Is this malpractice? Just exactly how negligent is this?

[Pneumothorax]

I'm a Caribbean student, and we "get" to rotate through all of the departments at our local hospital. I saw this autopsy, and here is what went down:

80 year old woman presents with sudden onset of severe stomach pain, vomiting, pain in her back and shoulders. Diagnosed with gastritis and sent home with prilosec....where she died.

Autopsy reveals major MI (there was a hole in the left ventricle!!!). She had reported no history of heart trouble, but there was evidence of several prior MIs.

When I heard the history, I immediately thought MI, but I linked the pain in the back and shoulders to cardiac mainly because she was dead, and, well...MIs tend to be rather deadly.

In any case, when I found out what they did in the ER here, I was aghast...but I wanted to find out here: did the ER on this third world island screw up? Would you have done an EKG?

This is purely a matter of curiosity. I don't know her family and the courts here don't really do anything, so its not like anyone is going to get into trouble. Unfortunately, I think....

So yeah, when do you order an EKG vs. just call the patient's symptoms gastritis and send them home?

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[quideam]

You would definitely get an EKG in the US.

 

[GeneralVeers]

You would definitely get an EKG. 100%.

She probably lived a fruitful and full life.

 

[deleted65604]

No, we wouldn't have been negligent in the US. We would have cathed her, put her in the unit, intubated her and put her on a balloon pump. A month later, after incurring a bill of millions of dollars, she would have died of hospital acquired pneumonia or line sepsis.

80 year old lady with severe CAD. The grim reaper was knocking on the door. Don't fight it. Death is not the enemy. The fear of death is the enemy.

 

[edinOH]

Sounds like she was having "the big one."

So you're in a hospital in this Caribbean island and you get the EKG, which prophetically, reveals "tombstones" in the anterior-lateral leads.

I guess now you give her some aspirin and presumably lovenox and maybe even thrombolytics. (assuming you have anything beyond aspirin). You describe where you are as a third world island. Just what is the standard of care for the treatment of MI in that community?

Regardless of if she was diagnosed with gastritis, an MI, or a sprained ankle, she was going to die.

 

[GeneralVeers]

If we didn't have lawyers threatening to sue me, I wouldn't be getting EKGs on all 80 years-olds. If you find an acute MI are you going to intervene? For me it would depend on their baseline health and functioning. If this was a healthy 80 year old who was independent and could live another 10 years, then I say get the EKG and intervene. If it's a debilitated or demented 80 year old, why stop the natural course of things?

 

[dchristismi]

I diagnosed a NSTEMI in a 101 year old the other day. What am I going to do about it? He had onset of SOB, but no CP. Family didn't want aggressive measures, which makes complete sense. Guy was pretty darn healthy for 101. Of course, you have to BE healthy to even make it to 101. (He didn't have any sort of cardiac history or HTN.)

Called the primary, who arranged for home health and oxygen for comfort so the patient could be (die) at home.

Sort of an extreme example, but what are you really going to do? Jarbacoa hit it on the money.

Now, my practice is full of relatively healthy snowbirds - it isn't uncommon to see 80 year olds who have sprained their ankles getting off a bicycle. These people, who have a very high quality of life would go to the cath lab here. Some of them do quite well. Some don't. It's impossible to tell. For example, I saw a takyosobo arteritis (dx at cath) in a very healthy 80 year old F with sudden onset CP/SOB who insisted she meet her regular golf foursome two days hence. She died the next day in the unit - because she had discussed it with her husband, who allowed cards to withdraw care when it became clear it would be a long course even if she pulled through.

Unfortunately, the legal climate here insist you do "everything" unless you essentially have permission not to. Death is not allowed. (Even in demented 90 year old nursing home rocks.)

 

[78222]

[YOUTUBE]http://www.youtube.com/watch?v=BYOE_b4aYD0[/YOUTUBE]

 

[AmoryBlaine]

It's malpractice by American standards not to order an EKG and admit an 80 year old w/ that story.

Whether or not she "deserves" the work-up is unfortunately not for us to decided. I have found that my predictions of pt trajectory once I admit them are not all that great. I bring people in thinking, "they will be dead in a day" but some of them do quite well. I bring people in thinking, "they are going to rule out" who end up going to urgent cath...

Maybe this gets better as you progress...

 

[geogil]

I diagnosed a NSTEMI in a 101 year old the other day. What am I going to do about it? He had onset of SOB, but no CP. Family didn't want aggressive measures, which makes complete sense. Guy was pretty darn healthy for 101. Of course, you have to BE healthy to even make it to 101. (He didn't have any sort of cardiac history or HTN.)

Called the primary, who arranged for home health and oxygen for comfort so the patient could be (die) at home.

Sort of an extreme example, but what are you really going to do? Jarbacoa hit it on the money.

Now, my practice is full of relatively healthy snowbirds - it isn't uncommon to see 80 year olds who have sprained their ankles getting off a bicycle. These people, who have a very high quality of life would go to the cath lab here. Some of them do quite well. Some don't. It's impossible to tell. For example, I saw a takyosobo arteritis (dx at cath) in a very healthy 80 year old F with sudden onset CP/SOB who insisted she meet her regular golf foursome two days hence. She died the next day in the unit - because she had discussed it with her husband, who allowed cards to withdraw care when it became clear it would be a long course even if she pulled through.

Unfortunately, the legal climate here insist you do "everything" unless you essentially have permission not to. Death is not allowed. (Even in demented 90 year old nursing home rocks.)

I just did a quick web search that turned up nothing. Do you mean Takayasu's arteritis?

 

[SoCuteMD]

I just did a quick web search that turned up nothing. Do you mean Takayasu's arteritis?

She probably meant takatsubo cardiomyopathy, aka "Broken Heart Syndrome."

 

[leviathan]

There are also other life-threatening things besides AMI that you need to consider with that patient, so you'd probably want more than just a 12 lead depending on the full story.

 

[dchristismi]

She probably meant takatsubo cardiomyopathy, aka "Broken Heart Syndrome."

Bingo. Not something I actually diagnose, so I don't really need to know how to spell it. It was a cards dx, but he came back to me to tell me to quit coming up with "cool" cases for him... although this one (That was the weekend where every EKG I touched went to the cath lab.)

 

[DocVirk]

She probably meant takatsubo cardiomyopathy, aka "Broken Heart Syndrome."

Better get a box of kittens, STAT

 

[Jeff698]

I obviously don't know this, but from reading your post it appears you have no direct knowledge of the case. You seem to be getting your information indirectly. We seem to be quite quick to draw conclusions here based on this information and decide what we would or would not have done. We've even labeled this malpractice.

I'm a bit amused, yet saddened, by this. I personally have no idea what symptoms this woman actually presented with, nor what conversations occurred between her and her physician. I am in no position whatsoever to judge whether there was malpractice or not. At a bare minimum, I understand that the concepts of malpractice and negligence are very much local issues and what might be considered the standard of care in my hospital, with my resources, might not be considered that elsewhere.

Once again, physicians are the world's greatest at shanking each other with next to no information to go along with it.

The best we can do in this situation is to present the facts as we know them and ask for opinions on how different physicians might approach the case.

I've personally sent 80 year olds home with little to no testing, depending on their symptoms and circumstances.

Like DrChristismi, I've sent home an elderly patient with an NSTEMI. In my case, I was also on two weeks later when he came back in in cardiac arrest. I pronounced him. I talked with his family (again) and told them the news. It wasn't unexpected, the patient and his family understood and accepted that death was an option and both decided there were worse things than death. Circumstances are important and are rarely relayed in the brief tidbits of information that appear on, say, internet forums.

I'll end with a plea to my colleagues. Please understand that, just as things you do and say may not be interpreted or understood correctly, the things you hear third hand about other physicians may be equally incorrect.

Thanks and take care,
Jeff

BTW, I've reread some of the additional posts here and think several of us agree on this. I didn't mean to chastise the entire forum. Sort of a personal hot button. Sorry

 

[Old_Mil]

If we didn't have lawyers threatening to sue me, I wouldn't be getting EKGs on all 80 years-olds. If you find an acute MI are you going to intervene? For me it would depend on their baseline health and functioning. If this was a healthy 80 year old who was independent and could live another 10 years, then I say get the EKG and intervene. If it's a debilitated or demented 80 year old, why stop the natural course of things?

A little something that comes to mind whenever the issue of quality of life vs. treatment comes into a discussion about med ethics.

"I have an M.D. from Harvard, I am board certified in cardio-thoracic medicine and trauma surgery, I have been awarded citations from seven different medical boards in New England, and I am never, ever sick at sea. So I ask you; when someone goes into that chapel and they fall on their knees and they pray to God that their wife doesn't miscarry or that their daughter doesn't bleed to death or that their mother doesn't suffer acute neural trama from postoperative shock, who do you think they're praying to? Now, go ahead and read your Bible, Dennis, and you go to your church, and, with any luck, you might win the annual raffle, but if you're looking for God, he was in operating room number two on November 17, and he doesn't like to be second guessed. You ask me if I have a God complex. Let me tell you something: I am God."

Dr. Jed Hill
Malice
1993

[YOUTUBE]http://www.youtube.com/watch?v=LqeC3BPYTmE[/YOUTUBE]

 

[PeepshowJohnny]

[youtube]BYOE_b4aYD0[/youtube]

Damn it, I miss Freddie.

 

[GeneralVeers]

A little something that comes to mind whenever the issue of quality of life vs. treatment comes into a discussion about med ethics.

Alec Baldwin has a point (for once). I don't believe in any supreme being, but if there is one, then he/she does not make his/her will known on Earth. Therefore someone has to make the tough decisions, and it cannot be anyone else other than those trained to deal with these issues (us).

 

[Old_Mil]

We're not trained to deal in such issues, and certainly our training in medicine does not qualify us to tread into such territory.

So I have to disagree. Baldwin was dead wrong; no human has any business playing diety in the life of another.

Unfortunately, it's a step more and more of our 'humanisticaly' trained physicians are willing to do as they get confused by an Orwellian definition of 'harm'.

 

[ZincFingers]

I prefer this Alec Baldwin.

"Because only one thing counts in this life. Get them to sign on the line which is dotted."

[YOUTUBE]http://www.youtube.com/watch?v=y-AXTx4PcKI[/YOUTUBE]

 

[Termwean]

They had a question about zincfingers on my step 1..I had NO f'ing clue what they were talking about. SO I looked it up and still had no clue.

 

[GeneralVeers]

We're not trained to deal in such issues, and certainly our training in medicine does not qualify us to tread into such territory.

So I have to disagree. Baldwin was dead wrong; no human has any business playing diety in the life of another.

Unfortunately, it's a step more and more of our 'humanisticaly' trained physicians are willing to do as they get confused by an Orwellian definition of 'harm'.

Sorry to burst your altruistic bubble, but someone has to make the decision. If not us then who?