I just completed another shift in the emergency room (which I do about once per month), and it continually amazes me the amount of non-emergent cases that comes through – but that’s for another rant.
So I’m reading that the family of John Ritter is suing the hospital for misdiagnosing his ascending aortic aneurysm. Galen certainly has some tough words for this. I’ll reserve opinion since I’m not familiar with the case.
We’re taught there are generally four causes of chest pain that can result in sudden death. They are myocardial infarction, pulmonary embolus, aortic dissection, or tension pneumothorax. According to the story:
He was initially misdiagnosed with an acute myocardial infarction, then with pericardial tamponade, the suit states.
Generally, an aortic dissection needs to be suspected in order to be diagnosed – Medpundit has written about this today. 96 percent of dissections can be identified based on some combination of these symptoms:
1) Immediate onset of aortic pain with a tearing and/or ripping character,
2) Mediastinal and/or aortic widening on chest radiograph,
3) A variation in pulse (absence of a proximal extremity or carotid pulse) and/or blood pressure (>20 mmHg difference between the right and left arm).
Working in the ER, the first priority would be to ensure the cause is not one of the four “sudden death” causes. If the pattern didn’t fit an MI, a chest X-ray (routinely performed) would rule out a pneumothorax. That leaves dissection and pulmonary embolism as causes next to rule out. Chest CT would be the key test that would have caught the dissection (98 percent sensitivity). If PE was suspected, a CT angiogram would have been ordered.
Since the hospital’s working diagnosis was acute MI, and then pericardial tamponade (likely diagnosed via echocardiogram), I suspect that the chest CT wasn’t performed quickly enough, since dissection wasn’t high enough on their differential diagnosis (again, I’m just speculating).
I can only sympathize with the emergency room that night. With an acute aortic dissection, seconds count, and it was an unfortunate event for all concerned. Was it malpractice? Tough to say. The question I’d be interested in would be how long it took for the ER to order that chest CT scan.
Related posts:
- John Ritter and the $67 million malpractice trial
- How to protect yourself from abdominal aortic aneurysms
- Code blue in the air
- John Ritter defendants: "They just lost less"
- Cardiac arrest and good business
- John Edwards calls reducing medical malpractice lawsuits a "good idea"
- Chiropractors and carotid dissection
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Reading this blog is somewhat terrifying….
Here is a real life real time question? My 65 yr old husband has been diagnosed with an ascending aortic anuerism. The cardiologist says that it is of a size that could indicate surgery although she is not pressing for surgery. He is overweight, has a history of high blood pressure, and a family history of heart attack. He also has been hospitalized overnight 3 times lately for rapid heartbeat…I think that is unrelated to aorta problem.
All not good. He is electing to NOT have the surgery….no matter what anyone says.
MY QUESTION IS…..if he goes to the hospital in an emergency situation, how can I help make sure he gets the treatment he may need at that time? What do I need to do and say and take with me?
My sister died from an Left anterior descending coronary artery dissection on November 16, 2006. She died four days after going to the ER with severe chest pain, cold sweats, nausea and upset stomach. I believe she also has tingling in her arm but not sure. She was sent home from the ER with a diagnosis of GERD!!!! Because she had a history of GERD, they did not even test further than a stress test and x-ray. Had they ordered a CT Scan and/or the artery test, that is more envasive. (Can’t think of what it’s called at the moment.) I ask does GERD cause cold sweats? Does it cause chest pain, well yes, but as I recall the pain is more intermittent, at least it was for me. Does GERD cause nausea and vomiting? Didn’t for me. And it certainly didn’t cause tingling in my arm/neck. I believe my sister could have had a chance at life had the doctors in that ER taken those chest pains and her other symptoms more seriously and done the tests needed to rule out any of the four deadly heart conditions that should have been ruled out. She may or may not have survived, but we will never know because she wasn’t given the chance. I can definitely sympathize with Ritter’s wife and family. They have every right to sue. And apparently others thought so too as they settled with her.
I am contemplating a law suit as well. I haven’t had the strength to do anything yet, but it may just be the time t do so.
Grieving MN sister
Dear Anonymous,
To be pro-active in your husband’s future care, it would be extremely helpful to have a list of all of your husband’s medication allergies and drug intolerances, a 100% acurate medication list, and a comprehensive but concise summary of all of his medical problems. Put at the top of this list “known ascending thoracic aortic aneurysm”. Both of you need to remember to politely, but clearly state that “I am known to have an ascending aortic aneurysm, and I have been told to remind you that this thing can suddenly tear or rupture causing chest pain. Please carefully consider this possibility in my case.” Being forewarned is immensely helpful to physicians in an emergency setting.
Blessings to you.
I am the survivor of an ascending aortic aneurysm and dissection. On December 2, 2003, I woke up with chest pressure and radiating pain to my back. My doctor’s office was unable to fit me in but sent me to a local medical center. During the chest x-ray, I passed out and when i woke up, the ER doctor told me I had a heart murmur. I told him that it had never been diagnosed and he said it was a very loud murmur. I was sent by ambulance to a nearby hospital. I was a 42 year old woman with no significant medical history, low cholesterol and blood pressure. I spent six hours in the ER. I had the CT scan and then,not one, but two echocardiograms because the technician who they had caught on her way home couldn’t believe what she was seeing. By 6:30 I was again in an ambulance and was transferred to another hospital nearby who specialized in cardiac care. As I lay on the gurney, trying to comprehend that I was about to go into open heart surgery and receive a mechanical valve, my husband suggested I call our three children and say hello. I spoke to each of them briefly and told them I loved them. As I hung up the phone, I told my husband I was going to pass out. My aorta dissected and I was rushed to surgery. Five hours later, I had survived the surgery. The surgeon shared with my husband that I had flatlined on the operating table and that it had taken significant time to stabilize me.
I do not have a lot of memory from the first few days of this event. But I will say that the doctors, nurses and staff of the ERs did everything they could to help. And the further I move away from that date in December, the more I realize that my survival was not just because of the amazing surgeon that was on call that night and operated on me but because of the dozens of people who did their best to help me. I have been told by my sister, who has been a nurse for almost 30 years, how low the survival rate is for an aortic dissection. I was right there, literally next to a surgeon, when mine occured. And I was SO fortunate to have made it through surgery. So despite how wondrous medicine is and how advanced it gets, I still think you need a little luck…thats the only way that I can explain why I am still here. And I agree with Dr. Rogers – picking up on it does depend on how often the doctors consider it. I have been told over and over that I did not have indicators for it – nothing that would have made them initially suspect that. For me, that is the scariest part. I can’t imagine how the ER docs do it – it must have been like trying to find a needle in a haystack.
I just felt like I had to share – I don’t know the true numbers of people that survive and as heart disease is the number 1 killer of women now, I do think we need a lot more education and awareness.
I have been in and out hospitals for the past 20 straight years. 18 with my Son and the last 2 with my Wife and I. I was 46 and had an Abdominal Aortic Anyuerism 8cm at time of Surgery. I was having lower back pain and had seen a couple of doctors, neither of which ordered a C/T scan. The pain management specialist sent me to have a MRI of my lower back. Half way through the MRI I was asked to come into the imaging booth where they showed me the AAA. Yep I was stunned, but not afraid. I was confident that since this was caught before it ruptured I would be fine. I had 18 inchs of Aorta replaced with Dacron tubing, Thanks to a Korean Christian Surgeon, Dr. Choi at Baltimore Washington Medical Center I am in excellant health now. I have met some very arrogant Docs and some very eloquent Docs, just people all the same, some with more talent some with not so much talent, but still like all of us flawed and fragile creatures of God. So the next time you want to blame the Docs for a bad diagnosis, before you do, go home turn on CNBC financial news and watch the ticker as Human Blood gets traded on the NYSE. I am convinced the people who buy and sell blood are the ones to blame, C/T and MRI Scans should be the NORM! Scans would be the norm if the American People had Political clout like the Health Insurance lobbiest had. The Scum who trade your blood futures try to please the shareholders before you. The God gifted Doctors and Nurses who sometimes work around the clock catch all the crap, not all of them got into healing for the money. They are a patsy for the blood traders. It wasn’t the Doctors I blamed for not diagnosing my AAA, it was the system.
It is simple math. Aortic dissections are uncommon, chest pain is common. If we scan every patient that comes through the ER. The miss rate of aortic dissection will be extremely low.
Your monthly insurance premium will be extremely high(er).
Not to mention that if you have multiple such episodes over your lifetime, you will receive a potentially cancer inducing dose of radiation.
Society must decide which it will be. Suing the doctor makes some lawyers very happy. It, unfortunately, does not solve the problem.
MD
I am not American and I am APPALLED by Americans suing about every thing.
Doctors don’t have super powers! They miss things but mostly, they do a damn good job.
Keep suing or complain about the price of health care. Choose one!
Reading a CT scan (CAT scan) is not like reading a book. There can be very subtle and ambiguous findings that even experts will not agree on. Similarly aortic dissection is difficult to diagnose. It WILL be missed. As many have pointed out, ordering CT scans on everyone with chest pain is NOT an answer. There will always be differences in the quality of health care. Not everyone can get the best surgeon for every operation. Just remember, law suits like this take millions of dollars OUT of the health care system. Money that could be spent improving health care. Doctors work incredibly hard. Have you ever worked 40 hours in a row? Without stopping? How about repeatedly, as in every 3rd day? Have you worked 12 hours on your feet without even a bathroom or lunch break? I have, and I can tell you it is not fun. Do you think a Doctor wants to miss a diagnosis, or doesn’t feel bad when a patient dies? Have you ever had the responsbility for someone’s death on your hands?
The problem is you have to distinguish between a mistake and negligence. Mistakes will happen. The way to improve them is analyze why mistakes are made and improve the system. Blaming individual doctors is not going to work. It’s just going to drive the best and brightest out of the business. Doctors that are negligent, on the other hand, should be crucified. I have no problem with that. There needs to be a systematic way to dinstinguish the two. Of course there will always be a gray area. But that should be focused on. As for the case of missed dissections, often symptoms that support the diagnosis are “cherry-picked” from ALL the symptoms the patient had, and present a very misleading view of the case. Diagnosing a patient, or reading a CT scan in retrospect is ENTIRELY different from doing it up front. People passing judgement on these doctors may be right, but until you’ve been there, you have no idea.
There is no comeback against the wise words of “Mortal Doc”.
He has said it all.
The bitter whining and baying for physicians’ blood will continue, but that is the ugly side of humanity.
Australian Anaesthetist.
THis comment is in refernce to grieving MN sister. I am truly sorry for your loss. But if you think that a regular aortic dissection is hard to pick up (which it is), a left anterior descending coraonary artery dissection would be virtually impossible!! THe majority of heart attacks that present with aortic dissection are due to dissection of the right coronary artery. it is possible your sister had an anomoly where the left anterior descending artery would be affected from an aortic aneurysm. i don’t know the specfics of your sister. however, an xray, cat scan of the chest, or ultrasound will not show an isolated LAD dissection. IT is very very rare. and i do see patients who have bad chest pain who just have GERD. hindisight is always 20/20, but only GOD knows it all. not doctors
Regarding various comments on the “cost” of a CT scan. In one study done on head CTs performed in an ED, the average cost billed to insurance was $300. (the study concluded that even at $300 it was not indicated for the symptom of headache). But don’t let your doctor bluff you on not doing a CT because it’s too expensive. I don’t know how much more a chest CT costs but it’s NOT the $3000 dollars someone suggested. Sure it might say some inflated number on the bill but your insurance co. is paying a few hundred dollars.
And even if it was $1000 extra, if you the consumer is so smart about your diagnosis, then ask for a CT and offer to pay for it. What, you’d pay $1000 a year for cell phone use but not for a CT that could save your life??? I think there should be a separate line in the ED where you can swipe your credit card and order whatever tests you think you need at the rates billed to the insurance co. A lab tech could come in and draw the blood and another tech does the CT or whatever (no, your doctor doesn’t usually do those test like they do on TV). then you could sit down with your harried ED MD and present the results. Pay up or shut up america.
Well I’ve read all of the comments and have the following opinion. There are difficult diagnosises that a competent doctor will miss, there are difficult diagnosises that will be missed due to incomptetnet doctors, and there are missed diagnosises by doctors who refuse to listen to the patient and/or their family because they couldn’t possibly know more than him/her.
My family physician missed the fact that I had endocarditis for 4 months. The first time I went to him I filled out the medical history sheet that I assume goes in the patient’s chart. I wrote on mine that I was born with a VSD (large) that had not been repaired because I had been generally asymptomatic. At age 17 they detected that the shrinking (but not closed) VSD was causing aortic valve prolapse and aortic insufficiency. Fast forward to 2003 and I get a nasty case of bronchitis I can’t shake. After a few rounds of antibiotics, then steroids accompanied by M-Clear cough syrup we finally beat the bronchitis. But then I presented over the next few months with a low grade fever, night sweats that became increasingly worse, prostititis, swollen hands and feet, painful joints, and eventually a dull pain between my shoulder blades. I was going downhill fast. About 3-4 weeks before I was diagnosed with IE I told him that I was worried that I might have it. He dismissed me and said you don’t even have a murmur. I guess a (now) small VSD and moderate aortic insufficiency can not be detected by the “average” doctor when he/she listens to your heart. I kept going downhill and I finally insisted that he run a blood culture on me. The culture was performed on a Friday afternoon and he called me on Sunday morning to let me know that it had already come back positive and was going to call me in some Cipro 750mg. On Monday I was so ill I called him back and insisted that I get an echo. The echo was perfomed Tuesday afternoon and I was admitted to the hospital Tuesday afternoon with infectious endocarditis. After 7 weeks of an IV regimine of Rocephin 2gm daily I had a cardiology consult (which my doctor didn’t think I needed) where I found out that I needed to have by aortic valve replaced and my VSD repaired. BTW I had a Ross Procedure at Duke.
OK doctors…was this a case of a difficult diagnosis that happened to be missed by my doctor or a case of malpractice? Remember that I filled out the patient history sheet stating that I had AI and a VSD. I reminded him of that and he said I didn’t have a murmur. I told him that after researching the symptoms of endocarditis I had all of the classic symptoms. I had to prod him to do a blood culture (even though my white count was higher every time it was taken) and an echo.
Guess what…I didn’t sue him. Not because I didn’t think he was negligent, but because I thought he was trying to help me the best he could. IMO his 2 main mistakes were not reviewing my past medical history (or not connecting that history with being at a higher risk of contracting IE) and NOT LISTENING TO THE PATIENT. When a complete stranger comes into the ER who do you think knows their body better…you who have known the patient for 2 minutes or the patient and/or family member? I honestly think that if doctors would actually listen to their patients better it might make it easier to make a correct diagnosis. I realize not all patients/family would be intelligent advocates for themselves, but that’s part of being a good doctor…having a sense for which patients can help you diagnosis their problem and which ones can’t.
Sorry for the thread jack on dissections. BTW…IMO I think dissections are much more common than most people think, but unless an autopsy is performed it is often considered a heart attack if the patient dies before being diagnosed.
I have enjoyed reading everyone’s comments. I think that as technology continues to advance we will have faster and safer imaging modalities (machines) which will in fact enable us to get detailed images of everyone who presents with chest pain. For instance today we have a lot more success in accurately diagnosing the cause of abdominal and pelvic pain in ER (compared to years ago) mainly thanks to the liberal use of ultrasound and CT scan.
You are right in thinking that your doctor should have considered endocarditis early on. Patients with persistent fever of “unknown origin” whether they have a murmur or not should have blood cultures done because subacute bacterial endocarditis is always in the list of possible causes. And it is lethal if not detected and correctly treated. Also, I have to say that oral Cipro (or any antibiotic) is almost never the correct drug for any infection serious enough to cause positive bacterial blood cultures. It is certainly not correct treatment for endocarditis.
Yes, physicians should extra vigilant to consider endocarditis in a patient like you who has a VSD and/or aortic insufficiency with or without a murmur.
I am sorry that you had your experience. Unfortunately I don’t know how to make all physicians (even myself) perform to the highest standards possible since they (we) are all humans with human failings. I hope and pray that you do well from this point forward.
I have to make a correction. The phrase “or any anbitioc” should have said “or any ORAL antibiotic”. Intravenous antibiotics are absolutely the primary treatment for bacterial endocarditis.
The error is regretted.
mortaldoc,
Thank you for your comments and your well wishes. Today (3/17) is the 4 year anniversary of my Ross Procedure. I had my annual follow up about 2 months ago and both valves are functioning perfectly and my slightly dilated aortic root (3.7cm) has not changed in 2 years. I realize that dissections are difficult to diagnose because the symptoms can mimic so many other problems. That’s why I think that when someone enters the ER with chest pain a simple list of questions may shed some light on whether or not this person may be at risk of aortic dissection. Since many cases of aortic dissecton accompany patients with bicuspid aortic valves, Marfans, or other connective tissue disease…asking them questions about their family history may be the “needle in the haystack” that doctors are looking for. If they have a family history of family members dying of “heart attacks” at a relatively young age that would be a major red flag. Also listening to the patient when they explain their symptoms may help doctors differentiate possible causes for those symptoms. I think part of the problem is that since ER docs don’t experience many patients arriving with aortic dissections it’s too easy to lump their symptoms with other, more common health issues that they see much more frequently. But one thing I’ve noticed in most of the testimonials here from dissection patients or their family members is that with treatment the symptoms did not subside…another red flag. That’s why I learned early on that I (or my family) had to be my own “patient advocate” and not feel too intimidated to question a doctor’s diagnosis and/or treatment. Some doctors don’t appreciate this, but when I’m sick and feel like there may something seriously wrong the last thing I’m worried about is bruising someone’s ego. I’d rather be wrong and apologize to the doctor later than be right but kept my mouth shut with catastrophic results.
I have a lot of respect for physicians and their dedication to helping people, but like other doctors have said here they are only human and will occasionally miss a diagnosis. That is where a well informed patient may make a difference in helping the doctor narrow down the possible causes for the symptoms they present when they arrive at the ER (or doctor’s office). This is assuming the doctor is willing to listen to the patient and take them seriously.
This may not be read by anyone since it has been a long time since Dr. Rogers posted his comments. I “Googled” Ritter’s cause of death after seing his wife on some Hollywood news show last night. She indicated that a “heart” painted on a mural of Mr. Ritter was directly over the spot where his aorta ruptured. Only problem… the heart graphic is on the high right side. a little education still needs to be done on the plantiffs side.
As per all these other posts…
Many of the case discussions involve disappointed and grieving family members of those that had a missed diagnosis. This is, of course, sad for the individual but is not reflective of the ED community as a whole. There is simply no impetus to write in and share a case in which rapid diagnosis was made and the patient did well. This is bias sampling which is common in anedotal reporting. As an emergency physician in Michigan, I can assure the public that AAA and Thoracic Dissection is part of every single lecture regarding heart disease and critical care ED medicine. There will always be missed diagnosis regarding virtually every chief complaint. It does not mean the physician community as a whole is uneducated or complacent. I had a man die in the ED who had this horrible disease and yet presented with resolved nausea/vomiting and had NO chest pain, NO abdominal pain and had a normal routine work-up including CXR. It can be tough to pick up and yes, doctors, it can be obvious and sometimes ignored. I don’t think Mrs. Ritter’s 67 million lawsuit is the kind of education that the medical industry embraces. That is simple hyperbole from a “Hollywood” mentality. That said, a loss is a loss, and we all deal with it in different ways.
Grand Rapids Emergency Physician. 20 shifts a month, 20 years and still going.
A side comment… Working one ED shift a month does not make one an “Emergency Physician” it makes one a physician that works in an emergency room… and the repeated use of the “F” word does not engender the respect we physicians seek to earn from our patient population.
In Sept.2000, my friend Kim Hawkins died suddenly of Aortic dissection. Thats what her autopsy report said. She was the manager of Kritinas Natural Ranch Market in Fresno, Ca. Is there any way a person could be ‘murdered’and some kind of drug or something could cause aortic dissection? My ex-husband Jim Belcher, who owns the health food store, collected a large death benefit he owned on Kims life. I excaped dyeing in an “accident”, that I knew my now ex had set me up for, by a strange comment he made afterwards. Jim still owns my life insurance policy, due to him having Company owned life insurance on all his employees. There are about four deaths that I know about. No proof, but I know…..
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