PCP Treats Chest Pain as GERD
Case #291
A 61-year-old man presented to the ED with chest pain in 2011.
EKG and serial troponins were negative.
An outpatient stress test was recommended, and he was discharged.
The patient followed-up with his PCP of 25 years, Dr. K.
A treadmill stress test was scheduled.
However, it could not be completed due to the patient’s claudication symptoms.
It does not appear that a chemical stress test was ordered after this, nor was any alternative testing done.
In January 2014, the patient decided to follow his PCP’s recommendations and start exercising.
He purchased a recumbent bike, but noted some chest discomfort while riding,
It seemed to improve when he switched to an upright bicycle.
He saw Dr. K, at which point he denied chest “pain” but did endorse chest “soreness”.
The patient denied arm symptoms, shortness of breath, and diaphoresis.
He noted that he had been taking Tums for heart burn.
An EKG was read as normal (not included in court documents).
Dr. K felt that it was most likely GERD, but documented that he could not rule out cardiac causes.
He recommended trying ranitidine for several days, and that he should return for a stress test if not improving.
Unfortunately, the stress test was never completed.
15 days after the appointment, his wife came home from work during a snow storm.
The patient was using a leaf blower to blow snow off the driveway.
The patient’s wife looked back outside 15-30 minutes later and saw him lying face down.
EMS arrived and he was pulseless.
They noted he had a large bruise on his forehead.
The patient was taken to the ED but could not be resuscitated.
Court records stated that his wife declined an autopsy.
His wife filed a lawsuit against the physician and his employer.
A family medicine expert was hired:
The plaintiff also hired a cardiology expert:
The plaintiff offered to settle for $2,000,000.
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The defense hired their own family medicine physician to defend Dr. K:
The defense also hired a cardiology expert:
The two sides could not come to a settlement agreement.
The lawsuit went to a jury trial.
The defense argued that the plaintiff’s case was based on a string of 10 assumptions which could not be definitively proven:
The defense attacked the plaintiff’s cardiology expert:
The defense also argued that the patient was partially responsible for his own death, due to issues with non-adherence to recommended treatments.
The plaintiff’s attorney argued that he had been starting to make lifestyle changes (including riding his recumbent bike), and that he had actually quit smoking in 2006 when he had a stroke.
The jury returned a verdict in favor of the defense.
MedMalReviewer Analysis:
I have mixed feelings about this case. On one hand, the patient had chest pain that had persisted through to his appointment, worsened with exercise, and the patient had multiple risk factors for coronary artery disease. I don’t work in primary care but it seems like the standard of care is to send this patient to the ED. The PCP fell for the GERD trap, one of the most notorious and widely publicized errors in chest pain patients. He chose to assume that the patient’s symptoms were caused by the more benign explanation, as opposed to organizing his differential/workup in a “worst first” manner. On the other hand, the plaintiff had no way to actually prove that he died of an MI. There are just way to many other viable possibilities here including head bleed, aortic dissection, PE, among others. MI is certainly the most likely explanation given the recent chest pain, but is far from certain. In my opinion, the PCP fell below the standard of care but the plaintiff faced an impossible task in proving causation, resulting in a defense verdict.
One thing that stood out to me about the patient’s description of symptoms is that he described it as chest “soreness” as opposed to pain. For some reason, chest pain patients often minimize their symptoms and will answer in the negative when asked if they have “chest pain”, because they feel that soreness or discomfort or pressure don’t qualify as “pain”. Paradoxically, this is one of the few scenarios in which patients will actually minimize their symptoms. We’re used to patients giving very dramatic descriptions of their pain and reporting numbers greater than 10 on the 1-10 scale for most other conditions. For some reason chest pain patients are more prone to minimizing their symptoms or trying to catch doctors on a technicality based on the adjective used to describe the sensation in their chest. Some of these adjectives do indeed have a positive or negative likelihood ratio for acute coronary syndrome, but none of them are anywhere close to being clinically useful to rule in or rule out ACS.
The patient was an attorney and his daughter-in-law is a nurse. This is basically a worst case scenario for a doctor who’s patient has had an unexpected bad outcome. The family knows how to navigate the legal system and is well connected, so they will get good advise about which law firm to contact. And a family member who works in healthcare often can find criticisms that may not be apparent otherwise.
It always makes me nervous when I see a defense attorney argue that a patient is responsible for their own death. There’s a big risk that the jury will view this a “victim blaming”, which is generally frowned upon in educated society and has a real possibility of backfiring. However, the facts certainly support this argument in some cases. It’s an easier argument to make when a patient leaves AMA or makes a poor decision that is immediately followed by their death. The defense attorney seems to have successfully argued this point in a sensitive but effective manner, judging by the fact that the jury decided the patient’s own actions were a “substantial factor” in his death.
I felt a little guilty/assumed it was purely my bias when my first thought was "wife *had* to consent to autopsy here if they were going to ever pursue malpractice" and then sure enough, defense makes that exact argument. Huge win for autopsies in this case!
Regardlless of the facts of or opinions regarding this case...
No autopsy = no proven cause of death = no ability to assign responsibility = no ability to determine, much less prove, the very first requirement of a sucessful malpractice suit...failure to meet the standard of care for the given specialty in the given community.
Personally, I believe that the patient died as the result of being hit in the forehead by a meteorite, causing massive intracerebral contusions and bleeding as well as a frontal bruise. In this case, without an autopsy, hard to argue otherwise...except for the absence of an obvious through-and- injury to the skull caused by an object travelling several hundred miles per hour.