Case Summary
This case involves a male who presented to the hospital for chest pain. The physician performed an EKG. However, the physician allegedly missed the evidence of acute anterior wall myocardial infarction. Serial troponin measurements were not performed. The physician misdiagnosed the patient with pericarditis.
The following day, the patient underwent open-heart surgery. During the surgery, the implementation of extracorporeal membrane oxygenation (ECMO) was used. This involves pumping blood outside of the body to a heart-lung machine that removes carbon dioxide and sends oxygen-filled blood back to tissues in the body. Blood flows from the right side of the heart to the membrane oxygenator in the heart-lung machine and then rewarmed and returned to the body. This method allows the blood to “bypass” the heart and lungs during surgery.
In this case, the patient’s inferior vena cava perforated. The patient developed a massive hemorrhage and died hours later. The autopsy and reread of the initial EKG confirmed a diagnosis of anterior wall heart attack that preceded the open-heart surgery.
Case Theory
The physician missed a diagnosis of myocardial infarction. The patient underwent unnecessary open-heart surgery that caused perforation of his inferior vena cava and death.
A heart attack or myocardial infarction is a dangerous event that occurs when normal blood flow into a section of the heart is suddenly blocked or disrupted, depriving the heart of oxygen. A properly diagnosed anterior wall heart attack has a survival rate of more than 30%. Many patients who physicians treat early recover favorably. The physician should have recognized the missed changes on the EKG.
Symptoms of a heart attack can differ from those of pericarditis. Heart attacks can come on suddenly or start slowly and progressively worsen over time. In pericarditis, chest discomfort generally occurs and subsides quickly.
Here, the failure to test serum troponin levels is far below the standard of care. Even a small elevation in troponin can indicate damage to the heart muscle. If the physician found high levels of troponin, the physician would have identified the heart attack, as nearly 100% of heart attack patients have an elevation of troponin within 12 hours. Physicians typically check troponin levels at regular intervals in all cardiac patients. Failure to do so here is a deviation from the standard of care.
Elevated cardiac-specific troponin levels may occur in pericarditis, in approximately 30% of cases. The failure to perform necessary testing, the misdiagnosis, and the unnecessary surgery, in this case, caused the death of this patient.
Expert Witness Q&A
- In patients who undergo open heart surgery, what responsibility do cardiothoracic surgeons have to order and review preoperative diagnostic testing such as EKG and troponin levels?
- What responsibility did the hospital have to ensure troponin levels were retested and additional EKG monitoring performed and read prior to surgery?
- What measures can the cardiothoracic surgery team perform to prevent inferior vena cava perforation during extracorporeal membrane oxygenation?
- Had the physician made the proper diagnosis, how would it have changed the patient’s prognosis?
- What are the symptoms of pericarditis and how do they differ from a heart attack?
- What was the proper course of treatment for this patient?
Expert Witness Involvement
Cardiothoracic Surgery
A cardiothoracic surgery expert can speak to the negligence in this case, including the perforation of the inferior vena cava and the failure to test and retest troponin levels as well as reread the EKG prior to surgery. The surgeon can estimate whether the patient received the proper medical care.
Emergency Room Physician
An emergency room physician can speak to the standard of care in the diagnosis of chest pain, reading of an EKG, and the violations of the standard of care.
About the author
Erin O'Brien
Erin O'Brien is a senior medico-legal writer and editor, with 25 years of experience authoring healthcare deliverables. Previously, Erin authored an award-winning column in the health and wellness sector, guest hosted a wellness radio show, and received an FMA Charlie Award for Excellence in Writing.
Erin has reviewed and completed case studies for thousands of medical malpractice cases, both plaintiff and defense nationwide, and was presented the US Chamber of Commerce Best Small Business Blue Ribbon designation. Erin is an experienced Medical Risk Consultant and device start-up project manager. She has consulted for numerous successful healthcare and bio-tech start-ups. After completing a Bachelor of Science degree at the University Of Wisconsin, Erin pursued an educational background in Healthcare Risk Management at the University of South Florida. Erin crafts her work with attention to detail, readability, healthcare marketing regulations, and medical standard of care.
