronic disease in elderly patients frequently mask AMI and can stear a complacent physician away from the true diagnosis. These patients may present with other symptoms and signs indicative of serious disease such as sweating at rest, increasing fatigue with less activity and shortness of breath. Physicians must maintain a high index of suspicion and entertain a full range of differential diagnosis when evaluating patients.
Other factors can complicate the decision making process such as the stoic patient with chest pain who wishes to leave the ER before receiving a complete evaluation. In this setting, it is important that the family be included in the evaluation so that all clinically relevant information is obtained. Enlisting the family's participation may also ensure that the patient does not leave the ER prematurely. But even if such a patient refuses admission and the physician is concerned about the possibility of serious disease, a compromise can be struck and the patient can be convinced to stay temporarily in the ER while repeated exams are performed and serial ECGs and cardiac enzymes are obtained thereby increasing the likelihood of detecting acute myocardial disease.
As you can see, the evaluation of chest pain is often highly subjective and imperfect. The differential diagnosis of chest pain alone (approximately 20 common and 15 not so common entities) is enough to dazzle and amaze any attorney as he/she strives to understand the facts of the case. It is no surprising that 20% of malpractice dollar losses by emergency physicians in the US involve the diagnosis and management of patients with acute chest pain.
The only way to make sense of any medical case, especially the complex one, is to have a knowledgeable physician review it and give you the medical insight and understanding you seek.
The physician should be an experienced, board-certified full-time practicing clinician who can review the medical records objectively without a particular bias for or against plaintiff or defendant physicians. This physician should also have substantial experience doing medical-legal case evaluation. The weaknesses and strengths of your case will be made clear to you and you will know whether the case should be dropped or litigated.
