Suggest: Broken Hearts and Broken Trust: The Devastating Consequences of Delayed Heart Attack Diagnosis
As leading legal consultants in the field of healthcare negligence, Discovery NP Legal Consultants understand the importance of prompt and accurate diagnosis when it comes to serious medical conditions like heart attacks.
Heart attack, also known as myocardial infarction (MI), is a condition in which the blood vessels of the heart become temporarily occluded, reducing the flow of oxygen-rich blood to the heart tissue, thereby risking death to the tissue. Obviously, it is a serious and clearly life-threatening condition that requires prompt diagnosis and treatment to prevent death.
However, diagnosing a heart attack is not always as easy as it may appear on the silver screen. It can be challenging, as the symptoms may be vague and nonspecific, and can mimic other conditions. Nevertheless, the healthcare team’s failure to recognize a heart attack can have serious consequences for the patient, including delayed treatment, preventable complications, and even death. Additionally, the consequences of misdiagnosis or diagnostic errors can be far reaching and deadly.
Liability of Healthcare Providers in Misdiagnosis or Delayed Diagnosis of Heart Attacks
Healthcare providers are expected to know what circumstances put a heart attack at the top of their list of possibilities, and when it should be ruled out, even when suspicion is low. When oversight by a diagnostician is caused by a careless approach or or reckless negligence in due diligence, the healthcare team should be held liable for those damages, and accountable for wrongful death. The professional liability involved with misreading cardiac imaging, poor ecg interpretation, and misunderstanding cardiac symptoms can be significant. Cardiac care and heart attack cases oftentimes involve mistreatment of cardiac risk factors and should be met with justice.
Knowing the Risk Factors
A reasonable and prudent healthcare provider–of virtually any specialty–is aware of the basic and common risk factors that play a role in the likelihood of a heart attack. This is a a matter of basic medical ethics and patient safety. These include:
- family history
- heart disease
- high blood pressure
- high cholesterol
When coupled with any symptoms (typical or atypical), heart attack should be high on the list of possibilities for any of these individuals, age notwithstanding.
Typical (and Atypical) Symptoms
It is the standard of care for healthcare providers in any setting–but especially in primary care, urgent care and emergency care settings–to be familiar with both the typical and atypical presentations of a heart attack. While chest pain is the classic hallmark symptom of a heart attack, you may be surprised to learn that not all patients experience chest pain, and some may have atypical symptoms. Other common symptoms–experienced with or without chest pain–may include NEW ONSET
- shortness of breath
- nausea or vomiting
- pain or discomfort in the jaw, neck, shoulder, or back
Clinicians should be aware of these symptoms and provide informed consent as well as consider the possibility of a heart attack in any patient presenting with these symptoms, especially in high risk patients.
Symptoms may be especially vague or atypical in the female or elderly population. And among young people– less than 40 years old– it is common, though not prudent, for healthcare providers to completely overlook or underestimate the possibility of a heart attack.
Understanding the Risk Factors for Heart Attack in Young Patients
When a young person has a heart attack, it is most generally the case that they have significant risk factors other than their age at play, so a thorough medical history is paramount in not missing this possibility.
In some states, young sufferers have the most to lose by way of economic damages if death or disability results (i.e. lost wages, loss of family wage earner etc.), so if the missed diagnosis can be traced to negligence, the healthcare provider is vulnerable to substantial liability.
Important Diagnostic Tests
Several diagnostic tools are available to help rule out or diagnose a heart attack:
- streess test
- electrocardiogram (ECG)
- blood tests
- cardiac catheterization
These tests can help identify changes in the heart’s electrical activity or detect markers of cardiac damage. Clinicians should be familiar with these diagnostic tools and use them appropriately to help diagnose a heart attack. Let’s break down just a few of these.
Also called an ECG, an electrocardiography is fast, affordable and readily available. There are very few excuses, then, for not performing one when an EKG machine is available.
An EKG can be thought of as a snapshot of multiple angles of the heart’s electrical activity taken simultaneously. Careful and skilled analysis of an EKG can reveal–among other things– disruptions in the electrical activity caused by dead or dying heart tissue ineffectively passing the signal along in the predicted pattern. This can give relatively precise information about the actual location of the suspected bloodflow blockage or damaged tissue in the heart.
Providers should never rely solely on the initial analysis given by the device itself, and should always have a provider, and–where facility policy requires it– a cardiology timely overread of the result to confirm its accuracy and completeness. Over-reliance on the EKG machine to think for the provider is not a defense for a case of a missed or delayed diagnosis of an MI. Both false negatives and false positives can occur.
A trial attorney taking a case of delayed diagnosis of an MI should not take the treating provider’s analysis for granted. They should consider hiring a specialized medical consultant that can independently analyze the sometimes subtly-positive results of any EKGs done and evaluate changes over time. Attorneys should be aware that not all nurse consultants are trained in, let alone proficient in this skill! This independent read can help exhonorate individual providers or identify any previously-unnamed potential defendants and can increase the value of the case.
Cardiac Blood Tests
Blood tests for heart attack include the measurements of Creatine Kinase (CK), Creatine Kinase MB (CKMB) and Troponin. CK and Troponin are released from the damaged heart muscle; however, CK can also originate from other organs, which is why CKMB, a more heart-specific measure is needed in concert with CK. The Troponin test is the most cardiac specific marker of the three; it only indicates cardiac injury. Therefore, a positive troponin level, especially a critical level, is highly reliable in identifying an actual MI in progress. In some circumstances, troponin can be measured and resulted at the bedside, or “point of care”.
These blood tests are drawn repeatedly at specific intervals per hospital protocols and standing orders to monitor for trends to determine if the levels are rising or falling, and at how high they peak if positive. Failure to order these simple, relatively fast, affordable, and reliable tests at the proper intervals to rule out cardiac involvement in a patient presenting with symptoms of an MI is breach in the standard of care. It goes without saying that ordering these tests and then failing to look at or respond to positive results may also lead to missteps in the differential diagnosis algorithm.
The value of the results of these blood tests and their clinical significance can be complicated to interpret, and require a trained eye, as there is complex interplay in the timing of their onset, peaking and duration of elevation. Legal nurse consultants or nurse practitioner consulting experts (NPCEs) who have extensive experience with cardiac patient populations can quickly interpret the implications of these tests in concert with the clinical presentation.
A negative EKG and blood tests does not put the patient experiencing “classic” chest pain “out of the woods”! In the presence of moderate suspicion, if an EKG is negative, then a scheduled stress test may be in order. Keeping the patient for observation inpatient vs sending them home is a matter of sound clinical judgment.
A stress test is a diagnostic tool, available both inpatient (they’re really not done inpatient, if anything would be a nuclear stress test at best or MUGA scan) and outpatient, used to rule out whether a patient has experienced, or is threatening a heart attack. If the electricity signals in the heart are not disrupted while the patient exercises on a treadmill, the healthcare provider can be more assured chest pain or related symptoms are not due to a diminished oxygen flow to the heart.
Failure to perform or order a stress test or referral for stress test, when it is indicated can put the healthcare provider at liability for damages resulting from a heart attack if the test would have been done by a reasonable and prudent provider.
A stress test is not advised on a patient that is potentially experiencing an active heart attack, as the exercise would increase the damand for oxygen and potentially lead to a worsening of the situation! Ordering a stress test for a patient with a positive EKG or certain positive blood tests, therefore, is not only negligent; it can be considered malpractice!
Because the algorithm for when a stress test is and is not a reasonable alternative to cardiac catheterization can be complex, a trial attorney can gain insight into whether the treating providers were reasonable by engaging a specialty medical consultant in the case review period.
If the patient’s testing is suggesting an active MI in progress, the patient should go to the cath lab as soon as possible. CMS HAS MANDATORY 90 mins door to balloon time) ,Also known as a “cardiac cath” or “angiogram”, cardiac catheterization is an imaging and treatment procedure used to diagnose and treat heart disease . The qualified interventional cardiologist inserts a long, thin tube called a catheter into a blood vessel in the arm or groin, and guides it up to the heart. Using dyes and radiography the anatomy of the blood vessels and their patency can be evaluated. During this procedure itself, the trained interventional cardiologist can perform life-saving interventions such as clearing blocked arteries with balloons and stents. There are risks to this invasive procedure, so it is not generally done unless there is extremely high clinical suspicion for coronary artery disease.
Considering the History of Present Illness (HPI)
In addition to knowing about and asking the patient about demographic and comorbidity risk factors and symptoms, healthcare providers have a duty to conduct a thorough history of present illness (HPI), which also provides important information that should clue the provider in to the possibility of a heart attack in progress.
A reasonable and prudent diagnostician knows to ask thorough questions to fully understand the nature of the presentation. Sometimes the patient doesn’t tell you until you ask the right question! Providers should be familiar with the PQRST method:
What Makes The Pain Worsen Or Get Better? (Precipitating/Palliative)
Red flags for a heart attack are pain that is worse with activity and better with rest.
What Is The Quality Of The Pain? (Qualities)
Pain that is described as “crushing”, “heavy”, or reported as “pressure” is suspicious. Burning or stabbing would point away from a heart attack as the culprit. Subjective descriptions using the phrase “it feels like an elephant sitting on my chest!” or similar, should always raise an eyebrow! Patients will often clench their fist and place it over their sternum when describing the pain associated with a heart attack. This unconscious sign is so common it even has a name: “Levine’s sign”. Observing this action in a patient should not be ignored!
Where Exactly Is This Chest Pain Located? (Region)
This question can produce insight because “chest pain that is “substernal” and potentially radiating to the arm or jaw should be more suspicious than “chest pain” that is in the clavicle area or on the side of the ribs.
How Bad Is It 0-10? (Severity)
This can vary depending on the person and their activity. However, over-reliance on this alone should be avoided. Low numbers should not be ignored in light of other telling characteristics listed, but high numbers should prompt a rule-out in and of themselves!
When Did It Start? (Timing)
Pain that has just started in the last few days or hours can be telling in light of other qualities that raise suspicion.
If a provider has thoroughly documented the responses to these probing questions in their documentation, and the evidence produced by the subjective responses push a heart attack way down the line on the differential, their thorough documentation may provide solid defensibility in the case of a missed heart attack. Even the best of us miss things; that doesn’t mean we are imprudent or unreasonable.
But…you sometimes don’t get answers to questions you never asked, and it is the healthcare provider’s duty, as part of the process of differential diagnosis, to collect a solid history of present illness including all these factors. Failure to do so puts them at liability if they go down the wrong differential path!
Finally, communication and collaboration among healthcare providers are essential for not missing a heart attack diagnosis. This is especially trough when there is interfacility transfer involved. Clinicians are responsible to work together to share information, coordinate care, and ensure that patients receive prompt and appropriate treatment. When labs are done at one facility, results should be communicated to the second; when medications are given in the field, those medications should be documented and communicated to the receiving facility. Failure to document or communicate leading to lapses in continuity of care can create deadly delays in treatment leading to damages up to and including wrongful death.
Depending on the standard of care for the setting and the provider’s specialty or level of education and training consultation with specialists, such as cardiologists or emergency medicine physicians, or transferring patients to a higher level of care may be in order, and providers who fail to activate or take advantage of these systems and resources are vulnerable to a medical negligence lawsuit.
Diagnosing a heart attack can be complex, and require some clinical judgement and critical thinking, to be sure. But despite what the opposing counsel’s testifying expert says, medicine is a science; not an art.
The algorithm for diagnosing an MI should be well-known by most diagnosticians–especially to cardiology, primary care, urgent care, and emergency room practitioners.
If your client suffered damages or death following a potentially delayed diagnosis of a heart attack or myocardial infarction (MI) that would have had a better outcome had it been detected sooner, you may have a strong case for medical negligence.
As medical malpractice trial attorney, your best chances of success in such a case is to engage a consultant who is intimately familiar with the risk factors, knows how to–not only recognize the symptoms, but also how to distinguish them from those of other conditions that can mimic an MI.
It is best if the consultant also has personal hands-on experience in ordering and evaluating results of diagnostic tests appropriately, gathering a complete and accurate patient’s medical history and history of present illness (including the PQRST assessment), and personally familiar with the standards of care and typical means of communications between providers and between departments.
Especially when you’re up against Big Medicine (aka the hospitals and their defense teams) it’s good to have all your ducks in a row! You’d better believe they have a medical consultant or ten up their sleeve… Find a legal nurse consultant or, ideally, a nurse practitioner consulting expert (NPCE) to help you: 1. know if you have a case and 2. win your case for your client if you do! Contact us today for more information.