My Second Lawsuit

My second lawsuit involved a patient I treated only a couple of weeks after the first, so of course both notices were served to me during the same month, nearly two years later. This made me wonder if I was going to keep getting sued over and over again, and if I was even going to even be able to continue to practice as a physician at all. This suit, however, I was expecting.

I felt particularly bad about this case, and I still do. I consider this disposition to be the worst mistake that I have ever made as a physician. Perhaps she would have died anyway...many of my patients have died even when I did everything "right." But I will always know that I didn't give her the best opportunity to survive because of my errors in judgement. I sent a woman home and she came back two hours later with CPR in progress. I got her heartbeat back, but it was too late.

I recall we were exceptionally busy that night, and she seemed at the time to be the most stable of all my patients. I was supervising an inexperienced Anesthesia intern who barely spoke English, and he was overwhelmed with his four rooms. Meanwhile, I also had an unstable patient with DKA, a hospital employee's family member with septic shock (who later died), an elderly patient with rapid atrial fibrillation, a patient with a cerebral hemorrhage, and a couple of backboarded patients in the shock/trauma rooms, along with a handful of other tenuous patients that were my responsibility as soon as I came on shift. It was a dangerous situation. I asked another faculty from the "minor side" of the ER to keep an eye on my intern while my second-year resident and I ran around putting out fires. Then I turned my attention to Mrs. Johnson.

Almost fifty years old, she presented with a ten year history of intermittent chest tightness, palpitations, and shortness of breath which had increased over the past couple of days. She carried a diagnosis of mitral valve prolapse which had been diagnosed by echocardiogram, and she had undergone two diagnostic heart catheterizations, both of which were entirely normal. The most recent cath was 6 months prior to our meeting. Review of her previous records confirmed all of this information, as well as a few similar presentations to the ED. "Just another anxious MVPer with chest pain," I must have thought. "Good thing she's already been worked up."

Her ECG revealed frequent and multifocal PVCs. Happily, but perhaps unfortunately, both her PVCs and her symptoms immediately resolved after a single dose of IV metoprolol. She was sweating a bit, but so was everyone else in the trauma rooms (we kept them at 80 degrees, by decree of the trauma surgeons). Her electrolytes were normal, but for some reason that I still can't justify to myself I didn't order cardiac enzymes. A certain Cardiologist I know would have been proud of me, I suppose.

I did discuss with her the possibility of admitting her for observation, but I didn't really push for it. She felt so much better that she wanted to go home. I didn't rush her out, and in fact I probably spent more time with her than I spent with some of my other patients who seemed to be much sicker. It's more difficult to discharge a "borderline sick" patient from the ER than it is to admit them, after all. I ultimately performed three serial ECGs, and I spent a lot of time (mis)calculating her risk. I cautioned her to return if her symptoms worsened, and I prescribed a beta blocker.

The rest of the story:

She reportedly developed chest pain on the way home but didn't return as advised. Her husband found her slumped over in the chair not long after they got home, and although her resuscitation was initially successful, she never left the hospital. I still had four hours left in my shift after she finally went up to the ICU, and I probably saw several more patients...but I don't remember any of them. I was stunned, my confidence shattered. When her husband, who was gathered in the hallway with some friends or family, pointed at me from across the ER and yelled out "That's the guy who sent her home!" I wanted to crawl into a hole. I met with him privately and apologized to him, but there really wasn't much that I could say. I'm so sorry. I made a mistake. She was feeling better, and I thought she was going to be OK.

Her autopsy ultimately revealed a nearly occluding lesion in the left main coronary artery, interestingly without evidence of myocardial infarction. The cardiac enzymes I neglected to obtain on her first visit were negative even after her resuscitation. But her prolonged down time and delayed return of circulation had left her with an anoxic brain injury, and so her life support was eventually withdrawn. Her husband filed suit against me, as I expected, but he later dropped it for some unexplained reason. That was definitely a huge surprise. I would have had a difficult time defending myself in this one, but once again, I never even had to give a deposition. Maybe my apology helped, I don't know.

This case, more than any other, taught me the difference between the EM physician's and the Internist's approach to emergency patients. I mistakenly evaluated this patient from the perspective of the Internist or Cardiologist rather than that of the emergency physician. In a nutshell, I think it comes down to where we draw the line of acceptable risk. Other specialists may be comfortable with a 1/1000 or even a 1/100 risk of a bad outcome. In the ER, we cannot afford to be. Until I learned this lesson, I really didn't understand the difference in approach. My overconfidence in her relatively recent and previously unrevealing cardiac workup and my resulting misinterpretation of the significance of her warning arrhythmia were fatal errors that I haven't repeated since (as far as I know).

I can only pray that she rests in peace.