where i trained, the heart score was followed pretty closely. this guy would have been admitted most likely. where im at right now, heart score of 4 with 2x neg trops and assuming the EKG was read correctly and was actually stone cold NSR, this would have been a tough sell to IM to admit and i know my colleagues would likely dc this.
When I was a resident, basically all chest pain no matter what went to a chest pain obs unit. Very few exceptions. Now I send almost all chest pain home. How I take care of trop/EKG negative chest pain is the biggest change I've seen in my 6 years out of residency.
I practiced in a community emergency department about 45,000 visits or less. I’ve been using the hard score and now favor the heart pathway score when evaluating adults with chest pain. Depending on the score you can use the regular heart score which seems to favor discharge versus the heart pathway and that when it’s for higher, they recommend observation and further evaluation. When I calculate the heart score pathway score on MDCalc there’s a function if you get yourself registered for free you can cut and paste it which I do into the EMR. Then quickly dictate a reason if the patient’s heart score is four or higher that either recommended admission or we discussed the risk and benefits, and the patient made the decision with medical decision capacity to go home watch for the following signs and symptoms and ensure appropriate follow up.
At least where I practice (urban academic center) standard of care in 2016 would have been to admit a HEART score of 4 (and this would also be consistent with the HEART pathway). Now we have hsTroponin, which has massively changed that practice. It's too bad there wasn't a detailed breakdown of the HEART score in this case because one of my biggest criticism was always that the history component is pretty subjective and can make a big difference in dispo. Based on what is included here I'd call this patient at most a 1 for history, so if the plaintiffs were calling it a 2 that could be the difference between discharge and admission based on the published HEART pathway.
Yes, I've noticed the same. History is very subjective. I think at some point I'm going to find a lawsuit in which the main crux is "you miscalculated the HEART score, they were a 4, not a 3".
The ED doctor correctly listed the differential diagnoses (AMI, CHF/pulmonary edema, costochondritis, hyperventilation, and musculoskeletal pain) and performed the appropriate tests (troponin I, d-dimer, chest x-ray, and EKG) to arrive at the correct diagnosis using the differential diagnosis method.
Thus, the Standard of Care was met.
The plaintiff needed to prove that the physician failed to diagnose the case.
The only way to do this is through the HEART Score.
Based on the data provided, the patient had a HEART Score of 4, as indicated by the history, age, and risk factors outlined in the plaintiff's MD opinion. Achieving this score requires a "highly suspicious" history of ACS or having "≥3 risk factors or a history of atherosclerotic disease." Given that the other scores are negative, this patient is considered medium risk.
According to the HEART Score study results, this patient should have been admitted to the hospital. The study itself recommends this course of action.
I've seen multiple reputable lectures stating that a single high sensitivity trop is adequate if the patient has had consistent pain for more than six hours.
I think admission strictly based on HEART score is going to be somewhat resource dependent. I work in a rural, critical access hospital. We can't perform stress tests or CT coronary testing in our hospital. Strictly following that pathway would mean a lot of transfers to the closest urban center, about 2 hrs away. This would create a huge strain on resources and significant cost for the patient. I'd I'm genuinely worried about the presentation I'll do it but it's not common.
I wish we knew how long this patient had been having chest pain. Not clear if it was 3 hours or 6 hours or 24+. I can definitely see how patients wouldn't want to be transferred 2 hours away (not to mention how long it will take for the bed to become available). Although if you're that far out, maybe the argument would be to just transfer anyway because it doesnt sound like anyone in your community is going to be doing a stress test at any point in the next few weeks. I think the challenge for us is if we just use our best judgment and tell them to follow-up with cards, or if we officially recommend 2 hour transfer knowing full well that 80%+ will sign out AMA and leave.
ACEP supports single high sensitive troponin for low risk chest pain. Technically this patient wasn’t low risk with heart score 4. Also possible as well if the ischemic event was already over and the troponin had already peaked. No test is perfect, so we aren’t perfect. I would think discussing with cardiology would have strengthened the case.
I haven't made a habit of quoting ACEP guidelines in my MDM, but maybe I should. I think consulting cards would have taken some heat off the EM doc but likely would not have prevented the lawsuit, maybe would have resulted in an even higher settlement as there was more insurance money to go after (I don't have good insight into the way these settlement negotiations work).
Also for the autopsy report I would want to know who did the autopsy. The careful examination of the coronaries needed to conclusively exclude MI, while not *that* hard, is not a trivial task. Was this autopsy performed by a forensic pathologist? A seasoned hospital autopsy pathologist or a surgical pathologist who has to cover the occasional autopsy? My guess is given he was found dead in his car a forensic autopsy was performed but it definitely depends on the jurisdiction and is by no means guaranteed if they were found in a locked car and it was known they were just at the ED for chest pain.
Excellent point... not all autopsies are done to the same standard! I wish attorneys would at least put in a one sentence blurb about the autopsy, but just like EKGs, they often gloss over it in such a superficial that you can't draw any honest conclusions.
Who did it also would potentially change the top line cause of death even when reaching the same conclusion. This is more of a pathologist vs non pathologist issue (again in some jurisdictions, the autopsy may not even be done by a pathologist), but “cardiopulmonary arrest” which I see VERY frequently as the cause of death in death notes at my hospital is NOT a cause of death. It is the state of being dead. Something has to cause the cardiopulmonary arrest. An arrhythmia can happen spontaneously, or as you said, could be secondary to infarction or even just ischemia. Was it an arrhythmia with clean as a whistle coronaries or were 4 vessels 95% occluded?
Always get at least two trops (much easier now with high sensitivity). For us, dispo depends on availability of outpatient follow up. Assuming this patient does not have a cardiologist, would likely admit as follow up in my area is difficult to obtain and therefore outpatient workup may not happen for weeks to months.
Do you have any hard and fast lines in the sand for follow-up? Example: If cards can see them in 7 days, then they schedule a stress test that will be in another 1-14 days depending on when patient is free to do it, is that fast enough?
I've thought about it but never pulled the trigger. I feel like I'm a better writer than a speaker. What would be a good format to try if I did it? Just discussing each case would be the easiest for me.
I wouldn't repeat troponins to make a decision. If the pain has been going on or happened several hours ago then repeating won't change anything as stated by the defendent's expert witness. If the story is concerning I will admit someone regardless of their heart score. If it is borderline and their testing is negative, I will inform the patient of everything and let them decide what they want to do offering them admission. In addition I set up outpatient followup if they don't have it with instructions to followup within the next 24-48h. Would you think that having a thorough conversation informing the pt and family and documenting everything would help justify a discharge if they ultimately elect to go home?
It could help justify the discharge in real time but unfortunately I do not think it will stop a lawsuit. If you send them home and they die, even if they understood the risk and made an informed decision, you're still going to get sued. Sad nature of the medicolegal world in which we work. FWIW I think its definitely worth getting the repeat trop, especially if using older trop assays (not the high sens).
Where can I find public records of medical malpractice suits online like this one? I assume they are exhibits from court cases, but I can't seem to find how to access them on any court websites. Can you point me in the right direction?
Its honestly a nightmare to find them... I mostly get tips now but I have to have at least a name of one of the parties and jurisdiction to even check, some courts don't even have records online and you have to ask the clerk to mail you records, etc... There's really not a central database you can search.
As far as I’m aware, the sensitivity and specificity of stress tests is actually rather poor.
I usually consider other factors, like has this pt ever had a cardiac work up before , how often do they come to the ER, etc. I discharge most pts with negative trops and unchanged ekg regardless of heart score, but sometimes I make exceptions If story sounds quite concerning and they’ve never had a cardiac work up.
It’s hard for me to know what I would have done just based on the info provided. Often times I get a gut feeling, practically ten seconds into talking to someone, about whether or not their presentation is concerning.
I am not a stress test expert but from the literature and guidelines I reviewed, I reached a similar conclusion. Unfortunately what drives lawsuits is usually not evidence-based, its narrative based. When a decedent's family hears there was a test that could have saved their life, its very upsetting regardless of how accurate the test is.
This is the pattern I've seen too. The more rural or community setting, they get sent home. Its kind of odd to say that the standard of care differs from location to location within the US.
where i trained, the heart score was followed pretty closely. this guy would have been admitted most likely. where im at right now, heart score of 4 with 2x neg trops and assuming the EKG was read correctly and was actually stone cold NSR, this would have been a tough sell to IM to admit and i know my colleagues would likely dc this.
When I was a resident, basically all chest pain no matter what went to a chest pain obs unit. Very few exceptions. Now I send almost all chest pain home. How I take care of trop/EKG negative chest pain is the biggest change I've seen in my 6 years out of residency.
I practiced in a community emergency department about 45,000 visits or less. I’ve been using the hard score and now favor the heart pathway score when evaluating adults with chest pain. Depending on the score you can use the regular heart score which seems to favor discharge versus the heart pathway and that when it’s for higher, they recommend observation and further evaluation. When I calculate the heart score pathway score on MDCalc there’s a function if you get yourself registered for free you can cut and paste it which I do into the EMR. Then quickly dictate a reason if the patient’s heart score is four or higher that either recommended admission or we discussed the risk and benefits, and the patient made the decision with medical decision capacity to go home watch for the following signs and symptoms and ensure appropriate follow up.
At least where I practice (urban academic center) standard of care in 2016 would have been to admit a HEART score of 4 (and this would also be consistent with the HEART pathway). Now we have hsTroponin, which has massively changed that practice. It's too bad there wasn't a detailed breakdown of the HEART score in this case because one of my biggest criticism was always that the history component is pretty subjective and can make a big difference in dispo. Based on what is included here I'd call this patient at most a 1 for history, so if the plaintiffs were calling it a 2 that could be the difference between discharge and admission based on the published HEART pathway.
Yes, I've noticed the same. History is very subjective. I think at some point I'm going to find a lawsuit in which the main crux is "you miscalculated the HEART score, they were a 4, not a 3".
The ED doctor correctly listed the differential diagnoses (AMI, CHF/pulmonary edema, costochondritis, hyperventilation, and musculoskeletal pain) and performed the appropriate tests (troponin I, d-dimer, chest x-ray, and EKG) to arrive at the correct diagnosis using the differential diagnosis method.
Thus, the Standard of Care was met.
The plaintiff needed to prove that the physician failed to diagnose the case.
The only way to do this is through the HEART Score.
Based on the data provided, the patient had a HEART Score of 4, as indicated by the history, age, and risk factors outlined in the plaintiff's MD opinion. Achieving this score requires a "highly suspicious" history of ACS or having "≥3 risk factors or a history of atherosclerotic disease." Given that the other scores are negative, this patient is considered medium risk.
According to the HEART Score study results, this patient should have been admitted to the hospital. The study itself recommends this course of action.
I've seen multiple reputable lectures stating that a single high sensitivity trop is adequate if the patient has had consistent pain for more than six hours.
I think admission strictly based on HEART score is going to be somewhat resource dependent. I work in a rural, critical access hospital. We can't perform stress tests or CT coronary testing in our hospital. Strictly following that pathway would mean a lot of transfers to the closest urban center, about 2 hrs away. This would create a huge strain on resources and significant cost for the patient. I'd I'm genuinely worried about the presentation I'll do it but it's not common.
I wish we knew how long this patient had been having chest pain. Not clear if it was 3 hours or 6 hours or 24+. I can definitely see how patients wouldn't want to be transferred 2 hours away (not to mention how long it will take for the bed to become available). Although if you're that far out, maybe the argument would be to just transfer anyway because it doesnt sound like anyone in your community is going to be doing a stress test at any point in the next few weeks. I think the challenge for us is if we just use our best judgment and tell them to follow-up with cards, or if we officially recommend 2 hour transfer knowing full well that 80%+ will sign out AMA and leave.
ACEP supports single high sensitive troponin for low risk chest pain. Technically this patient wasn’t low risk with heart score 4. Also possible as well if the ischemic event was already over and the troponin had already peaked. No test is perfect, so we aren’t perfect. I would think discussing with cardiology would have strengthened the case.
https://www.acepnow.com/article/new-guidelines-aim-to-help-the-evaluation-of-chest-pain/#:~:text=Recommendation:%20%E2%80%9CIn%20adult%20patients%20with%20recurrent%2C%20low%2Drisk,with%20other%20clinical%20policies%2C%20including%20the%202018
I haven't made a habit of quoting ACEP guidelines in my MDM, but maybe I should. I think consulting cards would have taken some heat off the EM doc but likely would not have prevented the lawsuit, maybe would have resulted in an even higher settlement as there was more insurance money to go after (I don't have good insight into the way these settlement negotiations work).
Also for the autopsy report I would want to know who did the autopsy. The careful examination of the coronaries needed to conclusively exclude MI, while not *that* hard, is not a trivial task. Was this autopsy performed by a forensic pathologist? A seasoned hospital autopsy pathologist or a surgical pathologist who has to cover the occasional autopsy? My guess is given he was found dead in his car a forensic autopsy was performed but it definitely depends on the jurisdiction and is by no means guaranteed if they were found in a locked car and it was known they were just at the ED for chest pain.
Excellent point... not all autopsies are done to the same standard! I wish attorneys would at least put in a one sentence blurb about the autopsy, but just like EKGs, they often gloss over it in such a superficial that you can't draw any honest conclusions.
Who did it also would potentially change the top line cause of death even when reaching the same conclusion. This is more of a pathologist vs non pathologist issue (again in some jurisdictions, the autopsy may not even be done by a pathologist), but “cardiopulmonary arrest” which I see VERY frequently as the cause of death in death notes at my hospital is NOT a cause of death. It is the state of being dead. Something has to cause the cardiopulmonary arrest. An arrhythmia can happen spontaneously, or as you said, could be secondary to infarction or even just ischemia. Was it an arrhythmia with clean as a whistle coronaries or were 4 vessels 95% occluded?
Always get at least two trops (much easier now with high sensitivity). For us, dispo depends on availability of outpatient follow up. Assuming this patient does not have a cardiologist, would likely admit as follow up in my area is difficult to obtain and therefore outpatient workup may not happen for weeks to months.
Do you have any hard and fast lines in the sand for follow-up? Example: If cards can see them in 7 days, then they schedule a stress test that will be in another 1-14 days depending on when patient is free to do it, is that fast enough?
I think I speak for a lot of people saying this; I would love to hear podcasts from you!!
I've thought about it but never pulled the trigger. I feel like I'm a better writer than a speaker. What would be a good format to try if I did it? Just discussing each case would be the easiest for me.
That sounds fantastic! Yes, discussing each case as well as the outcome would have me (and I am sure many others) HOOKED!
I wouldn't repeat troponins to make a decision. If the pain has been going on or happened several hours ago then repeating won't change anything as stated by the defendent's expert witness. If the story is concerning I will admit someone regardless of their heart score. If it is borderline and their testing is negative, I will inform the patient of everything and let them decide what they want to do offering them admission. In addition I set up outpatient followup if they don't have it with instructions to followup within the next 24-48h. Would you think that having a thorough conversation informing the pt and family and documenting everything would help justify a discharge if they ultimately elect to go home?
It could help justify the discharge in real time but unfortunately I do not think it will stop a lawsuit. If you send them home and they die, even if they understood the risk and made an informed decision, you're still going to get sued. Sad nature of the medicolegal world in which we work. FWIW I think its definitely worth getting the repeat trop, especially if using older trop assays (not the high sens).
Where can I find public records of medical malpractice suits online like this one? I assume they are exhibits from court cases, but I can't seem to find how to access them on any court websites. Can you point me in the right direction?
Its honestly a nightmare to find them... I mostly get tips now but I have to have at least a name of one of the parties and jurisdiction to even check, some courts don't even have records online and you have to ask the clerk to mail you records, etc... There's really not a central database you can search.
As far as I’m aware, the sensitivity and specificity of stress tests is actually rather poor.
I usually consider other factors, like has this pt ever had a cardiac work up before , how often do they come to the ER, etc. I discharge most pts with negative trops and unchanged ekg regardless of heart score, but sometimes I make exceptions If story sounds quite concerning and they’ve never had a cardiac work up.
It’s hard for me to know what I would have done just based on the info provided. Often times I get a gut feeling, practically ten seconds into talking to someone, about whether or not their presentation is concerning.
I am not a stress test expert but from the literature and guidelines I reviewed, I reached a similar conclusion. Unfortunately what drives lawsuits is usually not evidence-based, its narrative based. When a decedent's family hears there was a test that could have saved their life, its very upsetting regardless of how accurate the test is.
Varies based on local practice, in the rural setting world be close outpatient stress test in an urban setting would get admitted.
This is the pattern I've seen too. The more rural or community setting, they get sent home. Its kind of odd to say that the standard of care differs from location to location within the US.