Sixty-seven year old patient presents to hospital for elective EGD. Patient was seen and examined prior to the procedure and she was noted to be short of breath, in mild distress and not completing her sentences. According to GI MD note, patient's heart rate was 80 -90 with BP variable between SBP 80-110. Anesthesia MD charted that upon positioning patient on bed prior to induction, patient became bradycardic, hypotensive, pale and diaphoretic with chest tightness. The case was immediately cancelled and a stat ECG was obtained at 1048. The ECG showed acute anterolateral infarct (LAD) and noted to be STEMI.
GI MD orders a routine consult with cardiology at 1059. A second ECG is obtained at 1126 and has a computer interpretation of "consider anterior infarct". It was subsequently interpreted by ED MD to be NSTEMI.
Rapid response is called at 1130 and informed of patient's chest pain and "abnormal EKG". Since the patient was an outpatient, Rapid Response advised GI staff to transfer patient to ED as they noted it would "provide faster MD evaluation, admission, cardiology consult and cath lab intervention if needed versus a direct admit".
Patient arrives in ED at 1154. At the time of her arrival to the ED, patient was not complaining of chest pain but did feel short of breath. A chest X-ray was completed at 1215 and the differential diagnosis on the x-ray report included mild pulmonary edema and viral infection. At 1243 an elevated troponin was called to ED by the lab. A CT chest was completed at 1300 and demonstrated interstitial edema and small left and moderate right pleural effusions.
ED MD discussed the test results with the patient and her husband at 1340 and planned to start lovenox for NSTEMI. His impression was NSTEMI and community acquired pneumonia. At 1346 he admitted the patient to inpatient telemetry unit through the hospitalist APRN. The APRN entered another order for a cardiology consult at 1410 and it appears the cardiologist and his APRN became involved shortly thereafter since they ordered a stat echo at 1423. The echo was completed at 1509 and showed akinesis and hypokinesis of the anterior myocardium.
The cardiology consult timed at 1458 reflects that the patient had some chest pain and had a respiratory rate of 40. She was unable to complete a full review of symptoms due to her difficulty breathing. She was subsequently transferred to the cath lab at 1541. Upon arrival she was in severe respiratory distress and she was intubated at 1554. However, she went into PEA arrest at 1601 and passed away at 1618.
Summary of pertinent Timeline:
Time from GI MD's order for routine cardiology consult to time seen by cardiology: @3 1/2 hours
Time from initial ECG in GI lab showing STEMI to patient in cath lab: @5 hours
Questions:
Did the standard of care require the GI MD to contact cardiology immediately based upon the initial EKG showing STEMI and the patient's clinical deterioration in the GI lab?
Did the standard of care require the GI MD to enter a stat order for cardiology?
If GI MD did have such responsibilities, did her breaches of the standard of care more likely than not contribute to the delay in treatment?
Please note that GI MD did receive preop clearance from cardiology.
Files:
No questions yet!
Do you believe there might have been medical error?
Upon seeing an ECG showing acute MI the cardiologist should have been immediately called within 5 minutes, and. STAT consult ordered. Then it’s up to them how quickly to act. This was likely a preventable death.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The patient should have been transported to the ER or cath lab within minutes, not hours. This delay very likely caused injury via ongoing MI.
What makes you a good expert for this case?
GI practice for 26 years, 25,000 endoscopic procedures, work in close conjunction with cardiologists, surgeons etc.
How often do you encounter cases similar to this one in your practice?
We get pre-endoscopic cardiology risk evaluations daily, and sometimes run into unstable situations like this. I have the cardiologist on speed dial for such cases.
Do you believe there might have been medical error?
It appears standards of cares were followed by the providers with the information they had at the time of making decisions.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It is difficult to establish causality from non-specific and changing signs and symptoms.
What makes you a good expert for this case?
Gastroenterologist x 9 years practicing in outpatient and inpatient setting with anesthesia providers providing sedation.
How often do you encounter cases similar to this one in your practice?
Rarely have I encountered acute coronary syndrome in the setting of outpatient endoscopy.
Do you believe there might have been medical error?
The GI MD contacted cardiology within 11 minutes of the ECG being obtained. Of critical importance here is what exactly is meant by "routine consult"? Different hospitals/institutions have different consultation request mechanisms/formats. So for instance, if there was a page from GI MD stating "Hi, we have a 67 yr old pt in GI with chest tightness, diaphoresis, bradycardia, and ECG concerning for acute MI", then potentially regardless of how the page is ordered/sent (routine vs. urgent vs. stat), the essential information is there, and it's incumbent on cardiology to act on the result ASAP. But if there was simply a page saying "Please contact GI" and it was sent/ordered as routine, then this would be insufficient less it was followed up by something additional, e.g. a direct phone call to the cardiology MD on call. To the GI MD's defense (whether it's valid or not is ostensibly a separate matter), care was transferred to the ED 66 minutes after the initial ECG. From this point onward, it's the ED provider's responsibility to request/follow up on consultations, tests, etc, not to mention this was recommended by the rapid response team (follow up with cardiology, cath lab, etc.)...though on the other hand could say that GI MD (or someone) had the responsibility to convey this to the ED team. Another mitigating/important aspect here is that the ED MD's "impression was NSTEMI", which essentially was a misdiagnosis that ended up costing time.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The delays in cardiology evaluation led to ongoing, undermanaged acute MI, and the time to intervention was unacceptably long, with ample evidence ([initial] ECG, symptoms, etc.) suggesting it needed to occur sooner.
What makes you a good expert for this case?
I'm the director of endoscopy at my institution, Professor of Clinical Medicine, work closely with anesthesia, ED, and other services to manage and guide the care of outpatients and inpatients with considerably chronic morbidity as well as acute illness. I'm also familiar with the standard of care at numerous institutions in the US, having worked/trained all around the country.
How often do you encounter cases similar to this one in your practice?
Acute MI prior to starting EGD? Perhaps once per year. But dyspnea or chest discomfort or bradycardia prior to EGD, considerably more often.
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