real scenario

[beezar]

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Ok, interesting real scenario:

58 y male with h/o HTN, DM, good exercise tolerance, presents to you for a total knee arthroplasty. Preop EKG shows 1mm ST depressions and T-wave inversions leads II, III, aVF which were unchanged from an EKG 2 months prior. Labs normal. No previous heart workup. What do you do?

Well, like any good oral board response, you say: "I get a complete H&P to start with."

Do you have or have had any chest pain, shortness of breath? Do you get short of breath with exercise/activity? etc. etc.
All of his responses: No.

Well, you should be safe for surgery. (according to AHA/ACA guidelines... intermediate risk surgery + intermediate clinical predictors + good exercise tolerance = surgery). You should probably have someone take a closer look at your heart after surgery, because your EKG is not completely normal, but you should be fine for surgery, and risk is low.

You go over risks,benefits,alternatives, etc., answer questions, and he agrees to proceed.

OR course goes uneventfully and hemodynamics are stable. Two weeks postop, the pt suffers a massive, fatal MI. Autopsy shows significant coronary artery disease. The family subsequently sues you.

Did you do anything wrong? Do you think you should win or lose this case?

 

[huktonfonix]

In the words of Al Pacino, "You could get killed walking your doggy!" You should definitely win the case. The MI could have been caused by either stress during rehab vs loose plaque. Sounds like the risks and benefits were presented to the patient. Now he probably should have had a subsequent cardiac workup during his hospitalization for his TKA (unless your institution fast tracks them home the same day) but even that isn't mandatory. This is a bull lawsuit. did they sue just the anesthesiologist or everyone involved in the surgery. As long as everything is documented as you mentioned it should be good.

 

[Laurel123]

Thats infuriating! Even if this guy didnt have knee surgery he probably would have had the massive fatal MI. Who knows when a totally aymptomatic patient would get an elecive stress test anyway. I cant remember what sort of screening tests are done for patients these days, but do patients withou symptoms get screening stress tests?

 

[Noyac]

He could have had an event at anytime but the surgery definitely didn't help things at all. The pt became hypercoaguable post-op due to the insult of surgery which stirred up inflamatory mediators, etc. Any plaque/stenosis that he had prior to surgery just became a greater risk of infarcting. I'm not saying that the case shouldn't have been done or that it should have, thats a judgement call but I do think the surgery very likely had something to do with his demise.

 

[Planktonmd]

Thats infuriating! Even if this guy didnt have knee surgery he probably would have had the massive fatal MI. Who knows when a totally aymptomatic patient would get an elecive stress test anyway. I cant remember what sort of screening tests are done for patients these days, but do patients withou symptoms get screening stress tests?

Let me play devil advocate here:

You have a patient that is coming for elective surgery, he is asymptomatic, but has electrical signs of inferior subendocardial injury that have been there 2 months ago.
Now let's forget the AHA guidelines for a moment (they remind me of nursing protocols), and use simple common sense:
There must be a reason why the EKG is showing ST depression and T inversion in the distribution of the RCA and only there, wouldn't you be curious to know why??

 

[beezar]

Sorry haven't logged in for a long time.

But what happened in this real case scenario is that the anesthesiologist lost the lawsuit. His mistake was something that is not completely intuitive.... basically the family complained that the anesthesiologist said that the pt should go see someone for his heart, but did not actually make a referral to a PCP/cardiologist. The judge agreed, stating that if the anesthesiologist was going to "diagnose" heart disease, he is obligated to either follow up or refer the pt to another doc. Case closed.

What a load of crap.

 

[johankriek]

Sorry haven't logged in for a long time.

But what happened in this real case scenario is that the anesthesiologist lost the lawsuit. His mistake was something that is not completely intuitive.... basically the family complained that the anesthesiologist said that the pt should go see someone for his heart, but did not actually make a referral to a PCP/cardiologist. The judge agreed, stating that if the anesthesiologist was going to "diagnose" heart disease, he is obligated to either follow up or refer the pt to another doc. Case closed.

What a load of crap.

prolly close to a million settement im sure..

im certain the case did not go to trial. BUt you can argue your point asymptomatic patient with intermediate risk factors undergoing a int risk procedure. You can say as a physician I felt his cad was well controlled, which it was. what does the legal system want people like this to undergo. cabg or stent before surgery. CMON. The cardiologist would have said beta block him and gave his blessing.

This is the **** that makes practicing terrible. You are a target.. this could be anybody's case. and you get a few of these cases on your record and next thing you know you are a menace to society and they will barr you from practicing.

SO basically the answer.. get cardiology consultation on everyone of these cases. and if there isnt one.. dont do the case.. or better yet.. go work at an outpatient facility doing eyeballs.. or gi work..

 

[lushmd]

Sorry haven't logged in for a long time.

But what happened in this real case scenario is that the anesthesiologist lost the lawsuit. His mistake was something that is not completely intuitive.... basically the family complained that the anesthesiologist said that the pt should go see someone for his heart, but did not actually make a referral to a PCP/cardiologist. The judge agreed, stating that if the anesthesiologist was going to "diagnose" heart disease, he is obligated to either follow up or refer the pt to another doc. Case closed.

What a load of crap.

Of course. God forbid the pt actually cared enough about their own health to arrange their own follow-up (who knows, if they set it up themselves maybe then they would actually go to the appointment)... How fortunate that we're continuing the trend of allowing/even promoting the idea that its acceptable for pts to abdicate responsibility for their own health. Sorry, rant off...

 

[Planktonmd]

What a load of crap.

Exactly.
But this is what we, physicians, think, unfortunately the legal system doesn't care what we think because this system is created and maintained by lawyers, and they want to make money.
So, if you think a patient has coronary artery disease and you disclose your concerns to the patient and you tell him: "I think your chances of dying from this surgery are higher than the average person"
and he tells you:" I don't care let's just do it "
This patient's consent to the surgery has ZERO value in the hands of a malpractice lawyer, actually he will use it against you:
It will be presented in the following way:
Doctor, Did you tell my client that he had a higher than average risk of dying from this surgery?
You say: yes (you have no choice, you wrote it down on the chart).
then he asks:
Doctor, So you knew that my client could die from this surgery didn't you?
You say: yes (again it's there on the chart in your hand writing).
It doesn't matter what follows this question because he already established that you knowingly subjected his client to a fatal surgery, this is all that the jury is going to hear.
The patient's consent to the surgery will be presented as invalid since all patients are presumed stupid and illiterate in the eyes of the law, and there will be no way that you could convince the court that the patient actually understood the risk and willingly chose to proceed, because patients are simply not required or expected to understand anything.

 

[Idiopathic]

edit: TMI. See below

 

[Planktonmd]

This forum is not the right place to figure out if a certain case has merit for malpractice litigation, there are plenty of trial lawyers out there who will be happy to help you.
On the other hand if you are a lawyer or work for one, you need to do your own research.