Case Study: Failure to Diagnose Dissection of Ascending Thoracic Aorta Results in Settlement

Facts of the Case

A 39-year-old white male presented to the emergency department (ED) complaining of sudden onset of chest pain in his anterior central chest, difficulty breathing and radiating pain to his jaw. He rated his pain as 7/10. His blood pressure was 164/124. He did not have any syncopal or pre-syncopal episodes associated with the pain.

The patient had a previous history of sarcoidosis based on a positive lymph node biopsy. He did not smoke but did have a history of gastroesophageal reflux disease. Occasionally, he had mild elevations of his blood pressure but had never been treated for or diagnosed with hypertension. His family history was remarkable in that his father had multiple TIAs and CVAs and a history of deep vein thrombosis. The nursing staff appropriately placed the patient on oxygen and initiated cardiac monitoring.

The emergency medicine physician on duty was board-certified and had completed training in cardiothoracic surgery. He documented that the patient’s pain started in his chest when he was in a torque position. It then radiated to his teeth. The pain was worse with movement and deep breathing. He had both dyspnea and nausea. The physician was able to reproduce the pain in the patient’s lower parasternal area with palpation. He found the patient’s pulse and heart sounds to be normal. Two electrocardiograms were performed and interpreted as normal. A chest x-ray was performed and interpreted as normal by the emergency medicine physician and, subsequently, a radiologist. His troponin level was normal. The patient was then given aspirin, sublingual nitroglycerin, oxygen and Tylenol. Reportedly, he was then pain-free.

The emergency medicine physician called the on-call cardiologist and discussed this patient with him. They agreed to have the patient call the cardiologist the following morning to schedule an evaluation and outpatient stress test.

Prior to his discharge, the patient’s blood pressure was 157/100. Since he appeared to be stable and his symptoms resolved, he was discharged home with a diagnosis of atypical chest pain, gastroesophageal reflux disease and costochondritis. He was advised to take Prilosec to treat the gastroesophageal reflux disease and ibuprofen for the costochondritis.

Later that evening, the patient’s wife found him unresponsive. She called 911 and promptly initiated CPR. The EMS responders estimated that approximately 2-3 minutes had elapsed between the patient’s cardiac arrest and the commencement of CPR. EMS initiated ACLS and continued for approximately one hour before the patient’s return to the ED. However, the patient never regained consciousness and was asystolic. At the ED, despite ongoing CPR, the patient had no pulse or respirations and was intubated. A bedside echocardiogram demonstrated a pericardial effusion. Pericardiocentesis was attempted, but there was no spontaneous activity or blood pressure in response. He was then pronounced dead.

An autopsy was performed and revealed a 4-centimeter-long thoracic aortic dissection, which arose 1.5 cm above the aortic valve. The aortic dissection had communicated with the pericardium. There was a massive hemorrhage into the pericardium. Because of several critical issues in the care provided, this case was settled on behalf of the insured emergency medicine physician.

Expert Reviews

The sudden onset of chest pain is a common reason why patients present to either an ED or a primary care physician’s office. The evaluation of such pain is challenging. Unfortunately, a misdiagnosis often results in a medical malpractice lawsuit. Three conditions can cause significant morbidity or even death if misdiagnosed: Acute coronary syndrome, pulmonary embolus and dissection of the ascending thoracic aorta. However, many other disease processes can cause similar symptoms, thus contributing to the challenge of making the correct diagnosis. These disease processes include pericarditis, gastroesophageal reflux disease and musculoskeletal pain.

The ED physician documented that the onset of the patient’s chest pain occurred after he had torqued his torso. However, there was no further description of that activity in the record. This physician was able to reproduce the patient’s pain by palpating on the lower sternum. Therefore, the physician believed the most likely diagnosis was costochondritis, for which he prescribed an NSAID. However, he remained concerned that the patient might have an acute coronary syndrome and ordered one set of cardiac enzymes and two EKGs. He then contacted the cardiologist on call to discuss the patient’s symptoms and arranged for the cardiologist to evaluate the patient and perform a stress test the next day.

Prior to discharge, the patient’s blood pressure was significantly elevated. Even though the patient had been in the ED for less than two hours, and his blood pressure was still elevated, the patient was discharged. Shortly after he arrived home, the patient suffered a cardiac arrest and expired.

The cause of the patient’s sudden onset of chest pain was a dissection of his ascending thoracic aorta that dissected proximally down the ascending aorta and into the pericardial sac, resulting in acute cardiac tamponade and death. Dissection of the aorta is usually seen in elderly patients and is more common in males. It usually results from a degeneration of the media of the aortic wall and is seen as part of the normal aging process. When the dissection involves the ascending aorta, it is referred to as a type A (Stanford classification) dissection and carries a high risk of mortality and morbidity. As the planes of the wall of the aorta separate, occlusion of the arteries that branch off of the aorta may occur. Thus, patients who present with a dissection of the ascending aorta may concurrently exhibit signs and symptoms of either an acute myocardial infarction, symptoms of spinal cord ischemia or weakness and numbness of the arms. Additionally, such a dissection can result in acute aortic insufficiency and congestive heart failure. As occurred in this case, the dissection may enter the pericardial sac, resulting in an acute hemorrhagic pericardial effusion and tamponade.

Many physicians incorrectly assume that a patient who presents with a thoracic aortic dissection will almost always complain of back pain described as a tearing type of pain. Patients with an ascending thoracic aortic dissection most frequently complain of sharp anterior chest pain. Although such dissections are rare in patients under the age of 40, there are some underlying disease processes that may predispose younger patients to an aortic dissection. A family history of dissection or aneurysms should raise suspicions.

The most common hereditary disorder associated with aortic aneurysms and dissection is Marfan’s syndrome. However, dissections of the thoracic aorta also occur at increased rates in patients who have Turner’s syndrome or who have recently undergone aortic valve replacement, coronary artery bypass surgery or cardiac catheterization. Individuals with a history of syphilis, giant cell arteritis, rheumatoid arthritis or diseases that cause vasculitis are at increased risk. Patients with a history of bicuspid aortic valve are also at increased risk. Finally, aortic dissection has been associated with strenuous physical exertion such as heavy weightlifting. Because this patient reported that the onset of pain occurred after he had torqued his body, this may have been a causative factor in this case. Unfortunately, the medical record did not further describe the physical activity that provoked the pain.

This case was reviewed by multiple physician reviewers. Since acute dissection of the ascending aorta is a rare diagnosis, especially in a patient this young, the reviewers all agreed that it was unlikely that many ED physicians would have initially made a correct and timely diagnosis. Further, even if an earlier diagnosis had been made, it was unlikely that surgery could have been performed sufficiently quickly to save his life. However, the reviewers did focus on several critical deficits in the ED physician’s care. First, this patient should not have been discharged from the ED in less than two hours. He should have been admitted to the hospital. If this patient’s condition had then changed in the hospital, a prompt reevaluation might have resulted in the correct diagnosis and surgery.

Further, the physician failed to obtain more than one set of cardiac enzymes. This was a particular concern since only one test was performed shortly after the patient’s onset of pain. Because the ED physician was concerned that the patient might have an unstable coronary syndrome, the patient should not have been discharged until a second set of enzymes was obtained at least eight hours later. It takes several hours for these enzymes to rise. Finally, even when there are two normal sets of cardiac enzymes, there is always the possibility that the patient’s pain was caused by cardiac ischemia without any myocardial damage. Negative cardiac enzyme elevations cannot exclude this possibility.

The physician reviewers also addressed an additional and unusual area of concern. This ED physician had completed training in cardiothoracic surgery. Thus, the reviewers were seriously concerned that he would be held to a higher standard of care than a physician who had merely completed a residency training program in emergency medicine. Due to these factors and the patient’s age, settlement of this case was deemed the reasonable course of action.

Legal Analysis

One of the concerns in this case was whether the emergency medicine physician would have been held to a higher standard of care by virtue of his specialized training and expertise.

In a medical malpractice claim, the plaintiff must prove that the physician breached the prevailing professional standard of care. The standard of care is the level of care, skill and treatment that is recognized as acceptable and appropriate by a reasonably prudent physician under the same circumstances. The duty of a medical professional is not to cure or even to guarantee a positive outcome from treatment. Medical malpractice does not occur every time a medical treatment is not successful. The standard does not require the very highest degree of skill or care, but only that which a reasonably prudent physician would exercise in the same circumstances. The practice of medicine has never been an exact science, and doctors are not required to be right every time they make a diagnosis.

Evidence that a physician conformed to accepted community standards of practice will usually preclude a finding of negligence, although adherence to custom itself will not automatically insulate the physician from liability. In addition, the New York Court of Appeals has held that if a physician has superior knowledge or skill that exceeds local standards, he or she will be held to a higher duty of care. A medical specialist possessing that knowledge and skill equal to other specialists in his or her field will, therefore, be held to a higher standard of care than a generalist. This can result in a specialist being held liable in a situation where a general practitioner would not.

The physician’s failure to specifically describe the precipitating event that caused the patient’s symptoms was a factor in deciding whether to defend this case. The record merely stated the patient had “torqued” his body and yet provided no further details. The failure to explain and document what the patient meant by “torqued” seems to indicate that the physician may not have considered the possibility of an aortic dissection in a young male patient. From a risk management perspective, although it is important to document, the documentation must be specific and relevant. Further, if he had related the patient’s family history to the injury and symptoms, he might have then considered the fact that the patient was at an increased risk for an aneurysm.

A more serious concern in defending this case was the physician’s failure to retain a patient with chest pain of undetermined origin in the ED for more than two hours or at least to admit the patient to an observation unit to monitor his condition. This appeared to be a serious deficit in the patient’s care. He discharged the patient despite remaining concerns that the patient possibly had a cardiac condition. Moreover, the physician’s failure to respond to the patient’s elevated blood pressure of 157/100, taken just prior to discharge, raises concerns about communication between the nursing staff and the physician. The patient’s elevated blood pressure was neither addressed nor documented by the physician at the time of discharge. This raises the question of whether the physician was notified of, recognized, or addressed this change. It was particularly crucial information since the patient did not have a history of elevated blood pressure. The reason why a final set of vital signs is taken and reviewed just prior to discharge is to confirm whether it is a safe discharge as required by New York State regulations. Unfortunately, the resulting discharge was not a safe one.

Finally, the physician’s failure to document his thought processes showing how he reached his decision to discharge the patient and final diagnosis made the case indefensible.

When a patient dies soon after discharge from the ED, a hospital has a duty to report this event to the New York State Department of Health pursuant to NYPORTS, the patient adverse event reporting system. The hospital is then obligated to investigate the case and perform both quality assurance and root cause analyses. In some instances, the Department of Health will come to the facility to investigate what occurred. In the event of a patient death, this may include interviewing all relevant staff. Usually, the state investigators do not permit counsel or other third parties to be present at these interviews. However, attorneys at MLMIC Insurance Company are available to discuss the facts of the case with you prior to these meetings and assist you in preparing for such interviews. It is important to be prepared because if the Department of Health is not satisfied with the medical care provided, it may refer the physician to OPMC. If this occurs, the physician should promptly contact MLMIC to obtain the names of legal counsel who are experienced in OPMC matters.

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Sources:

1. https://pubmed.ncbi.nlm.nih.gov/10685714/
2. https://casetext.com/case/toth-v-community-hosp-at-glen-cove-1

This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.