When I was an intern early on in the Covid pandemic, the same thing happened at my hospital - cardiologists refused to take pts to the cath lab. It was okay for the ER doctors to go into the patients room, but god forbid the sacred cardiologist has to stand at the patients groin to do a procedure.
In their defense, it was a pretty bizarre presentation. Clear cut STEMI I'd still expect them to go to cath but there was a lot of ambiguity in this case.
I guess. You have an EKG showing an inferior STEMI, which is then corresponding with inferior wall motion abnormalities. A couple of months ago I had an elderly female patient who presented for diarrhea who ended up having a STEMI on her EKG (thank god the nurses decided to do one). Absolutely zero chest pain or dyspnea. Cardiac cath confirmed 100% occlusion. It happens. I feel like every ER doctor probably has a story like that if they’ve been practicing long enough. I hope you’re right, and that if she had chest pain they would have taken her right away.
Same. Also an intern in 19-20, and cardiologists, among other specialists, failed our patients and failed us. Thinking of the patients who coded off and on in the ED as their STEMI progressed because they had covid, or the post partum patients who continued to hemorrhage because they had covid, or the GIBs who died because they had covid. It was okay for us to be exposed, it was okay for us to bear witness to the cruelty put onto our patients by these negligent specialists, and it was okay for them to wash their hands of it in the name of the pandemic. I will never forget it, and I will never forgive them.
It’s a very real possibility that this was a falsely negative Covid PCR as well (it’s not well remembered how poorly sensitive the initial tests were, esp nasal swabs). Interpreting this case really requires knowledge of the locale (eg high prevalence such as NYC or somewhere like AZ)
I wonder why that was, specimen degradation while in transit to state labs? Different primers now for PCR? The "false negative viral swab" theory ties in so well to the influenza case from a few weeks ago about the guy who had a negative flu test but the PA decided it was probably a false negative when he actually had meningitis.
From the EP’s note, it seems the indication for obtaining the initial EKG on this patient was that “she was noted to be very tachycardic and irregular on the heart monitor”. I have a low threshold for obtaining an EKG, especially in an older patient, with unexplained tachycardia.
I knew it was a matter of time before a case like this would be litigated. In my shop cardiology would refuse to take patients to the catheter lab and 100% recommended thrombolytics. Interestingly neurosurgery would still take patients for procedure of large vessel occlusion strokes which is essentially a PCI of the brain. One could argue they are more rare than an interventional cardiologist. I, at the time, even proposed that we intubate the patient effectively cutting of the circuit which would reduce any airborne spread. This still didn’t satisfy cardiology. Sad. We were expected to where the same N95 for days and still see the known positive covid patients, but cardiology couldn’t even walk in the door let alone provide good patient care
I suspect there are a lot more cases like this out there. It will be very interesting to see how they're affected by the public health emergency laws that were put in place.
ICU got "gifted" some fancy ipad/ultrasounds from cardiology so that the ICU trainees could ECHO patients and real-time talk to cardiology/ICU consultant who could see images and probe placement.
Made me much better at my ECHO skills but also increased my COVID exposure 10 times...
I don’t understand the multiple points on the ekg being done for seemingly no reason, it says in the report she was tachycardic and had an irregular heart rate…
You're right, I searched the whole thing thinking about ischemic symptoms (chest pain, etc...) and didn't find any, but it was obviously due to the tachycardia. My mistake!
Maybe I glossed over this fact, but if the door to balloon time was going to be more than 90 minutes, why wasn’t thrombolytics considered? i’ve had success with this
Excellent point, I think it was probably because they weren't even convinced it was a STEMI despite the EKG showing STEMI. Clinical presentation was incongruent with the EKG. I think they had the capacity to get to cath lab in 90 minutes and just decided not too, and there was too much ambiguity to use thrombolytics.
Agree with the fact that it is unreasonable to get EKGs on everyone with general URI symptoms however, I suspect she was probably tachy (confirmed by initial EKG) in triage prompting the ED doc to order it even without complaints of chest pain. I would be hard pressed to NOT get a 12 lead in a geriatric patient with tachycardia, regardless of the complaint. Any information on the initial vitals?
Many hospitals were not prepared for the demand for PPE during the first years of the Covid pandemic, and I wouldn't be surprised if there was top-down pushback against doing unnecessary procedures because the facility didn't know when they'd get another shipment of masks, or where that shipment would come from. Necessary procedures are still necessary, but March 2020 was pure chaos in many places.
There was a lot of confusion then and wide variation from hospital to hospital... I supposed what is "necessary" can be up for debate, especially in unusual/edge cases like this.
PPE came from top down in many cases. I was given ONE N95 and expected to reuse this for months. Every time I went into a room with my worn out N95 I was at risk. Also cardiac cath requires more than a lone cardiologist and an
You've read the full documentation so I defer to your analysis, but I didn't get the sense the clinical team "was always going to take her to cath lab." To me (and my relatively uninformed opinion) that is actually the crux of whether this is malpractice. I read it as they would forego cath during admission with a positive COVID-19 test because that would push them to a diagnosis of myocarditis and there would be no clear indication/benefit to catheterization during her infection (right?). As you said, especially given the context, I do not think that would be negligent.
If the plan was always to cath her the day after the test came back regardless of the result, and the test was just to determine the level of PPE, then I think it was negligent to wait because in this case the test result is not actually changing clinical management and they are saying that *medically* she shouldn't be waiting 4 days to be cathed. If the test result was key to the decision of cath vs no cath, then I think it was reasonable to wait for the results, given the situation.
My understanding was that they were going to cath her even if it was actually viral myocarditis. It seems like most patients with severe myocarditis do end up going to cath just to make sure there's also not an element of ischemia contributing, but I'm not sure what cardiology guidelines there are for that scenario or what the actual practice patterns are.
One thing I’m a bit curious about: what real damages are even available? Refusing intervention for severe AS with mod MS and MR, she’s a dead woman walking (and quite possibly that was the actual precipitating cause of death as pointed out on Meddit).
Early COVID was horrible. We weren’t “allowed” to test patients at one hospital unless there were certain symptoms and documented exposure to a documented case. This obviously changed.
Hospitals tried to forbid masks in hospital staff. I wore one anyway. Then this changed and we were required to mask up. We were each given an N95 mask and a paper bag. We had to reuse this for months on end. At one point I had a plastic garbage bag on my head- jury rigged PPE. I bought a PAPR early on.
I watched multiple people- staff at the hospitals fall ill. There were 2 people per 1 person icu room. There were patients all over the hospital- there were new ICU’s set up in PACU’s. Resources were rerouted to critically ill patients. Staff was short everywhere.
I remember walking into one room- that had been a single room- and practically had to crawl over the second bed that had been crammed in there. It was at a weird angle so that it would fit.
I had privileges at 3 hospital systems and was actively taking call at multiple hospitals within 2 of those hospital systems.
Staff was very short and with PACUs full and resources redirected… medicine was practiced differently. It was *impossible* for hospitals to run as they had during non COVID times. This is why there’s some amount of lawsuit immunity. Otherwise there would be lawsuit after lawsuit.
When I was an intern early on in the Covid pandemic, the same thing happened at my hospital - cardiologists refused to take pts to the cath lab. It was okay for the ER doctors to go into the patients room, but god forbid the sacred cardiologist has to stand at the patients groin to do a procedure.
In their defense, it was a pretty bizarre presentation. Clear cut STEMI I'd still expect them to go to cath but there was a lot of ambiguity in this case.
I guess. You have an EKG showing an inferior STEMI, which is then corresponding with inferior wall motion abnormalities. A couple of months ago I had an elderly female patient who presented for diarrhea who ended up having a STEMI on her EKG (thank god the nurses decided to do one). Absolutely zero chest pain or dyspnea. Cardiac cath confirmed 100% occlusion. It happens. I feel like every ER doctor probably has a story like that if they’ve been practicing long enough. I hope you’re right, and that if she had chest pain they would have taken her right away.
Same. Also an intern in 19-20, and cardiologists, among other specialists, failed our patients and failed us. Thinking of the patients who coded off and on in the ED as their STEMI progressed because they had covid, or the post partum patients who continued to hemorrhage because they had covid, or the GIBs who died because they had covid. It was okay for us to be exposed, it was okay for us to bear witness to the cruelty put onto our patients by these negligent specialists, and it was okay for them to wash their hands of it in the name of the pandemic. I will never forget it, and I will never forgive them.
It’s a very real possibility that this was a falsely negative Covid PCR as well (it’s not well remembered how poorly sensitive the initial tests were, esp nasal swabs). Interpreting this case really requires knowledge of the locale (eg high prevalence such as NYC or somewhere like AZ)
it is also true that poor collection technique is often the reason for false negatives. It is true today but more so at the start of the pandemic.
Excellent point. The earliest tests were a disaster compared to what we have now.
I wonder why that was, specimen degradation while in transit to state labs? Different primers now for PCR? The "false negative viral swab" theory ties in so well to the influenza case from a few weeks ago about the guy who had a negative flu test but the PA decided it was probably a false negative when he actually had meningitis.
From the EP’s note, it seems the indication for obtaining the initial EKG on this patient was that “she was noted to be very tachycardic and irregular on the heart monitor”. I have a low threshold for obtaining an EKG, especially in an older patient, with unexplained tachycardia.
You're right, I don't know what I was thinking when I wrote that.
I knew it was a matter of time before a case like this would be litigated. In my shop cardiology would refuse to take patients to the catheter lab and 100% recommended thrombolytics. Interestingly neurosurgery would still take patients for procedure of large vessel occlusion strokes which is essentially a PCI of the brain. One could argue they are more rare than an interventional cardiologist. I, at the time, even proposed that we intubate the patient effectively cutting of the circuit which would reduce any airborne spread. This still didn’t satisfy cardiology. Sad. We were expected to where the same N95 for days and still see the known positive covid patients, but cardiology couldn’t even walk in the door let alone provide good patient care
I suspect there are a lot more cases like this out there. It will be very interesting to see how they're affected by the public health emergency laws that were put in place.
Always loved the “We can’t go in, but we can totally send in echo to sit in the patients face.”
Early covid was definitely whack, but if the O2 requirements didn’t go up, probably not a false negative just based on my own experiences.
ICU got "gifted" some fancy ipad/ultrasounds from cardiology so that the ICU trainees could ECHO patients and real-time talk to cardiology/ICU consultant who could see images and probe placement.
Made me much better at my ECHO skills but also increased my COVID exposure 10 times...
I don’t understand the multiple points on the ekg being done for seemingly no reason, it says in the report she was tachycardic and had an irregular heart rate…
You're right, I searched the whole thing thinking about ischemic symptoms (chest pain, etc...) and didn't find any, but it was obviously due to the tachycardia. My mistake!
Maybe I glossed over this fact, but if the door to balloon time was going to be more than 90 minutes, why wasn’t thrombolytics considered? i’ve had success with this
Excellent point, I think it was probably because they weren't even convinced it was a STEMI despite the EKG showing STEMI. Clinical presentation was incongruent with the EKG. I think they had the capacity to get to cath lab in 90 minutes and just decided not too, and there was too much ambiguity to use thrombolytics.
Agree with the fact that it is unreasonable to get EKGs on everyone with general URI symptoms however, I suspect she was probably tachy (confirmed by initial EKG) in triage prompting the ED doc to order it even without complaints of chest pain. I would be hard pressed to NOT get a 12 lead in a geriatric patient with tachycardia, regardless of the complaint. Any information on the initial vitals?
Yep, you're totally right. The court records didn't include sets of vitals beyond what is mentioned here.
Many hospitals were not prepared for the demand for PPE during the first years of the Covid pandemic, and I wouldn't be surprised if there was top-down pushback against doing unnecessary procedures because the facility didn't know when they'd get another shipment of masks, or where that shipment would come from. Necessary procedures are still necessary, but March 2020 was pure chaos in many places.
There was a lot of confusion then and wide variation from hospital to hospital... I supposed what is "necessary" can be up for debate, especially in unusual/edge cases like this.
PPE came from top down in many cases. I was given ONE N95 and expected to reuse this for months. Every time I went into a room with my worn out N95 I was at risk. Also cardiac cath requires more than a lone cardiologist and an
IR suite. Other staff was stretched thin.
You've read the full documentation so I defer to your analysis, but I didn't get the sense the clinical team "was always going to take her to cath lab." To me (and my relatively uninformed opinion) that is actually the crux of whether this is malpractice. I read it as they would forego cath during admission with a positive COVID-19 test because that would push them to a diagnosis of myocarditis and there would be no clear indication/benefit to catheterization during her infection (right?). As you said, especially given the context, I do not think that would be negligent.
If the plan was always to cath her the day after the test came back regardless of the result, and the test was just to determine the level of PPE, then I think it was negligent to wait because in this case the test result is not actually changing clinical management and they are saying that *medically* she shouldn't be waiting 4 days to be cathed. If the test result was key to the decision of cath vs no cath, then I think it was reasonable to wait for the results, given the situation.
My understanding was that they were going to cath her even if it was actually viral myocarditis. It seems like most patients with severe myocarditis do end up going to cath just to make sure there's also not an element of ischemia contributing, but I'm not sure what cardiology guidelines there are for that scenario or what the actual practice patterns are.
One thing I’m a bit curious about: what real damages are even available? Refusing intervention for severe AS with mod MS and MR, she’s a dead woman walking (and quite possibly that was the actual precipitating cause of death as pointed out on Meddit).
Early COVID was horrible. We weren’t “allowed” to test patients at one hospital unless there were certain symptoms and documented exposure to a documented case. This obviously changed.
Hospitals tried to forbid masks in hospital staff. I wore one anyway. Then this changed and we were required to mask up. We were each given an N95 mask and a paper bag. We had to reuse this for months on end. At one point I had a plastic garbage bag on my head- jury rigged PPE. I bought a PAPR early on.
I watched multiple people- staff at the hospitals fall ill. There were 2 people per 1 person icu room. There were patients all over the hospital- there were new ICU’s set up in PACU’s. Resources were rerouted to critically ill patients. Staff was short everywhere.
I remember walking into one room- that had been a single room- and practically had to crawl over the second bed that had been crammed in there. It was at a weird angle so that it would fit.
I had privileges at 3 hospital systems and was actively taking call at multiple hospitals within 2 of those hospital systems.
Staff was very short and with PACUs full and resources redirected… medicine was practiced differently. It was *impossible* for hospitals to run as they had during non COVID times. This is why there’s some amount of lawsuit immunity. Otherwise there would be lawsuit after lawsuit.