On March 2, 2012, plaintiff’s decedent, a 41-year-old shipyard worker, presented to defendant hospital’s emergency room at approximately 1:00 a.m. with a history of smoking and a chief complaint of chest pain radiating to his neck/throat with nausea. The pain waxed and waned. He remained hypertensive (BP of 190/96) throughout his seven-hour stay in the ED. The laboratory values reported cardiac enzymes WNL, which helped rule out a myocardial infarction. However, the etiology for the abnormal EKGs was never explored. He received only Dilaudid and Zofran prior to discharge. There was no other treatment, no further work-up, no consult with a vascular surgeon.
While in the emergency room, the defendant physician ordered two EKGs. The first was machine-read as having a non-specific T wave abnormality. This helped rule out a heart attack, but suggested some cardiac event. The second EKG was misread by the physician, who found no change from the earlier study. However, the cardiologist’s over-read is substantially different, having found “T wave inversion now evident in lateral leads: consider lateral ischemic changes.” This finding and recommendation of an etiology should have raised the index of suspicion for dissection. With an aortic dissection, the blood leaves the lumen and as it enters, it separates the vessel’s inner layers, which reduces blood flow, causing ischemic changes. The EKG also had an axis deviation — the QRS complex was shifting, which again raises the suspicion of significant underlying pathology and also should have prompted further investigation.
The chest X-ray was also incorrectly read by both the ED physician and, the next morning, by the radiologist as “no acute process / no evidence of active cardiopulmonary disease.” The radiologist performed the misinterpreted over-read the day after decedent’s death, and so was not joined to the suit. The study clearly showed an aortic shadow and enlarged aorta, which are classic signs of dissection.
Plaintiff’s experts, one of whom “wrote the book on aortic dissection,” opined there was a breach in having missed the differential diagnosis and having failed to obtain a vascular consult in a hypertensive male, with a history of smoking, who presents with complaints of chest pain radiating to the neck and an EKG read that lateral ischemia is “now evident.” In such cases, a CT was mandated by the standard of care to rule out a dissecting aneurysm; alternatively, it could have been detected with a simple bedside echo, readily available in any ED. In fact, this is the most common pattern for dissection; it starts at the ascending aorta and extends into the descending aorta. This condition is repairable between 75-90 percent of the time if diagnosed / treated promptly.
Instead, the patient was discharged to home, where he was found unresponsive by his roommate shortly after discharge. Autopsy revealed that the cause of death was an aortic dissection with rupture into the pericardial sac. The pressure from blood building up in the pericardial sac caused the heart to stop beating. He left behind a wife and three children.[15-T-035]
Type of action: Medical Malpractice – wrongful death
Court: Portsmouth Circuit Court
Judge: F. Bradford Stillman
Date resolved: Feb. 6, 2015
Verdict or settlement: Settlement
Attorney for plaintiff: Judith M. Cofield, Virginia Beach