This case involves a 70-year-old female that presented to the emergency room with a history of deep vein thrombosis. She complained of developing back, chest, and arm pain and numbness. Her physician discussed the high risk of the patient developing coronary artery disease. A CT scan was ordered to look for blood clots in the lungs. No blood clots were found, but calcification in the coronary arteries was found. No EKG or other testing was ordered and the patient was discharged. The patient suddenly died the next day with the autopsy revealing the cause of death as relating to coronary artery disease.
Question(s) For Expert Witness
- 1. How often do you see patients with this type of presentation?
- 2. In general, what are indications that an EKG or other testing needs to be performed?
Expert Witness Response E-006392
I am a certified emergency nurse with 29 years of continuous experience in the emergency room. My current practice setting is an accredited heart and cardiac center. As a full-time staff and charge nurse, I care for an average of 4 patients per shift who present with symptoms that may represent cardiac ischemia. I prepare patients who present with a variety of symptoms for emergent cardiac catheterization. As an emergency room nurse, I adhere to the standard of care to utilize a high index of suspicion for myocardial ischemia.
I frequently assess and care for patients who present with classic symptoms of myocardial ischemia. Back pain is known to be associated with myocardial ischemia dependent on the area of the heart being deprived of sufficient blood flow. Emergency nurses are taught in basic nursing education and in continuing education (such as the Advanced Cardiac Life Support Course) that chest, arm and/or back pain may signal a potential life threat in the form of inadequate perfusion to the heart muscle. The standard of care for anyone, especially a patient over the age of forty who presents with chest and/or other associated pain, is to advocate for the patient and pursue the physician for continuous cardiac and vital signs monitoring, obtain an EKG within 10 minutes of arrival, obtain and result in cardiac enzymes to include a Troponin I immediately, administer aspirin. and administer oxygen. The standard of care as set forth by professional organizations, such as the American Heart Association and Emergency Nurses Association, is to further observe and monitor the patient and to repeat cardiac enzymes after 90 minutes. Cardiac enzymes may be repeated in six to eight hours, versus 90 minutes, dependant upon the patient’s progression and diagnostic findings. The nurse has a duty to advocate for the patient and access the chain of command if the physician declines to provide the above orders. I have served as an expert in matters with patients similar to this woman.