Lack of Monitoring Results in Permanent Cardiac Injury


Emergency Medicine Expert WitnessIn this case, the plaintiff from Minnesota drove himself to the ER with complaints of pain brought on by physical activity. The emergency room doctor had administered a test which was indicative of insufficient blood flow to the heart. The treating physician then ordered a cardiac monitor, as well as additional tests. These initial tests appeared to be normal. The patient was placed on a heart monitor, however the monitor was disconnected for some period of time during the patient’s admission, despite continuous cardiac monitoring being advised for his condition. Subsequent tests showed alarming findings, however the treating physician was not made aware of these findings. Another test revealed an acute heart attack. The patient ultimately survived, but was left with diminished cardiac function.

Question(s) For Expert Witness

  • 1. What is the normal work up for the complaints the patient in this case presented with?
  • 2. What is the standard of care for a patient with suspected MI?
  • 3. Could the outcome have been different had the patient's MI been diagnosed sooner?

Expert Witness Response E-000615

The usual workup for a patient like this is an electrocardiogram upon arrival, complete blood count (CBC), metabolic panel, portable chest x-ray, IV access and placement on a telemetry monitor. Depending on the history, pain control is indicated, sometimes with nitroglycerine. If the first set of enzymes and electrocardiogram are normal, a second set is done 90 minutes to up to eight hours later, depending on local protocol. If an MI is suspected, the above work up is initiated, nitroglycerin is administered, unless otherwise contraindicated, and heparin or lovenox is administered. If there is a strong suspicion for acute MI, the cath lab team is called, then the cardiologist, for evaluation in the cath lab. As for outcome, if he presented with symptoms that were over four hours old, the outcome may not have been different. I would defer to a cardiologist as to any different outcome if the MI were diagnosed earlier.

Expert Witness Response E-000754

It’s not clear in this synopsis what time intervals occurred between the initial and repeat cardiac markers. Use of TNK rather than PCI (interventional angioplasty) may be site and resource dependent. The radiologic comment of an LAD occlusion is unusual from a CT scan that was probably done to r/o alternative diagnoses. A male with the listed comorbidities would unfortunately have reduced cardiac function with an AMI of any duration. Based on this synopsis and my comments, I sense adherence to the usual SOC for an emergency physician.

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