Cardiology malpractice case involving NP. Real court documents.

[bbc586]

Expert Witness Case #2

This case concerns a 68-year-old man, referred to as Mr. A. He had a history of previous myocardial infarction and was cared for by his primary care doctor. After a long period of limited follow-up, his PCP encouraged him to see his cardiologist (Dr. H) after noting “more prominent ST-T wave...

expertwitness.substack.com

68-year-old man with history of MI seen by nurse practitioner.

Stress test ordered.

Results show ischemia, but no one communicates with each other about it.

I'll let you guess what happens while he is playing golf a week later....

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[Rocher]

Expert Witness Case #2

This case concerns a 68-year-old man, referred to as Mr. A. He had a history of previous myocardial infarction and was cared for by his primary care doctor. After a long period of limited follow-up, his PCP encouraged him to see his cardiologist (Dr. H) after noting “more prominent ST-T wave...

expertwitness.substack.com

68-year-old man with history of MI seen by nurse practitioner.

Stress test ordered.

Results show ischemia, but no one communicates with each other about it.

I'll let you guess what happens while he is playing golf a week later....

Strange that the patient's cardiologist is who seems to be the main defendant. The lack of a phone call regarding the stress test findings seems like the mistake.

 

[bbc586]

Strange that the patient's cardiologist is who seems to be the main defendant. The lack of a phone call regarding the stress test findings seems like the mistake.

Agree. This whole thing could have been avoided with a simple phone call.

 

[nlax30]

whole thing could have been avoided by then actually SUPERVISING the exercise portion of the stress which by this report showed significant ST changes w/ exercise.

 

[Infamous_MD]

In the post ISCHEMIA Trial era, wouldn't this have been medical therapy management anyways? No active ACS, no left main involvement and no HFrEF, treat medically first.

 

[timpview]

Shows you how quickly things can get turned on you..

- stress tests gets ordered on an asymptomatic patient which goes counter to guidelines
- expert witness says standard of care is immediate hospitalization which we know is bogus
- states standard of care is immediate phone call to referring provider which is also bogus (I assume test results were electronically sent to referring provider)
- states standard of care is immediate angiography which is likely true based on current clinical practice but more debatable in post ISCHEMIA world

 

[chocomorsel]

Strange that the patient's cardiologist is who seems to be the main defendant. The lack of a phone call regarding the stress test findings seems like the mistake.

Is Dr. H, the one who read the test the same Dr. H who was the cardiologist? And is Dr. P the same partner? Seems like so.
Seems to me like the NP was not being supervised appropriately. Do the NPs normally have to run each case by you guys? If not, isn’t that how things should be? This potentially could have ended differently if the NP had communicated with her supervisor. And of course if she had followed up on “her patient’s” results herself.
This is what happens when you employ a mid level. Their outcome is your outcome.

 

[greatnt249]

Shows you how quickly things can get turned on you..

- stress tests gets ordered on an asymptomatic patient which goes counter to guidelines
- expert witness says standard of care is immediate hospitalization which we know is bogus
- states standard of care is immediate phone call to referring provider which is also bogus (I assume test results were electronically sent to referring provider)
- states standard of care is immediate angiography which is likely true based on current clinical practice but more debatable in post ISCHEMIA world

One could also argue that the stress test (or modality, rather) was inappropriate in the setting of new resting EKG changes, which is apparently what led to the exercise MPI to begin with. Maybe I skimmed over the case too quickly, but I didn't see anything mentioned about why an EKG was even ordered.

In general, I agree that most patients don't need to be hospitalized for an abnormal stress test. However, in this guy's case, he had markedly abnormal stress EKG findings as well as inducible ischemia in a large portion of the LAD territory in addition to reduced ejection fraction from previous known study. Given the EKG changes alone, I suspect his Duke treadmill score would have put him in the intermediate-high risk category. At a minimum, I would have told the guy not to golf or do any more strenuous activity before getting him set up for a cath. I know this is controversial because, while in principle I don't go cathing asymptomatic patients, now that you have these stress test results in front of you, I feel like your hands are kind of tied at that point. Ultimately, this is complicated by the fact that I don't believe it was mentioned if he was even having any symptoms, which raises the question as to why any of this was ordered to begin with. This is a classic example of why tests shouldn't be ordered if you don't know what you're going to do with the results.

I would also like to point out that the stress test report is God-awful in trying to convey what is actually wrong. I try to write reports in such a way that, if a non-cardiologist was getting the results, they could at least get the gist of what they should do with the results. Writing "negative for exercise-induced ischemic symptoms, positive for exercise-induced ischemic changes, and abnormal for exercise-induced myocardial perfusion which reveals evidence of anteroapical and septal MI with ischemia" all in the same sentence is very clunky and, quite frankly, confusing...much like writing "partially-reversible ischemia" in a report in that it doesn't give much direction in the way of what to do with the results.