Through the Retrospectoscope

by Ann S. Lofsky, M.D., Board of Governors

Malpractice cases are always expert reviewed and tried with the benefit of 20/20 hindsight. While in retrospect, it might be obvious what went wrong or what could have been done better, things likely looked very different from the vantage point of the physicians who had to make timely medical decisions without prior knowledge of the end results of their actions. The case discussed here involves the quandary of whether a jury can understand that even following the standard of care can sometimes have a negative outcome:

A 28-year-old personal trainer was out running with a client for 30 minutes. When they finished, the trainer began walking in a circle to catch his breath. He had a blank stare on his face and then suddenly collapsed to the ground, losing bowel and bladder control. Paramedics were called, but he spontaneously regained consciousness five minutes later, complaining of heaviness in his chest.

He was taken to a hospital emergency room, where an EKG demonstrated sinus bradycardia of 55 with first degree AV block. Lab work and chest x-ray were within normal limits. He was treated with intravenous hydration and after being observed for several hours, he was discharged home with instructions to follow up with his primary physician. The patient called his own internist, who referred him to our insured, a board certified cardiologist.

What Would Be the Correct Work-up of This Patient?

On presenting to the cardiologist, the patient was noted to be a highly fit young man who exercised six days a week for at least one hour at a time. He explained that his first degree heart block had been diagnosed 10 years earlier as part of a routine physical, but other than the current episode, he had never had any symptoms. He had no cardiac risk factors, and his physical exam was entirely unremarkable.

The insured performed an echocardiogram, which showed no abnormalities. He next performed an exercise treadmill, which lasted 12 minutes with no arrhythmias and no ST segment abnormalities. The insured felt that the next step would be to place the patient on a Holter monitor to detect occult arrhythmias and then refer him to a neurologist to rule out a seizure disorder.

As this was being explained to the patient, the man stated that he was not feeling well. Still attached to the EKG from the treadmill, he slumped to the floor and had a grand mal seizure. The insured placed him on his back and instructed his office staff to call a code and to bring an oxygen tank and face mask. The code team responded five minutes later. They found the patient still in sinus rhythm but with labored, shallow respirations. He was intubated and placed on a gurney for transfer to the ER, which was two floors below the insured’s office.

Before the transfer was initiated, progressive bradycardia was noted on the monitor, and atropine was administered without effect. The paramedics took the patient to the ER with full CPR in progress. He ultimately expired in the emergency room after a one-hour code. An autopsy was performed, revealing a congenital anomalous left coronary artery.

Were Any Physicians Negligent in the Care of This Patient?

The patient’s family filed a lawsuit alleging wrongful death. The plaintiffs’ cardiology experts felt that the stress test should never have been performed due to the fact that the patient was “high risk.” In their opinion, the echocardiogram showed evidence that an anomalous coronary artery existed because the ostium of the left coronary was not visualized. They therefore felt that it was inappropriate to proceed with anything other than a coronary catheterization or a trans-esophageal echocardiogram (TEE). They argued that the stress test created ischemia, which ultimately led to the seizure and the arrest.

The plaintiffs’ experts were also critical of the resuscitative efforts, stating that the insured should have had a written emergency protocol in his office, a full crash cart, and a defibrillator so that there would have been no delay while waiting for a code team. They argued that the insured did not follow accepted guidelines for an exercise-testing laboratory. A cardiovascular surgeon stated that the insured should have started an intravenous line on the patient and provided oxygen. Since no written record of the code was generated, it was also alleged that proper interventions, including administration of nitroglycerin and epinephrine, had not taken place. The surgeon felt that with the proper treatment, this man would have had a good chance of recovery and could have been saved.

The expert cardiologists for the defense argued that it was entirely reasonable to perform an exercise treadmill and pointed out that indeed much of the literature recommends that stress tests be done even when a patient is known to have an anomalous coronary artery. They opined that the EKG was normal during the exercise test and that only after its termination did the patient experience a seizure and then evidence of ischemia.

It was hard to tell whether ischemia precipitated the seizure or whether the patient had an underlying seizure disorder further complicating this situation. The neuropathology report at autopsy revealed scattered neuronal eosinophilia that would be consistent with a history of prior seizures. The pathologist suggested that the hyperventilation after exercise precipitated a seizure, which then resulted in ischemia.

The defense cardiologists stated that intravenous lines are placed before stress tests only when done in conjunction with imaging studies or when myocardial infarction is being ruled out. They felt that it was not necessary for the insured to obtain a separate written consent for a treadmill exam. They did concede, however, that it was unfortunate that neither the code team nor the insured’s office had any antiseizure medications such as benzodiazepines or Dilantin. They also felt that administering nitroglycerin to this patient at the first sign of the bradycardia might have possibly saved his life.

Should This Case Be Tried?

The hospital settled out of this case for its responsibility for the crash cart supplies and the code team protocol. Because of the supportive defense reviews and the insured’s wish to defend his own care, no settlement offers were made prior to going to trial. The trial against the cardiologist lasted for one week, during which it was impossible to tell which way it was going, as both sides testified well. The jury deliberated for eight days before rendering a unanimous verdict for the defense.

The standard of care for physicians requires only that a physician do what a similarly trained and competent physician might choose to do given the same circumstances.Ultimately, a medical decision is something for each physician to make in light of all the circumstances of the individual case. Unfortunately, standard office medical equipment does not currently include a retrospectoscope to make that decision easier.