Legal Review & Commentary-Diagnostic failure causes death: $3.4 million verdict
Legal Review & Commentary-Diagnostic failure causes death: $3.4 million verdict
News: Failure to diagnose aortic dissection in a 43-year-old man resulted in his death approximately 24 hours after he first presented himself for medical care. The jury delivered a $3.4 million verdict against his family practitioner and the emergency room (ER) physician.
Background: The man became ill at work and walked to his company's health clinic. The clinic physician was not working that day, but the nurse called the man's family physician to report his symptoms, which included ear pain, neck stiffness, chest discomfort, and a "shocky" feeling down his spine. The company clinic visit concluded with his being sent home with the notion that he was suffering from stomach acid possibly brought on by a game of basketball the night before and some food he had recently eaten.
On the drive home, he was nauseated enough to pull over to the side of the road, but he never got sick. Shortly after getting home, his wife, who was trained as a nurse, insisted that they phone the family physician again. The family physician did not have time to see him in the office that afternoon, but he suggested they go to the hospital ER, which they did. Once at the ER, the man complained of severe mid-back pain and a pushing on the spine. A chest X-ray revealed nothing unusual. The family practitioner once again was contacted, and he requested that routine tests, including blood work, be done. The ER physician mistakenly reported there was blood in his urine, a fact admitted at trial. The misreported blood test results lead the ER physician to conclude that he was suffering from a kidney stone; however, he did not order an intravenous pyelogram (IVP), which is an accepted standard of care when a kidney stone is suspected. Further, the back pain was not isolated on one side or the other as is more common with a kidney stone. The man was admitted to the hospital, and even though his family practitioner made rounds at the hospital that evening, he did not visit his patient.
The next morning, the man's pain had intensified, and he passed away at about 1:30 p.m. The autopsy revealed that he had suffered from an aortic dissection, which is a relatively rare event, particularly given that the man was not predisposed to the condition or as old as most of the victims; however, the symptoms of the migrating pain, which started at the top and moved down, were typical, as was the spinal sensation. The plaintiff's estate alleged that if his family physician or the ER doctor had summarized the medical events and longitudinal progression of his symptoms, a correct diagnosis would have been made and attended to. The jury agreed and awarded the estate $3.4 million.
What this means to you: While on retrospective review of the facts of this case, the obvious diagnosis would be aortic dissection, there are many reasons that may not have been considered. The patient was very young for this type of a diag-nosis, and there is a wide range of clinical manifestations that would not fit into a category of "classic findings" that might point one in the direction of this life-threatening medical emergency.
"Sudden onset of severe sharp pain is, however, the single most common complaint of this type of event. In an emergency department evaluation, one would expect documentation of a review of systems, as well as a detailed history and evaluation to include questions related to the kind of pain; duration; what, if anything, caused relief or exacerbation; onset; and other symptoms that might be associated, such as gastrointestinal, respiratory, vascular, any comorbidity factors, risk factors, and vital signs," says Lynda Nemeth, RN, MS, JD, administrative director of quality and risk management for Norwalk (CT) Hospital.
"Key to diagnosis is the physical exam and a CAT scan of the thorax/abdomen, which does not seem to have been part of this emergency room evaluation. It appears from the background of the case that the emergency physician was focused on a primary diagnosis of a kidney stone, which did not match the patient's symptoms. Mid-back pain, especially located near the spine, is not typical of renal origin, therefore, the urinalysis and IVP would not be indicated," she adds.
"From a risk management perspective, I would question the experience level of the emergency physician and whether there had been previous patients who had presented to the emergency department with the diagnosis of aortic dissection. Liability generally rests with the facility in situations involving the emergency department and emergency room physicians. The private physicians, absent seeing and examining the patient themselves, will rely upon the emergency room physicians' assessment. The case background does not state whether aortic lesion or abdominal mass was considered as a differential diagnosis with documentation as to the rationale as to why it might have been ruled out. In educating the medical staff members in risk management and quality 'best practice,' physicians should be reminded to always document that they considered other diagnoses and through their experience and medical judgment ruled out other possibilities using the history taking, physical exam, and appropriate clinical tests to back this up," she says.
Reference
Estate of Dennis J. Fajfar, deceased v. Franciscan Sisters Health Care Corp., d/b/a St. Joseph Hospital, Claude Sadovsky, MD, Kishor Amjere, MD, Will County (IL) Circuit Court, Case No. 97L-716.
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