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Chest pain treatment options increase liability
Chest pain is one of the conditions most likely to lead to a charge of malpractice for two main reasons, says Diane M. Sixsmith, MD, MPH, FACEP, chairman of emergency medicine at New York Hospital Medical Center of Queens in Flushing.
The cause of chest pain can be difficult to diagnose and treat properly; but at the same time, current treatment strategies also mean that even the sickest patients can fare well if ED staff make the right decisions, she says. Thus, the stakes are high for both the patient and the ED, Sixsmith adds.
"Plaintiffs’ attorneys can easily claim that the patient would have fared better if only . . .’" she explains. "Risk factors are very important. If a smoker comes to my ED with chest pain, he gets admitted. No question."
Once acute myocardial infarction or acute coronary syndrome has been diagnosed, you must meet the standard of care for certain types of treatment, Sixsmith emphasizes. Not only is that approach best for the patient, but plaintiff’s attorneys also will seize the opportunity to show that you did not meet certain standards that are measurable and not a matter of judgment. For instance, you should require that appropriate drugs be administered within 30 minutes of the patient’s arrival and that the patient goes to the cath lab within 90 minutes of arrival, she continues.
Heparin, beta-blockers, and aspirin must be administered promptly when appropriate. Also, the ED should have a policy of obtaining a cardiology consult as soon as possible if the patient is unstable, Sixsmith says.
She outlines these other risk-reduction strategies for chest pain:
Missed aortic dissection a big risk
Be especially cautious with the possibility of an aortic dissection — the cause of actor John Ritter’s recent sudden death, Sixsmith says. Your defense attorney will have a difficult job ahead if a patient came to you with an aortic dissection, but you diagnosed indigestion and sent him home with an antacid.
Patients most at risk for aortic dissection are hypertensives, those with a family history or known history of aortic disease, and those with Marfan’s disease or Marfan's-type features, she states.
The presenting symptoms of aortic dissection often are confusing but usually start with sudden tearing chest pain, which may then migrate to the abdomen or lower back. Twenty percent of the patients present with neurological signs and symptoms.
Mortality for aortic dissection is 1% per hour after symptom onset, so early diagnosis is crucial. "A well-defined plan should be in place for prompt diagnosis of aortic dissection at any hour," Sixsmith adds. "That may mean making sure that your ED personnel can obtain a CT scan or transsophageal echo at any time, including 3 in the morning."